CULTIVATING N ETWORKS:
IMPLEMENTING SURGICAL
TELEMEDICINE
Margunn Aanestad
THE INTERVENTIONAL CENTRE,
RIKSHOSPITALET, FACULTY OF
MEDICINE, UNIVERSITY OF OSLO
THE DEPARTMENT OF INFORMATICS,
FACULTY OF MATHEMATICS AND
NATURAL SCIENCES, UN IVERSITY OF
OSLO
i
CULTIVATING NETWORKS:
IMPLEMENTING SURGICAL
TELEMEDICINE
by
Margunn Aanestad
Submitted as partial fulfilment of the
requirements of the degree
Doctor Scientarium
At the Faculty of Mathematics and
Natural Sciences, University of Oslo,
Norway
January 2002
ii
TABLE OF CONTENTS
1. Introduction
1
2. Telemedicine – visions and challenges
3
3. Related research
6
3.1 Technology-centred organisational change
6
3.1.1 Information Systems Research vs. Computer-Supported
Cooperative Work
7
3.1.2 Complex and indeterminate relationships and
processes
9
3.1.3 Zooming in on socio-technical interplay
11
3.1.4 The case for being specific about technology
12
3.2 How technology matters
13
3.2.1 Technology as an actor?
14
3.2.2 Information infrastructures
15
3.2.3 Cultivating, not designing information
infrastructures
16
3.2.4 Telemedicine as an information infrastructure
17
4. Research aims and methods
4.1 Research aims and questions
4.2 The case study
4.2.1 The Interventional Centre
4.2.2 Other hospitals and telemedicine activities
4.3 An interpretative study using qualitative methods
4.4 My role in the field work
4.4.1 Participant observation
4.4.2 Interviews
4.4.3 Focus and drift
4.5 Theoretical framework
19
19
19
19
21
22
23
23
24
24
27
5. Research findings
5.1 The work to make telemedicine work
5.2 Socio-technical negotiations
5.3 The network required to make telemedicine work
29
29
31
33
6. Implications and contributions
6.1 Implications for telemedicine
6.2 Contributions to ISR, CSCW and STS
6.2.1 Beyond single site use: the challenges of
growing networks
6.2.2 Micro- and macro-level design in use
6.2.3 Bootstrapping, detours and spillovers - or
designing for novel use in complex settings
36
36
38
7. Conclusion
44
iii
38
39
42
ACKNOWLEDGEMENTS
A Ph. D. study is not carried out in isolation, and I want to acknowledge the
help that I have received from others:
First of all, I have been lucky to have two interested and knowledgeable
supervisors: Jan Sigurd Røtnes, your enthusiasm, dedication and interest in
telemedicine were invaluable in making the telemedicine project as well as my
Ph.D. study possible, and it has been an important source of inspiration! Ole
Hanseth, thank you for your interest in my work and for your door always
being open when I wanted to see you. Your supportive attitude has been an
invaluable source of encouragement! A big thank you also for having
introduced me to a most stimulating academic community through suggesting
relevant and interesting literature as well as suitable conferences.
Colleagues and friends at the Systemarbeid group at the Department of
Informatics have supported me, and I want to express a sincere gratitude to
the whole group. Especially I want to mention Judith Gregory, Tone
Bratteteig, Sundeep Sahay, Eric Monteiro, Eevi Beck and Jo Herstad, who
have read and commented on my manuscripts and have been available for
inspiring discussions. A big, special thank you to Knut Rolland, my roommate for better and for worse through these years. I have greatly enjoyed and
benefited from your company!
I also want to thank the people that I have interviewed and interacted with
during my case studies, and especially the staff at the Interventional Centre,
Rikshospitalet, where I found a friendly “ home”. This department is a very
special place, where a diverse and dedicated group of people work to utilise
new technological possibilities for medical diagnosis and treatment. The staff
here was always supportive and interested in my work. Especially I want to
express my gratitude to the Head of Department, Erik Fosse, who took an
interest in my work and gave valuable feedback. Also I want to thank Ole
Jakob Elle, Nils Heimland, Bjørn Edwin, Tom Mala, and Eigil Samset for
interesting discussions and valuable input to my different papers, and Lars
Aurdal and Bjørn Erik Mørk for proofreading and commenting on my final
draft of the dissertation.
The academic community that I have become acquainted with has been a
great source of inspiration. I have perceived it as generous and welcoming, as
immensely stimulating intellectually, and I have met people with a sincere
interest in the study of technology in society. I am grateful to all researchers
that share their findings and reflections. I have had the privilege to participate
in several Ph.D. workshops and I am immensely grateful for the response and
comments from senior researchers within the field, among them Lucy
iv
Suchman, Bruno Latour, Matthew Jones, Marc Berg, Edgar Whitley and
Geoff Walsham. There are also other Ph.D. students who work with a
theoretical approach or practical focus which is similar to my own, among
them: Gunnar Ellingsen, Miria Grisot, Per Hasvold, Dixi Henriksen, Edoardo
Iacucci, Ulrika Josefsson, Frode Løbersli, Agneta Nilsson, Jens Kaaber Pors,
Ingjerd Skogseid and Brit Ross Winthereik. I have enjoyed getting to know
you and I have benefited from sharing my work with you! A big thank you
also goes to Ola Henfridsson, who visited Oslo during my write-up period,
and provided most helpful advice.
The work has been funded by the Norwegian Research Council, under the
programme for ICT in health care through grant no. 123861/320. This
financial support is gratefully acknowledged.
Last, but not the least: My parents deserve a big thank you for always having
encouraged me to go on. My dear Kjetil, Helge Andreas and Susanne: Thank
you so much for always being there and for your love and support!
Oslo, January 2002
Margunn Aanestad
v
ABSTRACT
This dissertation presents an interpretive study of the socio-technical change
processes that evolved around the introduction of telemed icine. The case study
reports from real-time transmission of audio and video, mainly from minimallyinvasive surgical procedures. In this work telemedicine is viewed as an instance of a
larger class of technologies where radical organisational change is expected to follow
from the deployment of communication network technologies. Thus the
contribution from this work is relevant also beyond telemedicine, for other kinds of
technology-related organisational change. It is particularly relevant for other attempts
at exploratory development of network technologies to support communication.
The first main theme of the work has been to analyse the socio-technical interplay,
and the dissertation describes the temporal unfolding of the ongoing and openended process of adaptations and socio -technical negotiations. From an array of
different perspectives the papers show how much work it takes from a host of actors
to actually accomplish telemedicine. Through a description that covers the range
from the everyday, mundane technical details to the large-scale network issues, a
number of complex and dynamic socio-technical relationships that exist for
multimedia communication networks are described. The process where the
technology and the organisation became mutually changed and adapted is described
in several of the papers, while other papers zoom in on e.g. the support work that
was required, and on the different ways to achieve safe and sufficient image quality in
the transmissions. A conclusion that emerges from this emphasis on the socio technical interplay is that a successful introduction of telemedicine is a far more
complex and long-term process than merely implementing it and using it.
Introducing telemedicine will require an ongoing and concurrent design-in-use of
both the new technology and of the organisation that deploy it.
A second main theme is related to the network character of telemedicine, and the
challenges related to handling of large and complex networks or information
infrastructures. Previous empirical research has demonstrated the limitations of
“control-oriented” approaches, but scarcely go beyond advocating evolutionary and
iterative approaches (e.g. “cultivation”) and have little to say on how to influence
such processes. This study describes in detail how one such “cultivation” process
evolved, and based on this some tentative conclusions and suggestions on how to
influence such processes are offered. The emphasis is on the role of the “stunts”,
individual transmission events with a short time horizon that were not part of a
“grand plan”. It is argued that these stunts helped address some problematic aspects
of cultivation strategies in practice; both the need for standardisation in such
“bottom-up” processes, and the “uphill battle” of starting to create an information
infrastructure almost from zero. A “bootstrapping” strategy is then suggested as a
general way to approach the challenge of starting to grow a network.
vi
PREFACE
This dissertation is submitted as partial fulfilment of the requirements for
the degree Doctor Scientarium at the Faculty of Mathematics and Natural
Sciences, University of Oslo, Norway. The work has been funded by The
Norwegian Research Council through grant no. 123861/320 with the
project title: “Utilisation of broadband technologies for minimal- invasive
therapies”.
The dissertation consists of six papers and an introductory chapter that
presents the problem area, relevant literature and the research goals and
methods. Then the findings from the case study are presented, followed
by discussion and conclusion. The individual papers, listed below, are
included as appendixes:
1) Margunn Aanestad, Ole Hanseth, Jan Sigurd Røtnes
and Trond Buanes: Supporting Computer-Supported
Collaborative Work – a case from telemedicine. In
Käkölä, Timo (ed.): Proceedings of the 22nd
Information Systems Research Seminar in Scandinavia
(IRIS’22): “Enterprise Architectures for Virtual
Organisations”, in Keuruu, Finland 7-10 August, 1999.
University of Jyväskylä, Computer Science and
Information Systems Reports, Technical Reports TR21, 1999, pp. 163-175.
2) Margunn Aanestad and Ole Hanseth: Implementing
Open Network Technologies in Complex Work
Practices: A case from telemedicine. Presented at IFIP
WG 8.2, Aalborg, Denmark, June 2000. Published in:
Baskerville, Stage, and DeGross (eds.): Organizational
and Social Perspectives on Information Technologies,
Kluwer Academic Publishers, Dordrecht, the
Netherlands, 2000, pp. 355-369.
3) Margunn Aanestad: The Camera as an Actor: Designin-use of Telemedicine Infrastructure in Surgery.
Journal of Computer-Supported Cooperative Work, in
press (2002).
vii
4) Margunn Aanestad, Bjørn Edwin and Ronald Mårvik:
Medical Image Quality as a Sociotechnical
Phenomenon. Presented at Information Technologies
in Health Care – Socio-Technical Approaches (ITHC),
Rotterdam, 6-7 September 2001. Shorter version
submitted to Methods of Information In Medicine –
special issue on socio-technical approaches. (Full
version included in dissertation).
5) Margunn Aanestad and Ole Hanseth: Growing
Networks: Detours, stunts and spillovers. In
Bjørnestad, Moe, Mørch and Opdahl (Eds.):
Proceedings of the 24th Information Systems Research
Seminar in Scandinavia (IRIS’24), Ulvik in Hardanger,
Norway, 11-14 August 2001. (Revised version
accepted fo r presentation at COOP’2002 – The Fifth
International Conference on the Design of Cooperative
Systems, June 2002).
6) Ole Hanseth and Margunn Aanestad: Bootstrapping
networks, communities and infrastructures. On the
evolution of ICT solutions in health care. Presented at
Information Technologies in Health Care – SocioTechnical Approaches (ITHC), Rotterdam, 6-7
September 2001. (Submitted to Methods of
Information In Medicine – Special Issue on sociotechnical approaches)
viii
0
Chapter 1
Introduction
The origi n and motivation for this work is primarily practical, as the Ph.D.
study was initiated by the participants in a telemedicine project. By addressing
some of the challenges of introducing telemedical technology in health care,
this dissertation aims at contributing to a sensible and successful
implementation. However, as my work is also situated within the Information
Systems research tradition, the aim is also to contribute to this body of
research through reflection on and abstraction from the telemedicine case.
Telemedicine, which literally means “medicine at a distance”, is a general term
that covers a vast range of different application areas and technologies. Many
definitions of telemedicine emphasise the distance aspect and the technical
mediation of health care work. Thus telemedicine technologies include both
still images attached to e-mails as well as live video-conferences transmitted
around the globe via satellite networks. A telemedicine transmission may be
directly patient-focused for diagnostic purposes, or indirectly e.g. for second
opinion discussions, or it can relate to teaching, meetings or general
administration of health care issues and cases. Despite high hopes,
telemedicine has been slower to come into routine use than has been
envisioned. Large and ambitious projects don’t meet the expectations or
dwindle away when the funding period runs out, while small and relatively
successful projects don’t grow and expand beyond a limited setting of use. In
the telemedicine community it is widely held that the diverse problems that
are related to technical and regulatory issues will be tackled in due course,
while the so-called “organisational issues” are often pointed to as the “real”
challenges. However, to integrate this insight into the projects and practice of
telemedicine is not straightforward, and it continues to be a central problem
area for telemedicine.
This dissertation aims at illuminating these challenges by focusing on the sociotechnical interplay1 related to the introduction of telemedicine. We need a better
understanding of how the technical and the organisational (or social) issues
are related and interwoven. The research questions (presented in Chapter
Four) are focused on examining the dynamics of this socio-technical interplay
and describe what it takes to get telemedicine going. The aim is to contribute
some conceptual resources with which to approach the challenges of fruitful
incorporation of telemedicine into a clinical setting. Thus this study is of a
1
‘Socio-technical’ is here used in a general sense, without specific connections to the Socio-technical
Theory that originated in the Tavistock Institute.
