Troels Mønsted

The Use of Narratives in Medical Work: A Field Study of Physician-Patient Consultations

Medical reasoning involves more than just summarizing clinical data and guidelines. Illness trajectories of chronic patients are often long, complex and full of uncertain information that requires interpretation. Understanding the complex interrelations is an important aspect of medical reasoning that displays narrative rather than scientific characteristics. While the qualities of the medical record as a repository of information or as a coordinative tool are well known, the role it plays in the unfolding of narratives in medical reasoning is less discussed. This paper examines this issue through a case study of patient consultations that take place as part of a distributed treatment of chronic heart patients. We found that the record, even though fragmented and to some extent incomplete, enables the physician to construct an ad hoc narrative. During the actual consultation, physicians and patients unfold a more detailed narrative, which we refer to as the re-emplotted narrative, that includes additional information and entails a collaborative exploration of uncertainties. While this may point to some inadequacies of the medical record as a supportive tool for the process of unfolding narrative, we suggest that is it in fact a crucial component of the medical reasoning activity that must be considered in design of supportive systems.

Physicians’ Progress Notes

This paper examines physicians’ progress notes, an artifact that, in spite of its obvious importance in the coordination of cooperative work in clinical settings, has not been subjected to systematic study under CSCW auspices. While several studies have addressed the role of the medical record in patient care, they have not dealt specifically with the role, structure, and content of the progress notes. As a consequence, CSCW research has not yet taken fully into account the fact that progress notes are coordinative artifacts of a rather special kind, an open-ended chain of prose texts, written sequentially by cooperating physicians for their own use as well as for that of their colleagues. We argue that progress notes are the core of the medical record, in that they marshal and summarize the overwhelming amount of data that is available in the modern hospital environment, and that their narrative format is uniquely adequate for the pivotal epistemic aspect of cooperative clinical work: the narrative format enables physicians to not only record ‘facts’ but also—by filtering, interpreting, organizing, and qualifying information—to make sense and act concertedly under conditions of uncertainty and contingency.

Designing Shared Electronic Records for Chronic Care

This paper reports preliminary findings from an ongoing research project on the development of IT support for communication and information sharing across institutional and professional boundaries within the Danish healthcare system. The project focuses on the treatment of patients with implanted ICDs (implantable cardioverter-defibrillator). These are chronic patients who usually see several different healthcare providers on a regular basis. The main findings so far are: (1) Most of the data produced and recorded as part of the care process are context-specific and often difficult to interpret unless you are an expert on the subject. Sharing these types of data across institutional and professional boundaries is not feasible. (2) Yet, it appears that a small subset of data can make sense across the different contexts and be of use to others. These data are good candidates for sharing. (3) In addition, there appears to be a need for creating new types of data specifically designed to meet the coordination needs across different contexts and expert domains. (4) The dilemma is, however, that the production of these new types of data must not require too much extra work.

Cooperative Epistemic Work in Medical Practice: An Analysis of Physicians' Clinical Notes

We examine an important part of the medical record that has not been studied extensively: physicians’ clinical notes. These notes constitute an explanatory medical narrative that documents the patient’s illness trajectory by combining each physician’s notes into a common text. Although several prior CSCW studies have addressed the role of the medical record in patient care, they have not dealt specifically with the role, structure, and content of these notes. In this article, we present a detailed analysis of a set of physicians’ clinical notes recording the acute hospitalization and subsequent treatment of a patient with chronic heart disease. We show that clinical notes are highly structured and conventionalized texts that promote conciseness while at the same time allowing physicians to express themselves in a precise and nuanced way. Based on this analysis, we argue that physicians’ clinical notes form the core of the medical record. They serve both as a ‘tool for thinking’ for the individual physician, enabling him or her to make sense of the patient’s past history and current condition, and as a coordinative artifact used by physicians, nurses, and other health care professionals. We conclude by discussing the implications of this research for the design of Electronic Medical Record (EMR) systems.

Keeping Distributed Care Together: Medical Summaries Reconsidered

Summaries in the medical record have traditionally offered health professionals good cognitive support by guiding reading of the medical record and supporting communication and collaboration in clinical teams. However, because of increased distribution of chronic care and fragmentation of the medical record, summaries are becoming increasingly incomplete and have lost some of their ability to mediate collaboration in clinical teams and support situated sensemaking. Based on findings from a project aimed at studying and designing IT to support collaboration among health professionals in distributed, chronic care, this article present a detail study of current use of summaries and discusses how a new type of summary can be designed to offer better support for distributed, chronic care. Overall I argue that we must maintain an appropriate balance between structure and flexibility, while reconsidering the readership, the authorship, and the maintenance of summaries.

