Variations in Oncology Consultations: How Dictation Allows Variations to be Documented in Standardized Ways
In-between 2016 and 2017 a new hospital information system (HIS) was introduced at several hospitals in Denmark radically changing the core work practices for a majority of the healthcare professionals. Promptly, the new HIS began to receive criticism from healthcare professionals for failing to live up to proclaimed expectations. To fully understand the problems experienced by the healthcare professionals we need to understand the fundamental nature of the work prior to the implementation. In this paper, we investigate patient consultations as they were performed prior to the implementation of the HIS at an oncology department. Reporting from a 1.5 year-long study, we find patient consultations were organized in three sequential activities: review, interaction, and documentation. Further, we find that the dictaphone served as a key artifact allowing physicians to enact flexibility in documentation while simultaneously providing them with the capability to communicate and coordinate with the medical secretaries. Our empirical findings suggest that the medical secretaries are critical for structured documentation of variations in health data and are the cornerstones that allow physicians to enact sentimental efforts when interacting with patients. These insights prove important in understanding the criticism aimed at the new HIS implementation since the implementation removed the dictaphone as a key artifact and instead introduced a new organizational structure where documentation was assumed accomplished in parallel with patient interaction. The transformation consequently shifted work, previously performed by the medical secretaries, to the physicians.
KeywordsAudio recordings CSCW Dictaphone Documentation Field study Healthcare Health data Information systems Medical secretaries Oncology Patient consultations Treatment trajectories Variations Work practices
We would like to acknowledge all the physicians, nurses, and medical secretaries at the Department of Oncology at Copenhagen University Hospital, Herlev, which allowed us to observe their work and spend time answering our questions. Without them, we would not have been able to do this research. Further, we would like to give a special thanks to all the patients at the oncology department who let us observe when they were interacting with physicians during their patient consultation. Moreover, we would like to thank Lisa Sengeløv, who allowed us to conduct the research at the oncology department. Finally, a special thank you for the constructive comments we received from healthcare practitioners and the anonymous reviewers when critically discussing our arguments presented in earlier versions of this paper.
- Aanestad, Margunn; and Tina Blegind Jensen (2011). Building nation-wide information infrastructures in healthcare through modular implementation strategies. The Journal of Strategic Information Systems, vol. 20, no. 2, pp. 161–176.Google Scholar
- Balka, Ellen; Pernille Bjørn; and Ina Wagner (2008). Steps toward a typology for health informatics. In CSCW’08. Proceedings of the 2008 ACM conference on Computer supported cooperative work, San Diego, CA, USA, 08–12 November 2008. New York: ACM Press, pp. 515–524.Google Scholar
- Bansler, Jørgen P.; Erling C. Havn; Troels Mønsted; and Kjeld Schmidt (2011). A study of the fragmentation of the medical record. In P. Bjørn; F. Kensing; and L. R. Christensen (eds.): IHC’11. Proceedings of the 3rd International Workshop on Infrastructures for Healthcare 2011: Global Healthcare, Copenhagen, Denmark, 23–24 June 2011. Copenhagen: IT University of Copenhagen, pp. 94–97.Google Scholar
