Rethinking resistance to ‘big IT’: a sociological study of why and when healthcare staff do not use nationally mandated information and communication technologies

Clinicians must continually manage the tension between standardisation and personalisation.

“They must, for example, continually manage the tension between standardisation (e.g. a guideline, protocol or algorithm) and personalisation (responding sensitively and with professional judgement to the unique features and unfolding story of an individual case).”

Technologies that are clunky, counterintuitive, liable to freeze or crash or which make the system run perceptibly more slowly become impossible to use in the busy, time-constrained world of public-sector health care.

“Technologies that are clunky, counterintuitive, liable to freeze or crash or which make the system run perceptibly more slowly become, for all practical purposes, impossible to use in the busy, time-constrained world of public-sector health care.”

Healthcare staff did not accept the government's depiction of the sick patient as a 'rational chooser' able and willing to decide between potential options using encoded information.

“They did not accept the government's depiction of the sick patient as a 'rational chooser', able and willing to decide between potential options using encoded information”

An aspect of the material limitation of Choose and Book was cost, both of the system and of the human infrastructure needed to service it.

“An aspect of this material limitation was cost, both of the Choose and Book system and of the human infrastructure needed to service it.”

We identified four specific foci of resistance to the Choose and Book technology by healthcare staff.

“Taking account of these influences, we identified four specific foci of resistance to the Choose and Book technology by healthcare staff.”

Healthcare staff resisted the significant material limitations of Choose and Book, especially when expected to use it within the tight time window of the clinical consultation.

“Second, they resisted the significant material limitations of the Choose and Book technology, especially when they were expected to use it within the tight time window of the clinical consultation.”

Referrals sent electronically frequently encountered downstream glitches, generating disproportionate volumes of work for staff to fix the problem.

“Referrals sent electronically frequently encountered downstream glitches in the system, generating disproportionate volumes of work for staff to fix the problem.”

Clinicians strongly resist pressure to behave in ways that they experience as breaching professional norms.

“These moral 'ends' are profoundly important to them and they strongly resist pressure to behave in ways that they experience as breaching these professional norms.”

Much human action in the healthcare setting is driven by ethical and normative concerns.

“Much human action in the healthcare setting is driven by ethical and normative concerns”

Clinicians struggle to align scientific-bureaucratic and humanistic institutional logics in the clinical encounter.

“Clinicians struggle to align scientific-bureaucratic (rational, technical, means-oriented) and humanistic (practical, ethical, endsoriented) institutional logics in the moment-by-moment unfolding of the clinical encounter.”

Choose and Book remained unpopular and was used reluctantly or not at all by many GPs despite political pressure and financial incentives.

“However, despite political pressure and financial incentives, Choose and Book remained unpopular and was used reluctantly or not at all by many GPs.”

Healthcare staff resisted the 'choice' policy that Choose and Book was introduced to support.

“First, they resisted the 'choice' policy that the technology had been introduced to support.”

Healthcare staff resisted the altered social roles and relations consequent on the use of Choose and Book.

“Finally, healthcare staff resisted the altered social roles and relations consequent on the use of Choose and Book.”

GPs and many of their staff resisted the interference of the expert system with local, contextual judgements.

“Third, GPs (and many of their staff) resisted the interference of the expert system with local, contextual judgements.”

The option of 'choice of hospital' enshrined in policy and inscribed in software effectively cast GPs as brokers of hospital performance metrics that they themselves questioned.

“For example, the option of 'choice of hospital' enshrined in the policy and inscribed in the software effectively cast GPs as brokers of a set of hospital performance metrics that they themselves questioned.”

Even the minority of participants who saw benefits to Choose and Book pointed out the high costs of achieving those benefits.

“Even the minority of participants who saw benefits to the Choose and Book system (e.g. that it put the patient in charge of following up the referral) pointed out the 'ludicrously' high costs of achieving those benefits.”

Aspects of both the policy and the technology itself meant that 'resistance' to each technology played out differently.

“However, aspects of both the policy and the technology itself meant that 'resistance' to each technology played out differently.”

There was a clear tendency for the Choose and Book technology to 'configure the user'.

“There was a clear tendency for the technology to 'configure the user'.”

When the theoretical model was applied to chronic disease management templates and the SCR, similar social and sociotechnical influences on how and why the technologies were resisted were found.

“When we applied this theoretical model to chronic disease management templates and the SCR, we found similar social and sociotechnical influences on how and why the technologies were resisted.”

Practices found they needed to invest heavily in administrators to support the 'automated' referral system.

“Practices found that they needed to invest heavily in administrators to support the so-called 'automated' referral system.”

There was a consistent tendency for clinicians and other healthcare staff to resist the technology's propensity to focus on tasks and processes ('means') rather than the ultimate goals of care ('ends').

“In short, we demonstrated a consistent tendency for clinicians and other healthcare staff to resist the technology's propensity to focus on tasks and processes ('means') rather than the ultimate goals of care ('ends').”

There were conflicting interpretations of the Summary Care Record programme by clinicians, service users, policy-makers, industry and technical designers.

“and conflicting interpretations of the programme by clinicians, service users, policy-makers, industry and technical designers.8,11”

• cites [8] Greenhalgh, 2010, Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study, BMJ sourceNot checked yet

  Not checked in the free run.

• cites [11] Greenhalgh, 2011, Why national eHealth programs need dead philosophers: Wittgensteinian reflections on policymakers’ reluctance to learn from history, Milbank Q sourceNot checked yet

  Not checked in the free run.

There was strong opposition by a minority of citizens and health professionals to the idea of centrally held medical records.

“Other findings included strong opposition by a minority of citizens and health professionals to the idea of centrally held medical records, 90”

• cites [90] Greenhalgh, 2008, Patients’ attitudes to the summary care record and HealthSpace: qualitative study, BMJ sourceNot checked yet

  Not checked in the free run.

Choose and Book remained unpopular and was used reluctantly or not at all by many practices.

“However, despite political pressure and financial incentives, Choose and Book remained unpopular and was used reluctantly or not at all by many practices.”

