See

discussions, stats, and author profiles for this publication at:

https://www.researchgate.net/publication/263491771

Patient care information systems and health

care work: a sociotechnical approach
Article in International Journal of Medical Informatics August 1999
DOI: 10.1016/S1386-5056(99)00011-8

CITATIONS

READS

359

390

5 authors, including:
Rob William Sanson-Fisher

Julie Byles

University of Newcastle

University of Newcastle

548 PUBLICATIONS 14,142 CITATIONS

345 PUBLICATIONS 4,841 CITATIONS

SEE PROFILE

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Study on global AGEing and adult health (SAGE) Waves 0-3 View project
Who decides and at what cost? Patient, surrogate and oncologist views of end of life
care View project

All in-text references underlined in blue are linked to publications on ResearchGate,

letting you access and read them immediately.

Available from: Rob William Sanson-Fisher

Retrieved on: 06 October 2016

International Journal of Medical Informatics 55 (1999) 87 101

www.elsevier.com/locate/ijmedinf

Patient care information systems and health care work: a

sociotechnical approach
Marc Berg *
Institute of Health Policy and Management, Erasmus Uni6ersity Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands
Received 9 November 1998; received in revised form 20 January 1999; accepted 25 January 1999

Abstract
Those who face the difficulties of developing useful patient care information systems (PCISs) often stress the
importance of organizational issues. Building upon recent sociological insights in the construction and use of
information technologies for (health care) work, this paper underscores the importance of these insights for the
development and evaluation of these systems. A sociotechnical approach to PCISs in health care is outlined, and two
implications of this empirically grounded approach for the practices of developing and evaluating IT applications in
health care practices are discussed. First, getting such technologies to work in concrete health care practices appears
to be a politically textured process of organizational change, in which users have to be put at center-stage. This
requires an iterative approach, in which the distinctions between analysis, design, implementation and evaluation
blur. Second, a sociotechnical approach sheds new light on the potential roles of IT applications in health care
practices. It is critical of approaches that denounce the messy and ad hoc nature of health care work, and that
attempt to structure this work through the formal, standardized and rational nature of IT systems. Optimal
utilization of IT applications, it is argued, is dependent on the meticulous interrelation of the systems functioning
with the skilled and pragmatically oriented work of health care professionals. 1999 Elsevier Science Ireland Ltd. All
rights reserved.
Keywords: Patient care information systems; Health care work; Sociotechnical approach; Electronic patient record; Medical
decision-making; System development; System implementation; Evaluation

1. Introduction
Developing a comprehensive medical information system, Morris Collen concluded
in his historical survey of medical informatics
in 1995, appears a more complex task than
* Tel.: +31-10-4088555; fax: + 31-10-4522511.
E-mail address: m.berg@bmg.eur.nl (M. Berg)

putting a man on the moon had been ([1] p.

464). Although we hear much more about
successes, certain benefits and the need to
implement patient care information systems
(PCIS)1 in health care, the fact is that most
applications to date have failed. Large numbers of systems never make it off the drawing
tableand if they do, they do not appear to
be transportable out of the specific context in

1386-5056/99/$ - see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved.
PII: S 1 3 8 6 - 5 0 5 6 ( 9 9 ) 0 0 0 1 1 - 8

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

88

which they were developed [17]. Although

precise data are lacking, a general handbook
on management information systems estimated that from the large systems that end
up being used as much as 75% should be
considered to be operating failures. They
might be in operation, but they are too cumbersome, too expensive or too functionally
deficient to be even remotely called a success
[8]. And in a recent overview of clinical data
systems, Jeremy Wyatt mentions a staggering
figure of 98% of software built for US government use that was unusable as delivered
[9].
Those who are facing the enormous
difficulties of developing useful PCISs often
stress the importance of organizational issues [10,11]. Building upon recent sociological insights in the construction and use of
information technologies for (health care)
work, this paper underscores the importance
of these insights for the development and
evaluation of these systems.2 A sociotechnical approach to PCISs in health care will be
outlined. After introducing the central starting points of this empirically grounded approach (Section 2), two implications of this
approach for the practices of developing and
evaluating IT applications in health care organizations are outlined (Section 3). First,
getting such technologies to work in established practices appears to be a politically
textured process of organizational change, in
which users have to be put center stage. This
requires an iterative approach, in which the

distinctions between analysis, design, implementation and evaluation blur. Second,

a sociotechnical approach sheds new light on
the potential roles of IT applications in
health care practices. It is critical of approaches that denounce the messy and ad
hoc nature of health care work, and that
attempt to structure this work through the
formal, standardized and rational nature of
IT systems. Optimal utilization of IT applications, it is argued, is dependent on the meticulous interrelation of the systems functioning
with the skilled and pragmatically oriented
work of health care professionals. These implications will and cannot take the form of
formulas for successful system development.
Rather, the sociotechnical approach is inherently critical of overly methodical guidelines
promising success. The implications this paper will sketch are intended to reorient the
way we tend to investigate and manage these
processes. It attempts to offer new perspectives rather than a list of critical success
factors; it engages in constructive critique
rather than in delivering yet another set of
guidelines for design and implementation.
This does not mean that the sociotechnical
approach is philosophical or merely academically, research oriented. To the contrary:
we claim that for a successful management
and realization of concrete development processes, such an approach will ultimately
prove to be more useful.

2. The sociotechnical approach: starting

points
1

PCIS is a broader term than e.g. electronic patient record,

but no sharp terminological distinctions are intended here. All
these systems denote IT applications whose core users are
doctors, nurses and other health care professionals.
2
Development remains an important topic even in the current era of off-the-shelf PCIS products. Such products are
never turnkey systems: they require extensive tailoring and
redesign to match local circumstances and needs.