1
more theoretical character than the bulk of the debate and research within the
telemedicine community. This dissertation is, however, intended to be of
practical use for personnel that are involved in telemedicine, but it will not
necessarily be directly applicable in a simplistic manner2. Rather than tick-box
lists for success factors, it provides tentative conclusions. Rather than specific
advice, it takes the form of warnings and cautions. Rather than coming up
with “the success strategy” for telemedicine, the dissertation aims at providing
the telemedicine community with a different understanding and a different
view on the fundamental challenges and the way to approach them.
The specific kind of telemedicine that has been studied here was the use of
broadband network technologies for minimally invasive surgery (mainly
laparoscopy), which allowed high-quality audio and video transmissions from
live operations to be transmitted in real-time. This dissertation reports from
one longitudinal case study at the Interventional Centre at Rikshospitalet,
Oslo, as well as from visits to four other major Norwegian hospitals that have
experience with using live video-conferencing technologies for telemedicine.
The structure of the dissertation is as follows: Chapter Two concerns
telemedicine visions and challenges. Relevant bodies of research from the
fields of Information Systems Research, Computer-Supported Collaborative
Work and Science and Technology Studies are briefly introduced in Chapter
Three. Chapter Four presents the research questions, the research method
and the setting for the case study. Chapter Five provides an overview and a
synthesis of the findings reported in the six separate papers, which are
included as appendixes. The findings are discussed and the implications both
for telemedicine and for design of information and communication
technologies in general are sketched in Chapter Six. Chapter Seven provides a
conclusion as well as suggestions for further research.
2
Practical and technical advice on telemedicine can be found in some of my other publications that are
not part of this dissertation. See eg. Røtnes, Aanestad and Buanes (2000) or Aanestad, Røtnes Edwin
and Buanes (2002, in press).
2
Chapter 2
Telemedicine – visions and challenges
The visions for telemedicine suggest an extensive and flexible communication
infrastructure to support diverse communication across levels of health care
and between different professional groups (From, Stenvold and Danielsen,
1993; Masys, 1998). A few examples of telemedicine visions (of which some
have materialised) may illustrate this diversity:
·
·
·
·
·
·
Transmitting the ECG signal of a heart patient from the ambulance
to the ECU (emergency care unit) at hospital before arrival may help
save valuable time.
A specialist at a hospital participates via videoconference in a patient
consultation together with a remotely located general practitioner
(GP). The aim is to decide whether the patient needs hospital-based
treatment or not. The patient (or the specialist) may avoid
unnecessary travel, and the GP’s competence will be increased.
Two or more hospitals may share a back-up radiologist on duty
during night-time, if x-ray images can be transmitted digitally and
diagnosed remotely. This helps rationalise work as it allows a more
efficient division of labour.
Remotely located surgeons may get a boost in their training if they
can follow surgery of rare or specialised cases via live two-way
videoconferences. This may rationalise education, both the
fundamental professional training and continuous medical education
(CME).
When a stroke patient leaves hospital, the hospital’s physiotherapist
and the local care provider need to communicate around the exercise
regime that the patient is supposed to follow for rehabilitation.
Looking at how the exercises should be done on a live videoconference will convey the details better than a purely textual
information transfer.
Video databases and other knowledge repositories may also give
access to state-of-the art knowledge to clinicians in remote locations
or resource-constrained areas.
For many of the applications, few people would deny that telemedicine would
bring an obvious improvement over today’s practice. For other applications,
the rationale behind is strongly related to ethical and political decisions on
how health care should be organised (Ekeland, 1999). Cost containment,
rationalisation and efficiency are steadily becoming more central issues in the
3
organisation of health care. At least some of the visions of telemedicine are
clearly compatible with this logic, as it promises a more effective organisation
of work and utilisation of scarce resources like specialists’ competence
(Nymo, 1993). Although clad in concepts like “improved access to care” and
“higher clinical quality”, telemedicine may be seen as a controversial political
issue in itself. This is especially the case when it comes to prioritising between
telemedicine and other budgetary posts, as large and ambitious telemedicine
projects may capture the decision makers’ attention and drain resources
needed elsewhere. This could be particularly problematic in developing
countries (Wright, 1997).
Apart from the political choices associated with telemedicine at such an
overall level, the day-to-day practical challenges of telemedicine mostly relates
to “getting it going” in order to show that it is possible, safe, beneficial and
economical to employ telemedicine technology at all. Relatively mundane, but
nonetheless widespread practical and technical problems, e.g. inadequate
image or sound quality or incompatible systems, may be related to immature
technology (Hobsley, McCloy, Jameson, Buckton and O’Hanlon, 1997).
Other issues in focus have been uncertainty concerning the diagnostic
accuracy (e.g. of digital and compressed images in pathology, dermatology or
radiology) and the related clinical safety of telemedicine diagnosis and therapy
(Holand and Pedersen, 1993; Forsberg, 1995; Black-Schaffer and Flotte,
1995). Trials of the diagnostic accuracy or therapeutic efficiency are often
modelled on the randomised controlled trials-ideal (See (Taylor, 1998) for a
review of the image quality discussions within telemedicine). Issues of
confidentiality, security, as well as regulations on clinicians’ responsibility are
often discussed (Stanberry, 1997, Stanberry, 1998a). Such legal issues also
require international agreements on cross-border jurisdictional issues
(Brahams, 1995, Nohr, 1999, Bailey, 1999, Stanberry, 1998b, Stanberry,
Rossignol and Menke, 1999) Central is also the theme of evaluation; the
general call for an evidence-based approach to telemedicine is often translated
into economic assessment, which often is pursued through cost-benefit
studies, and to calls for economically viable business models. (McLaren and
Ball, 1995; McIntosh and Cairns, 1997; Mair, Haycox, May and Williams,
1999; Håkansson and Gavelin, 1999, Lobley, 1997)
On a general level it seems that telemedicine has been slower to implement
than what was envisioned and expected (Yellowlees, 1997). It has been
difficult to get going, to go beyond single transmissions and limited projects
into routine use, and the “revolutionary” benefits have not yet shown up. A
recognition that the real challenges are not of a technical nature, but relates to
the organisational aspects, seems to be widespread in the telemedicine
community (Hartviksen and Rinde, 1993, p.30; Pedersen and Holand, 1993,
p.50; Darkins, 1996; Sheng, Hu, Au, Higa and Wei, 1997; Birch, Rigby and
Roberts, 1999). The matching of the technology to the organisation seems to
4
be challenging. Despite this awareness, these problems are not usually
explicitly addressed.
This study emphasises the need to look at the socio-technical interplay, i.e. how
technical and organisational issues interact. Achieving successful telemedicine
is not just about implementing a given technology, e.g. videoconferencing
systems, in an organisation. The development and introduction of
telemedicine requires the concurrent design and change of both technology
and organisation. On the one hand, “telemedicine technology” as such is not
fully developed and ready to be implemented. Applications that are developed
and in use do of course exist, e.g. for teleradiology, but in general we can
expect significant maturing, improvement and further development of the
technology. On the other hand, telemedicine is expected to bring about
radical changes in the organisation of health care work in order to support
work practices in an optimal way. Still, we do not have clear models for what
the “new health care” is going to look like. True, there exist visions and
scenarios, but to define requirements to the technology based on such vague
visions is a long shot. So we don’t know what the technology should look like
before we have a clearer idea of the usage. Conversely, the available
technology will be important in facilitating or initiating this novel usage and
ways of collaborating. So the technology and the organisation of health care
are closely intertwined and need to be developed simultaneously and together,
not just in parallel.
This dissertation therefore analyses the introduction of telemedicine as a sociotechnical change process. The aim is to understand the issues involved in such a
change process in order to be able to support a sensible and successful
development and implementation of telemedicine. In order to accomplish this
a cross-disciplinary theoretical basis and research approach is required. In
addition to being cross-disciplinary it should be constructive, i.e. rather than
providing an “after-the-fact” analysis of the process it should be able to
provide practitioners involved with telemedicine with valuable insight to the
ongoing development process. While such constructively oriented and crossdisciplinary research approaches do not abound in health care, it has been
exactly the focus of research in some other fields. In the next chapter some
relevant bodies of research that have formed the basis for this work will be
introduced.
5
Chapter 3
Related research
Below I briefly introduce some findings from a few empirically oriented
research fields that are partly overlapping. The first is the field of Information
Systems Research, which aims at informing design and development of
information systems. The field has a cross-disciplinary orientation and draws
on theoretical frameworks and research approaches from other areas; mainly
from organisation theory and parts of it also from the social sciences, like
sociology, anthropology and ethnography. Theories and methods from the
social sciences are also central within the field of computer-supported
cooperative work (CSCW), where detailed studies of technologies in work
practices attempt to uncover the needs and requirements of cooperative
work. Also here the aim is to inform the design of information and
communication technology to support collaborative work. Some researchers
from these two fields are also engaged in a discourse with researchers from
Science and Technology Studies (STS). Earlier this field might be called Social
Studies of Science, or Sociology of Scientific Knowledge, see e.g. (Edge,
1995) or (Williams and Edge, 1996) for a historical overview. In particular I
have found STS studies that use or are inspired by actor-network theory
valuable, as well as studies with a particular focus on information technologies
and medical work.
3.1 Technology-centred organisational change
The first topic discussed is technology-centred organisational change. I find
this a central topic, as telemedicine will require both organisational change in
order to be fully deployed, and it promises organisational change as one of its
results. However, as a case of technology-centred organisational change,
telemedicine exhibits an unusual degree of complexity and novelty, for at least
four reasons:
•
The organisational setting where it is going to be used (hospitals and
the health care sector) is immensely complex. Medical work is
knowledge-intensive and dependent on dynamic and ever-changing
knowledge. Criticality is a central issue and demands to speed and
correctness of decisions and actions are high. A patient’s trajectory
may be unpredictable, both in the short and long term. The
cooperation patterns are complex and extensive, and work requires
successful coordination of a large number of actors.
6
•
•
•
Furthermore, telemedicine is not just implemented in order to
rationalise existing work practices by providing a new technical tool,
as is the case with many other large information systems. It is also
expected to allow innovative use of the communication technologies
and induce radical change in the organisation of health care. For this
radically different health care we only have vague visions, not clearly
defined models for where we are going.
The technology used for telemedicine can be new and immature
prototypes, or off-the-shelf technologies of a generic and
customisable kind not specially designed for medical use. In either
case, it is reasonable to expect that telemedical technology will have to
be further developed or redesigned and appropriated. This will have
to happen closely related to real use, as the usage of the technology is
not pre-defined, but has to co-evolve together with the technology.
Thus rather than merely managing an implementation of a given
technology in a stable work practice, the challenge is to manage the
co-development of both simultaneously.
Last, but not the least; telemedicine is a network technology where
shared solutions and standards must be developed. Local and internal
solutions that are developed at each site are not sufficient to arrive at
a coherent, global network that allows easy communication. Even if
standardisation is crucial, it is not obvious where or by whom this
should be done. Even if this can be mandated by a public sector
authority on a national level, a comprehensive telemedicine
infrastructure will need to connect to international networks as well as
private sector institutions that may be outside the national authorities’
sphere of influence.
3.1.1 Information Systems Research vs. Computer-Supported Collaborative Work
With this in mind we will therefore discuss studies that address the sociotechnical interplay related to one or more of these challenges. A
somewhat gross generalisation may be to say that we may learn a lot
from CSCW researchers about exploratory design of new and open
communication technologies that allow innovative use, while IS
researchers know more about designing for complex organisational
settings. As CSCW is explicitly design-oriented, the unexpected benefits
as well as problems ha ve been addressed, and exploratory, bottom- up
development close to the real use situation has been advocated since the
field’s inception (Greenbaum and Kyng, 1991). However, there is limited
focus on settings and technologies that go beyond defined groups and
sites of a rather small size. With some exceptions (e.g. Button and
Sharrock, 1997, Hanseth and Lundberg, 2001), there is not much CSCW
research that explicitly discusses large-scale networks as a means for
collaborative work between organisations, and the complex and
integrated work practices this entails. IS research, on the other hand, has
7
traditionally been oriented towards larger design projects with more welldefined goals and aims. Often the organisational aims were related to
utilise the technologies’ potentials for rationalising primary work
practices, like for instance production or accounting. IS researchers have
thus had to go beyond the direct application of ethnographic insight to
design, as their projects could enrol different groups with different and
possibly conflicting needs and wishes. While IS research addresses many
of the problems of managing large scale projects, the primary focus is
also here on technologies within single organisations rather than
networks, as well as on relatively mature and well-known technologies.