- Bansler, Jørgen P.; Erling C. Havn; Kjeld Schmidt; Troels Mønsted; Helen Høgh Petersen; and Jesper Hastrup Svendsen (2016). Cooperative epistemic work in medical practice: An analysis of physicians’ clinical notes. Computer Supported Cooperative Work (CSCW), vol. 25, no. 6, pp. 503–546.Google Scholar
- Bardram, Jakob E. (2004). Applications of context-aware computing in hospital work: Examples and design principles. In SAC’04. Proceedings of the 2004 ACM symposium on Applied computing, Nicosia, Cyprus, 14–17 March 2004. New York: ACM Press, pp. 1574–1579.Google Scholar
- Berg, Marc (1996). Practices of reading and writing: The constitutive role of the patient record in medical work. Sociology of health & illness, vol. 18, no. 4, pp. 499–524.Google Scholar
- Berg, Marc (1997). Rationalizing medical work: Decision-support techniques and medical practices. Cambridge, Mass.: MIT press.Google Scholar
- Berg, Marc (2001). Implementing information systems in health care organizations: Myths and challenges. International journal of medical informatics, vol. 64, no. 2, pp. 143–156.Google Scholar
- Bjørn, Pernille; and Ellen Balka (2007). Health care categories have politics too: Unpacking the managerial agendas of electronic triage systems. In L. Bannon; I. Wagner; C. Gutwin; R. Harper; and K. Schmidt (eds): ECSCW‘07. Proceedings of the Tenth European Conference on Computer Supported Cooperative Work, Limerick, Ireland, 24–28 September 2007. Springer, pp. 371–390.Google Scholar
- Bjørn, Pernille; and Kjetil Rødje (2008). Triage drift: A workplace study in a pediatric emergency department. Computer Supported Cooperative Work (CSCW), vol. 17, no. 4, pp. 395–419.Google Scholar
- Bjørn, Pernille; Sue Burgoyne; Vicky Crompton; Teri MacDonald; Barbe Pickering; and Sue Munro (2009). Boundary factors and contextual contingencies: Configuring electronic templates for healthcare professionals. European Journal of Information Systems, vol. 18, no. 5, pp. 428–441.Google Scholar
- Blomberg, Jeanette; and Helena Karasti (2013). Reflections on 25 years of ethnography in CSCW. Computer Supported Cooperative Work (CSCW), vol. 22, nos. 4–6, pp. 373–423.Google Scholar
- Blomberg, Jeanette; Jean Giacomi; Andrea Mosher; and Pat Swenton-Wall (1993). Ethnographic field methods and their relation to design. In D. Schuler; and A. Namioka (eds.): Participatory design: Principles and practices. New Jersey: Lawrence Erlbaum Associates, pp. 123–155.Google Scholar
- Boulus, Nina (2009). Sociotechnical changes brought about by electronic medical record. In AMCIS’09. Proceedings of the Fifteenth Americas Conference on Information Systems, San Francisco, California, 6–9 August 2009. Paper 781.Google Scholar
- Boulus, Nina; and Pernille Bjørn (2010). A cross-case analysis of technology-in-use practices: EPR-adaptation in Canada and Norway. International Journal of Medical Informatics, vol. 79, no. 6, pp. 97–108.Google Scholar
- Bjørn, Pernille; and Nina Boulus-Rødje (2015). The multiple intersecting sites of design in CSCW research. Computer Supported Cooperative Work (CSCW), vol. 24, no. 4, pp. 319–351.Google Scholar
- Chen, Yunan; Victor Ngo; Sidney Harrison; and Victoria Duong (2011). Unpacking exam-room computing: Negotiating computer-use in patient-physician interactions. In D. Tan (eds.): CHI’11. Proceedings of the 2011 annual conference on Human factors in computing systems, Vancouver, BC, 7–12 May 2011. New York: ACM Press, pp. 3343–3352.Google Scholar
