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Cross-sector collaborations between academia, government, and private industry, known as Triple Helix configurations, are increasingly common. In the health Information Technology (IT) sector, such configurations often also include health delivery organizations where technology is implemented and used. The complexity of collaborating within and between multiple organizations can present hurdles for innovators that are seldom discussed in the literature. We outline challenges we encountered in cross-sector collaboration and offer some guiding principles for decision-makers, academics, industry partners, and health delivery organizations to successfully negotiate divergent approaches to innovation and implementation. We discuss an innovative project that aims to implement a researcher-designed adverse drug event reporting system into clinical care and integrate it with provincial and health authority IT systems. Based on our experience, implementing an interoperable health IT system must extend beyond technical integration to encompass meaningful stakeholder engagement to ensure utility for end-users and beneficial impact for participating organizations.

Background Existing systems to document adverse drug events often use free text data entry, which produces nonstandardized and unstructured data that are prone to misinterpretation. Standardized terminology may improve data quality; however, it is unclear which data standard is most appropriate for documenting adverse drug event symptoms and diagnoses. Objective This study aims to compare the utility, strengths, and weaknesses of different data standards for documenting adverse drug event symptoms and diagnoses. Methods We performed a mixed methods substudy of a multicenter retrospective chart review. We reviewed the research records of prospectively diagnosed adverse drug events at 5 Canadian hospitals. A total of 2 pharmacy research assistants independently entered the symptoms and diagnoses for the adverse drug events using four standards: Medical Dictionary for Regulatory Activities (MedDRA), Systematized Nomenclature of Medicine (SNOMED) Clinical Terms, SNOMED Adverse Reaction (SNOMED ADR), and International Classification of Diseases (ICD) 11th Revision. Disagreements between research assistants regarding the case-specific utility of data standards were discussed until a consensus was reached. We used consensus ratings to determine the proportion of adverse drug events covered by a data standard and coded and analyzed field notes from the consensus sessions. Results We reviewed 573 adverse drug events and found that MedDRA and ICD-11 had excellent coverage of adverse drug event symptoms and diagnoses. MedDRA had the highest number of matches between the research assistants, whereas ICD-11 had the fewest. SNOMED ADR had the lowest proportion of adverse drug event coverage. The research assistants were most likely to encounter terminological challenges with SNOMED ADR and usability challenges with ICD-11, whereas least likely to encounter challenges with MedDRA. Conclusions Usability, comprehensiveness, and accuracy are important features of data standards for documenting adverse drug event symptoms and diagnoses. On the basis of our results, we recommend the use of MedDRA.

Background Adverse drug events are unintended and harmful effects of medication use. Using existing information and communication technologies (ICTs) to increase information sharing about adverse drug events may improve patient care but can introduce concerns about data privacy. Objective This study aims to examine the views of patients and their caregivers about data protection when using ICTs to communicate adverse drug event information to improve patient safety. Methods We conducted an exploratory qualitative study. A total of 4 focus groups were held among patients who had experienced or were at risk of experiencing an adverse drug event, their family members, and their caregivers. We recruited participants through multiple avenues and iteratively analyzed the data using situational analysis. Results Of the 47 participants recruited, 28 attended our focus groups. We identified 3 primary themes. First, participants felt that improved information sharing about adverse drug events within their circle of care would likely improve care. Second, participants were concerned about data handling and inappropriate access but believed that the benefits of information sharing outweighed the risks of privacy breaches. Finally, participants were more concerned about data privacy in the context of stigmatized health conditions. Conclusions Current conditions for maintaining health data privacy are consistent with participants’ preferences, despite the fact that health data are susceptible to breaches and mismanagement. Information sharing that increases patient safety may justify potential privacy risks. Greater attention to patient concerns and the effect of social and contextual concerns in the design and implementation of health information technologies may increase patient confidence in the privacy of their information.

Rationale, aims, and objectives Local health administrators implemented chronic obstructive pulmonary disease and heart failure admission order sets to increase guideline adherence. We explored the impact of these order sets on workflows and guideline adherence in the internal medicine specialty in two Canadian teaching hospitals. Methods A mixed methods study combined shadowing care providers (250 h), meeting observation and interviews (11 h), and patient medical chart audits for heart failure (n = 120) and chronic obstructive pulmonary disease (n = 120) patients. The chart audits analysed details of the admission process and 14 guideline elements associated with heart failure (nine) and chronic obstructive pulmonary disease (five). Results A subset (10/14) of the evaluated guideline elements were included in the heart failure or chronic obstructive pulmonary disease order sets. Order set use significantly increased adherence to some (4/10) of these elements. However, our qualitative work uncovered a perception that use of these two order sets increased order duplication. Our chart audits supported this perception. Order set use increased order duplication for heart failure (92% vs 43%) and chronic obstructive pulmonary disease (75% vs 43%). Conclusion It is unclear whether, for these two hospitals, the gains brought by implementation of chronic obstructive pulmonary disease and heart failure admission order sets were worth their associated organisational shortcomings. Problems with order set implementation appeared to stem from poor integration with pre-existing complex organisational systems. Health administrators and clinicians interested in implementing order sets within their own hospitals need to remain cognizant of how these tools will fit into existing systems and practices.

