Eric Monteiro

Networks of action: sustainable health information systems across developing countries

Our paper is motivated by one simple question: Why do so many action research efforts fail to persist over time? We approach this question, the problem of sustainability, building on a perspective on action research identifying the pivotal importance of networks. More precisely, local action research interventions need to be conceptualized and approached as but one element in a larger network of action in order to ensure sustainability. A vital aspect of our perspective is that local interventions depend heavily on the support of similar action research efforts in other locations. This is essential for the necessary processes of learning and experience sharing. We suggest that the scaling (i.e., spreading) of intervention is a prerequisite, not a luxury, for sustainable action research. Empirically, we base our analysis on an ongoing, large-scale action research project within the health care sector (called HISP) in a number of developing countries. HISP provides a fruitful occasion to investigate key criteria for our approach to action research, namely sustainability, scalability, and capacity to be politically relevant to the participants. We contribute to three discourses: (1) models of action research, (2) lessons for health information systems in developing countries, and (3) more generally, IS implementations that are dispersed, large-scale, and have scarce resources.

Developing Information Infrastructure: The Tension Between Standardization and Flexibility:

This article explores the tension between standardization and flexibility in information infrastructure (II). Just like other large technical systems, the geographically dispersed yet highly interconnected II becomes increasingly resistant to change. Still, II design must anticipate and prepare for changes, even substantial ones, if infrastructure is to survive. An II contains a huge number of components that alternate between standardization and change throughout their lifetimes. These components are interdependent: when one is changed, others have to remain stable, and vice versa. The article examines theoretical concepts for frammg these aspects of an II. The empirical underpinning of the article is a study of two existing embryonic manifestations of II.

Social Shaping of Information Infrastructure: On Being Specific about the Technology

In this paper, we discuss conceptualizations of the relationship between IT and organizational issues. To move beyond an “IT enables/constrains” position, we argue that it is necessary to take the specifics of an information system (IS) more seriously. A theoretical framework called actor-network theory from social studies of science and technology is presented as promising in this regard. With respect to new organizational forms, the class of ISs which needs closer scrutiny is information infrastructures (INIs). They have characteristics which distinguish them from other ISs, namely the role and pattern of diffusion of standards. These standards are neither ready-made nor neutral: they inscribe organizational behavior deeply within their “technical” details. Diffusion and adoption of standards depart from other kinds of ISs by requiring the coordination of the surrounding actors, institutional arrangements and work practices.

Inscribing behaviour in information infrastructure standards

Abstract This paper focuses on the processes producing the standards which make up the technical back-bone of an information infrastructure. These standards are neither ready-made nor neutral. They are currently being developed, and they ‘inscribe’ behaviour in complex and non-transparent ways. We explore how this takes place, identifying by whom, where and how inscriptions are made. Our principal aim is to uncover the socio-technical complexity of establishing an information infrastructure, a complexity which so far has been severely underestimated by those involved. By studying the process of aligning and linking one inscription to other inscriptions, we also hope to learn more about the strength of inscriptions, that is, the degree to which an inscription actually succeeds in enforcing a desired behaviour. The empirical basis of our analysis is a case-study of standardization processes of health information infrastructure from Norway.

From Artefacts to Infrastructures

In their initial articulation of the direction of the CSCW field, scholars advanced an open-ended agenda. This continuing commitment to open-ness to different contexts and approaches is not, however, reflected in the contents of the major CSCW outlets. The field appears to privilege particular forms of cooperative work. We find many examples of what could be described as ‘localist studies’, restricted to particular settings and timeframes. This focus on the ‘here and now’ is particularly problematic when one considers the kinds of large-scale, integrated and interconnected workplace information technologies—or what we are calling Information Infrastructures—increasingly found within and across organisations today. CSCW appears unable (or unwilling) to grapple with these technologies—which were at the outset envisaged as falling within the scope of the field. Our paper hopes to facilitate greater CSCW attention to Information Infrastructures through offering a re-conceptualisation of the role and nature of ‘design’. Design within an Information Infrastructures perspective needs to accommodate non-local constraints. We discuss two such forms of constraint: standardisation (how local fitting entails unfitting at other sites) and embeddedness (the entanglement of one technology with other apparently unrelated ones). We illustrate these themes through introducing case material drawn on from a number of previous studies.