As has been argued before, the main challenges for telemedicine are related to
establishing a large-scale infrastructure, and doing this is not trivial. Before
quite a lot of the telemedicine infrastructure is in place and works, its benefits
cannot be demonstrated, and before benefits can be demonstrated, not many
will buy into it. A similar dilemma is widely encountered, also within the
CSCW community concerning groupware (Grudin, 1988; Markus and
Conolly, 1990, Grudin and Palen, 1995). The potential benefits do not emerge
for the individual user as a direct consequence of his or her adoption and use
of groupware, but requires that also other users use it in a proper way, which
is not easy to achieve. Large information systems that are often intended to
support central organisational processes (e.g. production or accounting) and
their proponents usually promise substantial benefits. When a new
production system is going to be introduced, there will be a defined
organisational mandate and a driving force, and there will exist more or less
realistic expectations to effects and benefits. Groupware on the other hand, is
less visible, mainly supports secondary tasks (e.g. communication,
coordination and general articulation work) that are not specifically the
domain of defined organisational groups, and for novel use the potential
benefits may not be convincingly established a priori. Thus groupware may not
expect the same managerial attention and support, and critical mass cannot be
mandated or “artificially” created e.g. through subsidising. Consequently it is
crucial to the success of groupware, but immensely difficult, to manage to
start such growth processes. Also within IS research such issues are discussed.
Ives and Jarvenpaa (1996) notes that “transformational technologies” (like the
web technology for intranets in their case) are seldom welcomed, backed and
supported by central organisational actors. Ellingsen and Monteiro (2001)
describes the “uphill battle” of evolutionary development, in a case where the
iterative and so far successful development project was overrun by a larger,
more ambitious and more visible project.
The issue is not just one of power, however important that may be. Even if all
would agree that a new technology (like telemedicine) seems to offer
indisputable benefits, the problem of handling complexity and novelty still
remains. How can we picture the truly novel vistas that open up? How can we
get the first users to participate even before the benefits have started to
8
emerge? The main problem with exploratory development in such cases is
that the daily duties and the primary work tasks usually take precedence over
the indefinite and vague visions. Many systems developers may have
experienced that it is difficult to enrol medical (and other) professionals in
long-term development project with uncertain outcomes. This deadlock is
also there when it comes to securing the necessary funds and support to get
going. Such problems are even more pronounced when the challenges are
related to building a complex and large information infrastructure, as it is for
telemedicine. Because the perceived lack of focus on this within most of both
IS research and CSCW, I therefore in the last part of this chapter briefl y
present a small, but growing body of research that starts to emerge both
within IS research and in other fields, which has a focus exactly on these
large-scale networks or information infrastructures.
3.1.2 Complex and indeterminate relationships and processes
It is widely recognised that information and communication technologies are
an important component of organisational change (Zuboff, 1988, Barley
1986, Markus and Robey, 1988, Walsham, 1993), and they are often
implemented in order to effect or support such change, as the term
“transformational technologies” suggests (Ives and Jarvenpaa, 1996).
Telemedicine can be put in this group, as one of the fundamental motivations
for the deployment of telemedicine is its promise of transforming health care
(Pedersen and Holand, 1993; Nymo, 1993).
The underlying “mechanisms” of technology-centred organisational change
have been much discussed, and fairly simple models of the causal
relationships have been prevalent. Markus and Robey (1988) distinguish
between three models; the technological imperative, the organisational
imperative and the emergent perspective. The previously dominant model,
the technological imperative, looks at technology as a given entity with
definite “impacts” or “effects”. The technology is seen as an outer force that
determines or strongly constrains the behaviour of individuals and
organisations (Markus and Robey, 1988: p.585). However, this view is not
sufficiently supported by empirical studies of technology-generated change in
organisations. The empirical studies present contradictory evidence and
inconsistent findings, and the effects of implementing information
technologies in organisations are widely divergent (Orlikowski, 1991; Robey
and Boudreau, 1999), even the effects of identical technologies in similar
settings (Barley, 1986; Barley, 1990). On the other hand, the second model of
organisational imperative places strong emphasis on the possibility for human
choice and rational control over the technology. However, empirical support
is limited also for this model. Such change processes are “complex and
messy” (Walsham, 1993: p. 53), and rather than witnessing a straightforward
execution of implementation plans researchers may observe that ”plans keep
9
being diverted, surprises arise constantly, opportunistic adjustments must be
carried out on the spur of the moment” (Ciborra, 1997: p. 72).
The emergent perspective holds that uses and consequences of information
technologies emerge unpredictably from complex social interactions (Markus
and Robey, 1988: p.588), and thus this perspective is less normative and
predictive than the other two. Organisational and technological change and
development is depicted as open-ended socio-technical negotiation processes
(Monteiro, 2000), and adaptations and re-adaptations occur in relation to
people’s ongoing sensemaking activities (Henfridsson, 1999). Well-known IS
studies that may be grouped within this perspective are e.g. (Kling, 1987;
Kling and Scacchi, 1982; Gasser, 1986; Barley, 1986). Some researchers
subscribing to this perspective have even started to question the assumption
of rational control that underlies central concepts such as design, construction
and implementation. To emphasise the unpredictability and non-controllability,
they have suggested different alternative metaphors that should help us to
conceptualise the task at hand in more appropriate ways.
In a seminal paper Wanda Orlikowski suggested that we should see
organisational change as an ongoing process of improvisation (in addition to the
elements of planning, deliberate design and managerial interventions that also
were present) (Orlikowski, 1996). She describes the situated micro-actions of
the actors in trying to make sense of a new information system through
appropriation and experimenting. However slow and subtle the changes
seemed, over time they added up to major changes. This “improvisational
model of organisational change” is then further developed to encompass
three different types of change that occur: anticipated (i.e. planned), emergent
(not anticipated or intended) and opportunity-based change, which consist of
ad hoc responses to occurring events, opportunities or breakdowns; i.e.
planned within a short time horizon (Orlikowski and Hofman, 1997). It is
argued that the management of change should be seen “more as an ongoing
improvisation than as a staged event” (ibid. p. 12). The concept of drift
(Ciborra, 1996) emphasise the limitations to (and almost impossibility of) a
top-down, rational, control-oriented planning approach, and there are several
empirical studies of ICT implementation that describe the findings in such
terms (Monteiro and Hepsø, 2000; Cordella and Simon, 2000; Ciborra, 2000).
Yet another metaphor is cultivation, which also emphasises the limitations to
control over the processes of change (Dahlbom and Mathiassen, 1993).
Cultivation evokes images of influence or shaping rather than control;
supporting a material that in itself is dynamic and possesses its own logic of
growth. These alternative conceptualisations help us to acknowledge the
complexity, the dynamic and emergent character, as well as the non-control.
However, these metaphors remain at the meta-level and they don’t go far
enough in capturing the actual dynamics of the change processes. More
detailed studies of the actual interplay between humans and technologies can
be found in particular within the two other fields mentioned, Computer10
Supported Cooperative Work (CSCW) and Science and Technology Studies
(STS).
3.1.3 Zooming in on socio-technical interplay
The move away from simple and rational models of technology introduction
has several parallels. Detailed and careful studies within CSCW of how work
actually was accomplished have revealed the inevitable limitations of formal
descriptions. Formal representations like work flow diagrams, procedures and
explicit plans neither governed how work was carried out, nor were they
adequate representations of it. Actual work, even much of what counts as
routine work, was characterised by highly situated and ad hoc problem solving
rather than by the rote execution of predefined task sequences (Suchman and
Trigg, 1991; Brown and Duguid, 1991). Procedures and plans were merely
one of several resources used to accomplish work (Suchman, 1987). Bricolage
and tinkering (Ciborra, 1994; Ciborra, 1996) are some concepts that have been
employed to draw the attention to such aspects of work. Other concepts that
fill in on our understanding of how work actually gets done, are workarounds
(Gasser, 1986), and articulation work (Strauss, Fagerhaugh, Suczek and Wiener,
1985; Schmidt and Bannon, 1992; Suchman, 1996), which both denotes the
additional work that has to be done just to get the “real” work done.
The implications of the CSCW work practice studies were the advice that
rather than to design technologies that attempted to sequence and structure
the work based on such formal representations, one should support the ad hoc
problem solving work activities by providing resources for it. Such resources
could include possibilities for second-level communication, means for
peripheral awareness and coordination mechanisms (Robinson, 1993; Bowers,
Button and Sharrock, 1995; Schmidt and Simone, 1996; Button and Sharrock,
1997; Bardram, 1997).
Several of these studies of work practices and technologies have emphasised
the intertwined nature of social and technical issues, as well as the contextdependent and situated nature of the results of this interplay (Kling and
Scacchi, 1982, Strauss et al, 1985). However, this emphasis is even more
prominent if we look at research within or in dialogue with the Science and
Technology Studies field (STS). Here, several studies of socio-technical
negotiation processes show how both the work practice and the technology
change through a process of reciprocal transformations (Timmermans and
Berg, 1997, Bijker and Law, 1992). For instance we may consider Marc Berg’s
studies of the use of formal tools in medicine, which includes protocols for
treatment, decision-support tools (Berg, 1997a) and computerised systems in
patient care (Berg, 1997b). Here the mutual transformations of tool and
practice were described in detail, as well as the work that was required to
make the tool work. The studies present a convincing argument for the
necessity of localisation of such tools, and of the ongoing character that this
11
process exhibited. Berg also suggests that we should push beyond the notions
of technologies as merely “supportive” and “facilitating” tools, and that it
might be fruitful to leave the somewhat programmatic demands that
technology should be ’transparent’ and open to human control. Instead we
should actively welcome the technologies’ transformational powers
sometimes made possible exactly by their non-transparency, and the opening
up of ‘new worlds’ that may result from this (Berg, 1998: p. 481).
Allocating technology such an equal standing with the human actors is a
move that originated within science studies. Several of the classic actornetwork theory studies have shown how a whole ensemble of heterogeneous
elements (humans, political measures, natural forces, technical devices etc.)
was necessary in order to achieve a specific result. Whether the achievement
was to turn a hypothesis into a scientific fact (Latour, 1987; Latour, 1988),
enable a Portuguese warship to travel around the globe (Law, 1986; Law,
1987), or establish an institution (Star and Griesemer, 1989); it required
ongoing work and effort in order to align and keep aligned the heterogeneous
network. These studies emphasise that order, success, or stability is not just
given, it is performed and achieved, through both technical and non-technical
means (Fujimora, 1987; Latour, 1991). Order and success are not always
achieved through tight control over the actor-network, as the early ANT
studies have emphasised. Recent research also suggests that actor-networks
may continue to exist exactly because there is disorder, instability and
incoherence. Flexibility and “fluidity” may be crucial in balancing the
demands from multiple loosely connected and incoherent networks (De Laet
and Mol, 2001; Singleton, 1998; Cussins, 1998; Mol, 1998; Law, 1999).
One of the major lessons I think the IS field can learn from these studies is
on the relational character of power and agency (Latour, 1986; Berg, 1999).
Instead of insisting on discovering technologies’ inherent and pre-determined
“effects”, we can investigate how the actor-network’s configuration produces
the effects that can be empirically witnessed. This perspective allows a novel
way to examine how technology contributes to the socio-technical change
processes.
3.1.4 The case for being specific about technology
To do so is particularly interesting and appropriate within IS research, as
technology is often taken for granted and black-boxed, and has been
neglected by some social constructivist accounts. Many IS studies that
examine the process of implementation and integration of IT from an actionoriented perspective are low on technical focus. While the detailed work
practices related to technology is carefully charted, the technical details are not
especially prominent (Orlikowski 1992; Orlikowski 1996; Gasser, 1986;
Barley, 1986; Barley, 1990). This tendency was criticised by Monteiro and
Hanseth (1995), who argue that an information system (IS) consists of a large
12
number of modules and inter-connections, thus it should be approached with
a varying degree of granularity, and we cannot indiscriminatingly refer to it as
IS, IT or computer systems. Their work on the development of technical
standards showed how mundane and “grey” technical details can be crucially
important, and they argue that to study information and communication
technologies without a sufficient level of precision would be what Kling
(1991, p. 356) characterised as a "convenient fiction" which "deletes nuances
of technical differences".
In a review of how IT was conceptualised in papers in the Information
Systems Research journal through ten years, Wanda Orlikowski and Suzanne
Iacono were “desperately seeking the “IT” in IT research”, without finding it
(Orlikowski and Iacono, 2001). Only in a few papers was the “IT artifact”
conceptualised in a sufficiently sophisticated manner, and usually technology
was “either absent, black-boxed, abstracted from social life or reduced to
surrogate measures” (Orlikowski and Iacono, 2001; p. 130). They conclude
that it is of critical importance to develop a more profound understanding of
and theorising about technology itself. They believe that “the lack of theories
about IT artefacts, the ways in which they emerge and evolve over time, and
how they become interdependent with socio-economic contexts and
practices, are key unresolved issues for our field and ones that will become
even more problematic in these dynamic and innovative times.” (ibid, p. 133).
3.2 How technology matters
If we shall allow technology a place in analyses of socio-technical change
processes we will need research approaches that are suitable to look at
“hybrids”:
“…adequate accounts of technological change require hyb rid explanations
that weave together human action and choice, the functions and features of
specific technologies, and the context of a technology’s use in a way that
attends to the micro-dynamics of situated practice” (Orlikowski and
Barley, 2001)
For analysing how people interact with technologies there are several
candidate theories suggested and used within the IS and CSCW field. Three
of the currently most prominent are actor-network theory, activity theory and
structuration theory. The latter two are fundamentally social theories and not
primarily focused on technology as such. However useful they may be to
explain the use of technologies, the integration, adoption and effects on the
organisation, they do not assist the researchers towards being specific on
technical details and characteristics. Actor network theory allows this, as the
theory doesn’t make a priori distinctions between human and non-human
13
actors3. Thus this theory makes it possible to analyse the technology as one
actor among the others. Such a move is of course controversial, and we have
to discuss how technology can be qualified as an actor.
