Marc Berg

Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors

Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means to achieving it. As researchers conducting separate studies in the United States, The Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their different social science perspectives (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors fall into two main categories: those in the process of entering and retrieving information, and those in the communication and coordination process that the PCIS is supposed to support. The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.

Overriding of Drug Safety Alerts in Computerized Physician Order Entry

Many computerized physician order entry (CPOE) systems have integrated drug safety alerts. The authors reviewed the literature on physician response to drug safety alerts and interpreted the results using Reasons framework of accident causation. In total, 17 papers met the inclusion criteria. Drug safety alerts are overridden by clinicians in 49% to 96% of cases. Alert overriding may often be justified and adverse drug events due to overridden alerts are not always preventable. A distinction between appropriate and useful alerts should be made. The alerting system may contain error-producing conditions like low specificity, low sensitivity, unclear information content, unnecessary workflow disruptions, and unsafe and inefficient handling. These may result in active failures of the physician, like ignoring alerts, misinterpretation, and incorrect handling. Efforts to improve patient safety by increasing correct handling of drug safety alerts should focus on the error-producing conditions in software and organization. Studies on cognitive processes playing a role in overriding drug safety alerts are lacking.

The practice of medical technology

In this article, we review 25 years of sociological scholarship published in Sociology of Health and Illness on medical technologies. We divide the literature into three theoretical perspectives: technological determinism views medical technology as a political force to shape social relationships, social essentialism emphasizes how medical technologies are neutral tools to be interpreted in social interactions, and technology-in-practice highlights the dialectic relationship between technology and its users in health care. While the technology-in-practice orientation allows social scientists to critique the high hopes and dire warnings embedded in medical technologies, we argue that the logical next step of this paradigm is to move beyond criticism and influence the creation and implementation of medical technologies.

Accumulating and Coordinating: Occasions for Information Technologies in Medical Work

This paper attempts to provide a relational understanding of the generative power of information technologies: an understanding that sees information technologies as embedded in workpractices. This theoretical undertaking, inspired by actor-network theory and work within CSCW, has a practical and political aim. The problems it discusses are directly relevant for the aims and hopes of CSCW: the design of systems that fit workpractices better than traditionally designed systems, and that enhance workers competencies and responsibilities. The paper depicts information technologies as reading and writing artifacts. Taking parts of the medical record as an example, the paper argues that those tools -- in relation with the reading and writing activities of nurses, doctors, laboratory systems -- can be seen to perform two roles in work practices. They accumulate inscriptions and coordinate activities of other entities in the work practice, and in that way afford the handling of more complex worktasks. This focus on the generative power of these artifacts leads to a reconsideration of the notions of ‘supporting’ work and ‘transparent’ technologies, and to a series of specific entry-points for a politics of IT.

Problems and promises of the protocol

Creating protocols (or guidelines, standards) for medical work is becoming big business. The pros and cons of protocols have been reiterated many times: advocates argue that protocols may enhance the quality of care, reduce unwanted variations in practice, and may help to render medical practice more scientific. Critics, on the contrary, argue that protocols will lead to cookbook medicine, to de-skilling, and to a reduced quality of care. In the continuing reiteration of these claims, they have more and more become removed from the actual practices of medical work and of the creation and use of protocols. Building on empirical research of these practices, this paper attempts to revitalise the debate. Four problems of the protocol are discussed: the protocol reinforces the tendency to perceive and describe medical action as an individual, formally rational process; the protocol contributes to the widespread illusion of the single answer; the protocol contributes to the loss of importance of information and interventions which are difficult to explicate and/or to quantify; and the protocol will lead to an increasing bureaucratisation and regulation of health care practices. Judicious use of protocols has several promises, which are discussed subsequently: explicating a scheme of actions creates a forum for discussion, and delegating parts of the decision-making process to a protocol may lead to personnel acquiring new competences.

The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review

Previous studies have shown the importance of workflow issues in the implementation of CPOE systems and patient safety practices. To understand the impact of CPOE on clinical workflow, we developed a conceptual framework and conducted a literature search for CPOE evaluations between 1990 and June 2007. Fifty-one publications were identified that disclosed mixed effects of CPOE systems. Among the frequently reported workflow advantages were the legible orders, remote accessibility of the systems, and the shorter order turnaround times. Among the frequently reported disadvantages were the time-consuming and problematic user-system interactions, and the enforcement of a predefined relationship between clinical tasks and between providers. Regarding the diversity of findings in the literature, we conclude that more multi-method research is needed to explore CPOEs multidimensional and collective impact on especially collaborative workflow.

Guest editors’ introduction: Actor‐network theory and information systems. What's so special?

In this editorial introduction Allen Lees definition of the information systems (IS) field is taken as the starting point: “Research in the information systems field examines more than just the technological system, or just the social system, or even the two systems side by side; in addition, it investigates the phenomena that emerge when the two interact” (Lee, A. “Editorial”, MISQ, Vol. 25, No. 1, 2001, p. iii). By emphasizing the last part of this, it is argued that actor‐network theory (ANT) can provide IS research with unique and very powerful tools to help us overcome the current poor understanding of the information technology (IT) artifact (Orlikowski, W. and Iacono, S., “Research commentary: desperately seeking the ‘IT’ in IT research – a call for theorizing the IT artifact”, Information Systems Research, Vol. 10 No. 2, 2001, pp. 121‐34). These tools include a broad range of concepts describing the interwoven relationships between the social.

Of Forms, Containers, and the Electronic Medical Record: Some Tools for a Sociology of the Formal

Formal tools (i.e., those tools that operate on circumscribed input using rules and that contain a model of the workplace in which they are supposed to function) are attributed central roles in organizing work within many modern workplaces. How should one comprehend the power of these tools? Taking the (electronic) medical record as an example, this article builds on recent calls to overcome the dichotomy between the formal and the informal and proposes an understanding of the generative power of such tools that does not attribute mythical capacities to either tool or human work. To do so, it is important to look both at the history offormal tools and to their real-time use in concrete work practices. These steps toward a sociology of the formal are crucial for a more comprehensive understanding and evaluation offormal systems in practice.

Drug safety alert generation and overriding in a large Dutch university medical centre

To evaluate numbers and types of drug safety alerts generated and overridden in a large Dutch university medical centre.

Guidelines, professionals and the production of objectivity: standardisation and the professionalism of insurance medicine

Does the increasing importance of guidelines in health care threaten the professional status of health care professions by reducing their professional autonomy? Or does it increase their position through enhancing their scientific status? In this paper, we focus on this apparent contradiction by studying how Dutch insurance physicians created and used guidelines for the evaluation of labour disability claims. Drawing upon the theoretical repertoire of science and technology studies, we studied the role of the notion of ‘objectivity’ in these developments. A specific redefinition of objectivity played a core role in the active alignment, by the insurance physicians’ profession, of the processes of guideline development and professionalisation. Simultaneously, it is argued, a specific conceptualisation of the position of the client was put to the fore. Guidelines, it seems, can be drawn upon creatively so that rather than embodying a potential constant threat to professional autonomy, they actually enforce it.