Making a Case in Medical Work: Implications for the Electronic Medical Record

Abstract

The introduction of the electronic medical record (EMR) is widely seen by healthcare policy makers and service managers alike as a key step in the achievement of more efficient and integrated healthcare services. However, our study of inter-service work practices reveals important discrepancies between the presumptions of the role of the EMR in achieving service integration and the ways in which medical workers actually use and communicate patient information. These lead us to doubt that technologies like the EMR can deliver their promised benefits unless there is a better understanding of the work they are intended to support and the processes used in its development and deployment become significantly more user-led.

Full text

Computer Supported Cooperative Work 12: 241–266, 2003.
© 2003 Kluwer Academic Publishers. Printed in the Netherlands. 241
Making a Case in Medical Work: Implications for
the Electronic Medical Record
MARK HARTSWOOD1, ROB PROCTER1, MARK ROUNCEFIELD2&
ROGER SLACK1
1Institute for Communicating and Collaborative Systems, University of Edinburgh, Scotland,
E-mail: {mjh;rnp;rslack}@cogsci.ed.ac.uk; 2CSCW Research Centre, Department of Computing,
University of Lancaster, U.K., E-mail: m.rouncefield@lancs.ac.uk
Abstract. The introduction of the electronic medical record (EMR) is widely seen by healthcare
policy makers and service managers alike as a key step in the achievement of more efficient and
integrated healthcare services. However, our study of inter-service work practices reveals important
discrepancies between the presumptions of the role of the EMR in achieving service integration and
the ways in which medical workers actually use and communicate patient information. These lead us
to doubt that technologies like the EMR can deliver their promised benefits unless there is a better
understanding of the work they are intended to support and the processes used in its development
and deployment become significantly more user-led.
Key words: collaborative work, CSCW design, electronic medical record, healthcare, membership
categorisation, service integration
1. Introduction
Current health and social care policy initiatives in the UK, and elsewhere, make
the provision of integrated services for health and social care, i.e., more patient-
centred and responsive healthcare delivery and improved resource utilisation, a
major priority (e.g., O’Hagan, 1998). Plans for implementing these initiatives
generally associate the current state of service fragmentation with the lack of infor-
mation integration and propose that service integration can be achieved through
the development and deployment of a common information infrastructure (e.g.,
Health Select Committee, 1999; NHS Executive, 1998). The electronic medical
record (EMR), offering rapid, location-independent access to consolidated patient
information, has become the technical embodiment of service integration initiatives
(Grimson et al., 2000).
While the relevance of the EMR to healthcare service integration may appear
self-evident, recent studies of EMR projects (e.g., Hanseth and Monteiro, 1998)
remind us of the pitfalls of relying on purely technical solutions to what are, at base,
socio-technical problems. What is often lacking is a proper understanding of the
nature of what inter-service working actually involves and where the problems lie.
As a contribution to the addressing of these issues, we present findings from a study

242 MARK HARTSWOOD ET AL.
of inter-service work in the context of UK psychiatric healthcare. The distinctive
contribution of the paper is to attend to the flexibilities of ordinary language use in,
and as a part of, doing the inter-organisational work of psychiatric healthcare. We
focus in particular on the role of mundane, interactional competencies: the work
of formulations and membership categorisation devices in achieving what comes
to be professionally adequate, accountable referral of patients from one health-
care service to another in the face of the ‘normal, natural troubles’ that this work
entails. While other studies of ordinary language use have attended to co-presence
and kinesics (e.g., Heath and Luff, 1996a), consideration of the flexibilities of
ordinary language use with regard to information sharing and record keeping, we
argue, been largely tacit.1In our use of the term ‘formulations’, we follow the
usage of Heritage and Watson (1980) wherein the utterance serves to “advance
the prior report by finding a point in the prior utterance thus (...) redeveloping
its gist, making something explicit that was previously implicit (...)orbymaking
inferences about its presuppositions or implications. They propose a direction for
subsequent talk by inviting (the interlocutor to respond to) what is formulated”
(Heritage, 1985, p. 104). Although Heritage is talking about news interviews, the
same kinds of work can be seen in the conversational exchanges of the healthcare
workers in our study.
Our findings suggest there are important discrepancies between the assumed
role of the EMR in affording inter-service working and the ways that healthcare
workers actually use and communicate information in the performance of psychi-
atric referral work. These lead us to our first point that, contrary to presumptions,
the EMR would do relatively little to ease the day-to-day problems of inter-
service working, at least as they manifest themselves in the context of current UK
psychiatric healthcare provision. It might be argued that this kind of healthcare is
characterised by vagueness and negotiation and so is, in some, sense untypical, but
other findings suggest that this is a recurrent feature of medical work. For example,
in their study of the work of a hospital radiology department, Symon et al. (1996)
note the importance of “... the negotiation and re-interpretation of information
(as opposed to straightforward giving and receiving) even in such an apparently
objective process as medical diagnosis”. Furthermore, our ongoing, wider research
into medical work suggests not only that issues highlighted in this paper have a
more general relevance but also, and importantly, supports our second point that the
representation, storage and transmission of information, by whatever means, needs
to take account of the lived reality of the work in which that information is used.
Our final point is not that greater healthcare service integration is an impossible
goal, nor that technologies like the EMR are irrelevant to its achievement. Rather,
it is that these technologies will only deliver their potential benefits if the processes
followed in their design, development and deployment are oriented to providing
sufficient opportunity for user-led evolution of both work practices and technolo-
gies. Socio-technical systems are mutually constitutive: implementing new systems
not only changes work practice but also impacts back on the system itself.