- Christophersen, Mads; Peter Mørck; Tue Odd Langhoff; and Pernille Bjørn (2015). Unforeseen challenges: Adopting wearable health: Data tracking devices to reduce health insurance costs in organizations. In M. Antona; and C. Stephanidis (eds): UAHCI’15. Proceedings of universal access in human-computer interaction 2015, Los Angeles, CA, 2 august - 7 August. Cham: Springer, pp. 288–299.Google Scholar
- Cicourel, Aaron V. (1990). The integration of distributed knowledge in collaborative medical diagnosis. In J. Galegher; R. E. Kraut; and C. Egido (eds): Intellectual Teamwork: Social and Technological Foundations of Cooperative Work. Hillsdale, New Jersey: Lawrence Erlbaum Associates, pp. 221–242.Google Scholar
- Clarke, Karen; John Hughes; Mark Rouncefield; and Terry Hemmings (2006). When a bed is not a bed: Calculation and calculability in complex organisational settings. In K. Clark; G. Hardstone; M. Rouncefield; and I. Sommerville (eds): Trust in Technology: A socio-technical perspective. Dordrecht: Springer, pp. 21–38.Google Scholar
- Corbin, Juliet M.; and Anselm L. Strauss (1991). A nursing model for chronic illness management based upon the trajectory framework. Scholarly inquiry for nursing practice, vol. 5, no. 3, pp. 155–174.Google Scholar
- Danholt, Peter; and Henriette Langstrup (2012). Medication as infrastructure: Decentring self-care. Culture Unbound: Journal of Current Cultural Research, vol. 4, no. 3, pp. 513–532.Google Scholar
- Eisenhardt, Kathleen M. (1989). Building theories from case study research. Academy of management review, vol. 14, no. 4, pp. 532–550.Google Scholar
- Ellingsen, Gunnar; and Glenn Munkvold (2007). Infrastructural arrangements for integrated care: Implementing an electronic nursing plan in a psychogeriatric ward. International journal of integrated care, vol. 7, no. 2, pp. 1–11.Google Scholar
- Forsythe, Diana E. (1999). “It's just a matter of common sense”: Ethnography as invisible work. Computer Supported Cooperative Work (CSCW), vol. 8, nos. 1–2, pp. 127–145.Google Scholar
- Fribo, Adam (2013). Epic og NNIT vinder milliardstor ordre på sundhedsplatform. Version2. https://www.version2.dk/artikel/breaking-epic-og-nnit-vinder-milliardstor-ordre-paa-sundhedsplatform-54867. Accessed 16 April 2016.
- Gerson, Elihu M.; and Susan Leigh Star (1986). Analyzing due process in the workplace. ACM Transactions on Information Systems (TOIS), vol. 4, no. 3, pp. 257–270.Google Scholar
- Glaser, Barney G.; and Anselm L. Strauss (1967). The discovery of grounded theory: strategies for qualitative theory. New Brunswick: Aldine Transaction.Google Scholar
- Hanseth, Ole; Edoardo Jacucci; Miria Grisot; and Margunn Aanestad (2006). Reflexive standardization: Side effects and complexity in standard making. MIS Quarterly, vol. 30, no. 2, pp. 563–581Google Scholar
- Herlev Hospital (n.d.-a). Hvem er vi. Herlev Hospital. https://www.herlevhospital.dk/afdelinger-og-klinikker/onkologisk/om-afdelingen/Sider/Organisering---Hvem-er-vi.aspx. Accessed 20 April 2016.
- Herlev Hospital (n.d.-b). Nøgletal. Herlev Hospital. https://www.herlevhospital.dk/afdelinger-og-klinikker/onkologisk/om-afdelingen/Sider/Organisering---Nøgletal.aspx. Accessed 20 April 2016.
- Herning, Lars (2011). Statens ansvar for epj. Regioner. http://regioner.dk/aktuelt/temaer/fakta+om+regionernes+effektivitet+og+-oe-konomi/statens+ansvar+for+epj. Accessed 13 April 2016.
- Herning, Lars (2016). Fakta om sundhedsvæsenet - sundhedsvæsenet i tal. Regioner. http://regioner.dk/Aktuelt/Temaer/Fakta+om+regionernes+effektivitet+og+%C3%B8konomi/Kopi+af+Fakta+om+sundhedsv%C3%A6senet.aspx. Accessed 12 April 2016.
