Ebook: Techno-Anthropology in Health Informatics

This book has been written by a group of renowned and experienced international researchers from nine countries, who share here how they have applied Techno-Anthropological methodologies to their research in a variety of different health informatics contexts. Bridges have been built in the process of editing and writing this book, and we are now actually building Techno-Anthropological research constructions in research environments in Denmark, Australia, Canada, Finland and Israel.

This is the third major work on Techno-Anthropology, following What is Techno-Anthropology? (2013) edited by Tom Børsen and Lars Botin and a special issue on Techno-Anthropology in Techné: Journal of the Society for Philosophy and Technology – edited by Galit Wellner, Lars Botin and Kathrin Otrel-Cass (2015).

In this current volume we specifically address methodology from ethnographic, anthropological, ethical, sociotechnical and participatory perspectives in a health informatics context, which is reflected in the structure of the anthology.

Techno-Anthropology is an emerging interdisciplinary research field that focuses on human/technology interactions and relations, and on how these can be understood and facilitated in context. This means that Techno-Anthropology has much to offer the health informatics and eHealth contexts when it comes to applying methods and techniques that can create an understanding of how citizens, patients, health care professionals, IT-professionals – and those who manage them – interact with technology. Techno-Anthropology, in its current configuration, also considers how technological innovation, development and implementation can be made in an appropriate and pragmatic way in relation to understanding work practices and in interpretations of technology in situated and contextual transfers of knowledge in constant negotiations. This means that there is a striving towards connecting science, engineering, social science and the humanities. The conglomeration of knowledge paradigms is what constitutes the interdisciplinary core of Techno-Anthropology, which paradoxically makes it both hard to defend and barrier-breaking in its essence.

The book's target audience is researchers and practitioners within the Health informatics field, as well as students and scholars within academia. It is our hope that this book will encourage people to apply Techno-Anthropology – quickly and correctly – in Health informatics, and inspire more researchers and practitioners to value and respect the competences of those using health informatics systems and applications, which are becoming an integral part of practicing health care to an increasing extent.

As editors, we have enjoyed our fruitful conversations, discussions, reflections and exchange of draft materials with the authors of this book. We hope that you will enjoy reading the book and will benefit from the insights it provides. We hope to inspire more researchers to join the emerging field of Techno-Anthropological research within Health informatics.

Lars Botin, Pernille Bertelsen and Christian Nøhr

June 2015

This chapter discusses the complementary role of Techno-Anthropological methodologies in relation to classical quantitative and qualitative methodologies. The chapter addresses the importance of evidencing the problems in health informatics and how these problems are framed in order to find appropriate solutions. It is the claim that problem based learning approaches (PBL) and inter-disciplinary teamwork is paramount in order to meet the current challenges of development and implementation of health informatics in the health care system. The triple aim of providing better health, better care at lower cost on a societal level is complemented by similar aims on an institutional and individual level in order to frame health informatics on a more holistic level. In order to achieve this goal we have to embrace concepts like co-creation and co-construction with users and actors. The aim of the chapter is condensed in methodological recommendations for Techno-Anthropological work in health informatics contexts.

Ethnography is the defining practice – and art – of anthropology. Among health information technology (IT) developers, however, ethnography remains a little used and undervalued mode of inquiry and representation. In this chapter we demonstrate that ethnography can make important contributions to the design and implementation of more user-oriented health IT devices and systems. In particular, we propose ‘rapid ethnography’ as a pragmatic strategy that draws on classic ethnographic methods, but emphasizes shorter periods of fieldwork and quick turnaround of findings to inform (re)design, programming and implementation efforts. Rapid ethnography is theoretically and empirically situated in science and technology studies' explorations of a) the entanglement of social and technical dimensions of technology use; b) how getting tools to ‘work’ requires aligning interests across a wide range of human and non-human actors; and c) the ways in which humans and technology transform each other as they interact. We provide two detailed case studies to illustrate the evolution and uses of rapid ethnography at a U.S. academic medical center. By providing deeper insights into the experiences of users, and the contexts and communities in which new tools are introduced, rapid ethnography can serve as a valuable component of Techno-Anthropology and health IT innovation.