3.2.1 Technology as an actor?
It is relatively easy to agree upon the fact that technology may enable,
constrain and structure action through its limitations and its affordances4
(Norman, 1988). Technologies may reflect, embody or materialise other
actor’s (e.g. the designer’s) intentions. Through the designer’s (or others’)
inscriptions the users’ scope of actions are attempted designed and configured
(Woolgar, 1991; Winner, 1985; Law, 1986; Akrich, 1992). Although this is an
important topic in itself, it is not the point of interest here, and we’ll go on to
discuss other ways in which technology can matter, that lie beyond the
intended and designed features.
Inscriptions may be more or less strong and inflexible, but in general we
should not consider them as static and given once and for all. The strength of
the inscriptions may be negotiable, for example depending on whether the
user is a novice or an expert and which resources are available to the user.
Also the effects of the inscriptions may not follow the designer’s pre-defined
plans; once the technologies are out in the “real world”, both intended and
unintended uses and effects may be observed. Technology may generate new
problems in addition to those it should solve, e.g. through what we may call
“bad” or inadequate design that hasn’t taken the situation of use properly into
account. But such unexpected effects aren’t always negative; novel
possibilities and unintended beneficial uses may also be the result. What will
turn out to be the central and less central aspects of a given technology aren’t
always easy to predict, but will have to be ascertained empirically during
practical use and exploration. An example of this is a study of the deployment
of Lotus Notes that shows how technical aspects that were not initially in
focus took on a special significance in a given context (Monteiro and Hepsø,
2000).
As the scale, complexity and level of integration of technologies increase, it
becomes more difficult to predict and anticipate the ultimate effects of
decisions. Interdependencies and consequences are often hidden until they
emerge as breakdowns, incompatibilities and problems, possibly in other
locations than the source of the decision or action. This is especially the case
3
Actor-network theory will not be extensively presented here, although I discuss some of the methodical
issues related to it in the next chapter. Readers that are not familiar with it may wish to consult the
overview that is provided in papers two and three.
4
A device’s affordances, its perceived and actual properties, (like knobs, handles, slots and so on) assist
our sense-making or perception of what the device is suited for, and provide clues to how it is
intended to be used.
14
for large and complex systems, which no single individual can oversee,
understand or control. The challenges and dilemmas related to this is
discussed within a growing body of research that studies such large-scale
networks and conceptualise them as information infrastructures.
3.2.2 Information infrastructures
Information Infrastructures was a term that came into public use with the
Clinton/Gore report in 1994, which launched the NII – National
Information Infrastructure. Researchers on information infrastructures have
used the term in order to emphasise the differences between these large-scale
networks and ordinary information systems. There is no hard-and-fast
borderline between what is an information systems and what is an
information infrastructure. Depending on the researcher’s perspective a large
information system may exhibit strong infrastructural characteristics, and the
emphasis of this term is on the challenges tha t arise when we cannot assume
that the technology is just used within defined organisational boundaries for
specific purposes. Some of the differences that sets information
infrastructures apart are the following (Star and Ruhleder, 1996; Hanseth and
Monteiro, 1997):
•
Information infrastructures are shared, common resources for the
community. They support and enable a wide variety of activities and
are not especially tailored to just one or a few. They reach beyond the
individual user, single event, specific application or local site. They are
also not just a collection of bilateral links, but a network, and the
essential feature that allows this reach is standardised interfaces.
•
Information infrastructures are fundamentally open with regard to the
number of potential users, use areas, nodes in the network, and the
boundaries of the infrastructure. The boundaries will be pragmatically
and temporarily defined, not a priori. There will always be nodes that
have connections with other nodes from the “outside” world, which
someone might want to include in the infrastructure.
•
An information infrastructure is a heterogeneous socio-technical
network, not just a technical communication network. The physical
connections and equipment, the technical standards, the conventions
of use, the technical and organisational support structures (e.g. from
local user support to the global standardisation bodies), the
organisation of work and cooperation and so on are parts of the
infrastructure. Such complex networks emerge only through time, and
an infrastructure is evolving on previous forms of infrastructures
rather than built “from scratch”. Any change or extension has to
relate to the existing “installed base”, and therefore the evolution of
information infrastructures takes time.
15
Large and complex projects pose several challenges to information systems
designers. However, these challenges become more pronounced when it
concerns information infrastructures, as the fundamental openness of the
information infrastructures makes them inherently uncontrollable. Usually
there is simply no actor with the mandate to instruct all the partners involved,
like there (at least in theory) may be within an organisation. The openness and
integration with other networks introduces dependencies and side effects,
which make the effects of actions hard, if not impossible, to predict. As the
information infrastructure grows, it acquires momentum (Hughes, 1983) and
may become increasingly entrenched and irreversible. Self-reinforcing effects,
path dependence and lock-ins are other terms from the field of network
economy used to describe this (Arthur, 1988; David, 1986). Therefore, when
concerned with information infrastructures it seems appropriate to talk about
technology as an actor, because it may appear to be beyond human control.
(Braa and Hanseth, 2000).
Having arrived at this point, it may seem that we are back to the
“technological imperative” view on technology, where the technology is the
determining force exerting influence on more or less powerless humans.
However, I believe it is possible to acknowledge the strong influence exerted
from the technology (the information infrastructure) without reverting to
“ordinary” technology determinist accounts. The effects of technology are
not seen as pre-defined and given, rather they are achieved in a way that at
least in principle is possible to study, examine and influence. The technology
has been co-evolving and co-developing with a host of other actors, it is not
some static and fixed effects that ha ve played out in a deterministic manner. If
we could chart the evolution of an information infrastructure, we could detect
how different actors contributed to the shaping of the information
infrastructure.
3.2.3 Cultivating, not designing information infrastructures
Facing the challenges posed by information infrastructures, evolutionary and
iterative approaches to design, realisation and change management seem
highly appropriate and indeed inevitable. We need to recognise and
acknowledge this uncontrollability, and a consequence of this is to view
design and change as involved and open-ended processes of socio-technical
negotiations (Monteiro, 2000), where social or technological objects, typically
considered as distinct and separate, are now considered intimately linked in
networks. The organisation as well as the product being developed should be
considered as unified socio-technical networks, which evolve according to a
non-predictable dynamic.
This appears to fit well with the emphasis of the alternative metaphors to
design introduced above, and in the remainder of this dissertation, cultivation is
emphasised as a promising strategy. The reason for this choice is that I
16
believe “cultivation” to a larger degree than “improvisation” allows a focus on
the technology itself in the process. In other words: the metaphor “invites us
to reconsider the role played by the object of alignment – technology”
(Ciborra, 2000: p. 32). Drift is clearly a relevant phenomenon if we are
concerned with large-scale and longitudinal descriptions, but doesn’t
contribute much to the everyday constructive work of designers and
developers as it emphasises the lack of control. Cultivation represents a
middle position that captures the role of both humans and technology. The
evolving socio-technical networks cannot be fully controlled, but designers do
have influence in the change processes. Cultivation is a concept that provides
us with a good basis for developing strategies for infrastructure development.
The contribution from the cultivation metaphor is that it directs our thinking
in some specific directions. We need to leave behind some of the “control”
ambitions, but even when the ‘material” isn’t entirely controllable, there still is
scope for intervention. The control strategies will have to be substituted with
a more constantly alert, “close”, and “caring” attention to the “growth”
process. Any action must be followed by an attentive watching for the
resulting effects. Emerging problems must be dealt with immediately instead
of being postponed to a subsequent evaluation phase. A cultivation approach
may thus require frequent revisions of plans and strategies, as well as patience
in allowing processes to take their time. In addition, the metaphor naturally
encourages an emphasis on the “nurturing”, or provision of adequate support
and resources, e.g. technical skills, support personnel, training. By doing so, it
also emphasises the role of the “gardeners” or the “farmers” that perform this
work, who often go unrecognised and overlooked (Star and Strauss, 1999),
despite the critical importance of their work. However, the term should not
be taken to imply that only small-scale development projects are feasible.
Rather it addresses the approaches to change management, and advocates change
strategies that are non-radical, proceeding in steps of a manageable size and
closely related to the existing material and institutional relationships already in
place.
In terms of actor-network theory, a cultivation strategy for an information
infrastructure corresponds to a situation where a well-aligned actor-network is
gradually modified into another well-aligned actor-network. Only one (or a
few) of the nodes of the actor-network is modified at a time. At each step in a
sequence of modifications, the actor-network must be re-aligned and
stabilised. Thus it evolves in a small-step, near-continuous fashion (Monteiro,
2000).
3.2.4 Telemedicine as an information infrastructure
Analysing telemedicine as an information infrastructure is relevant because it
is intended as a generic communication infrastructure for all of health care,
not only a limited set of individual and separate applications between a limited
17
number of institutions and individuals. A comprehensive telemedicine
infrastructure is socio-technical, it encompass more than the communication
technologies and it spans across different levels in health care, as well as
across geographical and professional boundaries. (From, Stenvold and
Danielsen, 1993; Masys, 1998). Evolutionary and iterative approaches would
thus seem appropriate also here.
However, such a comprehensive telemedicine infrastructure is not yet in
place, and the current challenges are more related to getting started in building
this infrastructure. These challenges are different from the above-mentioned
challenges of changing an already existing rigid, irreversible and entrenched
one. For telemedicine, growing large enough to benefit from the selfreinforcing effects is a crucial challenge, and the cultivation strategies must
take this into account. In the following chapter I will outline a research
approach that is aimed at describing one such process: the cultivation of a
fledgling information infrastructure - telemedicine.
18
Chapter 4
Research aims and methods
4.1 Research aims and questions
This study aims at:
Examining the dynamics of the socio-technical interplay that
evolves when telemedical technology is introduced in health care,
and thereby:
Contribute to a better understanding of “cultivation” processes,
and thereby inform strategies for “cultivating” telemedicine and
other information infrastructures.
The study primarily aims at contributing to the telemedicine field, by
providing a different way of conceptualising the challenges and issues
involved, as socio-technical change processes. Also general strategies for
developing telemedicine networks and applications will be suggested.
More specifically, I will study what it takes to “get telemedicine going”
and keep it going:
• Which problems and issues emerge when the technology is
introduced?
• What needs to be done, which adaptations have to be made?
• How does the process of exploration and implementation evolve?
This study could also be valuable to both IS research, CSCW and STS in
its own right, as an empirical case study of novel technologies for
cooperation and communication. However, I will also try to formulate
explicitly what may go beyond the telemedicine setting, and the
contribution to these fields mainly concerns strategies for the
development and “cultivatio n” of information infrastructures.
4.2 The case study
4.2.1 The Interventional Centre
The site for my main case study has been the Interventional Centre, which
was established in 1996 at Rikshospitalet in Oslo, Norway, through an Act of
Parliament in 1995. The mandate of the centre was to do research and
development of new methods and technologies for image-guided and
minimally-invasive therapies (Lærum and Stordahl, 1992; Fosse, Lærum, and
Røtnes, 1999).
19
A central part of the activities has been minimally-invasive (or “keyhole”)
surgery, which is different from ordinary (“open”) surgery. This case study
mainly concerned laparoscopic surgery, which is minimally-invasive surgery in
the abdomen. As the term implies, it minimises the “invasiveness” of the
procedure. Instead of a large incision to facilitate the surgeon’s direct vision
and manipulation of organs, instruments and optics for a video camera are
entered through small incisions that may be 5-10 mm wide. Thus both the
surgeon’s visual and tactile information, as well as the actions on the organs, is
indirect, or mediated by technology. The presence of a mediating technology
makes image-guided surgery a likely candidate for telemedicine. During a
laparoscopic procedure the video image is regarded as the main information
source for the surgeons, and it is relatively easy to obtain and transmit this
video signal. However, the central role of the video image places demands on
the transmission technology used for telemedicine, as the image quality
should be sufficiently high. It is generally acknowledged that broadband
networks would be the preferred choice of transmission technology, although
few health care institutions have access to them. The Interventional Centre
took part in one of the first attempts to utilise broadband networks for
surgical telemedicine. This happened in the ‘Development of Interactive
Medical Services’ (DIMedS) project from 1997 until 1999. Two Oslo
hospitals, Ullevål and Rikshospitalet, were involved in the project, and the
Swedish telecom operator Telia provided network access to a 34 Mbit/s
ATM network5. Ericsson Inc. provided state-of-the-art video-conferencing
equipment, and the Department of Informatics at the University of Oslo was
involved as a research partner.
Some of the potential use areas for surgical telemedicine encompass:
• live demonstrations for educational purposes
• live consultations between a novice and an expert, or between peers.