MAKING A CASE IN MEDICAL WORK 243
We begin with a brief review of the major motivations for the EMR, the progress
to date in achieving its promised benefits and some of the barriers encountered to
their realisation. We then describe the setting for our investigations and present a
series of extracts from an ethnographic study of medical work to illustrate our find-
ings. We conclude by discussing their implications for the EMR and for systems
design and development practice.
2. The Electronic Medical Record: Progress and Prospects
From the beginning, the EMR2has been seen as the solution to the need for timely
and location-independent access to comprehensive patient data that can be inte-
grated with respect both to type (clinicians’ notes, medical imaging, charts etc.)
and to time (a single patient-centred record of each and every interaction between
patient and healthcare service providers). With the growing demand for greater
coordination and cooperation between different healthcare services, these attributes
remain a powerful driver in the adoption of the EMR. Although the picture world-
wide is by no means uniform, it is nevertheless fair to say that progress to date
towards the introduction of the EMR has fallen significantly short of expectations
(Hanseth and Monteiro, 1998; Ellingsen and Monteiro, 2000). While the EMR is
now routinely found in both the primary and secondary healthcare sectors (van
Bemmel et al., 1997), this typically only takes the form of an EPR held by an
individual service such as a GP or clinical department (Schloeffel, 1998). The
EHR, i.e., the fully integrated EMR, bringing together the complete set of patient
information held across healthcare services is rare, even at the sector level and its
adoption remains a distant prospect.
Some of the difficulties experienced in using the EMR as a vehicle for service
integration simply reflect the scale of the organisations and services involved.
For large organisations with complex information needs, achieving even modest
levels of integration can be difficult in practice (Fincham et al., 1994). Large
organisations exhibit further complexities related to scale, numbers of distinct
roles and processes, and the richness and inter-relatedness of information in the
organisation. Information exchange practices and systems are rooted in local work
processes as well as wider patterns of co-ordination and communication. Attempts
to change practices and redefine roles and relationships may lead to resistance,
if those involved have different professional commitments, and understandings of
organisational processes and service provision. Issues relating to different commit-
ments, cultures and perceptions are further compounded in relation to integration
across organisational boundaries, – e.g., between primary and secondary healthcare
services.
Recent work (e.g., Sellen and Harper, 2002) manifests a more sceptical engage-
ment with electronic records in general, arguing that there may be important –
and as yet unreproducable – ‘affordances’ to paper-based systems. Certainly, the
continuing resilience of paper-based patient records in everyday medical work