Some 20 years ago, the term sociotechnical system design was used to indicate design
approaches that stressed the importance of
job satisfaction, workers needs, and skill enhancement [1214]. These approaches put
people and their working relationships center

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

stage and formed a long-needed antidote to

the technology-centered and topdown approaches that dominated system development. In current times, the term has drifted
from this direct focus on workers emancipation. Embracing a user-oriented perspective,
sociotechnical approaches emphasize that
thorough insight into the work practices in
which IT applications will be used should be
the starting point for design and implementation [8,15,16]. This is especially important in
organizations that pivot around the work of
professionals [17]. Since any potential benefit
that IT might bring to health care has to be
realized at the level of the concrete interactions with these tools, it is here that any
development or evaluation process should
start. Building upon previous research and
literature reviews [1820], the specificity of
the sociotechnical approach to IT applications in health care is characterized in the
following three points.

2.1. Health care practices are seen as

heterogeneous networks
In the sociotechnical approach, work practices are conceptualized as networks of people, tools, organizational routines, documents
and so forth [21,22]. An emergency ward,
outpatient clinic or inpatient department is
seen as an interrelated assembly of humans
and things whose functioning is primarily
geared to the delivery of patient care. The
work of doctors and nurses articulates with
the functioning of monitors, of order forms
and laboratory routines to keep an Intensive
Care patient stabilized, to treat an acute
traffic accident victim or to provide long term
care to a chronic diabetes patient. In performing these primary goals, secondary aims
have to be served as well. Teaching interns,
doing clinical research and meeting budget
objectives are all to be achieved by many of

89

the same people and tools, and often as part

of the care process itself [23,24].
The tools, documents and machines are
constitutive elements of these work practices. If one would pull away even a simple
object such as the order form from an average Intensive Care Unit, that work practice
could not continue functioning in its current
complex and smooth manner [25]. The roles
and tasks of doctors and nurses are tightly
interwoven with each other and with the operations of these other elements. Just like the
tasks and position of doctors have changed,
historically, with the coming of the stethoscope and the emergence of laboratory tests,
the current roles and tasks of health care
professionals are intertwined with the functioning of record systems and the architectures of their work environments [2629].
Simple forms and room designs structure the
way their work is organized, the way their
responsibilities are distributed, and the nature
of the doctornurse relationship.
The elements that constitute these networks should then not be seen as discrete,
well-circumscribed entities with pre-fixed
characteristics. Rather, these entities acquire
specific characteristics, roles and tasks only
as part of a network [30]. A physician is
only a physician in the modern western
sense because of the network of which s/he is
a part, and which makes his/her work and
responsibilities a reality. Without nurses,
record systems or the stethoscope, the Medical Doctor as we know it would and could
not exist. Because of this tight interrelation
between elements in a network, the introduction of a new element (as when a PCIS is
implemented), or the disappearance of an
element (as when a hospital stops training
junior residents) often reverberates throughout the health care practice. The introduction
of the patient centered record in the US at
the beginning of the twentieth century, for

90

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

example, necessitated changes in hospital architecture and the emergence of the new profession of medical record managers. It was
also tied to the changing position of the
physician from an enterpreneuring gentleman
to a methodical member of a team: it
changed record keeping from a private affair
to a matter of cooperation with (and potential criticism of!) colleagues [31,32]. Similarly,
shifting from paper-based recording practices
to electronic record keeping often makes
work practices (and especially the record-creating activities themselves) more visible, inspectable and manageable. This can have
large consequences for the interprofessional
relations within the hospital [33,34].
Yet although the effects and functions of
IT applications in work practices can be
highly consequential, the precise shape they
take is not pre-determined. They evolve
within the specific, socio-political contexts of
these practices. As Kling and Scacchi phrased
it, the introduction of technologies in work
practices is embedded in a larger system of
activity, (has) consequences which depend on
peoples actual behavior, and (takes) place in
a social world in which the history of related
changes may influence the new change [21].
The sociotechnical approach, then, is hesitant to speak of organizational issues or
human factors in its analysis of IT applications in work practices. Although it is crucial
to stress the importance of the social in a
predominantly technology-oriented environment [17,35], there is no distinct set of issues
that has to be dealt with in developing IT
applications. Nor are there pre-fixed human
factors that inevitably come to play. In the
practices that are at stake, technologies and
humans are closely interwoven, with more or
less frictions, aligned towards the performance of common tasks. Which issues and
factors are at stake depends on the network
in question. When the network changes, the

issues and factors are transformed as well.

An IT application in a health care practice
should be seen as forming a seamless web
rather than a Technology in an Organization
[22]. In addressing, managing and studying
this network, one should not attempt to pry
it apart in a social and a technical system.
Technology and organization do not occupy separate domains or operate according
to separate logics; nor does their relationship
develop in some unilinear way (the former
causing change in the latter or vice versa).
The interrelated elements constitute an assembly that should be dealt with as a whole
rather than as a Technical subpart for the IT
engineers and a Social subpart for the social
scientists [2,21,36,37].

2.2. The nature of health care work

The core activity of health care work practices is managing patients trajectories: doing investigations, monitoring, intervening
and re-intervening in order to at least temporarily cure or palliate patients problems
[2,24]. In all but a few instances, managing
patients trajectories is a collective, cooperative enterprise. Even the individually operating general practitioner communicates with
his/her colleagues. A fundamental characteristic of this work is its pragmatic, fluid character. Like other complex work activities, it is
characterized by the constant emergence of
contingencies that require ad hoc and pragmatic responses. Although much work follows routinized paths, the complexity of
health care organizations and the never fully
predictable nature of patients reactions to
interventions result in an ongoing stream of
sudden events. These have to be dealt with on
the spot, by whomever happens to be present,
and with whatever resources happen to be at
hand [2,24]. In addition, and partly because
of this phenomenon, health care work is typ-