This could be either acute (when problems arise) or planned
assistance, e.g. for follow-up after a training period.
• general supervision, mentoring, and accreditation in formalised
training programmes
• remote surgery (usually only considered for war or other catastrophe
situations)
• off-line video databases for educational purposes
5
ATM stands for Asynchronous Transmission Mode, and is a telecom standard for broadband
communication networks.
20
During the DIMedS project the emphasis was on the first use area: live
demonstrations of novel laparoscopic procedures. In addition discussions
between experts around specific patient cases occurred. However, one of the
central findings reported in this dissertation is how the usage “drifted” outside
these planned areas, and this is the emphasis in paper no. five in particular.
Also papers no. one and two provide more factual information on the
DIMedS project, both with regards to its aims and the actual project history.
Also other telemedicine activities that occurred in addition to the DIMedS
project were followed and studied, often consisting of demonstrations of
technologies and procedures. The Interventional Centre needed to
communicate with its research partners around technology development, and
also the dissemination of research results e.g. to medical conferences could be
done using video-conferencing technology. Usually the transmission used
ordinary ISDN-based videoconferencing systems, and on some occasions
satellite transmission was used. Also, after the DIMedS project ended, the
control room facilities were increasingly used by other departments at the
hospital, and the room acquired a role as a technical “hub” for most internal
and external transmissions of video and audio at the hospital. I also followed
a few of these transmissions.
4.2.2 Other hospitals and telemedicine activities
In addition to following the telemedicine activities at the Interventional
Centre through my three-year Ph.D. period, I have visited four other major
Norwegian hospitals. These include the two Oslo hospitals Aker and Ullevål,
the University Hospital in Trondheim (RiT – Regionsykehuset i Trondheim),
and the University Hospital in Tromsø (RiTø – Regionssykehuset i Tromsø).
All of these hospitals were (and are) significant participants in the Norwegian
telemedicine community.
The Norwegian Centre for Telemedicine was established in Tromsø in 1992,
and in 1993 it was appointed the role of a national lead institution for
telemedicine. It has been a pioneering institution for telemedicine research
and applications, both nationally and internationally. Ullevål hospital was the
other partner in the DIMedS project mentioned above. In addition it was
connected to a broadband network spanning the East Norwegian region, for
which Ullevål is the regional hospital. One of the most active hospitals in
using this regional network was Aker hospital in Oslo. This regional network
was in some instances coupled together with the Ullevål-Interventional
Centre link, so that the transmissions in the DIMEdS project were forwarded
to some of the regional hospitals as well, among them Aker hospital. The
National Centre for Advanced Laparoscopic Surgery is located at the
University Hospital in Trondheim (RiT). This centre trains surgeons in novel
laparoscopic techniques, and it offers a telemedicine service for follow-up and
support of remotely located laparoscopic surgeons.
21
4.3 An interpretative study using qualitative methods
The state of knowledge within telemedicine requires an exploratory and
qualitative study, and I locate myself within the interpretivist tradition. Given
the subject of this dissertation, telemedicine, it may have readers from the
health care community, where research is mainly guided by the natural science
model. The interpretive framework employed in this study departs from this
in fundamental aspects. The positivist approach of the natural sciences
assumes that phenomena can be observed objectively and rigorously, as there
are a priori fixed relationships between the elements. The aim of such research
is to increase the predictive understanding of the phenomena, primarily
through testing of theory. Good research is legitimated with reference to the
virtues of repeatability and re futability.
Researchers within the interpretive tradition would argue that there are
fundamental limitations to this approach when concerned with a research
object of a social (or socio-technical, for that sake) nature. Interpretive studies
attempt to understand phenomena via the meanings people assign to them.
Different people’s interpretation of the same situation differ (e.g. the
informants’ and the researchers’), and the aim is thus not an “objective”
account, rather a more relativistic, but shared understanding (Orlikowski and
Baroudi, 1991). Rather than attempting to generalise from a setting to a
population, the deeper structure of a phenomenon is sought. The research is
“aimed at producing an understanding of the context of the information
system, and the process whereby the information systems influences and is
influenced by its context” (Walsham, 1993:4-5).
The emergence of interpretivism in ISR have been inspired by the
phenomenological school of thought (Boland, 1985), by hermeneutics as well
as the methodological and epistemological reflections within ethnography and
anthropology (Klein and Myers, 1999). There is not one clearly defined set of
theories and methods that governs research, but several alternative
frameworks. If we leave aside the epistemological discussions, there is, at least
as far as Information Systems Research and CSCW are concerned, one good
pragmatic reason for the pluralism: These fields are concerned with action- or
change-oriented research aimed at design of technology. This constructive
focus fits with an eclectic use of theories, as no theories are made to explain
everything, and complex phenomena (like the socio-technical interplay) might
require complementary approaches.
Interpretivist IS research has extensively employed methods inspired by
ethnography (and to some extent ethnomethodology). Especially within the
design-oriented field of CSCW, ethnographies of work and technologies-inuse have always been seen as valuable and relevant (Suchman, Blomberg, Orr,
and Trigg, 1999). Ethnography is an approach for developing understanding
of everyday activities of people in their natural settings. An ethnographer does
not rely solely on accounts of behaviour, but studies what people actually do.
22
Also she doesn’t look only on single tasks or single individuals, but focuses on
relations between individuals. An ethnographic study may employ multiple
practical methods, the most common are participant observation, interviews
and document analysis, as well as use of recording media like video.
The ethnographic approach appears to fit well with the empirical and
descriptive approach of systems designers wanting to understand a work
practice and its subtleties well enough to be able to design a well-working
system. Terms such as “ethnographically inspired” or “quick and dirty
ethnography” (Hughes, King, Rodden and Andersen, 1994) may indicate a
tendency to take ethnography as a method for data collection, as a
supplement to the previously dominant cognitive and task-oriented
approaches. However, this easy adoption of ethnography as a data collection
technique has been criticised (Finken, 2000; Forsythe, 1999; Anderson 1994).
The criticism against such “common-sense ethnography” emphasises the
danger of what is often called “insider ethnography”, that the researcher may
“go native” and overlook the tacit assumptions of the informers rather than
questioning them. Also the need to anchor the practical data collection
methods to an underlying theoretical and philosophical framework is
emphasised. In the following I will therefore discuss my own use of
qualitative methods, and my role and situation in the fieldwork, as well as the
theoretical framework employed.
4.4 My role in the field work
This study was not intended to be a “proper” ethnographic study, and
does not depend solely on ethnographic data. However, the practical
methods have played a part, first and foremost participant observation.
4.4.1 Participant observation
The application for the grant that funded this Ph.D. project originated from
within the Interventional Centre, and I was therefore regarded as an “insider”,
although not formally as an employee. This was the case also with several
others in the medical and technical staff who were pursuing Ph.D. degrees. I
was a member of the DIMedS project group, but with a relatively passive role.
I participated in the project meetings and was responsible for collecting data
on the transmissions as well as taking part in writing the evaluation and final
report 6. Beyond that I did not participate to any substantial degree in
decisions concerning the project itself or the overall activities. When a
transmission was scheduled, I took part in the practical work together with
the technicians in planning and execution of the event. My practical role in
the execution of transmissions was that of a technician, assisting with camera
control, equipment set-up, and so on, which is primarily focused in paper
6
The forms used for data collection from each transmission, as well as a schematic overview over the
transmissions in the DIMedS project, are included as Appendix G.
23
one. This work occurred inside the operation theatre, in the external control
room, or in a lecture hall. In addition to the telemedicine activities I took part
in regular meetings and sporadic short projects of different kinds that were
not directly related to this Ph.D. project. During the latter one and a half years
my presence at the centre was less frequent and regular, due to lack of office
space and closure of the telemedicine project.
4.4.2 Interviews
More or less structured interviews have been another data source. I visited the
National Centre for Advanced Laparoscopic Surgery in Trondheim to study
the telemedicine service for support of remotely located laparoscopic
surgeons. For the purpose of this study, the interview was taped and fully
transcribed. I also performed some interviews at the Interventional Centre, in
particular for paper no. three (three interviews of one hour’s duration) and
five (two interviews of one hour’s duration, as well as several non-structured
discussions during surgical procedures). When the informants are cited in the
papers, the interviews have usually been taped and fully transcribed.
Most of the interviews conducted at the other hospitals were non-structured,
but focused on the organisation and execution of the support work, both the
technical and the organisational or logistic work tasks. These interviews were
open-ended and conducted more like informal conversations with people that
were directly involved with the telemedicine activities of the hospital. Often
the interviews were intermingled with walking around in the facilities and with
demonstrations of equipment and technical features. These interviews were
not taped, but notes were taken. The number of support persons interviewed
were: two at Aker, three at Ullevål, three at RiT and seven at RiTø. All
interviews were conducted in the workplace area, and most of the interviews
lasted around 45 minutes to one hour.
4.4.3 Focus and drift
In a well-known discussion of quality of interpretative research Heinz
Klein and Michael Myers suggest some criteria for evaluation (Klein and
Myers, 1999). As their emphasis is on interpretive research with a
hermeneutic orientation, I don’t feel that all of the criteria are equally
central to my aim, which is not to describe the participants’ sense- making
processes, but to get a broad understanding of the phenomenon and the
process of introducing telemedicine. However, I find the fundamental
principle of the hermeneutic circle, from which they derive the other
principles, to be useful in structuring the following discussion. The
principle states that one approaches the understanding of a complex
phenomenon in an iterative way, through an ongoing movement between
a precursory understanding of the parts and an emerging understanding of
the whole, and then back to a renewed understanding of the parts. The
24
researcher’s preconceptions are a necessary and inevitable starting point,
not just a source of bias, but will often have to be modified or even
abandoned. It is thus pertinent to make as transparent as possible the
fundamental assumptions that governed the research. The researcher’s
preconceptions should be challenged and modified through interaction
with the phenomenon under study, and I will attempt to discuss some of
the ways this process played out in my study.
As I have followed the telemedicine activities throughout a three years’
period, my focus and understanding of the case has changed. During the
first year I had a focus on technical issues and did extensive literature
studies on compression and digitisation of video, on methods for image
quality evaluation, as well as some practical tests and evaluations on
video compressed with different compression algorithms. At this stage I
had not yet been exposed to the research fields I discussed in the previous
chapter, and I merely participated in the day-to-day work at the hospital
without having an explicit research agenda. In addition to the focus on
digital video, I was also interested in the micro- level interactions between
the humans and the technology, and I observed and took part in the
technicians’ and nurses’ work. This was partly guided by my own
underlying fascination with the interplay between humans and
technology, which again was influenced by my previous training and
work experience as a service engineer for medical equipment. I think my
technical background ha s sensitised me to the existence and the
complexity of the technical work, as well as letting me participate in it
and appreciate the innovative work that occurred. When I started reading
CSCW literature, I felt that an ethnographic-style approach seemed
compatible with what I was doing. It looked like “quick and dirty”
ethnography (Hughes et al., 1994), but as I spent at least 50 % of my time
during the first couple of years at the Interventional Centre it was of a
longer duration than most “quick and dirty” studies.
I have not found this degree of participation a problem when I’m
reporting from the field study, rather the opposite. Within interpretive
research one does not view the researcher as a detached and objective
observer in the first place, and thus involvement, e.g. in the form of
participant observation, does not in itself constitute insurmountable
epistemological problems. But still there are some challenges associated
with such an approach, related to avoiding doing “insider” ethnography,
which means taking explanations at face value and not questioning the
underlying assumptions. I have felt the context switching between the
practically oriented hospital and the academic community to be beneficial
in to avoid this kind of situation. Initially I did not feel that the required
readings and courses had very much practical relevance for the day-today decisions that had to be made in the telemedicine project. However
25
intellectually stimulating it was, its rather vague and general guidelines
(if there were any at all) felt far removed from the demands of practical
work. Also much of the focus in the practically oriented literature was on
software development, which was not central in this case. The issue was
rather selection and integration of off-the shelf devices like microphones,
cameras, codecs, routers and so on. However, as time went by I was
increasingly able to appreciate the value of the findings from these
research fields, although they were not applicable in any simplistic
manner. I still feel this tension, or rather a distance between the “two
worlds”, and I think that my increasing focus on abstract and conceptual
issues as time went by was related to a decreasing involvement with the
practical work. I believe that research results should also be “translated”
back to the practitioners, who need it in the daily work, and I have
attempted to bridge the gap through journal and conference papers that
try to make the insights relevant to practitioners.
During the latter period of the study, I was less involved in practical
telemedical work and more engaged in the academic discourse. Having
been so closely involved with the practicalities of the telemedicine
activities, my findings were not wholly dependent on “materialised”
accounts like interview transcripts or written documents, and thus I was
able to reconfigure the material I remembered according to my current
theoretical purpose and interest. I could rethink and reinterpret the case
related to e.g. issues concerning the process itself, and to the general
issues of strategy and network growth. This ability has made me worry
over the possibility this implies of creating overly rationalised accounts
and unjustifiably reinterpreted stories. On the other hand, my interests
and research agendas will necessarily make my way of telling the story
different from how other project members would tell it, and an
interpretation is what researchers are supposed to deliver. To keep this
balance, I have tried to have a “validity check” through giving most of
my manuscripts to interested members of the staff and other involved
persons and hearing their responses and objections to them. Also I have
discussed my findings and preliminary conclusion at two internal staff
meetings in the department. This story is one way of describing and
analysing the phenomena, which is shaped by my interests and concerns.
