Abstract
Information and communications technologies (ICTs) in healthcare are often introduced with expectations of higher-quality, more efficient, and safer care. Many fail to meet these expectations. We argue here that the well-documented failures of ICTs in healthcare are partly attributable to the philosophical foundations of much health informatics research. Positivistic assumptions underpinning the design, implementation and evaluation of ICTs (in particular the notion that technology X has an impact which can be measured and reproduced in new settings), and the deterministic experimental and quasi-experimental study designs which follow from these assumptions, have inherent limitations when ICTs are part of complex social practices involving multiple human actors. We suggest that while experimental and quasi-experimental studies have an important place in health informatics research overall, ethnography is the preferred methodological approach for studying ICTs introduced into complex social systems. But for ethnographic approaches to be accepted and used to their full potential, many in the health informatics community will need to revisit their philosophical assumptions about what counts as research rigor.
Highlights
Information and communications technologies (ICTs) in healthcare are often introduced with expectations of higher-quality, more efficient, and safer care
Rapidly expanding field of research strongly influenced by doctors with an interest in computers. It emerged at around the same time as evidence-based medicine (EBM) and overlapped with the latter in several areas of work, notably the development of ICT systems to support large-scale epidemiological surveys and clinical trials; routinization of the use of Medline and other electronic databases; standardization of clinical practice via guidelines and automated decision support; and innovations such as computerized physician order entry (CPOE) aimed at reducing medical error [2,3,4]
We review how ethnography has been applied to study ICT use as social practice and propose that ethnographic approaches should be applied more widely in this field
Summary
What is ethnography? The ethnographer immerses him or herself in a social situation and collects naturalistic data (that is, realworld observations rather than under experimental conditions) in a pragmatic, reflexive and emergent way [13,15]. Ellingsen and Monteiro’s ethnographic studies of electronic patient record systems in different departments in a Norwegian hospital [37,38] showed that seemingly redundant (repeated) or ambiguous (similar but not identical) entries served an important function: they created a space in which different teams could share information while maintaining different interpretations of it They concluded that large, tightly integrated systems in which all data fields are rigidly standardized may be of less use in practice than smaller, more loosely coupled systems which make multiple, overlapping representations of knowledge possible [39,40]. Summary Whereas the dominant positivist paradigm in health informatics research tends to privilege the universal, the unified and the standardized (for example, the single, agreeable version of the electronic record in which each data item is entered only once and has a tightly-defined, non-negotiable meaning; common interoperability standards; shared protocols and guidelines, and so on), ethnographic studies have highlighted how collaborative work is achieved via multiple, iterative contributions to the emergent detail of particular situations. Competing interests The authors declare that they have no competing interests
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