Gunnar Ellingsen

A Review of 25 Years of CSCW Research in Healthcare: Contributions, Challenges and Future Agendas

CSCW as a field has been concerned since its early days with healthcare, studying how healthcare work is collaboratively and practically achieved and designing systems to support that work. Reviewing literature from the CSCW Journal and related conferences where CSCW work is published, we reflect on the contributions that have emerged from this work. The analysis illustrates a rich range of concepts and findings towards understanding the work of healthcare but the work on the larger policy level is lacking. We argue that this presents a number of challenges for CSCW research moving forward: in having a greater impact on larger-scale health IT projects; broadening the scope of settings and perspectives that are studied; and reflecting on the relevance of the traditional methods in this field - namely workplace studies - to meet these challenges.

Challenging expertise: On power relations within and across communities of practice in medical innovation

This article addresses the question of how practices perform power effects within and across communities of practice. It does so by drawing on a study of two medical innovation projects leading to radical changes of practice. Situated learning theory has to some degree acknowledged the asymmetry in power between masters and apprentices. Meanwhile, this study suggests that the novelty of new practices may lead to a contestation of the established master-apprentice relationship and even challenge the basis of the community of practice itself. We therefore argue that innovation processes may highlight the political processes and negotiations already at play in communities of practice. Hence, we investigate how communities of practice tried to control the new practices through mobilizing arguments, marginalizing opponents and building alliances. Consequently, the article argues that changing practices may be highly political.

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.

Managing communication availability and interruptions: a study of mobile communication in an oncology department

Wireless phones and text messaging are tremendously popular in many areas of society. However, they are still relatively unused in hospitals where pagers are a pervasive communication device that is notoriously difficult to replace. This paper studies pager and wireless phone use at the oncology department at University Hospital of North Norway. Participatory observation and interviews with physicians are used to provide qualitative analysis about the use, drawbacks and benefits of both technologies. A number of important issues are addressed that should aid designers of next generation mobile communication systems for hospitals. In particular, the data points towards specific features that will be crucial for the overall usability and acceptance of an integrated device that supports paging, voice and text services. Of particular importance will be features that allow users to manage their communication availability and avoid interruptions.

Infrastructural arrangements for integrated care: implementing an electronic nursing plan in a psychogeriatric ward

Purpose The paper contributes to the conceptualisation of “integrated care” in heterogeneous work practices. A dynamic perspective is developed, emphasising how integrated care is malleable, open, and achieved in practice. Furthermore, we explore the role of nursing plans in integrated care practices, underscoring the inherent difficulties of building one common infrastructural system for integrated care. Methods Empirically, we studied the implementation of an electronic nursing plan in a psychiatric ward at the University Hospital of North Norway. We conducted 80 hours of participant observation and 15 interviews. Results While the nursing plan was successful as a formal tool among the nurses, it was of limited use in practice where integrated care was carried out. In some instances, the use of the nursing plan even undermined integrated care. Conclusion Integrated care is not a constant entity, but is much more situated and temporal in character. A new infrastructural system for integrated care should not be envisioned as replacing most of the existing information sources, but rather seen as an extension to the heterogeneous ensemble of existing ones.

Integration and Generification--Agile Software Development in the Healthcare Market

The aim of this paper is to contribute to strategies applicable to vendors who want to move their locally designed and highly integrated systems to a larger market. A further aim is to explore how such systems developed for a local practice, and tightly integrated with the existing infrastructure, can be adapted to a larger market. We analyse the socio-technical mechanisms in play, the roles that the vendor and the users have in order to facilitate this, and the delicate interplay in relation to the other vendors. The analysis draws on the CSCW field, notions of generification of packaged software products, and boundary work. We argue that this process involves boundary work in relation to the installed base, as well as to other vendors and users. We also argue that the roles of the actors involved change during this process. The case described in this paper is the evolution of a system in which general practitioners can order laboratory services from the hospital electronically. The system integrates the general practitioners’ information systems with the laboratory information system in the hospital. The development of the system started out in close cooperation with one customer, but as it evolved more customers bought the system. The system has been designed in an iterative and evolutionary way using agile development methods.