It does not aspire to present the ultimate truth about telemedicine, but
provides a different perspective that I think will be valuable to the field.
The changing focus was not only shaped through my changing
understanding related to a growing familiarity with the research field and
literature. Also practical issues and contingencies have played a part. The
telemedicine project my study was associated with, closed down after one
year instead of three years, as was the original plan, so after the first year
I could not rely on a large amount of telemedicine transmissions for
26
observation. Also when I started the study, I found it easier to observe
and communicate informally with technicians and nurses, who were of
similar age and/or sex, than with the busy and “important” surgeons.
Observation of their work was not difficult to obtain at any point of time,
but I did not perform interviews until a later stage when I had more
defined research questions.
4.5 Theoretical framework
I have been using actor- network theory (ANT) in what we may call a
methodological or epistemological way, without necessarily emphasising
the ontological implications of some of its proponents’ claims. I have not
used actor- network theory as a theory in the ordinary sense, which
specifies what to look for in a study or states some propositions that can
be tested. Rather it has been a language or a vocabulary to talk about
what I observed and experienced, which was well suited to account for
material heterogeneity, as well as for the relations between the different
elements. That it emphasises an empirical approach and rejects a priori
constructs, like the distinctions between micro and macro issues, have
also been important features. The key concepts that I have used are
actors, alignment and translations, and then also the related terms of
enrolment and inscriptions 7 .
I have used the ANT vocabulary to describe how the socio-technical
negotia tion processes evolved, and few words on how I picture the
relevant actor-networks would be appropriate. An actor-network is not
just “there”, as an objective and self-contained entity. Any element in the
“telemedicine actor-network” is simultaneously member of other
overlapping, intersecting or neighbouring actor-networks. From this
multi- faceted membership conflicts and dilemmas may arise. One
example: A nurse’s tasks during an operation don’t necessarily have
much to do with the telemedicine transmission that is going to take place,
and she is a relatively passive actor in the “telemedicine actor-network”.
But, belonging to the nursing profession (a different actor- network), she
may have some values related to how to treat patients and preserve their
dignity in such exposed settings. In a given situation she may choose to
intervene in the telemedicine actor- network, e.g. to turn off the cameras.
Thus the telemedicine actor- network not a fixed entity, but it is defined
empirically, when it happens. How we delineate its boundaries will
depend on what we look for from which perspective.
7
See papers two and three for an introduction to the theory itself.
27
In the study I have had a rather “narrow” focus, and I have for example
not discussed extensively the current trends of management of health
care, neither have I primarily been after the central (human) actors
agendas, understandings and interests. The introduction of telemedicine is
a political process, where negotiations between different interests have to
be carried out. To disclose and bring into the open the premises for this
process would be valuable, and I believe that another (social) theory than
actor-network theory would more easily have led me in such direction.
This would clearly be relevant, but as argued in Chapter Three, it is also
pertinent to improve our limited understanding of how technology
contributes to socio-technical change processes.
In order to attempt to examine ongoing negotiations between the
elements (and their multiple associated and intersecting networks) I have
adopted and “inhabited” many different positions in the “telemedicine
actor-network”: that of the nurses, the technicians, the images, the
surgeons, the camera (i.e. the technology), and the strategists. This
attempt at standing in the actors position and depicting their “lived
reality” allows me to tell several related, although not entirely coherent
stories. I see this strategy as compatible with other ANT studies that
depicts the “ontological choreography” (Cussins, 1998) and coexistence
of various realities (Mol, 1998).
Due to my technical background I have been able to go more deeply into
the technical issues than a social scientist would be. My background has
first and foremost been a prerequisite for my participation in the technical
support work, and it has sensitised me to the complexity of the work and
the innovativeness of the technician’s solutions. I believe that such an
explicit focus on technology can bring new insights to light. One example
to show that the technical details are clearly relevant to a sufficient
understanding is related to the issue of image quality. E.g. in order to
appreciate the contribution from a mechanical (or robotic) camera holder
to transmitted image quality, one need to understand the inner workings
of compression algorithms. The fact that the single image frames are
coded relative to each other, makes motion, even small and almost
imperceptible trembling, greatly reduce the transmitted image quality.
This quality reduction in transmission goes far beyond what can be
observed locally, and a mechanical camera holder is thus far more than
an instrument to relieve the camera operator of a tiring task. The largest
part of its work is visible only at the remote side in a telemedicine
consultation. My knowledge of these technologies allowed me to study
image quality as a socio-technical phenomenon, not just as either a
technical or as a social phenomenon, involving power struggles between
different camps using e.g. rhetoric devices of “safe telemedicine”,
“objective evaluations” etc. to maintain their position.
28
29
Chapter 5
Research findings
Six individual papers are included in this dissertation:
1. Supporting Computer-Supported Cooperative Work: a case from
telemedicine.
2. Implementing Open Network Technologies in Complex Work
Practices: a case from telemedicine.
3. The Camera as an Actor: Design-in-use of a telemedicine
infrastructure.
4. Medical Image Quality as a Socio-technical Phenomenon.
5. Growing Networks: Detours, Stunts and Spillovers.
6. Bootstrapping Networks, Communities and Infrastructures. On
the evolution of ICT solutions in health care.
The papers vary in terms of the audience envisioned during the writing,
the theoretical emphasis, the time of production, and the degree of
“maturity”. I have therefore attempted to summarise the main results of
my study below in a more coherent way. One way to formulate the
overall theme is to use John Bowers’ expression: “the work to make a
network work” (Bowers, 1994). I will follow this theme from the very
practical work of the technical support personnel, via the “diplomatic”
work of socio-technical negotiations to the strategic work of “making
telemedicine happen”.
5.1 The work to make telemedicine work
When I started my field studies I was struck by the amount, criticality and
complexity of the technical support work. Before, during and after a
telemedicine transmission there was hectic activity in order to allow the
transmission to take place and flow smoothly. Parts of this work appeared
to be similar to aspects of TV or movie production, and it was
deliberately invisible and occurred literally “back-stage”. During most
transmissions I took part in this support work, and it is the main topic of
paper no. one (“Supporting Computer-Supported Collaborative Work: a
case from telemedicine”). Other aspects of this work are also described in
paper no. two (“Implementing Open Network Technologies in Complex
30
Work Practices: a case from telemedicine”). Both papers describe typical
tasks that were performed by the technicians at the Interventional Centre.
After these two papers were written I have performed interviews of
additional support personnel. In addition to the nine technicians and
others at Rikshospitalet, I have interviewed two persons at Aker hospital,
three at Ullevål hospital, three at the University Hospital in Trondheim
and seven at the University Hospital in Tromsø. All the persons
interviewed were directly involved with organisational and/or technical
support work around real-time video-conferencing telemedicine.
There were many differences between these sites: In Tromsø, the
National Centre for Telemedicine offered regular educational broadcast
(i.e. one-to- many) services to different groups of health care personnel, as
well as to patients and their families. Several studios were permanently
equipped, there were dedicated support personnel and standard guidelines
for the preparation and execution of a session. The scheduled
transmissions were listed in a course catalogue that was distributed to
most Norwegian hospitals. The other sites operated in a much more ad
hoc manner, where occasional transmissions between two or a few
partners were the focal point of work. Here the support personnel did not
have telemedicine as their only or primary work task. The set-ups of the
telemedicine technology varied in comple xity, e.g. number of cameras
and other devices to manage, and the setting at the Interventional Centre
was among the most complex. Also the set-ups usually were of a more
permanent character than that at the Interventional Centre, which for the
lecture halls were installed and dismantled for every single session.
However, it was commonly expressed at most sites that special
adaptations of the technical set- ups could be made to suit the demands of
the people involved in specific transmissions.
What was common to all sites was the importance and the multi- faceted
nature of the support work. The work was a mix of conceptual designoriented work and practical execution of specified tasks, which included
ad hoc problem solving and “ordinary” articulation work. The technical
personnel at most of the sites were involved in decisions concerning the
overall architecture of the permanently installed internal communication
network. This might relate both to the initial design and to further
expansions and modifications of it. The technicians at the Interventional
Centre were central in discussions regarding the design of the
communication infrastructure in the new facilities before the Centre was
moving to a new location.
In a short-term manner, the technicians had to plan the technical set-up
for the next transmission (what equipment was going to be used, which
image sources should be connected, how many microphones would be
31
needed etc.). For sites apart from Tromsø, this short-term planning work
was mainly structured by the specific transmission events. The
operational part of the work was related to the execution of the
transmission, e.g. on handling multiple cameras, other image and sound
sources. Making a detailed list of camera views and active microphones
and loudspeakers at given points in time was one way of securing a
smooth transmission. Before a transmission the connection to the other
side had to be established, and testing of image and sound transfer had to
be done. The transmission had to be monitored, problems that might
occur had to be solved as quickly and quietly as possible, the correct
image had to be selected, the sound levels adjusted appropriately etc. In
order to be able to do this a lot of “ordinary” articulation work was
necessary. Establishing and testing the connection had to be coordinated
with the support personnel at the other side, in order to get access to the
rooms that was going to be used, the head nurse might have to be
contacted, the equipment had to be installed and dismantled afterwards,
and so on. During a transmission the technical personnel at the two sites
usually communicated a lot on telephone in parallel with the
transmission.
Modifications of the network could also happen with a medium- level
time perspective, i.e. to solve problems of a general nature, not especially
related to a single transmission. One example of this was that I observed
that a technician at the Interventional Centre listed the frequently used
configurations of the sound matrix, which governs from which
microphones sound are taken and to which loudspeakers it is sent, and
programmed it to allow easy set-up (‘one-click’ instead of manual
selection of each node). Another example of what I have called designoriented work were several rounds of discussions, prototypes and tests of
the layout of a control pad that should allow ordinary users to manage a
session, e.g. to place calls, adjust sound levels and select image source on
their own.
5.2 Socio-technical negotiations
The introduction of surgical telemedicine at the Interventional Centre
spurred a process of change related to the introduction and use of this
technology that is still going on, three years later. The way work is
organised, people’s work tasks and skills as well as the department’s
routines mus t be adapted to the demands of the new technology.
Conversely the technology must be adjusted to suit to the organisation
and its values and structures. Most importantly, both must be further
developed simultaneously. To study these socio-technical negotia tion
processes between humans and technology has been one of my central
topics of interest. All the papers more or less explicitly discuss aspects of
32
the socio-technical dynamics from a range of different perspectives and
thus shed light over different aspects of this socio-technical negotiation
process.
Paper no. two (“Implementing Open Network Technologies in Complex
Work Practices: a case from telemedicine”) emphasises how the social
and technical was intertwined and claims that the change process was, by
necessity, context-dependent and emergent. The argument (implied by
the title) is that open, generic and customisable technologies will have to
be adapted and modified to fit specific use areas and settings. To discover
the limitations and novel potentials of e.g. video-conferencing technology
e.g. for radically different cooperation, the users will have to try it out
and adapt it in close relation to real use situations. To adapt such generic
technologies to medical work practices is not necessarily easy to achieve,
as the complexity and scale of the health care sector and the criticality
and the complex patterns of cooperation in medical work make the
conscious “design” of radical change in work and structures highly
problematic. Therefore the modification, adaptations and further
development have to occur iteratively, and the paper suggests that the
term “cultivating the hybrid collectif” (the heterogeneous ensemble of
technical and non-technical elements) is an appropriate metaphor to
capture the open-ended character of the process.
In paper no. three (“The Camera as an Actor: Design- in- use of
telemedicine infrastructure in surgery”) the emphasis is on the microlevel nature of the socio-technical alignment process. The paper shows
how both the work practices, the organisation, as well as the technology
changed, and the theoretical focus of the paper is on how the technology
itself participated in this change process. The technical devices that were
used came with predesigned features that were the main reason for
including them into the socio-technical network. However, when the
technology was included and installed, these features “came to life”; they
had effects and impacts that was not always intended and wanted. The
paper shows how the effects were not only related to the devices as such,
but to its location within the actor-network. The role, responsibilities and
resources available in a given position, as well as the relations (or lack of
such) to other elements were significantly shaping the effects of the
technology. By modifying the surrounding actor- network, the effects
could be changed. Through emphasising this relational nature of
“effects”, this paper comes up with “network configuration” as a central
term. The term configuration is intended to convey a sense of an only
temporarily stable make-up or composition of an actor-network. A given
configuration consists of a specified set of actors, where their position
and the links between them are defined. As such it has a given
distribution of burdens and benefits between the actors. This is not
33
always unproblematic, and the paper illustrates how the configurations
had to be modified due to the needs and wishes of some of the other
actants.
