Data work and practices in healthcare: A scoping review.

CONTEXT: In healthcare, digitization has been widespread and profound, entailing a deluge of data. This has spurred ambitions for healthcare to become data-driven to improve efficiency and quality, and within medicine itself to improve diagnosing and treating diseases. The generation and processing of data requires human intervention and work, though this is often not acknowledged. PURPOSE: The paper investigates who, where, by which means, and for which purposes data work is conducted which is crucial for healthcare managers and policy makers if ambitions to become data-driven are to succeed. To guide further research, it also provides an overview of existing research on data work and practices. METHODS: We conducted a scoping review based on a search for papers including the terms healthcare or health care combined with at least one of the following terms: data work, data worker*, data practice*, data practitioner* in Scopus and Web of Science. 74 papers on data work or practices in healthcare were included. ANALYSIS: The 74 papers were coded and analyzed regarding the following themes: the kind of data workers and practitioners, organizational settings, involved technologies, purposes, data work tasks, theories and concepts, and definitions of data work and practice. RESULTS: Data work is pervasive in healthcare and conducted by various professions and people and in various contexts. The field researching data work and practices is emerging, with publications spread across multiple venues. and there is a need for more precise definitions of data work. Further, data work and practices are useful concepts that have enabled the exploration of those efforts and tasks in detail. CONCLUSION: The research on data work and practices in healthcare is emerging and promising. We call for more research to consolidate the field and to better understand and support the work needed for healthcare to become data-driven.

Digital health care and data work: Who are the data professionals?

BACKGROUND: This article reports on a study that investigated data professionals in health care. The topic is interesting and relevant because of the ongoing trend towards digitisation of the healthcare domain and efforts for it to become data driven, which entail a wide variety of work with data. OBJECTIVE: Despite an interest in data science and more broadly in data work, we know surprisingly little about the people who work with data in healthcare. Therefore, we investigated data work at a large national healthcare data organisation in Denmark. METHOD: An explorative mixed method approach combining a non-probability technique for design of an open survey with a target population of 300+ and 11 semi-structured interviews, was applied. RESULTS: We report findings relevant to educational background, work identity, work tasks, and how staff acquired competences and knowledge, as well as what these attributes comprised. We found recurring themes of healthcare knowledge, data analytical skills, and information technology, reflected in education, competences and knowledge. However, there was considerable variation within and beyond those themes, and indeed most competences were learned "on the job" rather than as part of formal education. CONCLUSION: Becoming a professional working with data in health care can be the result of different career paths. The most recurring work identity was that of "data analyst"; however, a wide variety of responses indicated that a stable data worker identity has not yet developed. IMPLICATIONS: The findings present implications for educational policy makers and healthcare managers.

Innovations in clinical documentation integrity practice: Continual adaptation in a data-intensive healthcare organisation.

BACKGROUND: Numbers of clinical documentation integrity specialists (CDIS) and CDI programs have increased rapidly. CDIS review patient records concurrently with patient admissions and visits to ensure that information is accurate, complete and non-ambiguous, and query clinicians when they see opportunities for improving data. The occupation was initially focused on improving data for reimbursement, but rapid changes to clinical coding requirements, technologies and payment systems led to a quickly evolving role for CDI programs and changes in CDIS practice. OBJECTIVE: This case study seeks to uncover the ongoing innovation and adaptation occurring in a CDI program by tracing the evolution of a single CDI program over time. METHOD: We present a case study of the CDI program at the HonorHealth hospital system in Arizona. RESULTS: The HonorHealth CDI program holds a unique hybrid expertise and role within the healthcare organisation that allows it to rapidly adapt to support emergent demands both internal and external to the organisation, such as supporting accurate data collection for the COVID-19 pandemic. CONCLUSION: CDIS are a vital component in present data-intensive resourcing efforts. The hybrid expertise of CDIS and capacity for adaption and relationship building has enabled the HonorHealth CDI program to adapt rapidly to meet a growing array of clinical documentation integrity needs, including emergent needs during the COVID-19 pandemic. IMPLICATIONS: The HonorHealth case study can guide other CDI programs in adaptation of the CDI role and practices in response to changing organisational needs.

Data-work and friction: Investigating the practices of repurposing healthcare data.