This chapter demonstrates how ethnographically-oriented research on emergent technologies, in this case self-tracking technologies, adds to Techno-Anthropology's aims of understanding techno-engagements and solving problems that deal with human-technology relations within and beyond health informatics. Everyday techno-relations have been a long-standing research interest in anthropology, underlining the necessity of empirical engagement with the ways in which people and technologies co-construct their daily conditions. By focusing on the uses of a food tracking application, MealLogger, designed for photographing meals and visualizing eating rhythms to share with health care professionals, the chapter details how personal data streams support and challenge health care practices. The interviewed professionals, from doctors to nutritionists, have used food tracking for treating patients with eating disorders, weight problems, and mental health issues. In general terms, self-tracking advances the practices of visually and temporally documenting, retrieving, communicating, and understanding physical and mental processes and, by doing so, it offers a new kind of visual mediation. The professionals point out how a visual food journal opens a window onto everyday life, bypassing customary ways of seeing and treating patients, thereby highlighting how self-tracking practices can aid in escaping the clinical gaze by promoting a new kind of communication through visualization and narration. Health care professionals are also, however, acutely aware of the barriers to adopting self-tracking practices as part of existing patient care. The health care system is neither used to, nor comfortable with, personal data that originates outside the system; it is not seen as evidence and its institutional position remains insecure.

The British National Formulary underpins the way medical practice is made safe in the UK. Its move from book to digital product has been identified as welcome but with problematic aspects. This chapter describes and investigates the current use of the formulary in order to examine how a rapid, well-targeted project is designed and executed.

This chapter explores how Techno-Anthropology can contribute to more explicitly professional and ethically responsible reflections on the socio-technical practices involved in meaningfully engaging patients in health informatics research. The chapter draws on insights from health informatics research projects focused on chronic disease and self-management conducted in Tasmania during the last 10 years. Through these projects the paper explores three topics of relevance to ‘meaningful engagement’ with patients: (i) Patient Self-Management and Chronic Disease (ii) Patients as Users in Health Informatics research, and, (iii) Evaluations of outcomes in Health and Health Informatics Interventions. Techno-Anthropological reflections are then discussed through the concepts of liminality, polyphony and power. This chapter argues that beyond its contribution to methodology, an important role for Techno-Anthropology in patient centred health informatics research may be its capacity to support new ways of conceptualising and critically reflecting on the construction and mediation of patients' needs, values and perspectives.

Anthropology attempts to gain insight into people's experiential life-worlds through long-term fieldwork. The quality of anthropological knowledge production, however, does not depend solely on the duration of the stay in the field, but also on a particular way of seeing social situations. The anthropological perspective is grounded in socio-cultural theory and forged by a distinct relativist or contextualist epistemological stance. The point is to understand events, concepts and phenomena from the insiders' point of view and to show how this view relates to the particular social and cultural context. In this chapter, we argue that although anthropology has its specific methodology – including a myriad of ethnographic data-gathering tools, techniques, analytical approaches and theories – it must first and foremost be understood as a craft. Anthropology as craft requires a specific ‘anthropological sensibility’ that differs from the standardized procedures of normal science. To establish our points we use an example of problem-based project work conducted by a group of Techno-Anthropology students at Aalborg University, we focus on key aspects of this craft and how the students began to learn it: For two weeks the students followed the work of a group of porters. Drawing on anthropological concepts and research strategies the students gained crucial insights about the potential effects of using tracking technologies in the hospital.

One of the most important Techno-Anthropological intellectual virtues is the ability to make contextualized ethical judgments of new and emerging technologies. This Techno-Anthropological core competence is especially relevant in Health Information Systems Technologies, which is a field characterized by inherent ethical dilemmas such as the pros and cons of regulation of research databases with sensitive information, or storing and application of tissue and blood samples. In this paper we present a method to make ‘proper and quick’ ethical estimates in Health Information. The method guides its user to make ethical judgments by splitting the judgment process into four steps: 1) Identification of intended beneficial consequences, potential misuse, unintended side effects and long-term consequences for culture and society. 2) Linkage of intended consequences, misuse, side effects and cultural implications to appropriate ethical values. 3) Identification of ethical dilemmas related to a specific use of the Health Information Systems Technology under assessment. 4) Formulation of appropriate technological and institution design criteria that can transcend the identified ethical dilemmas. The methodology will be applied to a the discussions at a hearing on ethical challenges accompanying research involving health data organized by the Danish Council of Ethics and the case of risk reducing breast cancer surgery based on diagnosed genetic predisposition to breast cancer.