Electronic templates built into the local GP record and linked to the pay-for-performance QOF were used extensively by practice nurses but rarely by GPs.

“These were used extensively by practice nurses but rarely by GPs.”

Even when Summary Care Records were available as a one-click option, clinicians working in unscheduled care settings accessed them in only one case in five.

“Analysis of a large quantitative data set on out-of-hours encounters showed that even when SCRs were available as a one-click option, clinicians working in unscheduled care settings accessed them in only one case in five.8”

• cites [8] Greenhalgh, 2010, Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study, BMJ sourceNot checked yet

  Not checked in the free run.

The Summary Care Record was rarely accessed, for complex reasons.

“At the time, the SCR was rarely accessed, for complex reasons (again attributed by policymakers to 'clinician resistance' 116 ).”

• cites [116] Greenhalgh, 2010Not checked yet

  Not checked in the free run.

Creation of Summary Care Records was slow because many GPs refused to participate in the programme or allow their patients' data to be uploaded to the central database.

“Creation of SCRs was slow because many GPs refused to participate in the programme or allow their patients' data to be uploaded to the central database.”

The authors never saw a GP use Choose and Book directly during a consultation, even in Clover practice, which described itself as top of the local league table for percentage of referrals made using the system.

“We never saw a GP use the Choose and Book system directly during a consultationeven in Clover practice, which described itself as 'top of the [local] league table' for percentage of referrals made using the system.”

Of the four GP practices observed (Dale, Beech, Elm and Clover), the percentage of referrals submitted via Choose and Book was reported as 50-60%, 0%, 25% and 80-90%, respectively.

“Of the four GP practices we observed, anonymised as Dale, Beech, Elm and Clover, the percentage of referrals being submitted via Choose and Book was reported to us as 50-60%, 0%, 25% and 80-90%, respectively.”

The authors observed a number of examples in which the offer of choice introduced a distinct note of confusion into an otherwise smooth conversation, as the patient could not understand why they were being given the option of travelling to a distant and unfamiliar hospital.

“We observed a number of examples in which the offer of choice introduced a distinct note of confusion into an otherwise smooth conversation, as the patient could not understand why they were being given the option of travelling to a distant and unfamiliar hospital.”

Beech practice stopped using Choose and Book when financial incentives ceased.

“Beech practice stopped using Choose and Book when financial incentives ceased.”

At the time of data collection, Choose and Book technology was far from seamlessly interoperable with either the GP record system or the hospital system.

“Thus, at the time of data collection for our study, the Choose and Book technology was far from seamlessly interoperable with either the GP record system or the hospital system.”

Administrative staff often spoke of having to get to know the system through accumulated experience and trial and error.

“On the contrary, administrative staff often spoke of having to get to know the system through accumulated experience and trial and error.”

While Choose and Book is an electronic system, it was invariably implemented with the help of numerous paper and other material artefacts.

“While Choose and Book is an electronic system, it was invariably implemented with the help of numerous paper and other material artefacts.”

Almost all activity observed relating to Choose and Book took place in the administrative areas of the practice.

“Almost all the activity we observed relating to Choose and Book took place in the administrative areas of the practice.”

The authors did not encounter any examples of either doctors or patients seeking or using comparative performance data when considering referral preferences.

“Neither did we encounter any examples of either doctors or patients seeking or using comparative performance data when considering their referral preferences.”

Many GPs when observed directly simply did not comply with the policy requirement to offer choice.

“Many GPs when observed directly simply did not comply with the policy requirement to offer 'choice'”

This was partly because even those GPs who had tried using Choose and Book in real time during the consultation had found the technology (and the explanations the patient needed) too time-consuming to fit into a 10-minute consultation.

“This was partly because even those GPs who had tried using it in real time during the consultation had found the technology (and the explanations the patient needed to engage with its use as a 'choice' tool) too time-consuming to fit into a 10-minute consultation.”

A particularly striking finding was that neither local managers nor national policy-makers engaged with the arguments put by the GPs against the choice policy.

“A particularly striking finding on our data was that neither local managers nor national policy-makers engaged with the arguments put by the GPs against the choice policy.”

The capacity of the technology to generate 'personalised' lists of options depending on whether patients wished to choose by distance, car parking, food quality and so on was never instantiated.

“Tellingly, the capacity of the technology to generate 'personalised' lists of options depending on whether patients wished to choose by distance, car parking, food quality and so on was never instantiated.”

The mismatch between the PCT story and the GPs' collective story was highlighted when the reply-to-all function revealed how widespread and deep the strength of feeling was.

“This mismatch between the PCT story and the GPs' collective story was only highlighted when the reply-to-all function revealed how widespread and deep the strength of feeling was.”

A facility for patients to access such data in their local library in the district where Dale and Elm practice were located had no takers in 6 months.

“A facility for patients to access such data in their local library in the district where Dale and Elm practice were located had no takers in 6 months.”

One of the most consistent findings when observing GP-patient consultations was that choice of hospital either was not offered at all or was presented to the patient as an external requirement (something the GP 'had' to do).

“One of our most consistent findings when observing GP-patient consultations was that choice of hospital either was not offered at all or was presented to the patient as an external requirement (something the GP 'had' to do)”

Even when working as intended, Choose and Book required additional manual steps (supported by telephone calls and/or paper printouts) to achieve choosing a hospital and booking an appointment.

“Even when working as intended, it required a number of additional manual steps (supported by telephone calls and/or paper printouts) to achieve the goals of choosing a hospital and booking an appointment.”

At the time of fieldwork, the Choose and Book technology was far from 'plug and play'.

“At the time of our fieldwork, the Choose and Book technology was far from 'plug and play'.”

In some referral-related consultations in Dale and Clover, the GP generated an artefact (usually an internal form) prompting administrative staff to complete a Choose and Book referral, allowing the referral to count toward percentages even when the GP did not actively use the system.