- Hertzum, Morten; and Jesper Simonsen (2010). Clinical overview and emergency-department whiteboards: A survey of expectations toward electronic whiteboards. In SHI’10. Proceedings of the 8th Scandinavian conference on health informatics, Copenhagen, Denmark, 23–24 August 2010. Trondheim: TAPIR Akademisk Forlag, pp. 14–18.Google Scholar
- Huh, Jina; and Mark S. Ackerman (2012). Collaborative help in chronic disease management: Supporting individualized problems. In CSCW’12. Proceedings of the 2012 ACM conference on Computer Supported Cooperative Work, Washington, Seattle, 11–15 February 2012. New York: ACM Press, pp. 853–862.Google Scholar
- Jensen, Tina Blegind; and Margunn Aanestad (2006). How healthcare professionals “make sense” of an electronic patient record adoption. Information systems management, vol. 24, no. 1, pp. 29–42.Google Scholar
- Kane, Bridget; and Saturnino Luz (2009). Achieving diagnosis by consensus. Computer Supported Cooperative Work (CSCW), vol. 18, no. 4, pp. 357–392.Google Scholar
- Langhoff, Tue; Mikkel Hvid Amstrup; Peter Mørck; and Pernille Bjørn (2016). Infrastructures for healthcare: From synergy to reverse synergy. Health Informatic Journal, vol 24, no. 1, pp. 43–54Google Scholar
- Luff, Paul; and Jon Hindmarsh (2000). Workplace studies: Recovering work practice and informing system design. Cambridge: Cambridge University Press.Google Scholar
- Møller, Naja Holten; and Pernille Bjørn (2011). Layers in sorting practices: Sorting out patients with potential cancer. Computer Supported Cooperative Work (CSCW), vol. 20, no. 3, pp. 123–153.Google Scholar
- Møller, Naja Holten; and Paul Dourish (2010). Coordination by avoidance: Bringing things together and keeping them apart across hospital departments. In GROUP’10. Proceedings of the 16th ACM international conference on supporting group work, Sanibel Island, Florida, 7–10 November, 2010. New York: ACM Press, pp. 65–74.Google Scholar
- Møller, Naja Holten; and Signe Vikkelsø (2012). The clinical work of secretaries: Exploring the intersection of administrative and clinical work in the diagnosing process. In J. Dugdale; C. Masclet; M.A. Grasso; J.-F. Boujut; and P. Hassanaly (eds): From research to practice in the design of cooperative systems: Results and open challenges. London: Springer, pp. 33–47.Google Scholar
- Møller, Naja Holten; Pernille Bjørn; Jonas Christoffer Villumsen; Tine Hansen Hancock; Toshimitsu Aritake; and Shigeyuki Tani (2017). Data tracking in search of workflows. In CSCW’17. Proceedings of the 2017 ACM Conference on Computer Supported Cooperative work and Social computing, Portland, Oregon, USA, 25 February – 1 March, 2017. New York: ACM. pp. 2153–2165.Google Scholar
- Mønsted, Troels; Madhu C. Reddy; and Jørgen P. Bansler (2011). The use of narratives in medical work: A field study of physician-patient consultations. In ECSCW’11. Proceedings of the 12th European Conference on Computer Supported Cooperative Work, Aarhus, Denmark, 24– 28 September 2011. London: Springer, pp. 81–100.Google Scholar
- Powdermaker, Hortense (1966). Stranger and friend: The way of an anthropologist. New York: WW Norton & Company.Google Scholar
- Randall, David; Richard Harper; and Mark Rouncefield (2007). Fieldwork for design: Theory and practice. London: Springer Science & Business Media.Google Scholar
- Reddy, Madhu C.; and Bernard J. Jansen (2008). A model for understanding collaborative information behavior in context: A study of two healthcare teams. Information Processing & Management, vol. 44, no. 1, pp. 256–273.Google Scholar
- Region Sjælland (2016). Møde i MED-Hovedudvalget, 1. februar 2016. Region Sjælland. http://www.regionsjaelland.dk/omregionen/job-og-karriere/med-system/Moedeplan-2016/20160201/Bilag%20til%20referat_Overblik%20over%20scope%20for%20Sundhedsplatformen.pdf. Accessed 16 April 2016.