Informational continuity of care is a central component of effective health care delivery and patient management but is often not achieved, leaving patients to compensate for or suffer from the burden of informational discontinuity of care. Fragmentation and siloed care delivery and communication within and across care settings present significant challenges to informational continuity of care. This is especially the case in the context of adverse drug events (ADEs), the harmful and unanticipated outcomes of medication use. This paper introduces a project called ActionADE that is intended to bridge informational gaps related to ADEs by enabling the documentation and communication of patient-specific ADE information. It contributes to literature concerned with information sharing in healthcare through a focus on patient views about sharing medication information through the design of an ADE reporting system, and explores implications for system design within a sociotechnical framework.

Background There is a high degree of variability in assessing the preventability of adverse drug events, limiting the ability to compare rates of preventable adverse drug events across different studies. We compared three methods for determining preventability of adverse drug events in emergency department patients and explored their strengths and weaknesses. Methods This mixed-methods study enrolled emergency department patients diagnosed with at least one adverse drug event from three prior prospective studies. A clinical pharmacist and physician reviewed the medical and research records of all patients, and independently rated each event’s preventability using a “best practice-based” approach, an “error-based” approach, and an “algorithm-based” approach. Raters discussed discordant ratings until reaching consensus. We assessed the inter-rater agreement between clinicians using the same assessment method, and between different assessment methods using Cohen’s kappa with 95% confidence intervals (95% CI). Qualitative researchers observed discussions, took field notes, and reviewed free text comments made by clinicians in a “comment” box in the data collection form. We developed a coding structure and iteratively analyzed qualitative data for emerging themes regarding the application of each preventability assessment method using NVivo. Results Among 1356 adverse drug events, a best practice-based approach rated 64.1% (95% CI: 61.5–66.6%) of events as preventable, an error-based approach rated 64.3% (95% CI: 61.8–66.9%) of events as preventable, and an algorithm-based approach rated 68.8% (95% CI: 66.1–71.1%) of events as preventable. When applying the same method, the inter-rater agreement between clinicians was 0.53 (95% CI: 0.48–0.59), 0.55 (95%CI: 0.50–0.60) and 0.55 (95% CI: 0.49–0.55) for the best practice-, error-, and algorithm-based approaches, respectively. The inter-rater agreement between different assessment methods using consensus ratings for each ranged between 0.88 (95% CI 0.85–0.91) and 0.99 (95% CI 0.98–1.00). Compared to a best practice-based assessment, clinicians believed the algorithm-based assessment was too rigid. It did not account for the complexities of and variations in clinical practice, and frequently was too definitive when assigning preventability ratings. Conclusion There was good agreement between all three methods of determining the preventability of adverse drug events. However, clinicians found the algorithmic approach constraining, and preferred a best practice-based assessment method. Electronic supplementary material The online version of this article (10.1186/s12874-018-0617-4) contains supplementary material, which is available to authorized users.

In this paper, we present an account of the challenges faced while implementing a participatory design intervention in healthcare. We use examples from the development of ActionADE, an electronic application for sharing patient-specific adverse drug event information between hospitals (where adverse drug events are documented) and community pharmacies (where harmful drugs can be unintentionally re- dispensed). While developing ActionADE entailed extensive qualitative work, its implementation is contingent on our research team's action in the health data infrastructure arena, including developing and maintaining stakeholder relationships and addressing policy and governance issues. Competencies and skills in this area are often overlooked, yet are required to achieve successful uptake of participatory design interventions in health information technology.

Adverse drug events (ADEs) are the harmful and unintended consequences of medication use. ADEs have become a leading cause of outpatient visits, emergency department visits, and unplanned admissions to hospital. Many of these events are not strictly pharmacological, but rather are related to practical challenges in the coordination of care,prescribing, dispensing, and medication use, and may be preventable with new modes of documentation and communication for medication management. Action ADE is a CSCW intervention that aims to enable communication of patient ADE information across healthcare settings in the province of British Columbia, Canada. Implementing Action ADE requires negotiations of political agendas and policy change, evolving medical information system infrastructures, and the needs and practices of clinicians and patients. As the initial design phase for Action ADE comes to a close and we enter into our first phase of piloting and implementation, this poster provides a snapshot of five domains in which our project intervenes and highlights findings from our extensive qualitative work.