“In some of the referral-related consultations we observed in these two practices, the GP generated an artefact (usually, an internal form) that prompted administrative staff to complete a Choose and Book referral and send details of this to the patient, thereby allowing the referral to 'count' towards the percentages quoted above even when the GP did not actively use the system.”

Because the work of practice administration was complex and fragmented, paper artefacts such as notebooks, scribble pads and sticky notes were widely used.

“Because the work of practice administration was complex and fragmented (e.g.part-completed referrals were often put aside for hours or days pending a response to a query), paper artefacts such as notebooks, scribble pads and sticky notes were widely used.”

Compared with the near-100% reliability of placing a letter in an envelope and sending it to the hospital, the Choose and Book system was almost universally viewed as unpredictable and failure-prone.

“Compared with the near-100% reliability of placing a letter in an envelope and sending it to the hospital, the Choose and Book system was almost universally viewed as unpredictable and failure-prone.”

Many staff interviewed felt that the most significant aspect of the 'unreliability' of the Choose and Book system was not the technical aspects but the lack of booking slots.

“Many staff interviewed for our research felt that the most significant aspect of the 'unreliability' of the Choose and Book system was not the technical aspects but the lack of booking slots.”

Traditional referrals were materially much simpler and smoother than the complex, technically unreliable and difficult-to-use Choose and Book system.

“In contrast to this complex, technically unreliable and difficult-to-use system, traditional referrals were materially much simpler and smoother.”

The kind of knowledge the GP needed to select the best option for the patient-personal, relationally situated and professional knowledge-was not the kind available on the 'NHS Choices' website, which provided formal, regularised knowledge such as scores for food, parking, infection rates and mortality.

“Importantly, the kind of knowledge the GP needed to select the best option for the patient (personal, relationally situated and professional knowledge such as the trust and regard which this GP held for a particular consultant and how that consultant was likely to manage this condition in this patient) was not the kind available on the 'NHS Choices' website (which provided formal, regularised”

Services in other localities were typically organised differently, so a GP was typically very knowledgeable about a local hospital service but much less knowledgeable about comparable services in other localities.

“Services in other localities were typically organised differently (e.g. they called the 'same' clinic by a different name or subdivided the work of the specialty in a different way), so a GP was typically very knowledgeable about a local hospital service but much less knowledgeable about comparable services in other localities.”

Trying and failing to identify any available local appointments for the particular clinic of interest was one of the main frustrations voiced by GPs who had tried and given up on Choose and Book.

“As in the above example, trying and failing to identify any available local appointments for the particular clinic of interest was one of the main frustrations voiced by GPs who had tried (and given up on) Choose and Book.”

The cost of the Choose and Book system was particularly resented because it was perceived to reduce the quality of care that it was possible to provide.

“Importantly, the cost of the system was particularly resented given that it was perceived to reduce the quality of care that it was possible to provide:”

The commonest reason cited by GPs for bypassing Choose and Book and doing a traditional referral was that patients do not want a choice of where they are seen, they just want to attend the hospital nearest to them.

“The commonest reason cited to us by GPs for bypassing the Choose and Book system and doing a traditional referral instead was that, as in the example cited above, 'patients don't want a choice of where they are seen, they just want to attend the hospital nearest to them' (naturalistic interview with GP, Elm practice).”

A striking finding in this study was the limited understanding by either policy-makers or PCT managers of the detail of clinical work or the nature of the knowledge that informed referral practice.

“A striking finding in this study was the limited understanding by either policy-makers or PCT managers of the detail of clinical work or the nature of the knowledge that informed referral practice.”

The researchers identified a tension, sharpened by the electronic template, between different framings of the patient as individual and as one of a denominator population for disease X.

“We identified a tension, sharpened by the electronic template, between different framings of the patientas 'individual' (a person with a unique and perhaps idiosyncratic illness) or as 'one of a denominator population for disease X' (e.g. as 'moderately severe asthma' or 'grade 2 heart failure').”

The researchers observed many examples of GPs asking opportunistically about lifestyle or offering to take blood pressure or weigh patients when they had attended for a different problem, and entering data in the relevant field.

“though we did observe many examples of the GP asking opportunistically about lifestyle or offering to take a patient's blood pressure or weigh them when they had attended for a different problem, and entering data in the relevant field.”

93 consultations for chronic disease surveillance invariably centred on the evidence-based protocols inscribed in the QOF templates.

“As we have illustrated in detail elsewhere, 93 consultations for chronic disease surveillance invariably centred on the 'evidence-based' protocols inscribed in the QOF templates.”

• cites [93] Swinglehurst, 2012, Computer templates in chronic disease management: ethnographic case study in general practice, BMJ Open sourceNot checked yet

  Not checked in the free run.

GPs collectively had considerable scope to negotiate changes in the topic areas, decision models and financial reward systems linked to QOF.

“GPs collectively had considerable scope to negotiate changes in the topic areas, decision models and financial reward systems linked to these.”

The amount of time GPs needed to spend gathering and entering data to ensure the record was complete also rose after the QOF's introduction.

“and the amount of time that needed to be spent gathering and entering data to ensure that the record was complete (and hence eligible for QOF payments) also rose.”

Some nurses enacted conversationally disjointed encounters and persisted in steering the conversation rapidly back to the template agenda whenever the patient embarked on a wider narrative.

“Some nurses enacted conversationally disjointed (and, for the patient, frankly confusing) encounters as illustrated in Box 1, and persisted in steering the conversation rapidly back to the agenda set by the template whenever the patient embarked on a wider narrative.”

There was an annual round of negotiation that fed into the redesign of both the QOF targets and the linked software templates.

“There was (and, at the time of writing, still is) an annual round of negotiation that fed into the redesign of both the QOF targets (what actions GPs were rewarded for) and the linked software templates.”

At the micro level of the clinical consultation, the GP had little scope to alter the assumptions about good clinical practice inscribed into QOF software.

“At the micro level of the clinical consultation, the GP in the surgery had little scope to alter the assumptions about good clinical practice that had been inscribed into QOF software.”

The nurse in Box 3 repeatedly fails to pick up on the various problems that are concerning the patient (immobility, deafness, diarrhoea).