In this chapter we analyze aspects of how Danish student nurses acquire technological literacy during their clinical internship at a Danish hospital. The argument is supported by several cases from Esbensen's empirical work. We focus on a Techno-Anthropological study of how student nurses learn to engage in technological mediated relations, and discuss how we think the ideas of intersecting worlds help to analyze some of the difficulties, student's experience.

The links between a Personal Health Record (PHR) and an Electronic Health Record (EHR) have influences beyond the technical tethering. It should involve an analysis of the relations between users, healthcare professionals and technology. In order to provide fresh perspectives, the postphenomenological relations of embodiment, hermeneutic and alterity are analyzed and developed into augmented embodiment and quasi-doctor terminology.

Implementing health information technology (HIT) is a challenge that frequently results in unintended consequences post implementation. To better manage these consequences we need approaches that can proactively identify issues so we deal with them pre-implementation. It can be suggested that a reason unintended consequences occur is because of trade-offs between people's work practices and pre and post HIT implementation. If we can identify what these trade-offs are we can use them for proactive management of unintended consequences. This paper uses a case study of a perioperative information system and principles of social BPM and qualitative content analysis to develop a model of seven trade-off patterns that can be used to study HIT mediated change. It also discusses the implications of the model on the design and evaluation of HIT.

In this book chapter the authors review several Techno-Anthropologic approaches that can be used to improve the quality and safety of health information technology (HIT) by eliminating or reducing the incidence and occurrence of technology-induced errors. Technology-induced errors arise from interactions between health professionals, patients and/or HIT (i.e. software and hardware) and lead to a medical error. Techno-Anthropologic methods can be used to address these types of medical errors before they occur. In this book chapter they are discussed in the context of: (a) how they can be applied to identifying technology-induced errors and (b) how this information can be used to design and implement safer HIT. Important in this chapter is a review of several methods: traditional ethnography, rapid assessment of clinical information systems, video ethnography and photovoice as they are applied to the discovery of potential (i.e. near misses) and actual (i.e. mistakes) technology-induced errors.

A major challenge in the design of useful technological tools is effectively conceptualizing the context in which users engage the technology. Contextually specific research on activities of patients and their caregivers - and how those activities are supported by social and material arrangements - can result in insights for design of consumer health informatics technologies and infrastructural advancements that can better support patients outside of institutional settings. This chapter describes an ecosystem focused on activity – how activity is shaped by cultural institutions, and the negotiations that arise between actors and institutions.

Monitoring technology, especially sensor-based technology, is increasingly taken into use in care work. Despite the simplicity of these technologies – aimed to automate what appear as mundane monitoring tasks – recent research has identified major challenges primarily related to the technology's ability to meet the complexity of care work. Understanding intersectional challenges between these care technologies and care work is fundamental to improve design and use of health informatics. In this paper we present an analysis of interaction challenges between a wet-sensor at the task of monitoring wet beds at a nursing home. The analysis identifies the multifaceted nature of monitoring work and the intricacy of integrating sensor technology into the complex knowledge system of monitoring work.

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

Studying technology will often involve studying change – or in the perspective of this chapter should involve not just studying but also actively being involved with change. Your presence and the questions you ask shape the way people think and act and on the other hand their responses and your study of practice change the researchers perspective. For Techno-Anthropologist, this means that asking in specific ways about technology and having a focus on technology in the data collection and fieldwork will (should) influence what they see, the data they collect and their analysis – and also the way the informants think and the way people talk about practice and technology. The Techno-Anthropological researcher should be aware and actively use the potential for change in the empirical study of technology. In this chapter I exemplify and examine how and why change can be embraced and seen as an integral part of Techno-Anthropological studies in Health Informatics and beyond. This statement is supported through reflections on empirical examples, qualitative methods, and ethical and philosophical considerations on research and change. The chapter concludes that Techno-Anthropologists should actively consider and engage in the potential for change of the empirical studies of technology.