Background Adverse drug events (ADEs), harmful unintended consequences of medication use, are a leading cause of hospital admissions, yet are rarely documented in a structured format between care providers. We describe pilot-testing structured ADE documentation fields prior to integration into an electronic medical record (EMR). Methods We completed a qualitative study at two Canadian hospitals. Using data derived from a systematic review of the literature, we developed screen mock-ups for an ADE reporting platform, iteratively revised in participatory workshops with diverse end-user groups. We designed a paper-based form reflecting the data elements contained in the mock-ups. We distributed them to a convenience sample of clinical pharmacists, and completed ethnographic workplace observations while the forms were used. We reviewed completed forms, collected feedback from pharmacists using semi-structured interviews, and coded the data in NVivo for themes related to the ADE form. Results We completed 25 h of clinical observations, and 24 ADEs were documented. Pharmacists perceived the form as simple and clear, with sufficient detail to capture ADEs. They identified fields for omission, and others requiring more detail. Pharmacists encountered barriers to documenting ADEs including uncertainty about what constituted a reportable ADE, inability to complete patient follow-up, the need for inter-professional communication to rule out alternative diagnoses, and concern about creating a permanent record. Conclusion Paper-based pilot-testing allowed planning for important modifications in an ADE documentation form prior to implementation in an EMR. While paper-based piloting is rarely reported prior to EMR implementations, it can inform design and enhance functionality. Piloting with other groups of care providers and in different healthcare settings will likely lead to further revisions prior to broader implementations.

The aim of this manuscript is to identify for the reader how communication gaps during handovers from hospital personnel to parents after pediatric day surgery can endanger patient safety. Variables analyzed include parent-reported quality of communication and hospital safety culture, medication safety, surgical wound care, and nausea and vomiting knowledge. Data are obtained via a 21-item questionnaire. The reader is informed of a technique for communication quality measurement that combines naturalistic observation of the discharge process, a theoretical model of discharge communication and safety domain modeling and analysis. The reader is informed via the discharge communication and safety domain model of the areas posing the most risk to patient safety in the post-discharge period.

This paper looks at the challenges associated with consolidating and leveraging patient information recorded at various points in a distributed, multi-jurisdictional health care system. We draw on insights from two ethnographic case studies to illuminate varied issues related to interoperability of information management systems. Our first case study is an investigation of duplicate medical charts which exist in several ambulatory care clinics located on the same campus at an acute care hospital. The second case study is an ongoing exploratory project intended to develop an understanding of information collection, storage and handover procedures in the pre-hospital care chain, a health care domain that includes varied actors and organizations with different information needs. Whereas findings from our case studies show that achievement of interoperability will be difficult, our analysis suggests ways to begin to overcome these challenges.

Background: Patients commonly transition between health care settings, requiring care providers to transfer medication utilization information. Yet, information sharing about adverse drug events (ADEs) remains nonstandardized. Objective: The objective of our study was to describe a minimum required dataset for clinicians to document and communicate ADEs to support clinical decision making and improve patient safety. Methods: We used mixed-methods analysis to design a minimum required dataset for ADE documentation and communication. First, we completed a systematic review of the existing ADE reporting systems. After synthesizing reporting concepts and data fields, we conducted fieldwork to inform the design of a preliminary reporting form. We presented this information to clinician end-user groups to establish a recommended dataset. Finally, we pilot-tested and refined the dataset in a paper-based format. Results: We evaluated a total of 1782 unique data fields identified in our systematic review that describe the reporter, patient, ADE, and suspect and concomitant drugs. Of these, clinicians requested that 26 data fields be integrated into the dataset. Avoiding the need to report information already available electronically, reliance on prospective rather than retrospective causality assessments, and omitting fields deemed irrelevant to clinical care were key considerations. Conclusions: By attending to the information needs of clinicians, we developed a standardized dataset for adverse drug event reporting. This dataset can be used to support communication between care providers and integrated into electronic systems to improve patient safety. If anonymized, these standardized data may be used for enhanced pharmacovigilance and research activities.

In recent years considerable attention has been focused on the potential of the Internet as a means of health information delivery that can meet varied health information needs and empower patients. In this article, we explore utilization of the Internet as a means of health information consumption amongst young women with breast cancer who were known Internet users. Focusing on a population known to be competent at using the Internet allowed us to eliminate the digital divide as a possible explanation for limited use of the Internet for health information-seeking. Ultimately, this allowed us to demonstrate that even in this Internet savvy population, the Internet is not necessarily an unproblematic means of disseminating health care information, and to demonstrate that the huge amount of health care information available does not automatically mean that information is useful to those who seek it, or even particularly easy to find. Results from our qualitative study suggest that young women with breast cancer sought information about their illness in order to make a health related decision, to learn what would come next, or to pursue social support. Our respondents reported that the Internet was one source of many that they consulted when seeking information about their illness, and it was not the most trusted or most utilized source of information this population sought.

The starting point for this special issue on CSCW and Dependable Healthcare systems is the recognition of ‘dependability as an essential and under-researched, CSCW problem. Self-evidently, societys dependence on computer-based systems continues to increase, while the systems themselves – embracing humans, computers and engineered systems – become ever more complex. These trends coincide with pressure for systems to be brought to market faster and at lower (and more predictable) cost. Achieving sufficient dependability in these systems, and demonstrating this achievement in a rigorous and convincing manner, is of crucial importance to the fabric of the modern Information Society. Much progress has been made in achieving high dependability in computer hardware and software but wider systems involving computers, people and organisations are often disastrously unsuccessful and the cause of huge financial losses or worse. It is evident that satisfactory resolution of this dangerous situation demands major breakthroughs in understanding the fundamental problems that arise in attempts to build systems involving complex interactions amongst numbers of computers and human beings. Our interest in this special issue is in the issues of developing improved means of specifying, designing, assessing, deploying and maintaining complex computer-based systems in those contexts where high dependability is crucial – in this case health care systems. The enormous growth in the use of communications and information technology in all aspects of healthcare provision including electronic patient records, data warehouses, integrated clinical, biomedical and administrative computer systems, telemedicine applications, computerized workflow and order entry, presents healthcare professionals with a wide range of opportunities and challenges in healthcare delivery.

