Collective expectations—Individual action implementing electronic booking systems in Norwegian health care
Introduction
The implementation of electronic booking systems in the Norwegian health care sector is expected to produce several public goods. It is expected to modernise the way patients are referred to hospitals from primary care. Patients will be allowed to choose which hospital they would like to go to and the date and time which suit them. This novel system is also believed to improve patient- and information flow substantially.
We aim at examining two key aspects with electronic booking, namely how the standards inscribed in the booking system shape medical work. We also consider how these standards bring to the surface a social dilemma (between collective and individual interests) in the matter of how the involved actors reflect on the consequences of the system. Both these two issues must be handled in order to actualise the purpose of electronic booking.
One type of standards in the booking system is the standardised services offered by the hospital. These services are supposed to be clear-cut with clear responsibilities for both the hospital-physicians and the general practitioners. The other type of standards is those that prescribe a certain way of doing medical work in relation to the medical services offered. Those standards may be denoted as procedural standards ‘delineat[ing] a number of steps to be taken when specified conditions are met’ [1]. Procedural standards in the booking system are related to an array of medical conditions that must be fulfilled before the general practitioner can place the booking. That is, before the general practitioner can place a booking the patient must go through a list of examinations coordinated by the general practitioner. Each successful booking implies that the medical conditions for when and how to book a service has come into play.
Successful implementation of electronic booking also requires that professionals and administrative staff cooperate across space, levels of administration, and professional boundaries. Accordingly, the challenges of implementing an electronic booking system are a complex combination of technological and social aspects and we analyse this combination by using actor network theory (ANT) [2], [3]. This theory is well-suited as it treats social and technical issues on equal terms and as it allow us to examine how the interplay exists and how it works.
Each of the individuals who are involved in the procedure of electronic booking has to participate in a collective coordinated action in order to actualise the intended purpose with the system [4]. However, collective action is a vulnerable condition that always implies a conflict between individual and collective interests [5]. This conflict can be looked upon as a dilemma, which needs to be clarified before collective action will take place. Such dilemmas are present in users’ reflections on advantages and disadvantages with the booking system. At this we find it appropriate to include elements from the theory of collective action [5], [6] as an attempt to establish a more comprehensive and detailed understanding of social processes which is active when establishing complex socio-technological systems.
Our overall research question is as follows: How do the standards in the booking system shape medical work, and how do these standards enforce the conflict between collective and individual interests.
Firstly, taking into account the pervade uncertainty of medical work [7], [8], [9] we examine how the hospital physicians inscribe a certain behaviour into the booking system through the standardised services offered. In that sense, the booking system becomes an actor that defines under which conditions the general practitioners can use the services. We analyse how the general practitioners relate to this new actor and how they make the patient fit into the standardised services or categories offered. Accordingly, the question we ask is who fits into the categories and who does not and how do the general practitioners deal with uncertain cases. We also illuminate how the procedural standards in the booking system inscribe a certain way of work for the general practitioners and how the specialists in that way seek to control under which conditions patients may be referred to the hospital. However, according to ANT the booking system becomes an autonomous actor in its own right, and we illuminate how this actor is not fully controllable by the hospital physicians, which may lead to unpredictable results.
Secondly, we examine how physicians as reflexive individuals [10], [11] find themselves in a social dilemma when talking about consequences of electronic booking. On the one side the physicians recognize booking as an advantage for the patients and the overall health care system and find it plausible to use the system. On the other side, they find that regular use of the system adds additional burden to their already heavy workload and find it less plausible to use the system. For instance, prioritising patients is usually the responsibility of the hospital physicians, but through the standards inscribed in the booking system this responsibility is undertaken by the general practitioners. The general practitioners are expected to ensure that patients are treated equally and just. Sometimes this implies resisting making the appointment at the first date available and thus book services with regard to what is best for the collective. However, this may turn out to be in conflict with the general practitioners’ individual interests such as referral of the patient as quick as possible to the hospitals. This becomes increasingly more evident as the general practitioner in each case books the appointment with the patient present.
Empirically we report from a booking project initiated at the University Hospital of North Norway (UNN) and the use of the booking system among general practitioners.
The remainder of this paper is organised as follows. The next section elaborates more thoroughly on the theoretical foundation and is followed by a reflection on the research design. After that the background and the status of the electronic booking project is provided. The next section presents some case vignettes, which contain illustrations of physicians’ use of the booking system. The discussion and the conclusion appear in the following two sections. The conclusion also provides some guidelines for design.
Section snippets
Theory
Streamlined information flow presupposes standardisation of interfaces between different information systems (such as the patient administrative system, the hospital-based electronic patient record (EPR), and the general practitioners’ EPR) and has been given considerable attention in recent years [12]. However, this requires common ways of doing things across contexts as a way to support distributed collaboration. In this light, standardisation becomes a foundation for ensuring a certain
Methods
We report from an ongoing field research [26] on implementing electronic booking in the North Norway Health enterprise. The study setting is the University Hospital of North Norway and general practitioners using the booking system. The hospital is the northernmost and smallest of the Norwegian university hospitals. It has approximately 4500 employees, including 400 physicians and 900 nurses. It has 600 beds of which 450 are somatic and 150 psychiatric. Together with 10 local hospitals, the
Booking as a collective good
Traditionally when a patient is referred from the general practitioner to the hospital for further examination and treatment the hospital will, depending on the hospital's resources and the patient's current condition, decide when to summon the patient to an appointment to the outpatient clinic in question. Whenever this decision is made the patient is informed by mail and hopefully the appointment is suitable for the patient. When the patient shows up in the outpatients’ clinic, the usual
Acting at a distance
Defining conditions, i.e. procedural standards under which the general practitioners can order services express a settled relationship – frozen discourse [13] – between the hospital physicians and the general practitioners. By using the booking system, the general practitioners must take into account “what, when and how” the system defines work. The booking system accordingly serves as the hospital physicians’ prolonged arm—it becomes an actor that acts at a distance [2].
The general
Conclusion and implications
In an ANT perspective we argue that the booking system as an actor has not been able to establish sustainable alliances with the other actors in the network, such as the general practitioners, their EPR and their paper-based referral routines. As we also have underscored, integration between the EPR and the booking system may only partially solve the problem. This makes the socio-technological network vulnerable and especially in cases where the patient's condition is complex.
At the moment it
Acknowledgment
This work has been funded by the Norwegian Research Council under the Program for Communication, ICT and Media (KIM).
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