The process of mutual transformations of technologies and humans may
occur within a department as described above. The same kind of
discussions, negotiations and changes may also occur within a medical
discipline that employs telemedicine technology. Several issues and ways
of working together will have to be settled and agreed upon
(standardised). A central issue in telemedicine has been the safety of
remote clinical work. Image quality has been a central topic in several
disciplines, like teleradiology, telepathology, teledermatology and not the
least within surgical telemedicine. Minimally- invasive surgery’s reliance
on a high-quality video image as the sole source of visual feedback from
the field of surgery has made it one of the main proponents for broadband
network technologies, which allows high-quality video transmission.
Paper no. four (“Medical Image Quality as a Socio-technical
Phenomenon”) addresses this issue of safe and sufficient image quality.
The paper is a polemic against the dominant trend in the telemedicine
discourse to reduce the issue to a question of establishing the “threshold
value” of safe and sufficient image quality, and to focus only on the
technical parameters of the digitising and transmission technology.
Instead, through analysing how the surgeons used the image information
in work and telemedical cooperation, the paper argues that the resulting
image quality is shaped by a multitude of technical and social factors.
More importantly for practical telemedicine, however, is the fact that
image quality doesn’t appear to relate only to the image itself. Multiple
augmentative and compensatory strategies are employed, both of a
technical and organisational nature. Devices to help keep the camera
from moving, as well as still image transfer were regarded as important
compensations for sub-optimal image quality. Institutional features like
where a given operation was performed, who was allowed to operate,
who was eligible for telemedically transmitted advice, and so on,
appeared to play a significant role. Thus, trust in the visual information
received appeared to be distributed across the surrounding actor-network
rather than being exclusively allocated to the image itself.
5.3 The network required to make telemedicine work
Learning how to use broadband technologies for surgical telemedicine
was a context-dependent, exploratory and more or less continuously
ongoing process. Describing this process as an example of
“improvisation” or “cultivation” as opposed to traditional technology
design or construction would therefore seem reasonable. But this
34
emphasis on the limitations to human rational control over change
processes might be misinterpreted and assumed to imply things like
“there is no planning”, or “planning is of no use”. This is not the
intention, and it is also not what the case story shows.
However emergent and context-dependent the process was, it was not
arbitrary. There definitely were goals and values that influenced the
direction and coordination of the activities. With respect to the DIMedS
project, the broad goal of establishing a telemedicine infrastructure was
flexible enough to be modified and shifted according to changes in
external conditions and lessons learned from experience. The actual
strategy to reach the goals, or the way forward, was drafted in a shortterm and context-dependent manner. The perceptions of how the goals
were to be understood were shaped along the process, and the other
actors involved were important in this shaping process. Other
departments and hospitals had their own interests and agendas, but to
achieve successful telemedicine all (or at least many) had to be made to
cooperate; the network had to be aligned. This process of enrolment and
alignment was not planned and executed by one single individual or
institution only, but through interactions between all the actants in the
network.
These issues are in focus in paper no. five in particular (“Growing
Networks: Detours, stunts and spillovers”), which provides the history of
telemedicine activities at the Interventional Centre. The paper describes
some of the planned and unplanned events that occurred and show how
the long-term plans were mixed up with the ad hoc designed responses
and actions (detours) during the evolution of the process. External and
internal problems arose; issues and opportunities emerged or were
deliberately created and were exploited in a conscious and skilled
manner. The strategy employed was goal-oriented without being overly
control- focused; it was simultaneously deliberate and emergent. The
paper’s emphasis is on the multiple roles of specific transmissions, the
“stunts”, which could be more or less profiled events of using the
telemedicine technology. As it turned out to be rather difficult to enrol
many surgeons into the project, different medical professionals were
invited to arrange meetings and lectures together with their partners at the
other hospitals, using the broadband link. The stunts were planned within
a short time horizon (from hours for the simple ones to weeks for the
complex and high-profiled ones), and the y were undertaken to
demonstrate the benefits of the technology. The expected benefits were
thus largely contained “within” the stunt itself; it was not intended to
have an immediate lasting effect on practice. That the Interventional
Centre was able to offer assistance and full technical support during the
planning and execution, helped to lower the costs for the partners that
35
were invited to try this out. The benefits were immediate, and did not
require costly or long-term commitments. However, the stunts also
generated usage and thus opportunities for learning for the technical
support personnel and project members. The work that went into the
execution of a transmission were primarily geared towards succeeding,
but in addition experience was gained, and some of it were in retrospect
relevant beyond the immediate situation and could be transferred to a
different setting. If one manages to accumulate this “spillover
knowledge” that occurred as a secondary effect, one will be better
equipped for the next round, by possessing more knowledge and a better
technology.
Telemedicine is a network technology and it requires partners with whom
to communicate. To identify partners and start to establish the necessary
infrastructure is also a challenge. The last paper, “Bootstrapping
networks, communities and infrastructures: On the evolution of ICT
networks in health care”, discusses the building of information
infrastructures. Telemedicine is a kind of technology that will require a
rather large infrastructure for its expected effects to be realised, but
currently this infrastructure is close to zero, and the main challenges are
related to getting started at all. This is not trivial, and the paper discusses
challenges related to network effects like self-reinforcing mechanisms
and network externalities. The self-reinforcing mechanisms are useful to
“drive” network growth, but they usually don’t start to work before the
network has reached a certain size. The networks initially needs to be
“pulled up”, hence the title of “bootstrapping”. Achieving critical mass is
a well-known concept in this relation (Markus and Conolly, 1990), and
the paper discusses the multiple dimensions of critical mass. By this we
mean that the users are not equal (as is implicitly assumed by the critical
mass concept), there may be significant differences in users’ preferences,
and in characteristics of use areas and technologies. For example, a
survey of different departments at Rikshospitalet revealed very diverse
preferences and needs as related to telemedicine (Synnestvedt, 2000).
The challenge is then related to how to handle this heterogeneity of the
socio-technical network, and the paper suggests some ways to devise
strategies that are sensitive to this. Rather than subsidising users to
achieve critical mass, a careful sorting of users, use areas and
technologies may allow one to start with just a few users that gets
benefits even without a large network. The sequence of introducing new
users, use areas and technologies need to be carefully considered, and
sensible choices here may allow a network to reach the point where the
self-reinforcing mechanisms start to work and drive further growth.
36
Chapter 6
Implications and contributions
The findings from my study of the socio-technical dynamics that evolved
around surgical telemedicine can be found in the individual papers, and were
briefly presented in the previous chapter. In the description I especially
emphasised the following aspects of the process:
• It was situated and dependent on the local context. The changes and
adaptations that were made of both technology and work practice
were related to locally specific features, e.g. the facilities, the demand
of the specific medical procedures, the work routines, which
individuals were involved, the particular transmission events and so
on.
• The process was not entirely planned. Some changes were
planned, some were not intended, while other changes came about
after seizing opportunities. The initially vague and broad goals
were formulated and reformulated during this process.
• The process was more or less continuous, it was not restricted to an
initial implementation phase. The changes were not evenly distributed
over time, but were often triggered by e.g. problems, new technology
that was brought in, new use areas, new users, different personnel
situations, growing usage and so on. Redesign, modifications and
expansions were thus closely related to real use, and were not
designed in a previous planning stage.
Describing this process as an example of “improvisation” or “cultivation”
as opposed to traditional technology design or construction would
therefore seem reasonable. That both the process itself and its outcome
were situated, emergent and highly dependent on local context, have
some obvious corollaries for telemedicine strategy that go against the
commonly accepted truths within that field:
6.1 Implications for telemedicine
Telemedicine can’t be implemented – it must be cultivated. Telemedicine
is not just a new tool to be introduced and deployed in an organisational
context. Rather the technology, its use, the local organisation as well as
the health care sector will have to go through a prolonged development
process. Central to such a process will be the local “rooting” of the new
technology, related to among other things the local facilities, the specific
technical devices in use, the kind of medical work, the individuals and the
organisational context. Such a “rooting” will have to occur at every site
37
where telemedicine is to be used. Thus telemedicine spread cannot be
achieved through a swift roll-out of a standardised, pre-developed, testedand-tried solution, expected to be deployed and instantly used. Use of
telemedicine doesn’t just occur; it must be achieved or “performed”
through an ongoing adaptation and development process. The emerging
configurations of the socio-technical actor- network must be constantly
evaluated, adjusted and maintained. This ongoing process will not just
consist of adaptations and modifications of the technologies and the
organisation, but of further development of both the technical solutions
and the organisation simultaneously.
This case study has described how much it takes to accomplish successful
telemedicine transmissions, instance by instance. Even under favourable
circumstances (e.g. access to high-quality technology, knowledgeable support
personnel and longstanding relationships with partners), not many things
could be taken for granted. Successful telemedicine required dedication and
the ability and resources to improvise. The particularities (e.g. the people
involved, use area, content etc.) made one instance of use different from the
next. Developing telemedicine in use is a process that requires time and
adequate support and resources, above all technically skilled personnel that
are able to work in cooperation with the medical users. Equally necessary will
be strategists with the ability to let go of traditional control-focused
approaches to planning. Ambitious and detailed plans will be a waste of time
and resources, as deviations, exceptions and drift are to be expected and
should be exploited rather than avoided. So, plans should either be general
and broad, or if they are detailed they should be limited in scope and have a
short time perspective. Furthermore, plans should be frequently revised and
reformulated if necessary. Cultivating telemedicine means a more involved
and close process than merely introducing and then using and forgetting
about a new tool.
But before we discuss further what this case study may contribute beyond
the field of telemedicine, we’ll briefly discuss a common objection to the
cultivation-type of strategies that are advocated for the design, realisation
or change of information infrastructures. “Cultivation” implies an
emphasis on the limitations to human rational control over change
processes. This might provoke objections, not the least from within
health care, where there is a strong ethos of pursuing clinically useful and
economically viable results. This is reinforced by the evidence-based
approaches to treatment and (to a lesser degree) to technologies. Thus, to
advocate ”cultivation” approaches might be interpreted as letting go of
rational control over costly and controversial technology projects within
health care, and as such, exactly the opposite of what is needed.
38
I do not argue that we shall abandon the ideals of useful and effective
technologies. Cultivation strategies are not intrinsically good, and don’t
ensure “democratic design” or that the “best” technology will always
win. On the contrary, they may allow more room to single players at the
expense of others. Evolutionary strategies may provide the initial actors
with an advantage of defining telemedicine early. The “champions” that
are interested in and drives the work on telemedicine are often technically
interested clinicians in middle level positions, where there is some scope
for action, resources and autonomy. Thus they are already in a position
they might want to strengthen or maintain, and have the possibility to do
so when there is not a strong central force to control them. This could be
the explanations for studies that find indications that telemedicine seem
to reinforce existing hierarchical organisations, rather than change them
(Ekeland, 1999).
In sum, cultivation strategies are not advocated because they are “good”,
but because they represent the only possible way. With cultivation
strategies, the scope for intervention is clearly lower than what is
promised by the control approaches, but it is not non-existent. The main
contribution from this case study is that it allows some tentative
conclusions to be drawn regarding precisely this issue; how it may be
possible to influence such processes.
6.2 Contributions to ISR, CSCW and STS
The findings reported in the previous chapter as well as the above advice
ought to have a familiar ring to researchers both from Information
Systems Research, Computer-Supported Cooperative Work and Science
and Technology Studies. Within all these research fields one will find
studies that criticise the simplistic models of “implementing a tool”. As
was discussed in chapter three, the transformations of both the
technology and the work practice or organisation are already described
and analysed. Also the emphasis on the performative and provisional
nature of order and stability fits well with well-known insights from
Science and Technology Studies.
6.2.1 Beyond single site use: the challenges of growing networks
This in-depth study of the introduction of surgical telemedicine enriches
our understanding of the details of the socio-technical change process.
However, in addition to being an account that is sensitive to the everyday,
mundane details, this dissertation has a focus on the usually downplayed
temporal dynamics of the process (Boland, 1999) and may thus
contribute to our knowledge about what “cultivation” actually takes or
entails.
39
The study indicates what design according to a cultivation strategy
actually looks like related to handling of multimedia communication
networks for telemedicine. The case is representative and relevant for a
class of technologies and phenomena that we may expect to be of
growing importance: large-scale networks that are intended to effect
radical change in complex settings and sectors. Because telemedicine is a
network technology, focusing on the individual sites will not be
sufficient. The challenge of bottom- up development of a complex and
large information infrastructure is the central challenge that needs to be
addressed if successful telemedicine is to be achieved. This has not been
sufficiently addressed by existing research, beyond stating the need for
deploying evolutionary and iterative approaches. Cultivation strategies
for networks may be inevitable, but they are certainly problematic in
practice. Two aspects will be discussed in the following:
•
•
A central problem is related to the need for standardisation, as
standards are a crucial and constitutive element of information
infrastructures. However, a cultivation strategy seems antithetical
to a uniform solution and standards. If we allow exploratory,
“bottom- up” and ad hoc design, how can the proliferation of
fragmented and incompatible solutions be avoided? What will
happen when there is no central authority with the responsibility
for standardising? Can we talk about bottom- up standardisation,
or is it a contradiction in terms?