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

ified by ongoing negotiations about the nature of the tasks and the relationships between those who execute the tasks [38,39].
The sociologist Hughes [40], for example, has
documented how experienced nurses often
help inexperienced residents by suggesting the
way towards the diagnosis, or by hinting
towards the necessary treatment. These are
subtle interactions: the doctors are formally
responsible for these actions, and their social
status disallows them to be too ignorant too
openly. Likewise, physicians in Dutch hospitals often informally negotiate with nurses
that the latter order routine drugs, or give
intravenous injections, while they are officially not allowed to do that.
Health care work is further characterized
by its distributed decision making, by multiple viewpoints and by its inconsistent and
evolving knowledge bases [38,41,42]. During
the patients trajectory, many authors and
events exert their influence on the course of
events. There is rarely one individual who
truly oversees the whole chain of events and
decisions. More often, the shape of the trajectory is the contingent result of small decisions
and steps taken by individuals from diverse
backgrounds and with varying viewpoints
about what is the case and what should be
done.
All these features of health care work point
towards the importance of the last characteristic to be discussed here: the articulation
work that keeps such complex practices going. The sociologists Gerson and Star, speaking about complex work activities in general,
describe this work as such:
all the tasks involved in assembling,
scheduling, monitoring, and coordinating
all of the steps necessary to complete a
production task. This means carrying
through a course of action despite local
contingencies, unanticipated glitches, incommensurable opinions and beliefs, or in-

91

adequate
knowledge
of
local
circumstances. [Since] no formal description of a system (or plan for its work)
canbe completeevery realworld system
thus requires articulation to deal with the
unanticipated contingencies that arise. Articulation resolves these inconsistencies by
packaging a compromise that gets the job
done, that is, that closes the system locally
and temporarily so that work can go on.
[38] (cf. [24,43])
Although it can be seen as the glue that
holds complex work practices together, articulation work tends to be paradoxically invisible to outsiders [44,45]. It does not result in
clear-cut products, it is not highly valued,
and it is generally not even recognized in
work descriptions or by managers. It will
come as no surprise that in health care, primarily nurses and assistants perform this
work.
The sociotechnical view of work, then, is
at odds with traditional views of work prevalent within IT development in at least two
ways. First of all, it emphasizes the need to
address cooperative work processes rather
than discrete tasks for individuals. Most discussions and concrete attempts in health care
informatics focus on the individual doctor or
nurse, and model his/her decision making
process as if that could be depicted as a
sequence of logically distinguishable steps
[18,46,47]. Most concrete designs seem to
encompass a rather restricted view of collaboration: a design that assumes individuals
using the computer alone, for individual
tasks, which have to be completed before
another user might continue [48]. They might
focus on the importance of order entry, but
they will rarely focus on the way order entry,
for example, is intermingled with the larger
process of assessing/reassessing patient
statusand developing the care strategy
[49]. And they may pay much attention to the

92

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

development of a nicely looking clinical

workstation, but just how this workstations
functions will be used in meetings or by
residents that are constantly interrupted
rarely receives sufficient attention [49,50].
Second, the sociotechnical view of work
fundamentally undermines the idea that the
essence of work practices can be caught in
pre-fixed workflows, clinical pathways, formal task descriptions or other formal models
[38,51]. Such descriptions are useful (see also
further), but it should not be forgotten that
they are only highly incomplete, summarized
and rigid depictions of the modeled work
practices. There is no a priori or algorithmic
connection between any particular formal description of an action and its specific occurrence [52]. Any concrete work activity only
unfolds in the doing, in constant interaction
with the contingent circumstances that make
up the situation in which it is located [51]. A
gynecologist confronted with a newly pregnant patient, for example, can leave the standard path of actions because of a myriad of
reasons. The patient might be so insecure
that she foregoes some routine tests in order
to comfort her; she might skip a standard
blood test because she knows that a colleague
whom is also treating this patient will perform this test anyway; she might not ask
certain standard questions because of a particularly painful history of a stillborn child.
The list is endless.
This issue is important to stress because
rationalist, technology-centered discourses
are still all-pervasive within our field. Such
discourses emphasize the messiness of current
work practices, the need to weed out variability in practice, and the opportunities of
PCISs, protocols and other such tools to
finally bring structure and rationality to
the work of doctors and nurses. This issue is
complex and multifaceted, and cannot be satisfactorily dealt with here [2,5357]. Yet

given the dangers of importing too much

pre-fixed structure in health care work, and
given the resources that are currently spent
on creating more fine-grained, more directive
protocols for more aspects of this work, it is
imperative to continue querying what good
all these efforts will bring. In the light of
increasing evidence that too much structure
obstructs worktasks and puts additional burdens on health care personnel [55,58,59],
careplans are being produced and promoted
as if more is better. In the light of abundant
sociological evidence as to information-richness of free text and the practical efficacy of
brief, handwritten notes [16,28,60], such practices are being scolded as non-scientific, unprofessional and outdated [61,62]. This is
not to say that there are no problems with
current practices, or that formal tools hold
no promise-far from it (see Section 3.2). Yet
as I will argue in Section 3, we will only be
able to fully realize these benefits when we
adapt a more empirically informed view of
the work of doctors and nurses, and a more
modest view of what these newest solutions
can bring.

2.3. Empirical orientation, with emphasis on

qualitati6e methods
It follows from the above characteristics
that the sociotechnical approach emphasizes
the importance of deep empirical insight into
the work practices in which an IT application
will be used. It is imperative to acquire insight into the ongoing workflow and negotiated orders [63] of these practices before we
can even begin to consider developing (or
buying) a system. Similarly, we need to know
what the specific network that constitutes a
health care practice looks like before we can
think of realizable implementation strategies
or meaningful evaluation criteria. The sociotechnical approach is thus skeptical of ratio-

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

nalist models in which the existence of

common goals, predetermined tasks and a
limited number of formal procedures is
assumed and therefore found wherever one
looks [15]. Models may aim at universality,
at being generalizable over individual
health care practices, but this should be a
bottom up exercise, generalizing from
empirical cases. It should not be a top
down approach of creating universal domain
information models in which all concrete
instances of actual health care practices
should fit. Nor should we loose ourselves
in trying to map the basic structure of
medical knowledge; to create a foundation
upon which then all individual instances of
medical action could be easily mapped. Such
exercises are fruitless at bestand all too
often result in stifling and rigid frameworks
[64].
The required empirical knowledge can
be made available in two ways, which
should both be used. First, end users should
be involved (see Section 3.1), and second,
qualitative research methods need to be employed. The use of interviews is generally not
adequate for the level of insight required:
ideally, participant observation forms the
starting point of any sociotechnical development or evaluation process. It is difficult to
acquire a feeling for the intricate interrelations between health care professionals and
(paper or electronic) documentation techniques without having seen the work patterns
itself. Likewise, to get a grasp on the flows
and forms of information a health care
professional handles in a specific patient
care scenario [49], we cannot limit ourselves to interviews or surveys. Without
detailed, on-site insight, an adequate grasp
of what IT functionalities should be available in what form is practically impossible
[65].