The focus on digital data for improved management and quality of healthcare is paramount. In particular, the vast volumes of accumulated data in clinical systems have created high hopes for repurposing data to serve secondary purposes beyond the practices of direct clinical care, such as research, improvement and efficiency. This article contributes with an understanding of the pivotal, but often unnoticed "data-work" involved in such efforts. The article is based on a regional project in Danish healthcare, in which nine hospital departments were given the task of developing new indicators for quality to substitute the previous accountability regime based on Diagnosis-Related Groups. Using the concept of "friction," we analyze the challenges of turning clinical ideas into data-supported indicators and of collecting data from existing repositories. Especially, we turn attention to the interaction between clinicians and it-personnel to focus on the interdisciplinary and collaborative aspects of this work.

The emergence of new data work occupations in healthcare: The case of medical scribes.

PURPOSE: Increasing demand for more and better documentation as well as digitalization of healthcare entail shifts in competencies and roles of healthcare occupations and professions. As a result of this data-centric technological development, new kinds of work and occupations emerge of which medical scribes are an example. To investigate and provide a case of an emergent occupation focused on 'data work', we describe the emergence, growth and stabilization of medical scribes, outline their history and provide a literature overview. METHOD: We conducted a review of the literature on medical scribes in academic journals until 2017. These publications are categorized according to the country of study, medical specialization, method, focus, attitude to the use of medical scribes, and the reasons given for the use of medical scribes. We outline the history of the emergence of medical scribes and provide a summary of the existing research publications on medical scribes. FINDINGS: We identified 60 papers of which a majority are based on cases from the USA; conducted in emergency departments; based on quantitative methods; focus on economic feasibility and satisfaction; are positive towards the use of medical scribes; and link the use of medical scribes to the implementation of electronic health records (EHR). There is a distinct lack of research on medical scribes themselves and their interaction with physicians, patients, and EHR. CONCLUSIONS: Medical scribes have emerged as a new data-work occupation as a response to increased demands for documentation and digitalization through EHRs. Research on medical scribes has hitherto focused on efficiency and economic feasibility of scribes, and there is a need to look into the interaction of medical scribes with physicians and patients as well as look at opportunities for redesign of EHR. More generally, there is a need to look beyond the most prominent professions such as physicians and nurses in discussions of digitization and datafication of healthcare, and investigate how new and previous tasks are (re)distributed between occupations and professions.

Translating value-based health care: an experiment into healthcare governance and dialogical accountability.

This article analyses an experiment into healthcare governance in Denmark inspired by principles of value-based health care and intended to re-orient the focus of healthcare governance from 'productivity' to 'value for the patient'. The region in charge of the experiment exempted nine hospital departments from activity-based financing and accountability based on diagnosis-related groups, which allegedly incentivised hospitals in 'perverse' and counterproductive ways. Instead, the departments were to develop new indicators from their local practices to support and account for quality and value for the patient. Drawing on the actor-network theory concept of 'translation', this article analyses how the experiment was received and put into practice in the nine departments, and how it established new kinds of accountability relations. We argue that the experiment provides fruitful inspiration for future governance schemes in healthcare to embrace the local complexities of clinical practices. In particular, we argue that the locally developed indicators facilitated what we call 'dialogical accountability', and we discuss whether this represents a feasible way forward for value-based health care.

Factors affecting physicians' use of a dedicated overview interface in an electronic health record: The importance of standard information and standard documentation.

BACKGROUND: It remains a continual challenge to present information in user interfaces in large IT systems to support overview in the best possible way. We here examine how an electronic health record (EHR) supports the creation of overview among hospital physicians with a particular focus on the use of an interface designed to provide clinicians with a patient information overview. The overview interface integrates information flexibly from diverse places in the EHR and presents this information in one screen display. Our study revealed widespread non-use of the overview interface. We explore the reasons for its use and non-use. METHOD: We conducted exploratory ethnographic fieldwork among physicians in two hospitals and gathered statistical data on their use of the overview interface. From the quantitative data, we identified where the interface was used most and conducted 18 semi-structured, open-ended interviews framed by the theoretical framework and the findings of the initial ethnographic fieldwork. We interviewed both physicians and employees from the IT units in different hospitals. We then analysed notes from the ethnographic fieldwork and the interviews and ordered these into themes forming the basis for the presentation of findings. RESULTS: The overview interface was most used in departments or situations where the problem at hand and the need for information could be standardized-in particular, in anesthesiological departments and outpatient clinics. However, departments with complex and long patient histories did not make much use of the overview interface. Design and layout were not mentioned as decisive factors affecting its use or non-use. Many physicians questioned the completeness of data in the overview interface-either because they were skeptical about the hospital's or the department's documentation practices, or because they could not recognize the structure of the interface. This uncertainty discouraged physicians from using the overview interface. CONCLUSION: Dedicating a specific function or interface to supporting overview works best where information needs can be standardized. The narrative and contextual nature of creating clinical overview is unlikely to be optimally supported by using the overview interface alone. The use of these kinds of interfaces requires trust in data completeness and other clinicians' and administrative staff's documentation practices, as well as an understanding of the underlying structure of the EHR and how information is filtered when data are aggregated for the interface.