“the nurse (either consciously or unconsciously) repeatedly fails to pick up on the various problems that are concerning the patient (immobility, deafness, diarrhoea).”

The range of quality indicators in the QOF is far more limited than the breadth of conditions seen in general practice.

“the range of quality indicators in the QOF is far more limited than the breadth of conditions seen in general practice”

The researchers never saw a GP start at the top of an electronic template and work methodically and structurally through to the end of it.

“In contrast, we never saw a GP start at the top of an electronic template and work methodically and in a structured way through to the end of it”

Practice nurses tended to follow chronic disease templates more or less as intended, working through the relevant template for each successive patient in designated clinics.

“Practice nurses tended to follow these templates more or less as they were intended to be used, working through the relevant template for each successive patient in a designated 'asthma clinic', 'diabetes clinic' and so on.”

GPs were typically influenced by the financial rewards that came with compliance with completing the data fields and following the management recommendations inscribed in the QOF templates.

“He or she was typically (and understandably) influenced by the financial rewards that came with compliance with completing the data fields and following the management recommendations inscribed in the QOF templates.”

Other nurses were highly skilled in managing the tension between the patient as unique individual and the patient as a case of disease X, responding creatively to prompts within a dialogue constructed around the patient's narrative.

“However, other nurses were highly skilled in managing the tension between the patient as unique individual and the patient as a 'case of disease X', responding creatively to prompts within a dialogue constructed around the patient's narrative.”

The existence of the QOF and its material intrusion into the clinical consultation became increasingly controversial among GPs after its introduction.

“The existence of the QOF, and its material intrusion into the clinical consultation by way of pop-up prompts and template-driven surveillance of chronic diseases (such as ischaemic heart disease, diabetes, asthma and depression), became increasingly controversial among GPs after its introduction”

Relatively few nurses saw the use of the templates as interfering with their professional role.

“It is perhaps for this reason that relatively few nurses saw the use of the templates as interfering with their professional role.”

There was a great deal of resistance to the intrusion of the template and the QOF data collection process into the local, unfolding detail of individual consultations.

“There was a great deal of resistance, however, to the intrusion of the templateand the QOF data collection processinto the local, unfolding detail of individual consultations.”

The GPs in the data set were very comfortable with the role implied in the policy and inscribed in the technology: to oversee the proactive, evidence-based management of chronic diseases.

“The GPs in our data set were also very comfortable with the role for them as implied in the policy and inscribed in the technology: to oversee the proactive, evidence-based management of chronic diseases.”

Clinicians typically found the QOF templates the quickest and easiest way to collect required data in a way that allowed auditing and submission for payment.

“Indeed, clinicians typically found the templates the quickest and easiest way to collect the required data in a way that allowed them to be audited and submitted for payment.”

The expert system developed for chronic disease surveillance encountered far less resistance than that developed for referral to hospital.

“This example illustrates how the expert system developed for chronic disease surveillance encountered far less resistance than that developed for referral to hospital.”

The paper's data did not suggest major adverse perceptions of the material properties of the QOF templates.

“Our data did not suggest major adverse perceptions of the material properties of the QOF templates.”

Few clinicians were resistant to the material and practical aspects of the QOF technology.

“In sum, few clinicians were resistant to the material and practical aspects of the QOF technology.”

The clinicians in the data set perceived QOF to be a highly efficient way of covering a large population of at-risk individuals and preventing expensive-to-treat complications.

“The clinicians in our data set perceived QOF to be a highly efficient way of covering a large population of at-risk individuals and preventing expensive-to-treat complications.”

GPs in particular went to great lengths to use the QOF technology to its maximum potential.

“GPs in particular (who were usually in a profit-share arrangement) went to great lengths to use the technology to its maximum potential, as illustrated by the example in Table 2.”

While completing the QOF boxes, the doctor also managed to attend to the patient's poignant narrative but in a way that fell short of full conversational engagement.

“While doing so, the doctor also manages to attend to the patient's poignant narrative but in a way that falls short of full conversational engagement.”

From the GP practices that chose not to join the pilot in the early adopter sites, the most common and strongly expressed reason was data protection.

“From the GP practices that chose not to join the pilot in the early adopter sites, a number of reasons were given.The most common and strongly expressed was data protection.”

In 2008-10, many GP practices refused to join the SCR scheme.

“In 2008-10, many GP practices refused to join the scheme.”

Their reservations appeared gradually to lessen as more and more practices joined.

“However, their reservations appeared gradually to lessen as more and more practices joined.”

• cites [16] Greenhalgh, 2013, Introducing a nationally shared electronic patient record: case study comparison of Scotland, England, Wales and Northern Ireland, Int J Med Inform sourceNot checked yet

  Not checked in the free run.

Several participating unscheduled care centres decided not to push use of the SCR until the hit-rate had risen.

“several participating unscheduled care centres had decided 'not to push' use of the SCR until the hit-rate had risen.”

SCRs were not easy to access.

“SCRs were not easy to access”

Repeated low hit-rate quickly led doctors to stop trying to call up patients' SCRs.

“Repeated low hit-rate quickly led to a change in behaviour patternthe doctors no longer even tried to call up patients' SCRs.”

Even when the hit-rate rose significantly as more SCRs were created, some records that should have been accessible still came up as blank.

“Even when the hit-rate rose significantly as more SCRs were created, some records that should have been accessible still came up as 'blank'.”

The upload phase tended to be highly disruptive for practices because the system was slow or inoperable for clinical consultations during the upload period.

“This phase tended to be highly disruptive for practices as the system was slow or inoperable for clinical consultations for the duration of the upload period.”

Explaining to patients about the forthcoming go-live and opting out was time-consuming, especially for clinicians who took a position of equipoise.

“explaining to patients about the forthcoming go-live and the options for opting out was time-consuming, especially if the clinician took a position of equipoise and sought to set out arguments both for and against having a SCR.”

Fewer than half of GP practices in participating sites agreed to upload any patient details to the central Spine to create SCRs in the early adopter phase.

