Information infrastructuresfrom a practice view12.09.2014

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Agenda

• Information Infrastructures• Hospital IIs• (work) practice view

• Case: Information Infrastructure in the heart transplant process

• Conclusions

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“..enabling, shared, open, heterogeneous, socio-technical, and built on an installed base”

(Hanseth, 2000).

Hospital information infrastructure

• includes information systems in a hospital• + work practices• + information routines, conventiones of use…• Hospital II today:

– Large centralised systems• EPR Electronic Patient Record• PAS Patient Administrative System• PAS/RIS Picture archive + radiology system

– Variety of specialised systems• Labs (clinical chemistry, microbiology, immunology, …)

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Growth of hospital II

• Not ‘from scratch’• Design starts from local needs

– Veriety of small specialised systems addressinglocal information management needs

– Local: departments, unit, laboratories, – Specialised: category of disease, diagnosis etc.

• Often user initiated – with ‘no control’– 1995 Rikshospitalet: 160 systems– …?

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User needs

• Information and communication practices• Examples:

– Paper forms to structure information gathering– Archives to organize storing of information

• From paper to digital form– Efficiency, easy to retrieve data, access, sharing

with other etc.

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Example: ‘Berte’

• Berte: system for paediatric cardiology at RH (children withcongenital heart diseases, national centre)

• initiative of the head of the section• installed in 1990

“in Berte there is a diagnosis system where there are more than400 cardiac diagnoses, and it is possible to diagnosis every singlephysical part of the heart. This details are very important for thissection and for the surgeons, but of very little interest forpaediatricians”

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Berte (cont.)

“in our department we are very specialized. What we need toprovide, we need to have, and need to convey to the surgeons andin between us is very specific for our field and we talk a differentlanguage from the rest of the doctors in the paediatric department.Many of them don’t understand what we say. That means that thesystem integrating the whole hospital or the regional hospitals inNorway will be too general for our purposes”.

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Medical work is collaborative

• Social and collective process• Interdisciplinary• Across locations• Across time• Berg: ‘managing patient trajectories’

• Critical need for sharing information and easyaccess

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Collaborative practice...

EPR/

ADT

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Reality looks more like this:

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II as a shared resource for work

• Shared:– Many users– Multiple users

• Enabling– not narrowly specified but open to new uses and

possibilities – Multiple usages

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A practice view

• Work practices: networks of people, tools, organizational routines, documents etc. “in the doing”

• Actual practices – not formal descriptions• Not in a vacuum: context + history• Zooming in - zooming out

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• One specific practice• Constellation of practices• Information and communication practices• Practices of making information flow

Methodological note on how to study IIs from a practice view• Star: «boring things»• Bowker: «infrastructural inversion»

– foregrounding the truly backstage elements of work practice

• II is «transparent to use»• Becomes visible when it breaks

– E.g.the server is down• Articulation work vs primary work

– E.g. how doctors document their practices while they are‘practicing’

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The case

• Heart transplants - process• Background• Patient process• Information flow + information systems• Information needs• Multiple usages of information: logics

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Heart Tx at Rikshospitalet

• First adult in 1983; first child in 1986.• 720 patients had a heart-transplant in

Norway (pr. 1.1.2012)• 30-35 patients per year• Ca. 90 % of organs from Norway, and 10 %

via Scandiatransplant.• One transplant center• Part of Scandiatransplant

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Heart transplant process

• Distributed work process– Within the hospital, many departments– Across hospitals– Across levels of care

• Interdisciplinary collaborative process (cardiology, thoracic surgery, immunology)

• My focus: coordination of work practices and the use of information artefacts

• Before/after surgery: complex process of information production, collection, selection – to reduce uncertainties.

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Phase 1

Referral TransplantSurgery

WaitingPeriod

Post-operativerecovery

EvaluationPeriod Follow up

Acceptance to RH Match for TxAcceptance to WL

-DistrictHospital

-Cardiology-Tx Coord.-SpecializedExamination-Immunology

-PeriodicalControls

-Thoracic Surgery-HarvestingTeam-Tx Coord.-Immunology

-ICU-Cardiology

-Cardiology

Phase 2 Phase 3 Phase 4

PHASES OF THE TRANSPLANT PROCESS

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Patient Journal

EROS

Information on patient

Virology

Exams

Labs

Social workers

HeartMeeting(acceptance)

Nyrebase/HLA Lab

Shared locallyWL printout

Matching Surgery

Info. back to

Journal

Scandiatransplant

Nyrebase

Research GroupsInformation

on donorScandiatransplantWL in the sytemsShared in Scandinavia

Sources of information

EPR

1

2

3

4

5

6 7

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ICU Thoracic Surgery

Cardiology Ward

Periodical control visits

ExamsLabsPatient Journal

Datacor

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Information flow in the process

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Name:___Pers.Num:___Adress:___Tlf.pr:___arbeidtlf:___mob:__Beeper:___ Sc.nr____

High:___Weight:___PVR:___date:___TLC:___tidl.toraxkir:____Txnr:____Date:____

ABO:___HLA:___CMV:____Transf:____Svskap:_____Tidlmøtt:__ScrT:___%date:___

ScrE:neg/pos___II:neg/pos___data___Siste serum:___Mrk:__

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Data on the waiting list:

Datacor screen for entering patient’s data

Euroscore calculation

Personal information

Patient category

Diagnosis

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Date of received samples Problem area: heart

Results of the HLA typing

Result of the blood grouping

Previous HLA typing

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Centralized Artefacts

Infra-departmentalArtefacts

Infra-institutionalArtefacts

Local Artefacts

Paper based Computer based

• Paper based centralized patient record (the patient journal).