244 MARK HARTSWOOD ET AL.
provides evidence for the importance of the socially organised practices and
reasoning which surround the use of the patient record, and for the often subtle
relationship between work practices and artefacts. Reservations about the impact of
electronic media on everyday medical work have been raised by numerous studies
that point to the unique, multiple affordances of paper-based records for viewing,
reviewing, annotating and amending data (Hanseth and Monteiro, 1998; Heath and
Luff, 1996b; Sellen and Harper, 2002). The issues raised by the adoption of new
media extend beyond problems stemming from the absence of familiar affordances,
however, and beyond even the difficulties of evolving work practices and artefacts
in the face of change. For example, requirements for speed and flexibility in inter-
action may be at odds with the wider EMR goals of consistency, standardisation,
structure and completeness: evidence, perhaps, of a certain naivety on the part of
policy makers and EMR designers as to the character of the patient record, the
purposes that it serves and the information sharing practices that have evolved
along with it (Berg, 1997; Berg and Bowker, 1997; Garfinkel, 1967; Hanseth
and Monteiro, 1998; Heath and Luff, 1996b). Many of these problems are further
magnified when the EMR is required to satisfy multidisciplinary and inter-service
needs (Hayes, 1997; Heathfield et al., 1994).
It is on the prospects for the EMR in an inter-service role that we focus in this
paper. In particular, we examine the features and problems of inter-service working,
and assess the potential impact of the EMR on current practices. Seen from the
perspective that equates service integration with information integration, the case
for the EMR as an enabler of inter-service working rests upon two important
assumptions. First, that sharing information unproblematically affords transpar-
ency of meaning and mutual understanding between the participants. Second, the
interactions between healthcare workers that (as we shall see) are a recurrent
feature of current inter-service working practices are to be understood as being
occasioned largely by the need to make good deficits in patient information that
arise from the lack of shareability in existing patient record systems. It follows
from these assumptions that sharing of patient information through the EMR will
promote service integration by making much of this interactional work redundant:
healthcare workers will no longer have to contact one another to find out what’s
in the patient record, because they will be able to read it for themselves. These
assumptions seem to be questionable, since to characterise these interactions as
merely the relaying of information is to fail to understand that transparency of
meaning cannot be taken as a given and to fail to grasp the constitutive role such
interactions play in arriving at some shared sense of what the meaning of infor-
mation actually is. We will see that the accomplishment of patient referral has
little to do with the formal structure or content of the patient record, but relies
on various features of healthcare workers’ mundane, interactional competences:
knowing how to preface, repair, produce formulations, tell stories, develop scen-
arios, and involves formulations about whether a patient fits referral criteria and
what help can be offered. We will also see how various membership categories and

MAKING A CASE IN MEDICAL WORK 245
category predicates are produced, oriented to, accepted or rejected as part of the
work of ‘negotiating the patient’.
We do not underestimate the difficulties of inter-service work, nor do we deny
that the EMR has a role to play in addressing them, but we do contend that the
EMR has accumulated rather a lot of ‘baggage’ – based on manifestly unrealistic
presumptions – and that these are much in evidence in healthcare policy making
and its implementation. It is not our aim to present a ‘straw man’ view of the EMR:
what we do argue for is the need to examine critically some of the suppositions
about the ‘problems’ the EMR is apparently intended to address and how it is
supposed to do this. Our concern is the extent to which debates about the EMR are
based upon poorly founded views of the healthcare workplace. As a contribution to
the empirical grounding of these debates, we present an ethnographic examination
of healthcare practice which is aimed at identifying more precisely the ways in the
EMR might impact on inter-service work. As Berg and Bowker (1997) argue:
... when the record is seen as an innocuous storage device, the appropriate
implementation is often seen as a ‘technical problem’, or as a matter of finding
the ‘appropriate interface’. When it is acknowledged that the medical record
is interwoven with the structure of medical work in fundamental ways, that
different medical record systems embody different notions of how work is
organised, different modes of configuring patient bodies, and so forth, we are
in a position to better understand and intervene upon the issues that are at stake.
The point that our studies continue to stress is the importance of situating informa-
tion work, whether paper- or electronically-based, within the everyday, practical
exigencies of a working division of labour. We are decidedly not suggesting that
information cannot be successfully shared and used via the EMR, rather we are
stressing the point that any such artefacts need to be designed with reference to
actual, everyday work.
3. The Case Study
The setting for our study is the toxicology ward within a large UK hospital. The
ward provides a specialised inpatient (secondary healthcare) service that allows for
joint medical and psychiatric assessment of patients following a suspected self-
harm incident, the majority of which involve an overdose of prescribed, or ‘street’,
drugs. Its main function is to provide necessary medical treatment and determine
the need for further psychiatric and social care, referring patients on as appropriate.
Because of its referral role – in effect negotiating the transfer of patients to other
care providers – the function it performs is commonly known as a ‘liaison service’.
The toxicology ward is a perspicuous setting in which to investigate the bene-
fits of the EMR, especially its relevance for healthcare integration. Its caseload is
typified by a high turn over, emergency admissions, short average hospital stay and
high rate of re-admission. Treatment of self-harm incidents may involve complex