“fewer than half of the GP practices in participating sites agreed to upload any patient details to the central Spine to create SCRs in the early adopter phase.”

In the longer term, a more significant problem was that information on the SCR often conflicted with the patient's own account.

“A more significant problem in the longer term was that, as clinicians told us and as our own observations confirmed, the information on the SCR often conflicted with the patient's own account.”

Connecting for Health's active programme of GP engagement, led by respected GP leaders paid a daily rate, met with some but limited success.

“Connecting for Health had an active programme of 'GP engagement' led by respected GP leaders who were paid a daily rate to visit their fellow GPs and champion the new technologyan initiative that met with some (albeit limited) success.”

Some clinicians did not like asking for consent to view the SCR.

“some clinicians did not like asking for consent to view the record.”

Practices seeking to join the SCR programme had to meet stringent data quality standards, often involving several weeks of cleaning GP-held records.

“practices seeking to join the SCR programme had to meet stringent data quality standardsa task that often involved several weeks of 'cleaning' the GP-held records in preparation for the upload.”

• AssumptionRests on an assumption: An extract is only as complete and accurate as the record from which it is created.

One of the paper's main findings was very low use of SCRs in unscheduled care settings in the early adopter phase in 2007-10.

“One of our main (and most controversial) findings was very low use in unscheduled care settings in the early adopter phase in 2007-10.”

Many local GP systems had been bought several years previously and designed for far fewer data than they currently held.

“Many local GP systems had been bought several years previously and designed for far fewer data than they currently held.”

Initially, apart from early integration issues, the biggest problem was the low hit-rate.

“the biggest problem initially was what was known as the 'low hit-rate'.”

Clinicians did not always trust the information provided by SCRs.

“clinicians did not always trust the information they provided”

There was much clinical interest, strongly supported by an interest group within the Royal College of General Practitioners, in an enriched clinical record created in a bespoke way for individual patients by their own GP.

“There was much clinical interest (strongly supported by an interest group within the Royal College of General Practitioners) in an 'enriched' clinical record created in a bespoke way for individual patients by their own GP.”

Even when clinicians trusted SCR information, they found it useful some but not all of the time.

“even when they did trust it, they found it useful some but not all of the time”

The empirical data in the Choose and Book case revealed that doctors', managers' and patients' actions are strongly influenced by their normative perceptions of how they are expected to behave by virtue of their social position.

“The empirical data in the Choose and Book case revealed that doctors' (and managers' and patients') actions are strongly influenced by their normative perceptions of how they are expected to behave by virtue of their social position”

Chronic disease management was oriented around the entry of data onto the template, though perhaps not reduced to it.

“Chronic disease management was perhaps not reduced to the entry of data onto the template but it was certainly oriented around that task”

The reluctance of doctors and others to help create the SCR stemmed at least partly from a lack of confidence in that expert system.

“and the reluctance of doctors and others to help create it stemmed at least partly from a lack of confidence in that expert system.”

The Choose and Book case illustrated a potentially more general phenomenon: resistance playing out as a clash between the abstracted, generalised knowledge and frozen discourses of the expert system and the situated, case-based ethical practices that doctors, nurses and even non-clinical staff felt driven to provide for their patients.

“this case illustrated what was, potentially, a more general phenomenon: 'resistance' playing out as a clash between the abstracted, generalised knowledge and 'frozen discourses' (see quote above, this section) of the expert system and the situated, case-based 'ethical practices' that doctors, nurses and even non-clinical staff felt driven to provide for their patients.”

The second case (chronic disease surveillance and QOF templates) highlighted tension between an expert system (evidence-based guidelines for chronic disease management linked to a national pay-for-performance scheme) and the exigencies of the local situation (patients do not behave as textbook disease cases or come with one problem at a time).

“Our second case, which considered the social practice of chronic disease surveillance and the technology of 'QOF templates', also highlighted to some extent the tension between an expert system (in this case, 'evidence based' guidelines for chronic disease management linked to a national pay-for-performance scheme) and the exigencies of the local situation (in this case, the fact that patients do”

The SCR was not an expert system in the same sense as Choose and Book or the QOF templates.

“The last case studythe social practice of unscheduled care and the SCR technologyis slightly different in that the SCR was not an 'expert system' in the same sense as Choose and Book or the QOF templates.”

The nurses whose work we observed became, to a significant extent, the fillers-out of the QOF templates.

“The nurses whose work we observed became, to a significant extent, the fillers-out of the templates.”

A nurse negotiated with her GP employers to allocate 30 rather than 15 minutes per patient.

“A good example of this is the nurse who negotiated with her GP employers to allocate 30 rather than 15 minutes per patient.”

The authors encountered examples of patients claiming a penicillin allergy not recorded on their SCR and vice versa.

“We encountered several examples of patients claiming a penicillin allergy that was not recorded on their SCRand vice versa.”

The most complete and accurate account of medication tended to come not from the SCR but from the patient or a close relative or friend who knew their here-and-now circumstances.

“The most complete and accurate account of the medication tended to come not from the SCR (whose information was distant in time and place) but from the patient, or from a close relative or friend who knew their here-and-now circumstances.”

To some extent, the SCR did inscribe a body of more or less contested expert knowledge, such as knowledge about what constituted immediate and necessary data about a patient in an emergency, what the minimum data set of sharable fields within any GP-held record should be, or which diseases or risk states should be classified as private or sensitive and therefore not shared.

“To some extent, however, it did inscribe a body of (more or less contested) expert knowledgefor example, knowledge about what constituted 'immediate and necessary' data about a patient in an emergency, what the 'minimum data set' of sharable fields within any GP-held record should be, or which diseases or risk states should be classified as 'private' or 'sensitive' (and, therefore, not to be”

A final issue accounting for resistance to accessing the SCR was reluctance to ask the patient for consent to view the record.

“A final issue accounting for resistance to accessing the SCR was reluctance to ask the patient for consent to view the record.”

The SCR became one of many sources of information, weighed against the patient, relatives and material evidence.