Techno-Anthropological Sensibilities in Health Informatics: Opportunities and challenges.

What kind of knowledges, skills and competences may be required by Techno-Anthropology engaging with health informatics? If we understand Techno-Anthropology to mean conducting anthropological analyses of the interwoven and mutually shaping relationship between organizing, technologies and actors in healthcare, such engagements and interventions can take many forms: Short-term consultancy work dedicated to achieving specific goals, long-term studies of broad changes in healthcare; management support within hospitals and public healthcare administration; or technology development with vendors of healthcare IT. The opportunities would seem to be manifold. Since the healthcare sector is a heterogeneous mix of interests, political agendas, professions et cetera, there is great merit in having people knowledgeable about this heterogeneity; able to facilitate meetings and processes between the various professions and organizations; and skilled in generating analyses and proposing new solutions. Also, people with insight into how action, technologies and organizing are interwoven and redistribute competences, responsibilities and risks are invaluable: Look at from afar, technologies seem to cause and determine social development, whereas detailed studies reveal that determinants and causes are both technical and social. The challenges include the one of making one's knowledge and skills legitimate and relevant to health informatics. Having a degree from arts or social sciences is not necessarily impressive for people with similar degrees in medicine, computer science, and business administration. Another challenge is to design an engagement with health informatics that will generate insights which often requires time, while also providing quick results for project sponsors or collaborators. The chapter points at three issues that seem to be central foundations for appropriate and quality-driven research and interventions of the 'quick and proper' kind: Modes of engagement; characteristics of the healthcare sector; and medical informatics and work.

Clinical overview: a framework for analysis.

In this presentation, we investigate concepts and theories for analysing how healthcare professionals achieve overview of patient cases. By 'overview' we mean the situation in which a healthcare professional with sufficient certainty and in concrete situations knows how to proceed based on available information upon a patient. Achieving overview is central for the efficient and safe use of healthcare IT systems, and for the realization of the potential improvements of healthcare that are behind investments in such systems. We focus on the theories of decision-making, sensemaking, narratives, ethnomethodology and distributed cognition. Whereas decision-making theory tend to be sequential and normative, we find the concept of 'functional deployment' in sensemaking theory, 'emplotment' in narrative theory, the focus on 'members' methods' in ethnomethodology and the inclusion of 'computational artifacts' in distributed cognition helpful.

Evaluation of a comprehensive EHR based on the DeLone and McLean model for IS success: approach, results, and success factors.

OBJECTIVE: The article describes the methodological approach to, and results of an evaluation of a comprehensive electronic health record (EHR) in the shake down phase, shortly after its implementation at a regional hospital in Denmark. DESIGN: A formative evaluation based on a mixed-methods case study, designed to be interactive and concurrent was conducted at two hospital departments based on the updated DeLone and McLean framework for evaluating information systems success. METHODS: To ascertain user assessments of the EHR, we distributed a questionnaire two months after implementation to four groups of staff (physicians, nurses, medical secretaries, and physiotherapists; n=244), and at the same time we conducted thirteen individual, semi-structured interviews with representatives from these four groups. Subsequently, seven follow-up focus group interviews were conducted with the four above-mentioned groups, in order to go deeper into specific user assessments. Simultaneously, focus group interviews with two IT departments and the implementation team were conducted, to gain insight into system provider assessments of the implementation process and the EHR. Before, during, and after implementation, 88 h of ethnographic observation were carried out, to give the researchers an understanding of the daily routine of staff, and their use of health records. Finally, daily system performance data were obtained, to gather factual information on system response and downtime. RESULTS: Overall, staff had positive experiences with the EHR and its operational reliability, response time, login and support. Performance was acceptable. Medical secretaries found the use of the patient administration module cumbersome, and physicians found the establishment of the overview of professionally relevant data challenging. There were demands for improvements to these and other functionalities, and for the EHR to be integrated with other systems and databases. LIMITATIONS: Evaluations immediately following implementation are inherently difficult, but was required because a key role was to inform decision-making upon enrollment at other hospitals and systematically identify barriers in this respect. The strength of the evaluation is the mixed-methods approach. Further, the evaluation was based on assessments from staff in two departments that comprise around 50% of hospital staff. A weakness may be that staff assessment plays a major role in interviews and survey. These though are supplemented by performance data and observation. Also, the evaluation primarily reports upon the dimension 'user satisfaction', since use of the EHR is mandatory. Finally, generalizability may be low, since the evaluation was not based on a validated survey. All in all, however, the evaluation proposes an evaluation design in constrained circumstances. CONCLUSIONS: Despite inherent limitations, evaluation of a comprehensive EHR shortly after implementation may be necessary, can be conducted, and may inform political decision making. The updated DeLone and McLean framework was constructive in the overall design of the evaluation of the EHR implementation, and allowed the model to be adapted to the health care domain by being methodological flexible. The mixed-methods case study produced valid and reliable results, and was accepted by staff, system providers, and political decision makers. The successful implementation may be attributed to the configurability of the EHR and to factors such as an experienced, competent implementation organization at the hospital, upgraded soft- and hardware, and a high degree of user involvement.