On Nov. 6, 2014, the Canadian government passed Bill C-17 (Vanessa’s Law), aimed at strengthening the powers of government to recall a drug that is shown to have harmful effects.[1][1] The bill is expected to strengthen postmarket surveillance and research, and allow the Minister of Health to

Aim. This paper reports a review of the literature on the association between critical care nurse staffing levels and patient mortality. Background. Statistically significant inverse associations between levels of nurse staffing and hospital mortality have not been consistently found in the literature. Critical care settings are ideal to address this relationship due to high patient acuity and mortality, high intensity of the nursing care required, and availability of individual risk adjustment methods. Methods. Major electronic databases were searched, including MEDLINE, EMBASE, and the Cumulative Index of Nursing and Allied Health Literature. The search terms included critical/intensive care, quality of health care, mortality/hospital mortality, personnel staffing and scheduling, and nursing staff (hospital). Only papers published in English were included. The original search was conducted in 2002 and updated in 2005. Results. Nine studies were selected from 251 references screened. All nine were observational. Six were conducted in the United States of America, one in Austria, one in Brazil, and one in Scotland. The unadjusted risk ratio of nurse staffing (high vs. low) on hospital mortality were combined meta-analytically (five studies). The pooled estimate was 0·65 (95% confidence interval 0·47–0·91). However, after adjusting for various covariates within each study, the individually reported associations between high nurse staffing and low hospital mortality became non-significant in all but one study. Conclusion. The impact of nurse staffing levels on patients’ hospital mortality in critical care settings was not evident in the reviewed studies. Methodological challenges that might have impeded correct assessment of the association include measurement problems in exposure status and confounding factors, often uncontrolled. The lack of association also indicates that hospital mortality may not be sensitive enough to detect the consequences of low nurse staffing levels in critical care settings.

Many projects have been undertaken to ensure that the Canadian health system is efficient, effective and publicly accountable. One common area for such initiatives is general management of the heal...

Background: Adverse drug events are unintended and harmful events related to medications. Adverse drug events are important for patient care, quality improvement, drug safety research, and postmarketing surveillance, but they are vastly underreported. Objective: Our objectives were to identify barriers to adverse drug event documentation and factors contributing to underreporting. Methods: This qualitative study was conducted in 1 ambulatory center, and the emergency departments and inpatient wards of 3 acute care hospitals in British Columbia between March 2014 and December 2016. We completed workplace observations and focus groups with general practitioners, hospitalists, emergency physicians, and hospital and community pharmacists. We analyzed field notes by coding and iteratively analyzing our data to identify emerging concepts, generate thematic and event summaries, and create workflow diagrams. Clinicians validated emerging concepts by applying them to cases from their clinical practice. Results: We completed 238 hours of observations during which clinicians investigated 65 suspect adverse drug events. The observed events were often complex and diagnosed over time, requiring the input of multiple providers. Providers documented adverse drug events in charts to support continuity of care but never reported them to external agencies. Providers faced time constraints, and reporting would have required duplication of documentation. Conclusions: Existing reporting systems are not suited to capture the complex nature of adverse drug events or adapted to workflow and are simply not used by frontline clinicians. Systems that are integrated into electronic medical records, make use of existing data to avoid duplication of documentation, and generate alerts to improve safety may address the shortcomings of existing systems and generate robust adverse drug event data as a by-product of safer care. [JMIR Public Health Surveill 2018;4(1):e21]

Participatory design is an approach to designing technological systems that differs from traditional approaches to design in many respects. The goal of participatory design is to encourage users of technological systems to actively participate in the process of designing technological systems. The end goal of participatory design is to enable users of technological systems to articulate their needs, and to develop technological systems that account for those needs. In this paper I attempt to extend the analysis of gender as a factor in participatory design initiative by focusing on the challenges of implementing participatory design in the context of non-profit women’s organizations. The context for my discussion is set by outlining a recent initiative to design a nationwide feminist computer network in Canada. Scholarship on participatory design, feminist organizing and the implementation of computer systems in non-profit organizations is discussed in relation to original research carried out in the Canadian province of Newfoundland. Organizational structures that differentiate feminist non-profit organizations from other organizational forms and the gendered nature of expertise are identified as particular challenges that must be addressed in order for participatory design to be successful when women’s groups are the participatory designers.

(1996). Women und computer networking in six countries. The Journal of International Communication: Vol. 3, No. 1, pp. 66-84.