246 MARK HARTSWOOD ET AL.
care pathways that call upon the services of acute medicine, toxicologists, psychi-
atrists, GPs, social services and community healthcare agencies. Yet, a succession
of independent inquiries has concluded that communications with, and between,
services involved in the provision of mental health care, are often very poor (e.g.,
Ritchie et al., 1994).
The investigation reported here is based upon twelve months ethnomethodolo-
gically informed ethnographic fieldwork (Hughes et al., 1993; Hughes et al., 1994)
in the toxicology ward. Detailed notes were made by the fieldworker of activities
observed and artefacts employed – e.g., healthcare workers’ notes, patient records,
and referral letters – as staff went about their everyday work. The conversations
ward staff had with each other – and over the telephone with healthcare workers
in other services – about work-related matters were recorded and transcribed, as
were discussions between staff and the fieldworker. The aim of our study was
to subject work within the toxicology ward to close empirical investigation. The
method used, ethnomethodologically-informed ethnography (Hughes et al., 1994),
observes in detail everyday working practices and seeks to explicate the numerous,
situated ways in which those practices are actually achieved, and the things that
such an achievement turns upon. The data includes copious notes and transcriptions
of talk of ward staff as they went about their everyday work. Such an approach is
attentive to the ways in which the work actually ‘gets done’; the recognition of the
tacit skills and cooperative activities through which work is accomplished as an
everyday, mundane, practical activity and in making these processes and practices
‘visible’. The method seeks to explicate the situated character of work, the work
seen as a practical production by social actors performing their activities within
all the contingencies of local circumstances, to portray the variety of activities and
interactions that comprise the ‘workaday’ of working life and the ways in which
these are understood and accomplished by those who do that work. The veracity of
findings was established using a number of recognised techniques. These included
triangulation, where the researcher attempts to identify discrepancies between what
members say they do and how they actually behave, thus uncovering tacit assump-
tions held, e.g., about the nature of a task or relationship. Comparisons were
also drawn between the activities of a member over time and between different
members, both to challenge the researcher’s own working assumptions and to
guide further observations. A final stage of verification was performed through
discussions of findings with toxicology ward staff.
4. The Work of The Toxicology Ward
Everyday work in the toxicology ward typically involves various forms of
‘categorisation’ work requiring the production, utilisation and display of various
categorisation devices as practical ongoing accomplishments. The identification of
‘relevance’ in the varied activities associated with working with patients who have
harmed themselves, assessing them and ‘disposing’ of them to other care providers,

MAKING A CASE IN MEDICAL WORK 247
requires the use of members’ knowledge of acts, actors and their contexts, organ-
ised as membership categories and category predicates. This involves knowledge
of the rights, expectations, obligations, knowledge, attributes and competencies
that are expectably and properly done by various persons and organisations. So,
for example, ward staff will be aware of the appropriate care for ‘depression’ as a
category of mental illness, which units are best placed, in terms of competencies,
to provide that care, and the necessary admission requirements and procedures.
Patients admitted to the toxicology ward may already be users of other psychi-
atric or healthcare services. This being the case, the members of the psychiatric
assessment team depend not only on the psychiatric history they get from the
patient but also the ‘collateral history’. The latter is what they refer to when they
obtain histories from persons other than the patient. It is routinely undertaken, espe-
cially where the patient is uncommunicative or evasive, or where the account given
appears problematic in some way – e.g., where there are accountable absences from
the account as given. Such collateral histories may be obtained from, for example,
GPs, relatives, other healthcare services and workers, and so on.
Two problems emerge in pursuit of this information, both of which are related
to wider issues of awareness and local knowledge. The first concerns knowing
whether this information is actually available. For example, a psychiatric assess-
ment team member might not know that another healthcare service already holds a
psychiatric history, and the patient might not divulge this information voluntarily.
The problem is mitigated somewhat if the patient has attended the toxicology ward
previously, especially if this earlier admission resulted in a transfer to a psychiatric
hospital. In this case, determining that a previous assessment is available requires
consulting the records of previous admissions held in the ward. It is here that the
limitations of the existing local paper-based record keeping system are perhaps
most evident. Detailed records are only kept to hand for three years. This is partly
for reasons of lack of space on the ward, but also because, for practical purposes
of making an assessment, entries are considered to lose their relevance with time.
For records beyond this period, staff make do with an index card record consisting
of just the patient name, DoB, date of admission and form of self-harm.
The second problem is one of establishing contact with other services, such as
the patient’s GP or social worker. A GP, for example, may be in a consultation, or
out of the surgery, necessitating a repeat call later in the day. If the GP cannot be
contacted, the psychiatric assessment team may fall back on speaking to someone
(e.g., another GP in the same practice) less familiar (or possibly completely unfa-
miliar) with the patient, or even to requesting that a receptionist read out the
patient’s notes over the phone. Overall, we observed communication behaviours
not unlike those noted by Coiera and Tombs (1998) in their study of medical staff
in a general medical ward in a UK hospital: “... an interruptive workplace ...
a bias by staff to interruptive communication methods [e.g., telephone calls], a
tendency to seek information from colleagues in preference to printed materials
...” (p. 673). As we argued earlier, it is easy to dismiss such practices as inefficient