CareCoor: augmenting the coordination of cooperative home care work.

OBJECTIVES: The present study aims to augment the network of home care around elderly. We investigate the nature of cooperative work between relatives and home care workers around elderly persons; present the CareCoor system developed to support that work; and report experiences from two pilot tests of CareCoor. METHODS: We employed ethnographic fieldwork methods and conducted participatory design workshops to throw light on the nature of cooperative home care work, and to elicit implications for the design of an IT system that would support the work of relatives and home care workers around elderly persons. The design implications led to the development of a prototype, called CareCoor, which is accessible via a tablet PC and on the Internet. CareCoor was subsequently evaluated in two pilot tests. The first lasted a week and included three elderly, their next of kin and the affiliated home care workers, while the second test lasted for six weeks and involved five elderly people, their next of kin and relevant home care workers. RESULTS: In the paper we make three major points, namely, (1) home care work is highly cooperative in nature and involves substantial coordinative efforts on the part of the actors involved, (2) the network of care around elderly can be augmented with new technology that allows all members of the network to follow, influence and be a part of the cooperative care of the elderly, and (3) CareCoor, the prototype introduced in this study, shows promise as it was well received during test and evaluation. CONCLUSION: Home care work is increasingly important due to the ageing populations of Europe, the USA and large parts of Asia. Home care work between relatives and home care workers is inherently a cooperative effort, and can be facilitated and augmented by new information technology such as CareCoor. The pilot tests of CareCoor revealed promising results and will be further developed and evaluated in a larger test.

Test the artefact--develop the organization. The implementation of an electronic medication plan.

OBJECTIVE AND METHODS: The paper aims to develop further insights into the process of implementation of IT in health care by describing findings from a study of a trial implementation of a newly developed electronic medication plan (EMP) in three hospitals in a county in Denmark. A sociotechnical perspective is applied to data acquired by the qualitative methods of participant observation and semi-structured open-ended interviews. CONCLUSIONS: The achievement of fit between IT technology and work processes in health care involves the establishment of new organizational structures that cut across the existing divisionalized hospital organization and a detailed alignment of artefact, functionality and work process. This process can be furthered by supporting 'communities of practice', i.e. informal groups of engaged clinicians. A sociotechnical perspective is beneficial to the analysis of such processes.

Evaluation of a computerized problem-oriented medical record in a hospital department: does it support daily clinical practice?

PURPOSE: Evaluation of a computerized problem-oriented medical record (CPOMR) for health care work. METHODS: A qualitative study of the daily use of a CPOMR at an internal medicine hospital ward over a period of 3 months, during which 66 patients were treated based on clinical information recorded in the CPOMR though back up by a paper-based record was available. The study is based on participant observation and interviews with the clinicians who had the most profound and extensive experience in the use of the CPOMR. Before and during the test-period the author attended project planning meetings, a training workshop in the use of the CPOMR for nurses and physicians and local coordination meetings. After the test, one focus-group discussion with physicians and nurses (6 participants; duration 11/2h) was conducted as well as 13 open-ended interviews (5 nurses, 2 social and health assistants, 4 physicians, 2 IT-people; duration: 16-42 min; average of 29 min). The interviewees formed the core group using the CPOMR. RESULTS: Use of the CPOMR led to more time spent documenting clinical work, fragmentation of patient situation into separate problems, and lack of an overview. CONCLUSION: The problem-oriented method for structuring a computerized medical record may provide a description of how physicians think or ought to think, but does not adequately support complex clinical work. While the CPOMR can be used for patients with few, simple problems who are admitted for only a short time, it is not useful for patients with a complex set of problems or for patients admitted for longer periods of time. This is in accordance with criticism of the paper-based POMR, the problematic points of which do not seem to be alleviated through computerization. The problem-oriented way of ordering information should be accompanied by a source- and time-oriented approach.