“The SCR became one of many sources of information, and was weighed against other sources including the patient, their relatives and any material evidence presented in the here-and-now”

Our data revealed that even when accessing the SCR resonated with the script of good professional practice, the SCR sometimes provided nothing more than an error message.

“Our data revealed how, even when accessing the SCR resonated with the script of good professional practice, the SCR sometimes provided nothing more than an error message.”

In relation to Choose and Book, the technology sometimes offered up no available outpatient slots for the desired referral.

“In relation to Choose and Book, the technology sometimes offered up no available outpatient slots for the desired referral.”

ICT programmes in health care fail partly because people do not use the technologies.

“Information and communication technology (ICT) programmes in health care fail partly because people do not use the technologies.”

• Also stated in: § Conclusion · plain

  “Lack of realisation of their hoped-for benefits was attributed mainly to the fact that they were not being used.[8][9][10][11]”

• cites [8] Greenhalgh, 2010, Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study, BMJ sourceNot checked yet

  Not checked in the free run.

• cites [9] Greenhalgh, 2010, Adoption, non-adoption and abandonment of an Internet-accessible personal health organiser: case study of HealthSpace, BMJ sourceNot checked yet

  Not checked in the free run.

• cites [10] Bratan, 2010, ‘Never heard of it’– understanding the public’s lack of awareness of a new electronic patient record, Health Expect sourceNot checked yet

  Not checked in the free run.

ICTs configure the user: their design implies particular roles and behaviours that users may find difficult or impossible to adopt.

“In some senses, they 'configure the user'that is, their design implies particular roles and behaviours that users may find it difficult or impossible to adopt.”

The clinical encounter is a social accomplishment, shaped and constrained by both social forces and the material properties of technology.

“Our theorisation depicted the clinical encounter (and other practices within health care) as a social accomplishment, shaped and constrained by both social forces and the material properties of technology.”

The consequences of ICT use and non-use by frontline staff feed back into organisational routines and wider social structures, shaping and constraining what is possible, reasonable, legitimate and appropriate in the frontline clinical and administrative situation.

“Furthermore, the consequences of ICT use and non-use by frontline staff feed back into organisational routines and wider social structures, shaping and constraining what is possible, reasonable, legitimate and appropriate in the frontline clinical and administrative situation.”

'Resistance' to ICT use is a complex phenomenon with both normative and sociomaterial components.

“'Resistance' to ICT use is a complex phenomenon with both normative and sociomaterial components.”

Individual 'resistance' to a particular ICT can be conceptualised as emerging as a product of the actor-network rather than as originating within the person's ideas, beliefs, competences and so on.

“This example illustrates how individual 'resistance' to a particular ICT can be conceptualised as emerging as a product of the actor-network rather than as originating within the person's ideas, beliefs, competences and so on.”

Resistance to ICT use is unlikely to be overcome using atheoretical behaviourist measures.

“It is unlikely to be overcome using atheoretical behaviourist measures, nor would attempts to do this be desirable.”

If GPs acquiesce with the external imposition of expert systems, the organisation's culture steadily changes from a local, personalised service to a distinctly bureaucratic ethos driven by nationally standardised operating procedures.

“If GPs acquiesce with the external imposition of expert systems, the organisation's culture steadily changes from a local, personalised service where staff and patients know each other by name to a distinctly bureaucratic ethos driven by (nationally) standard(ised) operating procedures.”

In fewer than half of the maternity units studied, midwives had been consulted at all about the nature of their work or the design of the IT system.

“They found that in fewer than half of the units had midwives been consulted at all about the nature of their work or the design of the IT system.”

• cites [56] Henwood, 2003, Articulating gender in the context of ICTs in health care: the case of electronic patient records in maternity services, Crit Soc Policy sourceNot checked yet

  Not checked in the free run.

PACS was popular and widely used because it scored highly on all four constructs of normalisation process theory.

“in contrast, Picture Archiving and Communication System (PACS; a digital image storage and retrieval package), was popular and widely used because it scored highly on all of the four constructs listed in the previous paragraph.19”

• cites [19] Murray, 2011, Why is it difficult to implement e-health initiatives? A qualitative study, Implementation Sci sourceNot checked yet

  Not checked in the free run.

Strong structuration theory can accommodate actor-network theory's notion that aspects of the social order can be inscribed in technologies, which may to some extent freeze certain position-practice relations within the technology.

“Secondly, SST can accommodate ANT's notion that aspects of the social order can be inscribed in technologies and this may to some extent 'freeze' certain position-practice relations within the technology.”

Strong structuration theory can be enhanced by selected concepts from actor-network theory.

“As we have argued previously, SST can be enhanced by selected concepts from ANT. 58”

• cites [58] Greenhalgh, 2010, Theorising big IT programmes in healthcare: strong structuration theory meets actor–network theory, Soc Sci Med sourceNot checked yet

  Not checked in the free run.

There is a powerful momentum towards general and universalising rules and processes, and away from the application of practical wisdom in specific contexts.

“There is a powerful momentum towards general and universalising rules and processes, and away from the application of practical wisdom (what Aristotle called phronesis) in specific contexts.”

In the case of Choose and Book, the classificatory rules and procedures driving and embedded in the software and its networks were informed by an oversimplified modernist image of the sick patient as a rational chooser.

“In the case of Choose and Book, the classificatory rules and procedures driving, and embedded in, the software and its networks were informed by another oversimplified modernist imageof the sick patient as a rational chooser”

Schemes in which organisations or clinicians are financially penalised or subjected to public release of performance data for not using a particular technology implicitly rest on simplified, behaviourist 'rational actor' assumptions.

“Likewise, schemes in which organisations or clinicians are financially penalised or subjected to public release of performance data ('named and shamed') for not using a particular technology, implicitly rest on what are arguably simplified, behaviourist 'rational actor' assumptions.”

The prompts and sanctions embedded within expert systems marginalise and downplay the in situ characteristics and contingencies of particular cases and encounters.

“The prompts and sanctions embedded within this system marginalise and downplay the in situ characteristics and contingencies of particular cases and encounters.”