- Reidl, Christine; Marianne Tolar; and Ina Wagner (2008). Impediments to change: The case of implementing an electronic patient record in three oncology clinics. In PDC’08. Proceedings of the Tenth Anniversary Conference on Participatory Design. Bloomington, IN, USA, 30 September - 4 October 2008. New York: ACM Press, pp. 21–30.Google Scholar
- Schmidt, Kjeld; and Liam Bannon (1992). Taking CSCW seriously. Computer Supported Cooperative Work (CSCW), vol. 1, nos. 1–2, pp. 7–40.Google Scholar
- Schmidt, Kjeld; Ina Wagner; and Marianne Tolar (2007). Permutations of cooperative work practices: A study of two oncology clinics. In T. Gross, et al. (eds.): GROUP’07. International Conference on Supporting Group Work, Sanibel Island, Florida, USA, 4–7 November 2007. New York: ACM press, pp. 1–10.Google Scholar
- Seidenfaden, Rikke. G. (2013). Læger: Dårlige it-systemer bringer patienter i fare. DR, 13 December 2013. https://www.dr.dk/nyheder/indland/laeger-daarlige-it-systemer-bringer-patienter-i-fare. Accessed 16 April 2016.
- Silsand, Line; and Gunnar Ellingsen (2016). Complex decision-making in clinical practice. In CSCW’16. Proceedings of the 19th ACM Conference on Computer-Supported Cooperative Work & Social Computing, San Francisco, CA, 27 February - 2 march, 2016. New York: ACM Press, pp. 993–1004.Google Scholar
- Strauss, Anselm (1985). Work and the division of labor. The Sociological Quarterly, vol. 26, no. 1, pp. 1–19.Google Scholar
- Strauss, Anselm L.; Shizuko Fagerhaugh; Barbara Suczek; and Carolyn Wiener (1985). Social organizations of medical work. Chicago: The University of Chicago Press.Google Scholar
- Sundhedsstyrelsen (2006). Bekendtgørelse om lægers, tandlægers, kiropraktorers, jordemødres, kliniske diætisters, kliniske tandteknikeres, tandplejeres, optikeres og kontaktlinseoptikeres patientjournaler (journalføring, opbevaring, videregivelse og overdragelse m.V.). Sundhedsstyrelsen. https://www.retsinformation.dk/Forms/R0710.aspx?id=11055. Accessed 4 December 2016.
- Svensson, Marcus Sanchez; Christian Heath; and Paul Luff (2007). Instrumental action: The timely exchange of implements during surgical operations. In ECSCW’07. Proceedings of the 10th European Conference on Computer Cooperative Work, Limerick, Ireland, 24 September - 28 September 2007. Dordrecht: Kluwer Academic Publishers, pp. 41–60.Google Scholar
- Wax, Murray L. (1971). Indian Americans: Unity and Diversity. Englewood Cliffs, NJ: Prentice-Hall.Google Scholar
- Werner, Oswald; and G. Mark Schoepfle (1987). Systematic fieldwork: Foundations of ethnography and interviewing. Newbury Park, CA: Sage.Google Scholar
- Winthereik, Brit Ross; and Signe Vikkelsø (2005). ICT and integrated care: Some dilemmas of standardising inter-organisational communication. Computer Supported Cooperative Work (CSCW), vol. 14, no. 1, pp. 43–67.Google Scholar
- Wulf, Volker; Kjeld Schmidt; and David Randall (2015). In V. Wulf; K. Schmidt; and D. Randall (eds): Designing socially embedded technologies in the real-world. London: Springer.Google Scholar
- Zhou, Xiaomu; Mark Ackerman; and Kai Zheng (2010). Doctors and psychosocial information: Records and reuse in inpatient care. In CHI’10. Proceedings of the 28th international conference on Human factors in computing systems, Atlanta, Georgia, USA, 10–15 April 2010. New York: ACM Press, pp. 1767–1776.Google Scholar
- Zhou, Xiaomu; Mark Ackerman; and Kai Zheng (2011). CPOE workarounds, boundary objects, and assemblages. In CHI’11. Proceedings of the 2011 annual conference on Human factors in computing systems, Vancouver, BC, 7–12 May 2011. New York: ACM Press, pp. 3353–3362.Google Scholar
- Zhou, Xiaomu; Kai Zheng; Mark Ackerman; and David Hanauer (2012). Cooperative documentation: The patient problem list as a nexus in electronic health records. In CSCW’12. Proceedings of the 2012 ACM Conference on Computer Supported Cooperative Work, Washington, Seattle, 11–15 February 2012. New York: ACM Press, pp. 911–920.Google Scholar