Seamless Integration: Standardisation across Multiple Local Settings

The pressure towards tighter or “seamless” integration of health information systems is a recurring issue with both practical and analytical relevance. It taps into a discourse in the IS literature in general and organisation and management science in particular. Unfortunately, the prevailing perception of integration in the IS literature is as a predominantly technical issue. The CSCW literature, however, is attentive to the socio-technical aspects of integration. Building on this – but supplemented with recent elaborations in science studies – we aim at exploring the unintended consequences of information systems integration. A user-led perspective implies emphasising the tailoring to local needs based on in-depth studies of the micro practices. We argue, however, that the condition for such an approach is radically undermined by politically motivated, regional changes towards integration with implicated standardisation. Enforcing order in the form of standards across multiple local settings, seemingly a prerequisite for tight integration, simultaneously produces disorder or additional work in other locations for other users. Empirically, our study is based on a large, ongoing integration effort at the University hospital of Northern Norway, specifically studying work practices and perceptions across multiple laboratories.

Mechanisms for producing a working knowledge: Enacting, orchestrating and organizing

Given that knowledge (intensive) work takes place immersed in truly heterogenous networks of knowledge representations (codified, narrative, embedded in routines, inscribed in artefacts), our analysis is geared towards how the transformation of these resources are enacted in the practise of everyday, knowledge work. First, we discuss the work, strategies and mechanisms implied in rendering knowledge as credible, trustworthy and relevant. Second, we analyse how sediments of historically superimposed layers of knowledge representations need to be enacted through selective repetitions, omittance and highlighting to preserve it as living knowledge. Third, supplementing the more cognitivelly oriented aspects of knowledge work, we discuss how codified knowledge representations organise, coordinate and delegate work. Empirically, we study clinical work in large hospitals, a type of work, we argue, that unduely has been left out of traditional listings of knowledge work

Standardization of Work: Co-constructed Practice

There is strong pressure to achieve greater uniformity, standardization and application of best practices in the service professions, a sector that is growing in presence and importance. At the same time, there is a conflicting demand for the delivery of high-quality (or high-priced or “knowledge-intensive”) specialized or localized services. Our article analyzes information systems-enabled standardizing of service work through an in-depth interpretative study of an ongoing standardization initiative within the field of nursing. Nursing provides a graphic illustration of the dilemmas involved in the standardization of service work. In nursing, standardization is commonly a feature of projects to improve both efficiency and quality in health care. In contrast to the dominant conception of standardization as a largely top-down, imposed process, we offer a view of standardization as incomplete, co-constructed with users, and with significant unintended consequences. The article contributes by (a) developing a theoretical perspective for the standardization of information-system-embedded service work and (2) providing operational and practical implications for system design and health care management.

Technology transfer vs. technological learning: It‐infrastructure and health care in developing countries

Abstract The notion of technological ‘transfer’ rests on a conception of technology as artifacts. This, as many have argued, neglects the crucial aspects of the social and cultural context of use. Technology has to be learnt rather than transferred. Based on this, we attempt to analyze the conditions and possibilities for technological learning about IT‐infrastructure in developing countries. In so doing, we distinguish between local, contextual learning and institutional or technological infrastructure for learning. These processes of learning need to take place in areas sheltered from international competition. Examples from Mongolia and South African health care are used to illustrate our points.

Conceptualizing common information spaces across heterogeneous contexts: mutable mobiles and side-effects of integration

The design and conceptualization of Common Information Spaces (CIS) has long been recognized as an important research topic within CSCW. Informed by recent developments in Actor-Network Theory (ANT), this paper contributes to the conceptualization of CIS across heterogeneous contexts. In particular, the paper develops a dynamic perspective on CIS emphasizing how CIS is malleable, open and achieved in practice. Furthermore, we argue that large-scale CIS efforts inherently tend to re-produce fragmentation as an unintended consequence of integrating heterogeneous sources of information. Empirically, the research is grounded in extensive field work in a major international oil and gas company.