BackgroundAll youth are susceptible to mental health issues and engaging in risky behavior, and for youth with chronic health conditions, the consequences can be more significant than in their healthy peers. Standardized paper-based questionnaires are recommended by the American Academy of Pediatrics in community practice to screen for health risks. In hospitals, psychosocial screening is traditionally undertaken using the Home Education, Eating, Activities, Drugs, Depression, Sex, Safety (HEEADDSS) interview. However, time constraints and patient/provider discomfort reduce implementation. We report findings from an eHealth initiative undertaken to improve uptake of psychosocial screening among youth. ObjectiveYouth are sophisticated “technology natives.” Our objective was to leverage youth’s comfort with technology, creating a youth-friendly interactive mobile eHealth psychosocial screening tool, TickiT. Patients enter data into the mobile application prior to a clinician visit. Response data is recorded in a report, which generates alerts for clinicians, shifting the clinical focus from collecting information to focused management. Design goals included improving the patient experience, improving efficiency through electronic patient based data entry, and supporting the collection of aggregated data for research. MethodsThis paper describes the iterative design and evaluation processes undertaken to develop TickiT including co-creation processes, and a pilot study utilizing mixed qualitative and quantitative methods. A collaborative industry/academic partnership engaged stakeholders (youth, health care providers, and administrators) in the co-creation development process. An independent descriptive study conducted in 2 Canadian pediatric teaching hospitals evaluated the feasibility of the platform in both inpatient and ambulatory clinical settings, evaluating both providers and patient responses to the platform. ResultsThe independent pilot feasibility study included 80 adolescents, 12-18 years, and 38 medical staff-residents, inpatient and outpatient pediatricians, and surgeons. Youth uptake was 99% (79/80), and survey completion 99% (78/79; 90 questions). Youth found it easy to understand (92%, 72/78), easy to use (92%, 72/78), and efficient (80%, 63/79 with completion rate < 10 minutes). Residents were most positive about the application and surgeons were least positive. All inpatient providers obtained new patient information. ConclusionsCo-creative design methodology with stakeholders was effective for informing design and development processes to leverage effective eHealth opportunities. Continuing stakeholder engagement has further fostered platform development. The platform has the potential to meet IHI Triple Aim goals. Clinical adaptation requires planning, training, and support for health care providers to adjust their practices.

It is argued that with the introduction of electronic medical record (EMR) systems into the primary care sector, data collected can be used for secondary purposes which extend beyond individual patient care (e.g., for chronic disease management, prevention and clinical performance evaluation). However, EMR systems are primarily designed to support clinical tasks, and data entry practices of clinicians focus on the treatment of individual patients. Hence data collected through EMRs is not always useful in meeting these ends. Purpose In this paper we follow a community health centre (CHC), and document the changes in work practices of the personnel that were necessary in order to make EMR data useful for secondary purposes. Methods This project followed an action research approach, in which ethnographic data were collected mainly by participant observations, by a researcher who also acted as an IT support person for the clinic's secondary usage of EMR data. Additionally, interviews were carried out with the clinical and administrative personnel of the CHC. Results The case study demonstrates that meaningful use of secondary data occurs only after a long process, aimed at creating the pre-conditions for meaningful use of secondary data, has taken place. Preconditions Specific areas of focus have to be chosen for secondary data use, and initiatives have to be continuously evaluated and adapted to the workflow through a team approach. Collaboration between IT support and physicians is necessary to tailor the software to allow for the collection of clinically relevant data. Data entry procedures may have to be changed to encourage the usage of an agreed-upon coding scheme, required for meaningful use of secondary data. And finally resources in terms of additional personnel or dedicated time are necessary to keep up with data collection and other tasks required as a pre-condition to secondary use of data, communication of the results to the clinic, and eventual re-evaluation. Consequences Changes in the work practices observed in this case which were required to support secondary data use from the EMR included completion of additional tasks by clinical and administrative personnel related to the organization of follow-up tasks. Among physicians increased awareness of specific initiatives and guideline compliance in terms of chronic disease management and prevention was noticed. Finally, the clinic was able to evaluate their own practice and present the results to varied stakeholders. Conclusions The case describes the secondary usage of data by a clinic aimed at improving management of the clinic's patients. It illustrates that creating the pre-conditions for secondary use of data from EMRs is a complex process which can be seen as a shift in paradigms from a focus on individual patient care to chronic disease management and performance measurement. More research is needed about how to best support clinics in the process of change management necessitated by emerging clinical management goals.

