Addressing the heterogenity of health care:
analytical and operational implications
Eric Monteiro
Norwegian Univ. of Science & Technology
and
Univ. of Oslo
www.idi.ntnu.no/~ericm
Integrated Health Records Workshop
Edinburgh, March 2006
1
The setting
Hospital
EKG, US, ..
Nursing doc.
EPR
PACS
PAS
Dept. clinical sys
Lab
”140 ?”
2
Publisher
The setting
GPs
Legal drugs
EPRs
Gov. auditing
Hospital
referrals
EKG, US, ..
ePrescription
Nursing doc.
EPR
Research DB
PACS
PAS
inventory, logistics
Pharmacies
Dept. clinical sys
Lab
Health registers
Lab
3
Medication depot
”140 ?”
(Good!) Reasons for fragmentation
• geographical
– regional, national, international
• institutional
boundaries:
– primary vs. secondary
– across organisations
– across departments within (large) hospitals
• professional
– physicians, nurses, physiotherapists, …
• time
– continutity of care across time
– chronic diseases
4
Trends
Standardise
Evidence based medicine
Clinical guidelines
Plan based care
Care pathways
”Best practices”
5
Individualise
“[U]niformity of output,
a major goal of routinization,
seems to be a poor strategy
for maintaining quality...
since customers often
perceive rigid uniformity
as incompatible with
[high] quality”
(R Leidner)
Models & architectures
“[T]o develop a set of standards based
on a general healthcare model,
as an essential starting point…
a common model
The standards will be defined as a framework
and architectures at several levels,
…will derive core functional requirements
specifications”
CEN/TC 251 WG1 Healthcare information modelling and medical records
6
Outline of argument: heterogenity reconsidered
• intrinsic & unavoidable (?) - but sometimes productive
•
1. micro-practices of use
–
–
–
•
•
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ultimately: trust
validation
quality
triangulation
2. strategies of implementation
–
level of completion
–
level of ambition
Illustrations + hints to analytical import
perfection
Nursing documentation
“It is a severe threat for the individuality and safety of patient
• professionalisation
care if important aspects of nursing care remain undocumented.
One cannot rely on information that is not documented. (…)
Ultimately, the documentation practices reflect the values of the
nursing personnel.”
Voutilainen (2004:79-80)
• legitimation
”It is expected that nurses obtaining appropriate and accurate
• quality of care
• efficienty,classification
information when they need it will improve the chance of making
better decisions about patient care.”
(Lee and Chang, 2004:38).
“Information technology has gained a larger and more fundamental
role in the management, distribution and storage of information in
healthcare. The patient record and electronic nursing documentation
is expected to reduce redundancy and increase access to up-to-date
information as an integrated part of the EPR”
8
(Hellesø and Ruland, 2001:799).
No plans – but plannig
-patient list
-operation chart
-patient chart
-obvervation form
- patient summary
9
Redundancy viewed productively: robust knowledge
•
triangulation
“I know that a lot of the information in the report is also written
elsewhere. Still I write it in the report to make sure she [nurse starting
– checking, validation – and ultimately: trust the next shift] is aware of my main observations and medication.
– ex.: writing of report
It’s important for her and helps her find out what focus on, where
to look for more detailed information [different forms], and so on”
“Checking medication with John”
•
learning/ focus of attention
– ex.: negotiations, what to skip/include
“No fluid is actually prescribed, but I believe we’re better off just
giving it to her [the patient] anyway…It has been said that she has
got 1500ml and that she should eat and drink. But the “old” lady will
probably not eat much anyway, so I believe she’s better off if we
give her fluid intravenously … also because of the heat…”
•
10
ongoing, performative
morning meetings
oral + written
repititons
Forms of redundancies
• function
– several know same function (substitution)
• effort
– repeat (emphasise / underscore)
• data
– multiple places (sources, systems, artefacts)
– same or ’similar’
11
(F Cabitza et al. 2005)
Perceptions of ”mess”
•
A jungle of information systems in hospitals
”You don’t get the test results or xrays…
I’ve got 3 different systems with 3
different login that I have to engage
with”
(Physician, Rheumatology)
12
(Tight) integration as ordering
• Vulnarble IT-dept.: demonstrate ability
PAS
LAB
EPR
RIS
”Obvious that our hospital should have DIPS
just like the other 10 in the region”
”We want DIPS…then we get everything we
need in one place”
”DIPS… a common architecture, integrated
modules, common logon”
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Relocated, not eliminated disorder
• Over time: mutated order
“The printouts in Dips EPR generate more and more chaos. Many
documents are already printed out. Then suddenly a new document
is produced with consultation date back in time. This document is
then inserted [automatically] 15-20 documents before the last
document”
• ex.: laboratory systems, clinical chemistry too simple
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Self-defeating effects
• Increased complexity as replacement was ”too risky”: keep the old alive, in
addition
Emergency numbers
Gateway machine
The Dips portfolio
Other
clinical IS
The old
PAS
Laboratory
systems
RIS
PAS
EPR
LAB
RIS
• additional work: lab sample – DIPS – gateway – old PAS – emergency number
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”Perfectionism would be dangerous”
•
Totalizing change efforts
– fall short of achieving their goals (of course)
– produce in themselves disorder (self-defeating)
”It'
s an argument about imperfection….That there are always many imperfections.
And to make perfection in one place (assuming such a thing was possible) would be to
risk much greater imperfection in other locations…
The argument is that entropy is chronic…. Some parts of the system will dissolve.”
J. Law
• C Perrow
tightly coupled
loosly coupled
linear
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complex
The preoccupation with the hygenic
• sorting out the mess; inscribed into
– methods (refinement, modelling, dev. phases)
– notions/constructs (modularisation, architecture)
– ideology
• taps into deep sentiments (Purity and danger)
• outcomes ??
– cost-effective ?
– dysfunctional ?
– risk & mega-projects (B Flyvbjerg)
• Embracing heterogenity
– inherent ”mess”
– multiplicity
17
vs.
Conceptualising heterogenity
• ongoing / performative
• unavoidable, immanent
• imperfections
• perfection dysfunctional
18