Targeted prevention in primary care aimed at lifestyle-related diseases: a study protocol for a non-randomised pilot study

BackgroundThe consequences of lifestyle-related disease represent a major burden for the individual as well as for society at large. Individual preventive health checks to the general population have been suggested as a mean to reduce the burden of lifestyle-related diseases, though with mixed evidence on effectiveness. Several systematic reviews, on the other hand, suggest that health checks targeting people at high risk of chronic lifestyle-related diseases may be more effective. The evidence is however very limited. To effectively target people at high risk of lifestyle-related disease, there is a substantial need to advance and implement evidence-based health strategies and interventions that facilitate the identification and management of people at high risk. This paper reports on a non-randomized pilot study carried out to test the acceptability, feasibility and short-term effects of a healthcare intervention in primary care designed to systematically identify persons at risk of developing lifestyle-related disease or who engage in health-risk behavior, and provide targeted and coherent preventive services to these individuals.MethodsThe intervention took place over a three-month period from September 2016 to December 2016. Taking a two-pronged approach, the design included both a joint and a targeted intervention. The former was directed at the entire population, while the latter specifically focused on patients at high risk of a lifestyle-related disease and/or who engage in health-risk behavior. The intervention was facilitated by a digital support system. The evaluation of the pilot will comprise both quantitative and qualitative research methods. All outcome measures are based on validated instruments and aim to provide results pertaining to intervention acceptability, feasibility, and short-term effects.DiscussionThis pilot study will provide a solid empirical base from which to plan and implement a full-scale randomized study with the central aim of determining the efficacy of a preventive health intervention.Trial registrationRegistered at Clinical Trial Gov (Unique Protocol ID: TOFpilot2016). Registered 29 April 2016. The study adheres to the SPIRIT guidelines.

Aligning Concerns in Telecare: Three Concepts to Guide the Design of Patient-Centred E-Health

The design of patient-centred e-health services embodies an inherent tension between the concerns of clinicians and those of patients. Clinicians’ concerns are related to professional issues to do with diagnosing and curing disease in accordance with accepted medical standards. In contrast, patients’ concerns typically relate to personal experience and quality of life issues. It is about their identity, their hopes, their fears and their need to maintain a meaningful life. This divergence of concerns presents a fundamental challenge for designers of patient-centred e-health services. We explore this challenge in the context of chronic illness and telecare. Based on insights from medical phenomenology as well as our own experience with designing an e-health service for patients with chronic heart disease, we emphasise the importance – and difficulty – of aligning the concerns of patients and clinicians. To deal with this, we propose a set of concepts for analysing concerns related to the design of e-health services: A concern is (1) meaningful if it is relevant and makes sense to both patients and clinicians, (2) actionable if clinicians or patients – at least in principle – are able to take appropriate action to deal with it, and (3) feasible if it is easy and convenient to do so within the organisational and social context. We conclude with a call for a more participatory and iterative approach to the design of patient-centred e-health services.

Achieving veracity: A study of the development and use of an information system for data analysis in preventive healthcare

Within healthcare, information systems are increasingly developed to enable automatic analysis of the large amounts of data that are accumulated. A prerequisite for the practical use of such data analysis is the veracity of the output, that is, that the analysis is clinically valid. Whereas most research focuses on the technical configuration and clinical precision of data analysis systems, the purpose of this article is to investigate how veracity is achieved in practice. Based on a study of a project in Denmark aimed at developing an algorithm for stratification of citizens in preventive healthcare, this article confirms that achieving veracity requires close attention to the clinical validity of the algorithm. It also concludes, however, that the veracity in practice hinges critically on the citizens’ ability to report high-quality data and the ability of the health professionals to interpret the outcome in the context of existing care practices.

Maneuvering a Pilot Implementation to Align Agendas Across Sectors

A prerequisite for pilot implementations in complex organizational settings is that the agendas of the stakeholders of the system are maneuvered into alignment. In this paper we present a study of the pilot implementation of the IT-supported, preventive intervention TOF (Tidlig Opsporing og Forebyggelse). A core element of TOF is an IT system that stratifies citizens into risk groups on the basis of self-reported lifestyle information and data retrieved from the medical records of the general practitioners (GPs). In addition, the system facilitates cross-sectoral coordination between preventive offers at the GP and at municipal health centers. We find that TOF succeeded in maneuvering the agendas of the involved stakeholders by gaining the foothold, legitimacy, and GP motivation required to carry out the pilot implementation.

Balancing Priorities: A Field Study of Coordination in Distributed Elder Care

Within elder care, an increased distribution of care poses strong requirements on the ability of health providers, to coordinate their activities across organizational boundaries. However, existing care administration systems do not offer sufficient support for collaboration and coordination among a heterogeneous ensemble of care providers. In this paper, we present findings from a field study of coordinative work in distributed elder care in Denmark. The purpose of this study is to further our understanding of the coordinative challenges of distributed elder care, and to inform design of new care administration systems. Overall, we found that caregivers at the care center fulfill a crucial role in prioritizing the scheduled activities in cases where opposed interests occur, which indicates a need for a care administration system, that not only supports the meticulous planning of activities, that are needed by the healthcare system, but also the work involved in balancing priorities.