The mantra of modeling and the forgotten powers of paper: a sociotechnical view on the development of process-oriented ICT in health care
Introduction
In the medical informatics literature as well as within health care organizations, the electronic patient record (EPR) has so far mainly been conceptualized and designed as a data-repository. In such a view, its advantages over the paper record lies first and foremost in its enhanced storage and retrieval functionality, including the ability to provide smart search functions, instantaneous and multi-location access, and the virtual integration of data elements stored in geographically disperse databases. In recent years, however, changes in the health care context and in ICT developments have led to a gradual shift in this conceptualization [1]. The move towards integrated care, in which care processes are redesigned around patients’ needs, the emergence of evidence-based medicine, and the development of guidelines and carepaths that more and more incorporate efficiency considerations all have led to an increased interest in process-oriented ICT [2]. Likewise, the recent popularity of ERP and workflow systems as models for health care systems development reflects the increased tendency to see the ‘core business’ of future EPRs to structure and support the ‘core business process’ of health care: the primary care process [3]. (As yet, this is more visible in the changing trends in commercial and in-house EPR developments than in the medical informatics literature). Although the importance of this new orientation is widely shared, it cannot be said that it has already led to unequivocally successful systems [4], [5].
Within the field of Informatics, a powerful, received tradition says that in order to informate something, we should first model it. We should abstract from the messiness and the concrete forms of the work practices for which the ICT application has to be designed, and capture its essence. This serves at least two interrelated purposes: it facilitates the interaction with the users in the process of requirements elicitation, and it is a necessary step in the generation of system requirements [6], [7]. In the case of process-oriented ICT, the essential core that the models aim to capture generally lies in the information flows between actors and/or the distribution of the actors’ responsibilities. Once these are mapped in flow diagrams, activity models, and/or data models, the ‘environment’ within which the information system is to operate is charted, and the work of designing (or ‘buying’ or ‘tailoring’) the system itself may begin1.
In this paper, we would like to ask the question whether a detailed modeling of (‘business’) processes is indeed the primary step we need to complete before we can hope to design a process-oriented EPR, or to acquire or tailor such a system. Building upon a sociotechnical understanding of ICT development, we will argue for a thorough reinterpretation and repositioning of ‘models’ in such development processes [8], [9]. We will do so through a reverse engineering of (some elements of) the paper predecessor of the EPR: the paper-based medical record. Scorned by many EPR enthusiasts, an understanding of its powerful (albeit indeed rusty and heavily burdened) role in making primary care processes possible can nevertheless help us to understand what models underlie its functioning, and how these models came about. Doing so, we will question another often repeated starting point within medical informatics: the claim that ICT will revolutionize health care, and that it will bring light into the darkness of current ‘paper-based’ practices [10], [11]. Since the overall view is that the EPR will ‘finally’ get rid of the messy and inadequate paper records that imprison data, that get lost and that are unreadable, serious analyses of the powers of paper records are hard to find [12], [13], [14].
Section snippets
What does the record do
As one of us has argued in detail elsewhere, record systems (whether paper-based or electronic) fulfill two functions that are crucial for current medical practice [15], [16]. First of all, record systems accumulate the data gathered during the course of a patient trajectory, resulting in a powerful ‘external memory’ [17]. This external memory is not a mere passive repository: by providing a specific structure and context to the data accumulated, the record's form enhances the information
What model, what modeling
Within the fields of study designated Software Engineering and Information Systems Science, much discussion has focused on what constitutes the ‘best’ modeling approaches, to be used in the analysis and design of software systems. Data Flow Diagrams (for modeling the functionality of a system), Entity Relationship Diagrams (for modeling the information structures of a system) and Class Diagrams (for modeling the objects a system deals with) are but a few of the manifold, often competing
Discussion
What does the above argument mean for process-oriented EPR design and implementation? One could still argue that there is a non sequitur here: from the insight that models sometimes do not seem to play a great role in the design of paper or electronic records, we can hardly conclude that adequate modeling should not play a role. We have spoken about order forms and progress notes, and that is surely something else than an integrated information system underlying the care process? These
Acknowledgements
The authors wish to thank Berti Zwetsloot, Eric Monteiro, the participants of the Actor Network Theory seminar (Tromso, Norway, June 2000), the IMIA-HIS conference (Heidelberg, April 2002) and the Rotterdam University research group Research on IT in Health Care Practice and Management (RITHM) for their comments and discussion.
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