93

Qualitative research methods are similarly

essential to any thorough evaluation of an IT
implementation. Simple quantitative measures (such as user satisfaction, usage indicators, time studies) may be useful, but
they need to be grounded in qualitative data
so that their meaning can be understood.3
Why is satisfaction high for function A
but low for B? What is the reason for fluctuating use times? Such questions can only
be thoroughly answered through detailed,
qualitative research [35,67]. The broad,
socio-cultural and political implications that
IT applications can have in health care
practices, moreover, is an additional argument for using qualitative evaluation methods. Since impacts can be wide-ranging and
unpredictable, pre-set measurement instruments often miss the most relevant changes
that take place, or loose track of the way
variables affect one another [68,69]. Finally,
qualitative research methods are the most
suitable way to study changes in tasks, roles
and responsibilities. We may do a time-study
of documentation practices, but if the nature
of a nurses tasks changes, the time-study
looses most of its relevance. Typically, implementing PCISs generates such changes, and a
central focus of the systems evaluation
should be a thorough investigation of these
[2].
3
More complex quantitative measures such as overall economic return, or overall impact on health care outcomes
have proven to be methodological nightmares, and have only
rarely yielded unequivocal results. Reasons are, amongst others, the broad and diffuse impact of the implementation of IT
systems in organizations, and the state of general structural
change in which most health care organizations find themselves. In a network in which professionals tasks are changing,
new views on quality are emerging and cultural notions of
what proper documentation means are transforming, it is
virtually impossible to distill and causally link the influence of
one fixed variable the IT application on another. See Ref.
[66] for a fair juxtaposition of quantitative and qualitative
evaluation methods.

94

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

3. Implications of a sociotechnical approach

Adoption of a sociotechnical approach has
implications for a range of issues within the
development and evaluation of IT applications in work practices. It changes the way
we think about the very concept of medical
information [55,70,71], it transforms our view
of the way IT is embedded within organizations [72,73] and it problematizes any suggestions of a formula for successful system
development [3,11,37]. It is impossible to do
justice to all these implications in the scope of
this article. Here, two implications will be
developed in some detail: the merging of the
activities of development and evaluation in
an iterative, cyclical process, and the positioning of the formal IT application within
the fluid and pragmatic nature of health care
work.

3.1. An iterati6e process in which system

de6elopment and e6aluation acti6ities merge
Developing an IT application in health
care practices can never be a process of simply installing and using a new technology
[15]. The deep intertwinement between technological and human elements of the networks at stake implies that any design and
implementation attempt is necessarily related
to widespread transformations in these networks. Whether the system developers are
aware of this phenomenon or not, these processes are inevitably political. They affect the
distribution of responsibilities and the hierarchies between professionals and between
professionals and management [45,70,74].
Different groups might see the technology as
a way to achieve their potentially conflicting
goals [59,75], and the technology, consequently, may embed values and assumptions
that are not shared by everyone [64,76,77].

The sociotechnical approach argues that

development projects should be seen and
managed as being the politically textured,
organizational change processes that they inevitably are. Closing ones eyes for these realities can only lead to failure through
resistance and even sabotage by users who
are not taken seriously [3,17]. System development projects, then, need to be user-centered. This implies more than a GUI, good
communication or adequate training programs. To obtain this support, to generate
commitment and to ensure user-driven design
and implementation, users need to be involved early, thoroughly and systematically
[49,78,79]. This is easy to state as a slogan,
yet hard to achieve in practice: balancing the
do-ability of a project and the granting of
user-input is a very complex task. Preventing
conflicts between users to thwart the project,
preventing the project to become a mere
users wish list, and keeping an overall, coherent information strategy in place are just a
few of the challenges that await any such
project [8,80,81].
The work of PCIS analysis, design and
implementation, then, can itself be described
in the same terms as health care work has
been described above: it is a collective, cooperative enterprise, which is characterized by
the constant stream of contingencies. Ongoing negotiations about the scope and aims of
the project, the role of the project management and the responsibilities of the project
team members are the rule rather than the
exception. Here as well, decision making is
distributed, and work is guided by multiple
viewpoints and inconsistent and evolving
knowledge bases [38,8284].
Because of the political nature of these
processes and the importance of the user, and
because of the fundamentally unpredictable
nature of these change processes, an iterative
approach to development is required. Start-

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

ing with central organizational needs,

systems have to be developed step by step,
so that the changes in technology and
work practices can evolve together [11].
Contrary to topdown design and implementation attempts, iterative approaches acknowledge the impossibility to foresee
all consequences, and they can creatively
draw upon encountered problems or unanticipated use in the further development of the
system. For traditional, topdown approaches, such inevitable effects can only obstruct the implementation and proper
functioning of the technology. Iterative approaches, on the other hand, allow for creative, organizational and technological
co-development.
Successful development processes, then, do
not emerge from attempts to install hegemonic systems whose rationality and power
subsumes all other elements. Rather, powerful technical systems compriseartful integrations between working practices and new
and old devices [37]. Such integrations should
be allowed to gradually emerge rather than
brought about through enforced revolution
[39]. This is even true for such seemingly
technical and elementary issues such as standards (compare, for example, the success of
the pragmatically structured, flexible and bottom up developed Internet protocols with
the small impact of the formalistic, layered,
inflexible and topdown structure of the
ISO/OSI alternatives) [72,85,86]. Growing
such systems implies entering into an extended set of working relations, of contests
and alliances [11,37]. In such a process, the
distinctions between system analysis, design, implementation and evaluation blur.
Strictly speaking, within a sociotechnical perspective it hardly makes sense to consider
them as separate activities [81,83]. Users are
involved from early on in the analysis, and