248 MARK HARTSWOOD ET AL.
and to presume that the EMR can be the answer. As we shall see, however, there
are sound professional reasons why the mundane technology of ‘talk’ is often the
psychiatric assessment team’s preferred medium for the conduct of inter-service
work.
Our analysis of the fieldwork data is based, in part, on the notion of recipient
design and turns on the selection of what Sacks called ‘membership categories’. It
seems useful at this point, therefore, to make some general introductory comments
regarding these. Hutchby and Woolfit (1994) define recipient design as communi-
cation “designed to be understood in terms of what the speaker knows or assumes
about the existing mutual knowledge between him or her and the recipient”. In
his paper ‘On the Analyzability of Stories by Children’ Sacks (1972) defines
membership categories as follows:
By this term I shall intend: any collection of membership categories, containing
at least a category, which may be applied to some population containing at least
a member, so as to provide, by the use of some rules of application, for the
pairing of at least a population member and a categorization device member. A
device is then a collection plus rules of application (1972, p. 332).
Sacks states that it is important to observe that a collection of categories goes
together so that, for example, mother and father might be seen to go together (in
the category ‘family’) in a way that mother and baseball player might not. Sacks
notes that “if a member uses a single category from any membership categorisation
device, then they can be recognised to be doing adequate reference to a person”
(1972, p. 333, italics in original). Membership categorisation device analysis offers
the possibility of explicating the psychiatric assessment team’s use of ordinary
language in their work of doing disposal and, as we shall show, this has important
implications for the role of the EMR.
4.1. REFERRAL WORK
The psychiatric assessment team do not typically treat patients (although they
may do some ‘work’ with them at the bedside), rather they identify what an
appropriate treatment might be and refer the patients to the appropriate follow
up healthcare services. The ‘disposing’ work in the toxicology ward involves a
continuous, practical and artful struggle to make a patient’s case fit particular
circumstances – either in the form of the requirements of the proposed admitting
service or/and related particular patient trajectories (Strauss et al., 1985). In this
process various kinds of information are effectively continuously reconstructed
and represented. The psychiatric assessment team, through the information they
elicit and represent, collectively shape patient trajectories and histories, providing
and eliciting information corresponding to particular desired outcomes. These
exchanges thereby epitomise the notion of ‘recipient design’ since effectively the
typical ‘diagnostic’ patterns are already embodied in the exchanges – that is, as