Background and Objectives: The advent of the Internet has made in-home monitoring a possibility for patients suffering from chronic disease, although few studies have examined this phenomena across different disease states. The goal of this review is to identify and evaluate studies where randomized control trials were used to evaluate Internet-mediated home monitoring systems designed to manage and support patients with chronic diseases.Methods and Results: We reviewed 454 abstracts of articles describing computerbased health interventions and read forty-three articles in depth. Seventeen articles met inclusion criteria and were selected for this review. Only completed randomized, controlled trials that reported physiological health outcomes of the intervention were included. Other results reviewed included the populations studied, the short and long term effectiveness of the interventions, costs and technology-related issues and health care provider communication. Internet-mediated home monitoring interventions appear to have some benefit for specific chronic diseases in specific circumstances. Few studies documented cost savings; none of those that did used consistent measures. Studies seldom addressed the challenges of introducing sophisticated interactive-monitoring systems into patients’ homes, the reasons for attrition from trials, or the effects of the intervention on the work of care providers or interprofessional practices.Conclusions: The interventions reviewed showed potential to enhance chronic disease management in some cases. However, the short duration of the studies made it difficult to generalize the results to wider home care settings or predict the effectiveness of such systems over the long and complicated courses of chronic diseases. Thus, despite hopes for significant cost and labour savings, Internet-mediated systems for monitoring chronic diseases in patients’ homes will likely complement rather than replace usual care.

In this paper we show how action research contributes to the design of health information systems by constructing knowledge addressing users’ concerns in a timely manner. Our aim conducting action research is to understand the work practices of the expected users and to bring this understanding to the design, ensuring that we are enabling users rather than constraining their work. We view this process as a knowledge translation process where researchers and users exchange and create new knowledge about technology and use practices. We argue that action research can be viewed as a knowledge translation process, where researchers and users co-construct a common context for design and use of technology. By providing insights from our two years of action research focusing on the design and use of emergency department information systems within a Canadian hospital, we identify four main activities essential for creating the research context as a knowledge translation context.

Virtually all health sector work requires a high degree of interaction with technologies, ranging from medical devices such as defibulators to electronic medical records. Although this chapter focuses on information technologies specifically, the definition is a broad one and includes any technologies that provide a means through which health information is made visible to, and circulated between, staff and practitioners who then act on that information as they manage patients’ health. Within this definition, heart monitors, which convey information about heart rate and heart rhythms over time, alerting practitioners to problems requiring action may be thought of as information technologies. More conventional definitions of information technologies would include electronic patient record systems which record test values and data about patients over time, in support of diagnosis and care planning. When successfully embedded in work practices, health information technologies can support managerial, clinical, and/or administrative staff as they work together with patients to produce health.

Throughout the world, information and communication technologies (ICTs) are increasingly being used in health care delivery. Information systems to support a wide range of health care activities including the collection of health information, the distribution of health information to citizens, and improved diagnoses and care have been developed to reflect the new political priorities of increased accountability, patient and public involvement, and evidence-based medicine.

Our aim in this concluding chapter is to reflect upon the relationship between gender, health, and ICTs, paying particular attention to the social contexts within which they become embedded. We return to the two key questions posed in the Introduction: How does exploring the socio-technical relations of ICTs in health care inform our understanding of gender? And to what extent can a closer understanding of gender as process, or of how gender ‘works’, inform and extend our knowledge of the ways in which ICTs are being developed, implemented, and used in health care contexts? This final chapter seeks to reflect on the ideas developed by individual authors in order to return to the overarching themes addressed in the book, to consider their implications for policy and practice, and, finally, to pinpoint future directions for research.

Introduction: Informing Gender? Health and Information Technologies in Context E.Balka, E.Green & F.Henwood All Change? Gender, Health and the Internet F.Henwood & S.Wyatt Gendered Identities and Caring: Health Intermediaries and Technology in Rural and Remote Queensland L.Simpson, M.Hall & S.Leggett Geeks Who Care: Gender, Caring and Community Access Computers L.Bella Cyber-Burdens: Emerging Imperatives in Women's Unpaid Care Work R.Harris Nursing Technologies? Gender, Care, and Skill in the Use of Patient Care Information Systems Z.Sharman Gender, Information Technology and Making Health Work: Unpacking Complex Relations at Work E.Balka Gendering Work? Women and Technologies in Health Care P.Armstrong, H.Armstrong & K.Messing Ungendering Women's Health: Information Systems and Occupational Health Indicators G.Le Jeune 'It Can See into Your Body': Gender, ICTs and and Decision Making about Midlife Women's Health E.Green, F.Griffiths & A.Lindenmeyer Conclusion: Reconfiguring the Gender, Technology and Health Relationship E.Balka, E.Green & F.Henwood

In this paper we outline a typology, which will be useful for those engaged in the design and customization of information systems in healthcare. Drawing on ethnographic case studies conducted in six healthcare settings in two countries, the typology outlined here is intended to identify possible sources of local variability of health care work practices, which need to be accommodated in local configurations of generic information systems.

Driven by citizen demand and supported by government, the area of e-health covers a wide range of socio-technical innovations in health service delivery and organization, ranging from electronic patient records and hospital administrative computer systems to end-user consumption of online health information. Information technology applications in the health sector have made it possible to consolidate numerous and varied sources of information. For example, patients and their families can use the internet to search for information about health and illness online. With the emergence of online health information, the internet was often viewed as an optimal way to disseminate health information because it offers privacy, immediacy, a wide variety of information and a variety of perspectives (Bischoff and Kelley, 1999). As the inter-net has expanded to address the demand for medical information on health-related topics (McLeod, 1998), optimism about internet health information seeking has cooled, and although emphasis on internet-based health information as a means to empowerment continues (Masi et al., 2003), many recent studies which have explored the dynamics surrounding online health information consumption present a more nuanced view (Henwood et al., 2003; Pitts, 2004).