95

feedback from early implementations immediately informs further analysis and design.
With design continuing during implementation, and evaluation informing analysis and
design, analysis, design, implementation
and evaluation become co-occurring activities. These processes should be organized and
managed as such, and the different expertise
required should be integrated in any PCIS
project team.
A modest and imperfect example of such
a process has been described in this journal
before [16]. In the adaption of a commercial PCIS package for Intensive Care
departments to the specific needs of a IC
in a Dutch Research Hospital, IC nurses
and an anaesthesiologist from the department in which the system would be placed
were trained so that they could take full
responsibility for the tailoring process. In
this way, the distinction between users
and designers truly blurred, and ongoing
evaluations from real-time use were constantly fed back into the ongoing tailoring
process. The pressure and presence of
real-time demands, and the ongoing cooccurrence of design and evaluation continually ensured an artful integration of the system with the surrounding working routines.
Part of the success of this implementation,
however, was due to the small scale of the
sociotechnical change: record keeping procedures in the wards around the Intensive Care
remained unchanged. This obviously generated problems when patients were transferred
between wards. A larger sociotechnical
change might involve introducing similar
packages on these surrounding wardsyet
one problem that is encountered is that the
vendor of the IC PCIS package does not
provide general ward packages that would
suit the needs of a surgical or internal
medicine ward. (See for other examples, e.g.
Refs. [11,49]).

96

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

3.2. The PCIS as a tool in health care work

What is it that IT applications can do in
health care work? If we ban all advertisement
rhetoric and tendencies towards hegemonic
systems, we can discern two modest yet potentially powerful roles that PCISs can play
in health care work. Information technologies
enable professionals and organizations to accumulate data-elements into meaningful
wholes and to coordinate complex processes
of interaction and collaboration [87]. They
collect and aggregate data entered (into a
graph, list or possibly a reminder) and so
afford new levels of overview, and they link
activities of doctors and nurses across different times and spaces [88]. ITs potential to
take over these tasks is often greatly exaggerated. The active and efficient way in which
paper-based documentation technologies can
perform these roles is generally underestimated. Also, even when IT applications are
omnipresent in a workpractice they only
touch upon a part of the information handling and coordination that takes place
[18,87,89 91]. Yet PCISs obviously may perform accumulation and coordination functions more powerfully than traditional paper
based documents could. IT applications can
bring their computational power to bear to
create summaries, graphs or reminders [92
94], and fast electronic links can ensure coordination between events taking place in
geographically separate locations.
In general terms, then, information technologies afford networks to span over larger
numbers of entities. Larger numbers of data
can be assembled and dealt with by the same
professional, and more events in more distinct spaces and times can be brought together. This is the generative power of formal
tools: in the interlocking of such tools with
human work activities, new competencies for
health care professionals can be produced,

and higher levels of complexity in work tasks

can be achieved [20,57,87,91].
Several important observations follow
from seeing the tool as being interrelated
with other elements in the performance of
overall tasks. First of all, conceptualizing IT
applications as tools that form artful integrations with health care professionals and
other instruments focuses the attention away
from overly ambitious attempts to replace
the paper record, or to clean up medical
decision making. IT applications should be
developed so that their practical strengths
articulate optimally with the practical
strengths of health care professionals and, for
example, paper documents. This is a different
and more fruitful focus than attempts to
mirror doctors reasoning or to create a
paperless environment. Too often, designers
and managers mistakenly invest in smart
machine solutions because they overestimate
the self-sufficient powers of IT, and overlook
the skills that are already present in the work
practice. In such circumstances, a more
dumb solution, with a retraining of already
rather skilled personnel, would often be
cheaper and easier [95]. Similarly, because
designers and managers underestimate the
richness and ecological flexibility of paper
documents, useful resources and work routines are often destroyed and replaced with
much less flexible and more expensive solutions [48,95]. IT is better in repetitively
amassing and monitoring data than in making patient-specific judgments about them. It
is excellent in fast transmission and search
capabilities, but it lacks papers ability to be
shuffled around, leafed through, and provide
overview [48,89].
Finally, this analysis returns us to the
seeming conflict between the fluid, cooperative and necessarily messy nature of work
practice and the formal, standardized and
comparatively rigid functioning of IT. As

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

stated in Section 2, one of the largest mistakes that PCIS developers can make is attempting to replace the messy and ad hoc
nature of that work with the straightforwardness and rationality that the system seems to
promise. One of the most dangerous yet
widespread tendencies in the field of PCIS
development is taking the tools characteristics as ideals to which the work practice
should be molded. Rather, the optimal utilization of PCISs is dependent on the meticulous interrelation of the systems functioning
with the skilled and pragmatically oriented
work of health care professionals. First of all,
formal tools such as PCISs only survive in
health care practices because of the skilful
work of health care professionals. Tools that
embed pre-fixed sequences of steps in a care
process, or that only allow certain modes of
data input would perish amidst the contingencies and pragmatic needs that characterize
health care workwere it not for the balancing acts of health care professionals. These
professionals translate vague answers into
one of the preset codes on the form, or
modify a proposed care path so that a patient
can spend a weekend with his family, or do
several diagnostic tests in one batch. They
often establish workarounds to trick the
system so that it keeps on functioning without interfering with the acute, practical situation at hand [96,97]. (One workaround, for
example, is a nurse resetting the computers
clock so that orders can be entered post hoc
[87]). Formal tools such as PCISs, then, paradoxically seem to be kept alive by the very
same ad hoc and pragmatic activities that
they are often set out to erase. The irrational practices that the rationalizing tools
would smooth out actually are a sine qua
non for the tools smooth functioning
[2,96,98].
The skilful activities of health care professionals keep PCISs functioning and in

97

properly developed PCISs, the functioning of

these systems in their turn enhances the professionals responsibilities and competencies.
In well-designed systems, coding data and
working upon preset carepaths can generate
the possibility to do research, or alleviate the
burden of routine tasks [57,87]. In the IC
PCIS system described above, for example,
the system helped calculate the fluid balance
in a way which saved the nurses time and
gave them continuous access to the current
value of the fluid balance (whereas with the
paper system, the actual value would only be
calculated once every 24 h) [16]. Similarly,
several general practitioner PCIS systems
have well-developed, simple coding schemes
built in, so that the GPs can code their
diagnoses and actions with a few simple
mouseclicks [94]. In a well-guided development process, the application and the health
care professionals enable each other to affect
each other in their mutual interactions.
When tools are carefully inserted in the pragmatically structured activities of nurses and
doctors rather than seen as a solution to this
messy nature, their skilful interaction with
the tool will afford it to exert, in its turn, its
generative power.