MAKING A CASE IN MEDICAL WORK 249
the psychiatric assessment team contact various referring healthcare services, they
‘have in mind’ appropriate, or preferred, outcomes. This typically involves iden-
tifying the patient’s care needs and appropriate healthcare service(s) to meet them.
Following from this, the psychiatric assessment team has then to negotiate access
to the service by following the appropriate access procedure.
The successful negotiation of referral depends on the psychiatric assessment
team being able to demonstrate a match between the patient’s care needs and the
services offered by a healthcare service. Each care provider can be thought of as
maintaining a ‘rule set’ that can be matched against the characteristics of a patient’s
presentation to determine the appropriateness of a referral. Although the service
offered by a specific care provider might appear to match the requirements of a
particular presentation, that care provider might maintain a number of exclusions:
e.g., age, gender, drug and alcohol use. The rule sets that we refer to are resources
that guide the sequential organisation of activity, rather than laying out a sequence
of work which is then blindly followed. As Suchman (1987) argues, it is clearly
the case that rule sets cannot thoroughly determine in advance and causally direct
in every detail courses of action. Rule sets are abstract constructions that need
to be to be applied in specific circumstances. They are accomplished activities.
This argument has been a feature of CSCW research almost from its beginning.
At its heart lies both an observed empirical reality about organisational life and a
desire to avoid underrating the skills and competencies that are required in even
the most routine of tasks. From this viewpoint, ‘routineness’ is observed to be
an accomplishment produced through the everyday, practised exercise of complex
skills.
In the examples that follow, we show the mundane, interactional competen-
cies involved in coming to shared inter-service understandings about a self-harm
incident.3In many of the examples, telephone conversations between the psychi-
atric assessment team and healthcare workers in other services figure prominently.
Unavoidably, we only had access to one side of such conversations and it might be
objected that we therefore are not able to present a full account of such events. We
argue, however, that given our attention to categorical aspects of the conversation,
this is not as problematic as it would have been had we been attending purely to
sequence. Further, the sense of what is being said by the other party is evident
in the response of the psychiatric assessment team member, who accountably,
demonstrably orients their side of the conversation to the matter at hand.
The various categorisations of everyday activity are separated and presented
here primarily for analytic purposes; in the hustle of everyday work the different
activities inevitably overlap and intermingle. These categorisations demonstrate
the practical accomplishment of various kinds of liaison psychiatry work by
the psychiatric assessment team, in particular their role as intermediaries with
responsibility for receiving from, and disposing to, the various healthcare services.
From the team’s point of view, the practical accomplishment of the work requires
knowing how to use the information, etc. relevant to the work and how the psychi-

250 MARK HARTSWOOD ET AL.
atric assessment team’s work meshes with the work of healthcare workers within
other services. What this identifies are the essentially subtle competencies involved
in developing mutual intelligibility, a competence essential to a whole range of
informalities involved in performing work activities, including ‘knowing how
others do their work’, ‘understanding shortcuts’, ‘knowing who to rely upon to get
things done’, and so on, competencies that that are unlikely to become redundant
or replaced by an EMR. Our case study underlines the centrality of transparency of
procedures rather than transparency of information for the psychiatric assessment
team’s work. In documenting the various attempts at reading and presenting the
‘record’ of a patient, we explicate the ways in which common understandings are
practical interpretive achievements rather than simple, measurable shared agree-
ments when, as Garfinkel (1967) writes, “if the interpretation makes good sense,
then that’s what happened.”
4.2. NEGOTIATING THE PROFESSIONALLY ADEQUATE DISPOSAL OF PATIENTS
As might be expected, some patients’ presentations cannot be matched exactly with
the rule set for a given healthcare service. There can also be a tension between the
requirements of the person making the referral (to achieve a satisfactory and timely
disposal) and the person accepting the referral (who may want to guard against
‘misuse’, and protect the limited resources available to the service). Thus access
to healthcare services often has to be negotiated and attempts to block access may
have to be overcome. One tactic observed in this respect concerns how the account
of the patient’s presentation is represented and the urgency of the case may be
tailored for different audiences. That is to say, the categories selected by the psychi-
atric assessment team are designed to elicit a certain response from the recipient –
the characterisation of a patient as, for example, ‘violent’ or ‘psychotic’ does the
work of getting that patient admitted to a particular ward or hospital. In attempting
to get their patients admitted, the psychiatric assessment team might choose from
a series of characterisations (examples might include delusional, psychotic, over-
dose, suicidal, violent and so on). It is the selection of the category ‘violent’, etc.
that accomplishes the work of doing ‘getting the patient admitted’ to the ward or
hospital. Of course the ‘game’ is not one-sided and those in receipt of the telephone
calls will also play the game.
When the Consultant Psychiatrist says that the patient is ‘psychotic’, this
membership categorisation device may be used for the practical purposes of getting
the patient admitted to the ward or hospital and may therefore not reflect the
category in which the patient will be finally registered. Not everyone included in
the membership categorisation ‘psychotic’ will be treated as psychotic when they
arrive at their destination. Just as there are good organisational reasons for ‘bad’
clinical records (Garfinkel, 1967), there are good organisational reasons for the
use of such membership categorisations. The universe of membership categorisa-
tions is (interpretively) flexible and designed for practical purposes of achieving