Here discourse about information technology in Canada’s health sector is examined. After an overview of the emergence of the Canadian Health Information Infrastructure, discourse within the Romanow Report is discussed in relation to three key themes: standardization, empowerment, and time/space compression. While an instrumental view of technology in the health care sector is the predominant discourse articulated in the report, we argue that, by emphasizing technology assessment, the Romanow Report makes room for a more nuanced analysis of technology implementations than is common to government reports. We conclude by suggesting how investigations of information and communication technology in the health sector, such as this, may offer opportunities to raise critical questions about technology and health policy from a communications perspective. Résumé : Dans cet article, nous effectuons une analyse de discours sur les technologies de l’information dans le secteur de la santé au Canada. Suivant un survol de l’infrastructure de la technologie de l’information sur la santé du Canada, nous passons en revue le discours du rapport Romanow relatif à trois thèmes clés : la standardisation, l’autonomisation et la compression espace-temps. Bien qu’une perspective instrumentale sur la technologie dans le système de soins soit le discours prédominant articulé dans ce rapport, nous soutenons que le rapport Romanow, en mettant l’accent sur la prospective, effectue une analyse plus nuancée des mises en oeuvre technologiques que celles qu’on lit ordinairement dans des rapports gouvernementaux. Nous concluons cet article en proposant que des études comme celle-ci, qui portent sur la technologie de ’information et de la communication dans le secteur de la santé, ont le potentiel, tout en privilégiant une perspective communicationnelle, de soulever des questions critiques sur les politiques en matière de technologie et de santé.

While investigating the resistance to the electronic triage system, ETRIAGE, at the emergency department of British Columbia Children’s Hospital, we revisit the wellknown CSCW-debate about THE COORDINATOR concerning the politics of standardized categories. Examining the history as well as the design of ETRIAGE, we reveal four basic assumptions about triage work in emergency departments, which are reflected in the design of the ETRIAGE application and related to the managerial agenda of controlling costs in hospitals. We find that ETRIAGE has an embedded surveillance-capability, which challenges the professional authority of nurses’ work and removes discretion from the individual. We argue that the resistance towards ETRIAGE should be understood in terms of experienced nurses’ disputing the assumptions about their professional practice that are embodied within such systems rather than general resistance to change or resistance to technology.

Qualitative research is often opposed to quantitative research. But numbers can play an important role in illustrating analyses in qualitative research. Their persuasive, concrete nature can help ensure the success of a workplace intervention, especially in the North American context, where numbers are treated very seriously. We describe a method of work analysis and transformation developed at the Conservatoire national des arts et métiers in Paris, where the meaning of the numbers used is critical. We think that the numbers used in work analysis have a different meaning from that in a “pure” quantitative study, where they are submitted to statistical procedures for hypothesis testing. Using examples from recent studies carried out in Québec and Canada in collaboration with unions or joint health and safety committees, we show that counting can be part of qualitative analysis, enrich our portrait of organizational and physical aspects of the work process, and help indicate pathways for workplace improvement.

The Community Engagement Model was developed as a tool for the production of health communication videos for broadcast on local television stations. The model, a hybrid of participatory video design and social marketing techniques, uses iterative design principles for both production and evaluation. This article reports on the use of this model for the design and production of a series of videos aimed at promoting awareness of the BC NurseLine (a 24-hour telephone health service) among Farsi speakers in the Greater Vancouver area. Statistical analysis of project-related data suggests that the use of an extensive, culturally engaged process to produce and evaluate the videos was integral to its success. The steps taken in this campaign are described to show how the Community Engagement Model can be used to produce effective, culturally sensitive, participatory media targeted at specific communities. Resume: Le « Community Engagement Model » (modele d’engagement communautaire) a ete developpe afin de produire des courtes videos de communication pour la sante, diffusees sur des postes de television locales. Le modele, un hybride entre les techniques de video participative et de marketing social, se sert des principes de design iteratif pour la production ainsi que l’evaluation. Le present document decrit l’utilisation de ce modele dans la conception et la production d’une serie de videos ayant pour but de mieux faire connaitre le BC NurseLine (service d’info-sante 24-h de la Colombie Britannique) aupres de la communaute farsi dans la region metropolitaine de Vancouver. Une analyse statistique suggere que l’integration d’un processus extensif et engage au niveau culturel, tant dans la production que dans l’evaluation de ces videos, a ete un facteur cle dans leur succes. Le processus suivi lors de cette campagne est decrit pour montrer comment le modele d’engagement communautaire puisse etre employe pour produire des medias participatifs, a la fois efficaces et adaptes aux specificites culturelles, ciblant des communautes specifiques.