4. Conclusion
The sociotechnical approach cannot be
seen as a simple solution to the many problems haunting PCIS development. It does not
automatically yield a list of superior system
requirements, nor does it answer the everyday problems of a manager in charge of an
implementation project. The approach raises
several issues that have no easy answers: how
to find the optimal form for the iterative
development process in an environment full
of economic pressures for fast results, divergent interests, and inflexible IT applications?

98

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

Where to find the optimal interrelation between the formal tool and the health care
professionals skills? Yet its view on health
care practices and health care work, and its
emphasis on empirical, qualitative insight
into these practices and processes will not
only improve our analytical understanding of
these phenomena. Approaching health care
practices as heterogeneous networks, and
recognizing the pragmatic and skilled character of doctors and nurses work is a crucial
first step towards PCISs that will articulate
more powerfully and more artfully with their
surrounding networks. Seeing the PCIS as
the outcome of politically textured negotiation processes, moreover, will help us face
this challenge up-front. It will also help us
recognize this technology for what it is: a tool
that may radically transform the shape and
structure of current health care practices.

Acknowledgements
I would like to thank Emilie Gomart, Els
Goorman and Berti Zwetsloot for the inspiration and comments that led to this paper.
This research has been made possible by a
grant from the Netherlands Organization for
Scientific Research (NWO).

References
[1] M.E. Collen, A history of medical informatics in
the United States, 1950 to 1990, Am. Med. Informatics Assoc. (1995).
[2] M. Berg, Rationalizing Medical Work. Decision
Support Techniques and Medical Practices, MIT
Press, Cambridge, 1997.
[3] C. Sauer, Why Information Systems Fail: A Case
Study Approach, Alfred Waller, Henley-onThames, 1993.
[4] J.B. Chessare, K.E. Torok, Implementation of
COSTAR in an academic group practice of general
pediatrics, MD Comput. 10 (1993) 2327.

[5] J.I. Levitt, Why physicians continue to reject the

computerized medical record, Minn. Med. 77
(1994) 17 21.
[6] P.B. Marr, et al., Bedside terminals and quality of
nursing documentation, Comput. Nurs. 11 (1993)
176 182.
[7] S.C. Schoenbaum, G.O. Barneu, Automated ambulatory medical records systems. An orphan technology, Int. J. Technol. Assess. Health Care 8
(1992) 598 609.
[8] K.C. Laudon, J.P. Laudon, Management Information Systems. New Approaches to Organization
and Technology, 5 ed., Macmillan, New York,
1998.
[9] J.C. Wyatt, Clinical data systems, part 3: development and evaluation, Lancet 344 (1994) 1682
1688.
[10] N.M. Lorenzi, R.T. Riley, M.J. Ball, J.V. Douglas
(Eds.), Transforming Health Care Trough Information: Case Studies, Springer, New York, 1995.
[11] C. Atkinson, V.J. Peel, Growing, not building, the
electronic patient record system, Methods Inf.
Med. 37 (1998) 206 310.
[12] R. Hirschheim, H.K. Klein, K. Lyytinen, Information Systems Development and Data Modeling
Conceptual and Philosophical Foundations, Cambridge University Press, Cambridge, 1995.
[13] E. Mumford, M. Weir, Computer Systems in
Work Design: the ETHICS Method, New York:
Wiley, 1979.
[14] A. Friedman, D.S. Comford, Computer Systems
Development. History, Organization and Implementation, Wiley, New York, 1989.
[15] R. Kling (Ed.), Computerization and Controversy:
Value Conflicts and Social Choices, 2nd ed., Academic Press, San Diego, 1996.
[16] M. Berg, C. Langenberg, I.V.D. Berg, J. Kwakkernaat, Considerations for sociotechnical design: experiences with an electronic patient record in a
clinical context, Int. J. Med. Inf. 52 (1998) 243
251.
[17] N.M. Lorenzi, R.T. Riley, A.J.C. Blyth, G.
Southon, B.J. Dixon, Antecedents of the people
and organizational asprects of medical informatics:
review of the literature, J. Am. Med. Inform. Soc.
4 (1997) 79 93.
[18] M. Berg, Medical work and the computer-based
patient record: a sociological perspective, Methods
Inf. Med. 37 (1998) 294 301.
[19] M. Berg, The politics of technology: on bringing
social theory in technological design, Sci. Techn.
Hum. Val. 23 (1998) 456 490.