NHS policy changes in the early 2000s were strongly influenced by the mind-set of late modernity.

“NHS policy changes in the early 2000s were strongly influenced by the mind-set of late modernity, with its various commissions and omissions.”

• cites [74] Giddens, 1990Not checked yet

  Not checked in the free run.

• cites [120] Dourish, 2011 sourceNot checked yet

  Not checked in the free run.

The standardisation imposed by expert systems and templates leads to a tendency to greatly oversimplify the nature of, and downplay the significance of, local situations and interactions.

“This leads to a tendency to greatly oversimplify the nature of, and to downplay the significance of, local situations and interactions.”

Much of the knowledge and judgement of healthcare professionals, particularly in primary health care, relies on being rooted in the immediacies of context.

“Importantly, much of the knowledge and judgement of healthcare professionals, particularly in primary health care, relies on being rooted in the immediacies of context.”

A GP's judgements about the referral of a patient to hospital have traditionally been informed by knowledge of the patient's personal history, knowledge of the workings of their own practice, and knowledge of local social relations.

“A GP's judgements about the referral of a patient to hospital, for example, have traditionally been informed by (a) knowledge of the patient's personal history (both medical and social), (b) knowledge of the workings of their own practice (including the various incentives, disincentives and practicalities of different options), and (c) knowledge of local social relations”

The sociotechnical system of the Choose and Book initiative was heavily influenced by the ideology of competition and by the salutary effects that competition was said to have on cost-efficiency, patient satisfaction and patient outcomes.

“The sociotechnical system of the Choose and Book initiative was also heavily influenced by the ideology of competition, and by the salutary effects that competition was said to have on cost-efficiency, patient satisfaction and patient outcomes.”

The policy of enforced competition between hospital providers was pushed forward with considerable confidence, deflecting attention away from that strategy's limited evidence base.

“This was ideological in that a policy of enforced competition between hospital providersdriven, it was assumed, by the rationally-choosing patientwas pushed forward with considerable confidence, deflecting attention away from that strategy's limited evidence base”

• AssumptionThe authors state this as an assumption: The policy of enforced competition between hospital providers was driven by the rationally-choosing patient.

The 'expert system' character of Choose and Book militates against using contextual knowledge, thus impoverishing the scope and quality of judgements.

“The 'expert system' character of Choose and Book militates against using such knowledge, thus impoverishing the scope and quality of judgements.”

Templates for chronic disease management built around national guidelines and a pay-for-performance system will tend to impose a highly standardised structure and set of priorities on the consultation.

“Similarly, templates for chronic disease management that are built around national guidelines and a pay-for-performance system will tend to impose a highly standardised structure and set of priorities on the consultation.”

Clinician decisions are not merely 'rational' but also practical and ethical, taking account of the situated details of individual cases, including engagement with 'what matters to people' to particular patients.

“To the extent that the clinician's role includes making decisions (perhaps on a shared basis with the patient), these are not merely 'rational' (i.e. based on the best available medical evidence) but also practical and ethicalthat is, they take account of the situated details of individual cases, including a serious engagement with 'what matters to people' to particular flesh-and-blood patients.77”

• cites [77] Sayer, 2011 sourceNot checked yet

  Not checked in the free run.

The complexity and unreliability of the automated referral system contrasted markedly with the policy expectation and the explicit promise on the Choose and Book website of greater reliability and efficiency.

“In sum, the detailed descriptions above of the complexity and unreliability of the 'automated' referral system contrast markedly with the policy expectation (and the explicit promise on the Choose and Book website) of greater reliability and efficiency because 'most of the communication is done via computers'.”

Staff whose identity and perceived role aligned closely with the structure and processes of the expert system focused entirely on the means of achieving the task and did not question the ends.

“Note that here, as elsewhere, staff whose identity and perceived role aligned closely with the structure and processes of the expert system focused entirely on the means of achieving the task and did not question the ends.”

Our findings suggest a significant mismatch between the model of clinical work underpinning the 'choice' policy and inscribed in Choose and Book, and the much more complex, granular and exception-filled nature of real-world clinical practice.

“Our findings suggest a significant mismatch between the model of clinical work underpinning the 'choice' policy and inscribed in the Choose and Book technology, and the much more complex, granular and exception-filled nature of real-world clinical practice.”

Both national and local policy-makers were characterised by a striking lack of engagement with the values, identities and relationships of general practice.

“Both national and local policy-makers were characterised by a striking lack of engagement with the values, identities and relationships of general practice.”

Applying the theoretical framework, the abstract systems inscribed within Choose and Book served to subvert and efface the local knowledge and contextual judgement that enabled referral to be truly personalised and aligned with professional care.

“Applying our theoretical framework, the abstract systems inscribed within Choose and Book served to subvert and efface the local knowledge and contextual judgement that enabled the referral to be truly personalised and aligned with professional care as defined in Chapter 3 (see Applying the normative anchor: medicine's internal goods).”

The framing of Choose and Book use as a 'quality standard' by PCT staff, and their refusal to engage with GPs' concerns about threats to quality, is an example of the silencing effects that Boltanski writes about.

“The framing of Choose and Book use as a 'quality standard' by PCT staff, and their refusal to engage with the GPs' concerns about threats to quality, is an example of the silencing effects that the French sociological theorist Luc Boltanski writes about in criticising neo-managerialism's concerted, ill-advised constriction of the space for meaningful conversation and debate about the role of”

• cites Boltanski 113Not checked yet

  Not checked in the free run.

The pressure from policy-makers on the medical profession to comply with a restricted taxonomy of readily classifiable disease states reflects the kind of technology-work mismatch described by Brown and Duguid in a range of work settings.

“The pressure from policy-makers on the medical profession to comply with a restricted taxonomy of readily classifiable disease states that map unproblematically to particular investigations or treatments reflects the kind of technology-work mismatch described by Brown and Duguid 50 in a range of work settings.”

• cites Brown and Duguid 50Not checked yet

  Not checked in the free run.