Currently, a wide variety of healthcare technologies are being implemented in private homes, hospitals, nursing homes, etc. with the triple aim of improving people's health, improving the quality of care, and reducing costs related to healthcare services. In this chapter, we discuss how different actors in a public-private partnership co-developed a heterogeneous system around the Smart Floor to ensure that both new healthcare practices and residents' routines were inscribed into the new healthcare technology. We argue that implementing the Smart Floor was not just a question of buying a technology and integrating it during construction—it required co-development with the healthcare staff. The floor is more than a technology placed under the floor surface in a resident's apartment; rather, it is a heterogeneous network of human and non-human actors communicating with each other. In this chapter, we illustrate how the heterogeneous technological system was co-developed and redesigned during knowledge sharing processes with companies, lead-users, and healthcare staff. We also discuss how care practices have changed as a result of the Smart Floor system. In particular, healthcare staff members no longer feel a need to disturb elderly residents with routine in-person checks. Domesticating the technologies for different groups of actors required not only coordinating communication among sensors, the interface, the portable nurse call (smartphones), and alarms, but also accepting the use of surveillance technology.

Innovations in healthcare information systems promise to revolutionize and streamline healthcare processes worldwide. However, the complexity of these systems and the need to better understand issues related to human-computer interaction have slowed progress in this area. In this chapter the authors describe their work in using methods adapted from usability engineering, video ethnography and analysis of digital log files for improving our understanding of complex real-world healthcare interactions between humans and technology. The approaches taken are cost-effective and practical and can provide detailed ethnographic data on issues health professionals and consumers encounter while using systems as well as potential safety problems. The work is important in that it can be used in techno-anthropology to characterize complex user interactions with technologies and also to provide feedback into redesign and optimization of improved healthcare information systems.

The usability of health information technology (IT) is increasingly recognized as critically important to the development of systems that are both safe to use and acceptable to end-users. The substantial complexity of organizations, work practice and physical environments within the healthcare sector influences the development and application of health IT. When health IT is introduced in local clinical work practices, potential patient safety hazards and insufficient support of work practices need to be examined. Qualitative methods, such as clinical simulation, may be used to support Techno-Anthropologists design and evaluate new technology navigating in the intersection between people and technology and between various interests in forms of experts and stakeholders. This chapter will introduce the reader to clinical simulation, present the general guidelines and recommendation conducting simulations and describe a simulation lab in Copenhagen. Illustrative examples and references to specific projects will be part of the contribution.

Human Factors (HF) methods are increasingly needed to support the design of new technologies in order to avoid that introducing those technologies into healthcare work systems induces use errors with potentially catastrophic consequences for the patients. This chapter illustrates the application of HF methods in developing two health technologies aiming at securing the hospital medication management process. Lessons learned from this project highlight the importance of (i) analyzing the work system in which the technology is intended to be implemented, (ii) involving end users in the design process and (iii) the intermediation role of HF between end users and scientific/technical experts.

As costs for healthcare are rising in society, information systems are often seen as enablers of new cost-saving healthcare processes. But an on-going deployment of a wide range of new kinds of systems requires close attention to interoperability between new and legacy systems. Another challenge is to assure that the healthcare professions are given realistic opportunities to play an active part in designing the new ways of working that the new, integrated systems are designed to support. We argue that a feasible way to approach such a user participation in design of work processes and systems is to extend well known user-survey and strategy-mapping methods with the new value-based healthcare approach which invites health professionals to participate in strategic assessments of health outcome and costs along the care chain in which they work. We also argue that such a combination of practical research methods resonates well with Techno-Anthropology's foregrounding of ethical considerations to inform the interdisciplinary cross-fertilization of interactional competencies in health informatics research.