• Containing: • F1 form• G form: Checklist (Information for heart

transplant and after transplantation)

• Electronic patient record (including the Administrative patient system)

• Waiting list paper printout• Order form for Clinical Chemistry Lab• Order form for IMMI Lab• Order form for Microbiology Lab• Order form for other service departments• Form for acceptance for transplant

• Nyrebase system and HLA Lab system at IMMI

• Datacor system in Thoracic Surgery

• Transport plan for the incoming of heart-, heart/lung and lung recipients to transplantation

• ScandiaTransplant database

Cardiology• The cardiology ward daily patient list• Recipient form for evaluation for heart-

transplant in the cardiology department• Binder

Surgery• Donation plan paper form • Necro Organ paper Form

Immunology• Local paper based patient record at IMMI

• Local database (cardiology)

Dept ofThoracicSurgery

IMMISection for transplant

immunologyDept of Cardiology

Analysis:•Chemistry Lab•Microbiology lab

Transplant coordinators(Thorax surgery dep.)

Department/organization

Database/system

Paper forms

Patient Record

EPR

Examinations:Echolab, CardLabRad Lab, Ul. Lab

EROSPACS

RIS

HLA/Nyrebase

Scandiatransplant

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IMMIImmunology

Transplant Section

Clinical deps:•Cardiology•Thorax surgery

ScandiaTransplant

Other laboratories:•Blood bank•Microbiology lab

Transplant coordinators(Thorax surgery dep.)

Department/organization

Database/system

Paper forms

HLA Lab/NyrebaseScandiatransplant

Scandiatransplant

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Logics of information use

1. Patient-centered logic2. Treatment-centered logic3. Activities-centered logic4. Event-centered logic

• Multiple logics of Information ordering• Multiple effects

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Patient-centred logic

• Medical history of each singular patient• Chronological order• What has been done, what results, what are the next

steps• Checklists across shifts, EPR, referral• Connecting recipient and donor• Not integrating disciplines and professions

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«The patient has been at the medical departmentpreviously. In March 1989 the diagnosis has been of a dilated cardiomyopathy (…) The patient has beenpreviously evaluated at (…) and in principle he is accepted for transplant. The patient is hospitalizedbecause he has been lately feeling unwell…on the dayof hospitalization the patient had pain in the head …»

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Treatment-centred logic

• HTx as specific treatment• Category of patient• Quality of the process• Research oriented• Located in meetings, conferences, research

articles, scientific community• Not identities of patients but aggregated data• EPR as source of info, Datacor, personal

databases, Scandiatransplant

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5,8 5,3

02468

101214161820

Bypass

Valves

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200120022003200420052006

Heart operations in Norway 2006 ‐ 30‐day mortality (%)

heart transplant surgeries32

«from 1983 to 1999 317 heart transplants have beenperformed, an average of 23 transplants per year, 82% of the recipients were males, 50% had heart failure due to coronary heart disease. The survival rate after oneand ten years is 85% and 53% respectively with a significant higher survival rate among recipientsyounger than 50 at transplant, especially if the graftwas from a donor younger than 35 years»

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«in 2000 there was a discussion because Norway hadexported a high number of livers. Usually they exportabout 10 per year, but in 2000 it was up to 35. Thus theboard decided that Norway should be refunded from the recipients’ hospitals for the all the medicalequipment used like liquids or machines to treat bodiesand organs before the surgery»

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Activities-centered logic

• Concurrent tasks and patient trajectories• Logistic issues.• Articulation work for managing many patients:

– Different schedules for the same day,– Same stage, different places (WL)

• Organize movements in time and space of many patients

• Daily patient list in departments, weekly plans

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Event-centered logic

• Heart transplantation as surgical procedure• Specific event• Minimize uncertainties• Two directions:

– Define as much as possible temporal and spatial boundaries of the transplant surgery

– Rely on flexibility of schedules and plans• Donation plan, waiting list

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Four co-existing logics1. Patient-centered logic

– Information ordered chronologically,– Makes visible the medical history of each patient– Checklists across shifts, EPR, referral – Not integrating disciplines and professions

2. Treatment-centered logic– Information is aggregated (no identity of patient)– Makes visible heart transplant as specific treatment – Specific category of patients – Quality parameters, risk factors

3. Activity-centered logic– Information is organized to care for many patient trajectories– Organize movements in time and space of many patients – Daily patient list in departments, weekly plans

4. Event-centered logic– Information is organized to define as much as possible temporal – and spatial boundaries of the transplant surgery– Heart transplantation as surgical procedure – Minimize uncertainties; Donation plan, waiting list

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Co-ordering

– Logics are not separated and isolated– It is interesting to look at their co-existance in

practice• Co-existance takes different forms in the practices: it

may be an harmonious co-existance, but also maycreate contradictions and tensions

– Strenght? other more silent modes?– No single logic can do on its own

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Conclusion

• Information Infrastructure and multiplicity:– II means different things to different groups– Multiple systems– Multiple work practices– Multiple users + users’ needs– Multiple logics of use

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