The picture of nurse compliance and GP resistance is far more complex than the expectation that nurses always complied and GPs always resisted.

“It might be expected that nurses always 'complied' with the templates and GPs (who never formally followed them) always 'resisted' them, but the picture is far more complex.”

The policy of financially rewarding proactive surveillance and the technology enabling it were resonant with shifts in professional roles that were occurring anyway.

“In this sense, the policy of financially rewarding proactive surveillance of such conditions and the technology that enabled this to be done systematically and in a structured way were all resonant with shifts in professional roles (especially that of the practice nurse) that were occurring anyway.”

The Table 2 example affirms cost as a key element of resistance by illustrating how financial benefit can lead to extreme forms of compliance.

“This example thus affirms cost as a key element of resistance by illustrating, perhaps, how financial benefit can lead to extreme forms of compliance.”

The sheer number of QOF items and the pervasive intrusion of prompts and reminders in almost every adult consultation makes it impossible for the consultation to follow a traditional interaction around the presenting problem.

“The issue is not that the policy is wrong in principle, or that the QOF produces role conflict for the GP, but that the sheer number of QOF items and the pervasive intrusion of prompts and reminders in almost every adult consultation makes it impossible for the consultation to follow a traditional interaction around the 'presenting problem'.”

The QOF was strongly aligned with the new managerialism introduced by the New Labour government in the early 2000s, including a policy of transparency and close monitoring of performance towards nationally set targets.

“In this sense, the QOF was strongly aligned with the new managerialism being introduced by the New Labour government in the early 2000sa policy of 'transparency' (i.e. the collection and public release of performance data) and close monitoring of this performance towards nationally set targets.”

• cites [164] Harrison, 2002, New Labour, modernisation and the medical labour process, J Soc Policy sourceNot checked yet

  Not checked in the free run.

The QOF template technology aligned with a wider shift in the role of the practice nurse towards surveillance and preventative care of chronic diseases.

“In relation to roles and relationships, the QOF template technology aligned with a wider shift in the role of the practice nurse towards surveillance and preventative care of chronic diseases.”

Local GPs were particularly irritated because they did not benefit directly from SCRs for their own patients.

“This was particularly irritating for local GPs because, as explained above, they themselves did not benefit directly from the existence of SCRs for their own patients.”

There was not enough slack in local GP systems to accommodate a further demand on their running capacity.

“There was simply not enough slack in the system to accommodate a further demand on their running capacity.”

A data item acquires the qualities of relevance, urgency, sensitivity and so on only in relation to particular scenarios and particular contexts.

“Rather, a data item ('rash on penicillin', 'attention-deficit disorder'or even the person's home address) acquires the qualities of relevance, urgency, sensitivity and so on only in relation to particular scenarios and particular contexts.”

The mismatch was that doctors were usually unaware of the clinical caseload in walk-in centres, which tended to be minor injuries or illnesses rarely requiring prescribed medication.

“The mismatch was that the doctors were usually unaware of the clinical caseload in walk-in centres, which tended to be minor injuries or illnesses that rarely required prescribed medication.”

Much of the tension in the chronic disease surveillance/QOF case could be explained in terms of internal social structures and the scripts about good practice that guided health professionals' behaviour.

“Again, much of this tension could be explained in terms of internal social structures and the scripts about 'good practice' that guided health professionals' behaviour.”

Even when the SCR contained a complete and accurate list of current GP-prescribed medication, it still did not reflect what some of the sickest patients were actually taking.

“even when the SCR contained a 'complete and accurate' list of current GP-prescribed medication, this still did not reflect what some of the sickest patients were actually taking.”

The notion of a professional role as purely the product of all the relationships in the network is inadequate to explain all of our findings.

“However, we found the notion of a professional role as purely the product of all the relationships in the network (as with the quote from Berg in Chapter 1) inadequate to explain all of our findings.”

If a patient was unconscious, the key information need was not current medication but rapidly changing physiological variables such as blood glucose or oxygen saturation levels.

“If the patient was unconscious (e.g. in diabetes or epilepsy), the key information need was not the current medication but rapidly changing physiological variables such as blood glucose or oxygen saturation levels.”

The actions of this nurse are better explained using a layered ontology than a single plane of endlessly entangled translations.

“The actions of this nurse are, we contend, thus better explained using a layered ontology than a 'single plane of endlessly entangled translations'.”

This change was achieved through human agency, driven by dispositions and professional values.

“This change was achieved through human agency, driven by dispositions and professional values: the nurse had insisted that her 'job' was not merely completing the templates, important and evidence-based though these were.”

People become particular actors as a result of their position in the sociotechnical network.

“The second way in which ANT allowed us to extend and enhance SST was the notion that people become particular actors as a result of their position in the sociotechnical network.”

In both the SCR and Choose and Book cases, even when the technology supported rather than conflicted with good professional practice, its physical unreliability and/or sheer material complexity tended to generate unintended consequences for the clinician, patient or organisation.

“In both cases, even when the technology supported rather than conflicted with 'good professional practice' (and especially when it did not), its physical unreliability and/or sheer material complexity tended to generate unintended consequences for the clinician, patient or organisation.”

ANT did not allow us to theorise these unintended consequences adequately, because a key finding in our data set was how these unintended consequences grated uncomfortably with clinicians' perceptions of their professional role, their duties to their patients and their definition of excellent, ethical practice.

“However, we found that ANT did not allow us to theorise these unintended consequences adequately, as a key finding in our data set was how these unintended consequences grated uncomfortably with clinicians' perceptions of their professional role, their duties to their patients and their definition of excellent, ethical practice.”

In relation to the SCR, the very idea of a source of complete and accurate data on a patient's medication and allergies, available at the touch of a button to someone with appropriate authorisation, depends heavily on the button providing reliable access to the promised data fields when it is touched.

“For example, in relation to the SCR, the very idea of a source of complete and accurate data on a patient's medication and allergies, available 'at the touch of a button' to someone with appropriate authorisation, depends heavily on the button providing reliable access to the promised data fields when it is touched.”