Common Information Spaces along the illness trajectories of chronic patients

The Norwegian healthcare sector, like the rest of the Western world, faces major challenges related to the need to coordinate work within and across institutional anddisciplinary boundaries. The main materialization of the ongoing efforts of streamlining healthcare services is the formalization of healthcare work through the Electronic-Based Record (EPR). In this thesis I explore one particular aspect of these efforts: nursing care and the formalization of nurse’s written accounts in the EPR-based nursing record.Nurses play an essential role in ensuring that there is a well-functioning organization and a seamless management of patient trajectories. With increased emphasis on integrated care as the standard model for delivering healthcare services, the contribution of the nursing profession to the overall delivery of care is increasingly acknowledged.This thesis explores how nursing is documented in practice and how the EPR-based nursing module is integrated in specific nursing work practices. Empirically the thesis is based on ethnographically inspired fieldwork at the Department of Rheumatology at St. Olavs University Hospital in Trondheim and the Department of Special Psychiatry at the University Hospital in Tromso. In both cases I have studied nurse’s documentation practice and the integration of the EPR-based nursing record into their everyday work.The thesis has a strong focus on how things are done in practice. The set of papers presented as part of this thesis make some of the work involved in formalizing nurse’s written accounts visible and also present the EPR-based nursing record in practice. The main contribution of the thesis is a detailed, empirically underpinned exploration of the efforts of introducing the electronic-based nursing module in practice. I apply a process-oriented perspective on the nursing record that stresses how it is situated, its temporal nature, how it is regularly (re)negotiated and achieved in practice.Integrating the EPR-based nursing record with the aim of improving information sharing is extremely difficult. In the Trondheim case it is demonstrated how efforts of formalizing nurse’s work through the EPR introduced new types of informal elements. In fact, the informal, redundant and unstructured aspects of nurse’s work that initially were considered to be a problem became essential for the new formalized practice to work. Similarly in Tromso, the standardization of nursing plans unintentionally subverted the possibilities for interdisciplinary cooperation. Rather, it was the existing and heterogeneous (informal/formal and oral/written) documentation and communication practice that contributed to interdisciplinary work and made up and served as a premise for a good nursing plan.The thesis contributes to theory by presenting a dynamic perspective on the nursing record as resilient, open and achieved in practice. The thesis contributes to the literature within Computer Supported Cooperative Work (CSCW) on informal documentation practices and expressions of redundancy by demonstrating how these are transformed when new technologies are being implemented. Also the thesis contributes to the existing CSCW literature by demonstrating the necessity of accommodating temporal differences that arise from separate and different intragroup processes.The aims and goals related to the EPR change and expand over time and in relation to multiple stakeholders. For example, in the Tromso case the nursing plan, which started out as tool for nurses, gradually turned into a resource management tool. Such transformations of ambitions are typical in information system projects and should not come as a surprise - primary work transforms things into something different where technologies find new areas of application.In order to succeed in integrating tools such as the EPR-based nursing record with work, one needs to move beyond simplistic strategies of replacing the existing information sources. The strategy to pursue is to find mechanisms that strengthen the relations between the parts. For practice this implies balancing rational aims and practical applicability when designing and implementing new tools. Also, it involves paying closer attention to what is non-common, for example what types of information sometimes remains specific for the various professionals, and why.Methodologically, the interconnected and mutually dependent entities of material arrangements and practices of different professionals underscore the need for doing empirical studies in a work setting by following the whole process of implementing a new system (before, during and after). Also, in order to make research findings practically relevant, researchers should engage themselves in arenas that enable learning to take place, where knowledge can be shared and where local competence and capacity are cultivated. Rather than presenting a fixed set of requirements as implications for design, we should struggle to build relationships between politically contrasting interests, for example between vendors, managers and the users. Design implications are in this sense not fixed once and for all, but instead serve as a starting point for discussion, reflection and negotiated changes with various stakeholders.

The Role of Integration in Health-Based Information Infrastructures

In this paper, we contribute with empirical insight into the complexity of establishing and sustaining integration between different information infrastructures in health care. An overall concern is to elaborate on how, despite many obstacles, the integration effort moves forward. We see this as a collective achievement, where users have an essential role in terms of mobilizing and coordinating the other actors as well as maintaining the integration. These activities are not limited to a specific project; they emerge from and are part of day-to-day practice. Empirically, we focus on a large integration initiative between the laboratory systems at the University Hospital of Northern Norway and the electronic patient records used by general practitioners in the Northern health region. Together with the vendor, Well Diagnostics, the hospital initiated a project aimed at establishing a new laboratory requisition system that enabled GPs to send requisitions electronically to the hospital laboratories. Theoretically, we draw on the concept of information infrastructures, and supplement this with Actor Network Theory.