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

[20] M. Berg, Of forms, containers and the electronic

medical record: some tools for a sociology of the
formal, Sci. Techn. Hum. Val. 22 (1997) 403 433.
[21] R. Kling, W. Scacchi, The web of computing:
computer technology as social organization, Adv.
Comput. 21 (1982) 190.
[22] W.E. Bijker, J. Law (Eds.), Shaping TechnologyBuilding Society. Studies in Sociotechnical
Change, MIT Press, Cambridge, 1992.
[23] P. Atkinson, Medical Talk and Medical Work,
Sage, London, 1995.
[24] A. Strauss, S. Fagerhaugh, B. Suczek, C. Wieder,
Social Organization of Medical Work, University
of Chicago Press, Chicago, IL, 1985.
[25] M. Berg, Practices of reading and writing. The
constitutive role of the patient record in medical
work, Soc. Hea. Illn. 18 (1996) 499524.
[26] S.J. Reiser, Medicine and the Reign of Technology, Cambridge University Press, Cambridge,
1978.
[27] B.L. Craig, The role of records and of recordkeeping in the development of the modem hospital
in London, England and Ontario, Canada, c.
18901940, Bull. History Med. 65 (1991) 376 397.
[28] H. Garfinkel, Studies in Ethnomethodology, PrenticeHall, EnglewoodCliffs, NY, 1967.
[29] H. Tellioglu, I. Wagner, Work practices surrounding PACS: the politics of space in hospitals. (1997),
in press.
[30] B. Latour, Science in Action, Cambridge University Press, Cambridge, 1987.
[31] J.D. Howell, Technology in the Hospital. Transforming Patient Care in the Early Twentieth Century, Johns Hopkins University Press, Baltimore,
MD, 1995.
[32] R. Stevens, In Sickness and in Wealth: American
Hospitals in the Twentieth Century, Basic Books,
New York, 1989.
[33] J. Bowers, Making it work: a field study of a
CSCW Network, Inf. Soc. 11 (1995) 189 207.
[34] E. Egger, I. Wagner, Negotiating temporal orders:
the case of collaborative time management in a
surgery clinic, Comp. Supp. Coop. Work 1 (1993)
255275.
[35] B. Kaplan, Addressing organizational issues into
the evaluation of medical systems, J. Am. Med.
Inform. Soc. 4 (1997) 94101.
[36] G.C. Bowker, S.L. Star, W. Turner, L. Gasser
(Eds.), Social Science, Technical Systems, and Cooperative Work: Beyond the Great Divide,
Lawrence Erlbaum, Mahwah, NJ, 1997.

99

[37] L. Suchman, Working relations of technology production and use, Comp. Supp. Coop. Work 2
(1994) 21 39.
[38] E. Gerson, S.L. Star, Analyzing due process in the
workplace, ACM Trans. Office Inf. Syst. 4 (1986)
257 270.
[39] G. Button, R.H.R. Harper, Taking the organisation into accounts, in: G. Button (Ed.), Technology in Working Order. Studies of Work,
Interaction, and Technology, Routledge, London,
1993, pp. 98 107.
[40] D. Hughes, When nurse knows best: some aspects
of nurse/doctor interaction in a casualty department, Soc. Hea. Illn. 10 (1988) 1 22.
[41] S. Timmermans, M. Berg, Standardization in action: achieving universalism and localization in
medical protocols, Soc. Stud. Sci. 27 (1997) 273
305.
[42] S.L. Star (Ed.), Ecologies of Knowledge: Work
and Politics in Science and Technology, State University of New York Press, New York, 1995.
[43] K. Schmidt, L. Bannon, Taking CSCW seriously:
supporting articulation work, Comp. Supp. Coop.
Work 1 (1992) 7 40.
[44] S.L. Star, The sociology of the invisible: the primacy of work in the writings of Anselm Strauss,
in: D.R. Maines (Ed.), Social Organization and
Social Process: Essays in Honor of Anselm
Strauss, Aldine de Grnyter, Hawthome, 1991, pp.
265 283.
[45] I. Wagner, Hard times. The politics of womens
work in computerized environments, Eur. J. Womens Stud. 2 (1995) 295 324.
[46] J.M. Nyce, I.I.I. W. Graves, The construction of
knowledge in neurology: implications for hypermedia system development, Al. Med. 2 (1990) 315
322.
[47] T. Winograd, F. Flores, Understanding Computers and Cognition. A New Foundation for Design,
Ablex, Norwood, NJ, 1986.
[48] P. Luff, C. Heath, D. Greatbatch, Tasks-in-interaction: paper and screen-based documentation in
collaborative activity, in: J. Turner, R. Kraut
(Eds.), Proceedings of the Conference on Computer Supported Cooperative Work, ACM Press,
New York, 1992, pp. 163 170.
[49] E.L. Drazen, J.B. Metzger, J.L. Ritter, M.K.
Schneider, Patient Care Information Systems: Successful Design and Implementation, Springer, New
York, 1995.
[50] K. Henderson, Flexible sketches and inflexible
data bases: visual communication, conscription

100

[51]

[52]
[53]
[54]
[55]

[56]

[57]

[58]

[59]

[60]

[61]

[62]

[63]

[64]

[65]

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

devices, and boundary objects in design engineering, Sci. Techn. Hum. Val. 16 (1991) 448 473.
L. Suchman, Plans and Situated Actions. The
Problem of HumanMachine Communication,
Cambridge University Press, Cambridge, 1987.
M. Robinson, Double-level languages and co-operative working, AI Soc. 5 (1991) 3460.
S.L. Star (Ed.), The Cultures of Computing,
Blackwell, Oxford, 1995, p. 1995.
M. Berg, Problems and promises of the protocol,
Soc. Sci. Med. 44 (1997) 10811088.
M. Berg, E. Goorman, The contextual nature of
medical information, Int. J. Med. Inf. (1998) in
press.
P.E. Agre, Formalization as a social project, Q.
Newslett. Lab. Comp. Hum. Cognition 14 (1992)
2527.
M. Robinson, As real as it gets taming models
and reconstructing procedures, in: G. Bowker, L.
Gasser, L. Star, B. Turner (Eds.), Social Science,
Technical Systems, and Cooperative Work,
Lawrence Erlbaum, Mahwah, NJ, 1997.
E. Goorman, M. Berg, Modelling nursing activities: electorinc patient records and their discontents, in press.
G. Symon, K. Long, J. Ellis, The coordination of
work activities: cooperation and conflict in a hospital context, Comp. Supp. Coop. Work 5 (1996)
131.
R.H.R. Harper, K.P.A. OHara, A.J. Sellen,
D.J.R. Duthie, Toward the paperless hospital?, Br.
J. Anaesth. 78 (1997) 762767.
R.S. Dick, E.B. Steen (Eds.), The Computer-Based
Patient Record: An Essential Technology for
Health Care, National Academy Press, Washington, DC, 1991.
C.J. McDonald, Physicians needs for computerbased patient records, in: M.J. Ball, M.F. Collen
(Eds.), Aspects of the Computer-Based Patient
Record, Springer, New York, 1992, pp. 3 11.
A. Strauss, R. Bucher, D. Ehrlich, L. Schatzman,
M. Sabshin, The hospital and its negotiated order,
in: E. Freidson (Ed.), The Hospital in Modern
Society, Free Press, New York, 1963, pp. 147 169.
O. Hanseth, E. Monteiro, Inscribing behavior in
information infrastructure standards, Acc. Man.
Inf. Techn. 7 (1997) 183211.
D.E. Forsythe, Using ethnography to build a
working system: rethinking basic design assumptions, in: 16th Symposium on Computer Applications in Medical Care, McGraw-Hill, New York,
1992.

