Keywords:Contexts, Data, Communication, Location, Complexity

Citing this page:

Jones, P. (2000) Hodges' Health Career - Care Domains - Model: Health and Social Care Informatics
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Introduction

This section seeks to highlight what many clinicians know and take for granted, but what can confound and perplex those from outside health and social care. Although we all apprecaite and recognise as users of care service several facets, care is a complex business...

The kaleidescope of care

A problem that has a yes or a no answer is not much of a problem. "If it is bounded already" as Ravetz (1988) explained, then a great deal is (probably) known and the problem is tractable. A difficulty in health is that our problems are rarely presented logically formulated. Professionals do impose boundaries on their patient's problem via their 'roles', and the process of diagnosis. In clinical and social welfare situations few problems can be reduced to one or two 'yes' or 'no' (closed) questions. Training of health professionals stresses the need to avoid closed questions in assessment and other therapuetic situations. Health like so many aspects of social life and social science is inherently 'fuzzy'. This fuzziness arises from several sources, but especially:

The staff groups involved - directly and indirect - patient contact and the management of the same.

The professional disciplines involved and their respective knowledge bases and 'political' influence.

The location of staff - their physical base.

Where they actually work - context.

Their role and others expectations of their role.

The data, information and knowledge they need to record; process (discuss); produce; and disseminate.

Everyone recognises that (the obvious) that health is complex. Perhaps understanding the subtleties of that complexity might be of benefit, ensuring a better understanding of the problem, this can be done by expanding just three of the aspects above:

It is these sources of fuzziness and many others besides that frequently 'trip us up' when it comes to understanding our information use and support via ICT solutions. Why should this be? Situations can be complex, but they can be straightforward to understand. Surely, things that are simplistic are more likely to be taken for granted, but complexity is easy to spot? So being forewarned is to be forearmed? Of course, it is never as straightforward as this. The distinctions made above may appear to be quite exclusive, but they are not. For example, the items listed in types of interchange can also be thought of as forms of communication, or examples of media. This is one subtlety, but there are many others. Health care is multiaxial:

Imagine that in addition to standing for communication / relationships between people, the structure labelled - exponential complexity - could also represent items within a particular context. Now picture two or three of these mandelas placed over each other with more links between. Welcome to the world of health care. The complexity makes astrophysics seem straightforward - well almost. Let us not forget that health covers all the forms illustrated, plus the 'inner world' of the individual. It is no small wonder then that Pettegrew & Logan (1987) wrote:

'Health communication has no overarching theory from which to proceed, nor an exemplar of research. This lack of coherence is due to three conditions: the peculiar nature of the health care context, the vast range of communication phenomena to study, and the fact that communication has been studied from the point of view of other disciplines.'

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Of course health informatics is not seeking to capture all of these contexts and health dimensions, although the scope of some health ICT projects has seemed very ambitious in the past. Even if they are not capturing all the contexts, health informaticians and policy makers must take full account of them.

MAKING SENSE - WHAT'S THE DIAGNOSIS?

Representation of information presents major challenges to computing and clinical personnel. Humans have also evolved methods to help in cognitive economy. Diagnoses function as a means to compress information. The majority of lay people have a basic knowledge of what a specific diagnosis entails: treatment; need for hospitalization; recovery; the probable duration of time off work; after effects; and necessary nursing care. (The emphasis here is on 'basic knowledge'. Or perhaps this assumption on my part accounts for patient's compaints that they receive scant information about what is going to happen to them.)

Returning to definitions - what looks like data can be information. Coding schemes are used to help research, resource management and more recently the clinical use of computers in health care. Consider "7B140;" although data like in appearance when expanded it represents - "Suture of Ureter". NHS-CCC (1994) Is this information or data? What does "7B140" mean to a member of the coding team? Specific coding schemes are introduced elsewhere, but at present what relevance has data compression for nurses?

In an ideal world if nurses were truly information orientated they might demand (ask politely!) how much their professional bodies, health and social policy actually expand their information requirements as opposed to compressing them? They might also query the efficiency of the ICT tools that are now taken for granted in many areas of work. If businesses struggle to answer such questions, is it any wonder that health comes 'unstuck'?

PROJECT MANAGEMENT = SYNCHRONISED WAVE MANAGEMENT

My knowledge here is rudimentary, but the logistics and distribution speak of "just in time" stock management; the commercial world talks of "time to market"? What is the window of opportunity for a given product. In health what is our "time to market"?

Change is often characterised as a wave. If you are ready you can ride the surf - the crest of the wave - being an innovator. The rise of the web and .com explosion are examples of people trying to catch the wave. In health care several waves must be synchronised:

How long will this latest policy be 'current';

If we train now the staff can use the system from day-one;

The current network is not up to the task;

Staff do not have any sense of ownership here;

The procurement takes so long the technology will be out of date.

Amid all the technology, infospeak and speed of change it is easy to get disheartened to believe that there is no way to encapsulate the chaos to impose some order. Borgmann (1999) and Brown and Duguid (2000) suggest new perspectives. The former reduces the information rich environment into three types of terrain; three 'orders' of information:

from reality (MAPS)

for reality (RECIPES)

as reality (RECORDINGS)

Borgmann's analysis of information offers the reader insights into the need to balance these orders of information, amid all the hype that 'infoculture' has provoked. Borgmann's information orders are for Brian and I very poignant, a sign that perhaps we are not only really on a journey, but heading the right way. It does not take a feat of imagination to substitute:

from reality (the HCM)

for reality (MODELS)

as reality (HEALTH RECORDS)

Brown and Duguid (2000) are cynical of the IT industry view that most human interactions can be reduced to a sequence of bits and bytes. Their warning serves to direct us to the forms of representation and models at hand. As health information strategies become (truly?) person-centered the question remains: are these representations up to the (clinical) task? The links below develop this discussion.

Health care has been medically led, and this historical legacy contributes its own set of problem s. Diagnosis was quickly latched onto as a (the) data item to formalize. Selection and representation have a become a major preoccupation in health informatics.
	From here the health (nursing) record is discussed - what does it contain? What form does it take? What options are there for information management innovators?

© Peter Jones 2000

References

Borgmann, A. (1999) Holding onto Reality, University of Chicago Press.

Brown, J.S., Duguid, P. (2000) The Social Life of Information, Harvard Business School Press.

Pettegrew, L.S., Logan, R. (1987) Health Care Contexts IN Handbook of Communication Science, Berger, C.R., Chaffee, S.H. (Eds.) Sage Publications Ltd, Chap. 22,675

Ravetz, J. (1988) The Trouble with Truth: VOICES, Channel 4 (Terrestrial) TV. UK.

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