In this paper we discuss configurability as a form of appropriation work. We suggest that making technology work requires an awareness of the multiple dimensions of configurability carried out by numerous actors within and outside of the organizations in which new technologies are introduced in efforts to support cooperative work. Through discussion of the introduction of a wireless call system into a hospital, we provide an overview of these dimensions -- organisational relations, space and technology relations, connectivity, direct engagement, and configurability as part of technology use and work - and we suggest that in increasingly complex technological and organisational contexts, greater attention will need to be focused on these dimensions of configurability in order to make things work.

Shapiro [38] recently argued that participatory design practitioners should consider pursuing a reformist agenda through engagement with the procurement and development of systems in the public sector. This paper considers the challenges, contradictions and possible arenas for success in the context of a reformist participatory design agenda [38], by reflecting on recent work undertaken from a stance similar to that advocated by Shapiro [38] in a public sector agency. The intention of the paper is to stimulate and extend discussion about arenas in which the political goals that characterized participatory design in its early days can be pursued, and extend discussions about the role of politics in contemporary participatory design [14].

Technology and equipment are often identified as contributors to adverse medical events, however technology is seldom the focal point of investigation as a source of medical error or adverse event. It is often seen as both a means of reducing error (e.g., automated drug dispensing machines) or as a major contributing factor to adverse events (e.g., through cog- nitive overload). Here we review literature about the governance of technology in health settings, which is addressed in relation to patient safety. We outline the challenges of addressing technology governance issues in the health sector, provide an overview of governance processes, and suggest that technology related adverse events have been largely conceptualized as device and user problems rather than system or socio-technical problems, which is reflected in governance processes associated with medical devices. A recognition of the situatedness of medical practices implies that new forms of governance may be required that place greater emphasis on socio-technical and systems issues. © 2006 Published by Elsevier Ireland Ltd.

In June 2003, a large, Canadian tertiary care facility introduced automatic drug dispensing machines on all units when it opened up a new building. In this paper, we provide an overview of the automatic drug dispensing system (ADS) implementation at the hospital. Our findings, based on daily field observations and interviews during and after implementation, with regular follow-up visits to the field site illustrate how the introduction of the ADS brought to light work practices that sometimes compromised patient safety. We suggest that utopian views of automatic drug dispensing machines obfuscate the challenges inherent to implementing such systems, and deter stakeholders from performing rigorous evaluation of the costs (both social and economic) and benefits of investing in such systems. Our work contributes to debates about the socio-technical efficacy of automating medication dispensing and delivery, and suggests that the balance of power in the patient safety equation lies in the work context and implementation issues, and not just the technology. For technology implementations to be successful considering that technologies frequently cross over jurisdictional boundaries, planning and implementation have to be conducted at a system wide level.

In this paper, we discuss the challenges of altering computer systems that are increasingly characterized by high degrees of system configurability for use in complex organizational and technological work contexts. We suggest that configurable systems are often accompanied by additional system intermediaries, which in turn introduce new challenges for users' ability to adequately configure systems in practice.

The notion that the design of technology is only fully completed when in use [23] is shared by many who now investigate user participation in design and the domestication of new technologies. Taking this idea as our starting point, we developed a research to action project with a major Canadian hospital. Our goals were to address technology implementation issues that arose as most units in the hospital moved to a new building, in which most technology (ranging from wired beds to drug dispensing machines) was new. This paper reports our findings from this project. Emphasis is placed on how institutional arrangements influenced the range of socio-technical possibilities that could be pursued [7]. Work practice problems are discussed in relation to the meso or organizational contexts, including organizational, vendor and staff actor networks.

Summary Objectives: While recognized that global actors influence health information system design, studies of health informatics have largely focused on micro politics of technology design and implementation. Here a problematic patient care information system (PCIS) is discussed in relation to federal and provincial policies and corporate strategies to demonstrate that our understanding of health informatics can be enhanced by linking micro studies of health informatics to larger macro contexts. Methods: Interviews and document study. Results: Although the extent to which federal initiatives influenced (or failed to influence) provincial and hospital initiatives remains debateable, events initiated at one level (the hospital’s decision to implement software, initiated at the organizational level) are influenced (perhaps indirectly) by developments in other contexts (federal /macro changes gave an initiative more weight; provincial initiatives such as the Labour Accord altered the industrial relations environment in which system development occurred). Conclusions: Micro-studies of work practice, invaluable in addressing interactions between technologies, users and work practices, often fail to account for the historic reach of global actors, although it is often these historic circumstances that contribute to present-day interactions between user, information system and organization, and that find expression – often indirectly – in daily work practices.

Allowing a group of users to produce and transmit some annotations in common digital documents is nowadays a major issue for groupware systems. In this paper, we report a psychological and ergonomic study carried out on this topic in the mechanical design domain. We observed a collective design process that took place in a series of face-to-face meetings attended by the members of a design team. Our results show the minor role played by textual annotations, contrasting with the great number of figurative annotations. We also highlight that the function of annotations is not to develop parts of the solution but to provide the team members with contextual descriptions of the problem and the solution. These results are a first step towards a model of annotations in a collective face-to-face situation. They also provide interesting tracks for elaborating specifications of annotations in mediated situations.