The uphill battle of evolutionary development: Before quite a lot
of the telemedicine infrastructure is in place and works, its
benefits cannot be demonstrated, and before benefits can be
demonstrated, not many will buy into it. How can we get the first
users to participate even before the benefits have started to
emerge? Even if all would agree that a new technology (like
telemedicine) seems to offer indisputable benefits, the problem of
handling complexity and novelty still remains. How can we
picture the truly novel vistas that open up and how can we get
started?
6.2.2 Micro- and macro-level design in use
I have used the term “design” for all kinds of modifications, adjustments,
extensions and combination of technical devices that occur as a response to
upcoming problems and emerging possibilities in use. I have used the term
rather “loosely” not in order to redefine what “design” is, but because I want
to draw the attention to what’s happening outside the professional designer’s
work. Much of the further development of telemedicine will occur in real use
situations, where users and local technicians are more prominent actors than
40
the professional designers. Further development will go beyond traditional
software or hardware development, and one central issue will be related to
finding useful ways to use telemedicine technologies.
As telemedicine is a network technology, standards will be crucial in allowing
it to work at all. However, the paper on image quality (no. four) should show
that the task is not just about agreeing on a standard, in that case the
minimum-level requirements to transmission bandwidth. Successful
telemedicine cannot be put on a formula; it requires real-time handling of the
elements involved in the real use situation, in the particular context. The main
part of this work describes exactly these ongoing socio-technical negotiations,
and it shows that design of telemedical technology is not just about agreeing
upon and defining what technology should deliver. It is first and foremost
about finding a way to make things work in the given context, something that
requires a robust and flexible heterogeneous socio-technical network.
However, centrally mandated standards are not prominent in current
telemedicine, rather the opposite. To a certain degree, regulations of e.g.
clinicians’ responsibility, clinical and technical safety, and reimbursement fees,
attempt at standardising some of the institutional features of telemedicine.
Regarding for example how facilities should be equipped, which devices to
choose, what video digitising standards to go for, how to organise technical
support, how to plan and execute a transmission, how the practical
responsibility should be shared between the sites, how “professional-looking”
a transmission should be, and so forth, for these aspects of telemedicine there
is a lot of local variations and there exist no centrally mandated standards.
Still, the sheer practical necessity of being able to communicate demands
some alignment also on such issues. If we shall move beyond a collection of
bilateral links to a “true” network that allows flexible communication, it will
be necessary to link together the “islands” of diverse use and make them
cooperate.
Such standardisation-in-use could happen in “clean-up” phases following
periods of experimenting, as is suggested by Hanseth and Lundberg (2001),
who studied the implementation of Picture Archiving and Communication
Systems in hospitals. From the present case it seems that for a different
technology involving real-time communication, standardisation-in-use
happened in a different way. I want to argue that the real-time transmission
events were significant in this respect, as they implied an intersection of the
different ways of organising and performing telemedicine. The practical
necessity demanded a temporary alignment of the local material and
institutional relations, so that the two different actor-networks could be
coupled together and communication could occur.
The design work that occurred around the telemedicine technology at the
Interventional Centre was to a large degree structured by these specific
41
transmission events, the “stunts”. Design of the internal infrastructure
happened both as a result of preparation and planning for future events, and
as a result of experiences and evaluations of previous ones. The local design
work occurred in a “pendulum process” structured by these events: Between
the events (i.e. offline) local and internal design work occurred; it consisted of
designing or modifying the configurations of the actor-network (i.e. what
entities should be included and what their relations should be). During an
event (when online or connected) these network configurations were
“exposed” to the demands of the communication situation. Design occurred
as a continuing movement between the shielded, local, and offline shaping of
the local part of the network and the connected and exposed situation of
being shaped, changed, adjusted, and standardised by the meeting of other
demands. These transmission events were the points where the internally
designed configuration had to become aligned with the partners’ (i.e.
standardised). What had to be standardised was first and foremost the
minimum technical requirements to the interface, in order to be able to
connect at all. Also the procedures, conventions, and technologies that helped
organise a transmission, how the responsibility was shared, how agreements
were reached, as well as the “style” and level of ambition with respect to how
professional-looking the production was, were aspects that were made visible
and “spread” through interaction between partners.
Not only is this temporary alignment important for the local adaptation and
articulation of demands. The actual transmission is also the vehicle through
which innovative solutions and high professional standards become visible
beyond the local site. If one site is able to seamlessly switch between all the
relevant sources of information, e.g. x-ray image, overview image,
laparoscopic video, and an anatomical sketch on a PowerPoint-slide, this will
probably be approved by the receivers. Mistakes and glitches will be very
visible in such a setting, and we may expect that the actors later will attempt
to avoid making the same mistakes. Thus “standards” and “design” of how to
organise and perform telemedicine thus spread through these instances of
communication. If we imagine communication between a growing number of
partners, we may see how shared standards may emerge from the multitude
of local negotiations, because of the need for alignment when connecting to
the communication partner. Connecting to different partners could thus be
part of a deliberate design strategy, a way to expose oneself to the drifting (i.e.
change, learning and development) that inevitably occurs when networks are
coupled (Holmstrøm and Stalder, 2001). It could even be possible to attempt
to sustain specific directions for the drifting (Henriksen and Pors, 2001) over
others, through selecting the partners to connect with. “Deliberate drifting”
could be a term to denote such a design strategy.
We may thus suggest that for network technologies that facilitate real-time
communication, parts of the standardisation process could very well be such
real-time interaction events where the different local actor-networks become
42
connected. However, this process does not necessarily move towards a final
closure and stability. As Timmermans and Berg have argued, universality (or
standards) is always local universality and rests on distributed work of
“continuous balancing of temporary agreements, suspended disbeliefs, or
mini-social contracts.” (Timmermans and Berg, 1997: p.297). Any stability
will be only temporary, as a point from which to embark on the next round of
change.
6.2.3 Bootstrapping, detours and spillovers - or designing for novel use in complex settings
As has been argued before, the main challenges for the telemedicine
proponents are related to starting to build a large-scale infrastructure, and
doing this is not trivial. Often a huge problem is that the daily duties and the
primary work tasks usually take precedence over the indefinite and vague
visions of exploratory development projects. Many systems developers may
have experienced that it is difficult to enrol medical (and other) professionals
in long-term development project with uncertain outcomes. This deadlock is
also there when it comes to securing the necessary funds and support to get
going.
This dissertation proposes a “bootstrapping strategy” as a way to address
these challenges. In the early phases of network growth, before it is possible
to count on and exploit self-reinforcing effects, a good strategy may be to
‘deliver a better today’ rather than ‘promise a better tomorrow’ (Weick, 1999:
p. 51). A bootstrapping strategy aims at building on and gradually expanding
what is already there, without relying on something that is not there. When
for example access to external resources or control over other users is limited,
the easiest way forward may be to make do without it. For example, the
benefits of network technologies are usually very much related to how many
other users there are, both directly as the number of potential communication
partners and indirectly, through the emergence of network externalities.
However, it is possible to devise sensible use that doesn’t require large
infrastructures (e.g. many other users) in order to be useful. Then it will be
sensible to do this as a first step and let the infrastructure to grow larger
before other kinds of more demanding usage is attempted.
A bootstrapping strategy involves a conscious selection of strategies based on
the situation, around issues like: Which users to include first? What use areas
should we start with? What technologies should we choose? It is a mindset
that is aware of the necessity to “navigate” in a context of multiple and
heterogeneous actors. The easiest route towards network growth should be
selected, but this may not always be possible to carry through completely. In
the real world one will need to engage in pragmatic compromises and tradeoffs. A bootstrapping strategy is not something novel or exceptional, but a
formulation of common sense advice that also may be found elsewhere.
43
Jonathan Grudin’s paper on “eight challenges for developers”, (Grudin, 1994)
is one example of this. Here we find several pieces of advice for introducing
groupware that are clearly compatible with what we term “bootstrapping”.
Some examples of the suggestions are: Rather than replace existing
applications with new, extend and augment them with useful features. Find
ways to provide benefits to all users. Find niches or design use that doesn’t
require a large mass of users, and ‘target the users’ i.e. select appropriate user
groups first.
In this telemedicine case the actual devices for overcoming this deadlock, (or
the “bootstrap” by which the network was pulled up) were the staged events,
the “stunts”. Although being detours, not conforming to the ideal or original
plans of the project, they were useful. Even if a “bootstrapping logic” wasn’t
explicitly formulated at that stage, these events were examples of it, as they
had a relatively short-term horizon and did not demand long-term
commitments. The stunts provided immediate benefits at low cost, as they
augmented the already existing activities of regular meetings, teaching and so
on. Individuals with an interest in telemedicine were the first to be invited to
try out the technology for use areas that did not demand too much technical
adaptations and changes. The project members tried to predict and prepare
for future needs in order to allow for such an indeterminate and exploratory
development. For example, the video studio (or control room) was installed
and equipped even if one didn’t know the exact usage it would have, because
some basic needs were expected to be general. The strategy of selecting
modular, open and flexible technological solutions allowed for replacement
and gradual expansions.
The strategy of creating stunts seemed to have been useful, not the least when
we consider the situation after the project ended. Useful experience was
gained and disseminated. Today there is extensive use of the transmission
facilities at the Interventional Centre by other departments, both for
transmissions within the hospitals as well as external transmissions.
44
Chapter 7
Conclusion
This dissertation has presented an interpretive study of the socio-technical
change processes that evolved around the introduction of telemedicine. The
case study reported from real-time transmissions of audio and video, mainly
from minimally-invasive surgical procedures. In this work, telemedicine is
viewed as an instance of a larger class of technologies where radical
organisational change is expected to follow from the deployment of
communication network technologies. Thus the contribution from this work
is relevant also beyond telemedicine for other kinds of technology-related
organisational change. It is in particular relevant for other attempts at
exploratory development of network technologies to support communication.
The first main theme of the work has been to analyse the socio-technical
interplay, and the dissertation has described the temporal unfolding of the
ongoing and open-ended process of adaptations and socio-technical
negotiations. From an array of different perspectives the papers have shown
how much work it took from a host of actors, to actually accomplish
telemedicine. Through a description that covers the range from the everyday,
mundane technical details to the large-scale network issues, a number of
complex and dynamic socio-technical relationships that exist for multimedia
communication networks have been described. The process where the
technology and the organisation became mutually changed and adapted was
described in several of the papers, while other papers zoomed in on e.g. the
support work that was required, and the different ways to achieve safe and
sufficient image quality in the transmissions. A conclusion that emerged from
this emphasis on the socio-technical interplay was that a successful
introduction of telemedicine will be a far more complex and long-term
process than merely implementing it and using it. Introducing telemedicine
will require an ongoing, concurrent design-in-use of both the new technology
and the organisation that deploy it.
A second main theme has been related to the network character of
telemedicine, and the challenges related to handling of large and complex
networks, or information infrastructures. Previous empirical research has
demonstrated the limitations of “control-oriented” approaches, but scarcely
gone beyond advocating evolutionary and iterative approaches (e.g.
“cultivation”) and have little to say on how to influence such processes. This
study has described in detail how one such “cultivation” process evolved, and
based on this some tentative conclusions and suggestions on how to influence
such processes have been offered. The emphasis has been on the role of the
“stunts”, individual transmission events with a short time horizon that were
not part of a “grand plan”. It was argued that these stunts helped address
45
some problematic aspects of cultivation strategies in practice; both the need
for standardisation in such “bottom-up” processes, and the “uphill battle” of
starting to create an information infrastructure almost from zero. A
“bootstrapping” strategy was then suggested as a general way to approach the
challenge of starting to grow a network.
When particular issues are in focus, it inevitably implies that other issues are
relegated to the background. This work has focused on the socio-technical
negotiations at the expense of the “social” negotiations between different
human stakeholders (individuals, organisations and groups) with their
respective agendas, interests and strategies. There are many issues around the
institutional structures and their influence that would be interesting to study.
Some of the central factors shaping future telemedicine will for example be
regulatory regimes, jurisdictional issues, economic mechanisms like
reimbursement practices, competition between hospitals and between regions,
the role and actions of standardisation bodies, the attitudes of professional
associations and so forth. The influence of these would be valid and pertinent
topics for further research on telemedicine.
However, the future challenges of developing a heterogeneous information
infrastructure will in essence be related to managing complex socio-technical
relationships. Relevant research will thus have to explicitly include also the
characteristics of the technology into its analyses, like I have attempted to do
here. However, this work is based on a limited amount of empirical data, and
the conclusions offered with regard to strategies for handling these challenges
are only tentative. This is partly inevitable when they attempt to describe an
emergent pattern instead of an already established fact. However, to go
beyond the tentative conclusions offered here, further studies that are focused
on analysing growth and change of information infrastructures, with an
emphasis on the scope for intervention in these processes, could be valuable.
46
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