[66] C.P. Friedman, J.C. Wyatt (Eds.), Evaluation

Methods in Medical Informatics, Springer, New
York, 1997.
[67] B. Kaplan, Qualitative research methods for evaluating computer information systems, in: J.G. Anderson, C.E. Aydin, S.J. Jay (Eds.), Evaluating
Health Care Information Systems, Sage, Thousand
Oaks, CA, 1993.
[68] R. Kling, Computerization and social transformations, Sci. Techn. Hum. Val. 16 (1991) 342 367.
[69] D.E. Forsythe, B.G. Buchanan, Broadening our
approach to evaluating medical information systems, in: P. Clayton (Ed.), Proceedings of the
Fifteenth Symposium on Computer Applications
in Medical Care, McGraw-Hill, New York, 1992.
[70] P.E. Agre, Institutional circuitry: thinking about
the forms and uses of information, Inf. Tech. Libr.
14 (1995) 225 230.
[71] S. Kay, I.N. Purves, Medical records and other
stories: a narratological framework, Methods Inf.
Med. 35 (1996) 72 87.
[72] S.L. Star, K. Ruhleder, Steps towards an ecology
of infrastructure: design and access for large information spaces, Inf. Syst. Res. 7 (1996) 111.
[73] W.J. Orlikowski, The duality of technology: rethinking the concept of technology in organizations, Org. Sci. 3 (1992) 398 427.
[74] K. Schneider, I. Wagner, Constructing the dossier
representatif: computer-based information-sharing
in French hospitals, Comp. Supp. Coop. Work 1
(1993) 229 253.
[75] Y. Engestrom, R. Engestrom, O. Saarelma, Computerized medical records, production pressure and
compartmentalization in the work activity of
health centre phsysicians, in: Proceedings of the
Conference on Computer-Supported Cooperative
Work CSCW 88, ACM Press, New York,
1988:65 84.
[76] D.E. Forsythe, New bottles, old wine: hidden cultural assumptions in a computerized explanation
system for migraine sufferers, Med. Anthr. Quart.
10 (1996) 551 574.
[77] J. Bowers, The politics of formalism, in: M. Lea
(Ed.), Contexts of Computer Mediated Communication, Harvester, Hassocks, 1992, pp. 232 262.
[78] J. Greenbaum, M. Kyng (Eds.), Design at Work:
Cooperative Design for Computer Systems,
Lawrence Erlbaum, Hillsdale, NJ, 1991.
[79] F. Kensing. J. Simonsen, K. Bdker, MUSTa
method for participatory design, in: Participatory
Design Conference 96, 1996.

M. Berg / International Journal of Medical Informatics 55 (1999) 87101

[80] J. Weedrnan, The structure of incentive: design

and client roles in application-oriented research,
Sci. Techn. Hum. Val. 23 (1998) 315345.
[81] H. Scarbrough, J.M. Corbett, Technology and Organization. Power, Meaning and Design, Routledge, London, 1992.
[82] L. Suchman, R.H. Trigg, Artificial intelligence as
craftwork, in: S. Chaiklin, J. Lave (Eds.), Understanding Practice. Perspectives on Activity and
Context, Cambridge University Press, Cambridge,
1993, pp. 144178.
[83] G. Walsham, Interpreting Information Systems in
Organizations, Wiley, Chichester, 1993.
[84] W.J. Orlikowski, Improvising organizational transformation over time: a situated change perspective,
Inf. Syst. Res. 7 (1996) 6392.
[85] O. Hanseth, K. Thoresen, L. Winner, The politics
of networking technology in health care, Comp.
Supp. Coop. Work 2 (1994) 109130.
[86] O. Hanseth, E. Monteiro, M. Hatling, Developing
information infrastructure: the tension between
standardization and flexibility, Sci. Techn. Hum.
Val. 21 (1996) 407426.
[87] M. Berg, Accumulating and coordinating: occasions for information technologies in medical
work, Comp. Supp. Coop. Work (1999) in press.
[88] K. Schmidt, C. Simone, Coordination mechanisms: towards a conceptual foundation of CSCW
systems design, Comp. Supp. Coop. Work 5 (1996)
155200.

101

[89] E. Nygren, P. Henriksson, Reading the medical

record. I. Analysis of physicians ways of reading
the medical record, Comput. Methods Programs
Biomed. 39 (1992) 1 12.
[90] J. Lave, Cognitzon in Practice, Cambridge University Press, Cambridge, 1988.
[91] E. Hutchins, Cognitzon in the Wild, MIT Press,
Cambridge, 1995.
[92] J.C. Wyatt, Clinical data systems, part 2: components and techniques, Lancet 344 (1994) 1609
1614.
[93] P. Degoulet, et al., The component-based architecture of the HELIOS medical software engineering
environment, Comp. Progr. Med. Biol. 45 (Suppl.)
(1994) S1 S11.
[94] J. van der Lei, et al., The introduction of computer-based patient records in The Netherlands,
Ann. Intern. Med. 119 (1993) 1036 1041.
[95] K. Henderson, The role of material objects in the
design process: a comparison of two design cultures and how they contend with automation, Sci.
Techn. Hum. Val. 23 (1998) 139 174.
[96] L. Gasser, The integration of computing and routine work, ACM Trans. Office Inf. Syst. 4 (1986)
205 225.
[97] S.L. Star, Layered space, formal representations
and long-distance control: the politics of information, Fundamenta Scientiae 10 (1989) 125 154.
[98] H.M. Collins, Artificial Experts. Social Knowledge
and Intelligent Machines, MIT Press, Cambridge,
1990.