MAKING A CASE IN MEDICAL WORK 251
something – perhaps in preference to making a hard and fast categorisation that
‘sticks’ with the patient.4The implication is that a patient is represented as being
in whatever state for the practical purposes of getting him or her into this ward or
hospital and not because he or she is in this or that state. This does not, of course,
mean that the patient may be labelled in just any old state and that this will stick,
there must be some aspect of the patient’s presentation that affords the mobilisation
of this or that membership category.
In what follows we present a series of utterances made by a Consultant Psychi-
atrist which are aimed at getting his patient a place in a hospital. The goal is to
dispose of the patient adequately but the Consultant faces a problem in that the
healthcare workers at the hospitals that he telephones have to be convinced of the
appropriateness of placing the patient in the hospital in which they work, given that
they have limited resources available. Of course, things are a little more complex
than this in that the hospital might not be appropriate for the patient or the hospital
might not want to see that patient for whatever reason.5However, it is the task of
the Consultant to formulate the candidate patient’s admissibility to these receiving
institutions and we will show how this is achieved over the course of a number
of telephone conversations with various potential admitting institutions. In what
follows, we will see that the Consultant Psychiatrist uses a number of membership
categories to make reference to the patient – all of which might be seen to apply to
the membership category ‘psychiatric patient’.6What Sacks (1972) calls category-
bound activities formulate the patient as a psychiatric patient and in part enables
the various categorisations chosen: the patient can be schizophrenic, very poorly,
violent, paranoid, in a post-ictal state and so on, and still be the same patient.
The point is that these category-bound activities realise this flexibility within the
membership categorisation ‘psychiatric patient’.
Over a series of telephone conversations with various hospitals, the Consultant
Psychiatrist seeks to get the patient a bed. What is important from our point of view
is the manner in which the Consultant selects various membership categorisation
devices to arrange for the appropriate disposal of the patient. Some background
details might furnish appropriate context: the patient had been admitted again the
previous night after smashing up his house and attacking his parents with an axe. In
the morning the patient was claiming that the doctors had been stealing money from
him and injecting him with heroin. Knowing that there are no intensive psychiatric
care unit (IPCU) beds locally, the Consultant attempts to get the patient a place
at a local psychiatric hospital (Moorhouse), which he knows has no facilities for
violent patients. In what follows we will show how the Consultant marshals a series
of formulations in order to dispose of the patient. The Consultant makes a number
of candidate formulations using a series of membership categorisations – he notes
that the patient is “one of those cases that should not have been admitted to a
general hospital”; he further formulates the patient as being ‘psychotic’ and finally
characterises the patient as having ‘paranoid delusions’. We can see the manner in
which the Consultant mobilises a universe of potential descriptors and the ways

252 MARK HARTSWOOD ET AL.
in which he artfully uses membership categorisations devices in order to support
the case he makes that the patient should be in a psychiatric hospital and not the
general hospital where he is now.
The formulations used to dispose of the patient do not appear to work and the
Consultant Psychiatrist calls another consultant; getting through to his secretary,
the Consultant Psychiatrist formulates the urgency of the call (and, of course,
the case) saying “it’s important, we’ve got two burly guards sitting on top of
him”. Speaking to the consultant, the Consultant Psychiatrist notes that the patient
“needs to be somewhere” and proceeds to formulate the case in a different manner,
stating that it “looks like a post-ictal psychotic state, so he needs to be in, it might
settle quite quickly”. Here it is notable that the Consultant Psychiatrist, having
formulated the need for the patient to be in the hospital, proceeds to state that the
condition might “settle quite quickly”. Having presented the condition as serious
to the IPCU, the Consultant Psychiatrist now presents it as something that will
settle down in order to get the patient a place. This is something of a turn-around
yet the formulation is designed to achieve the same task. During discussions with
the consultant, the Consultant Psychiatrist establishes that there are no beds avail-
able “this side of the river” and that other potential hospitals are unwilling to take
patients from outwith their catchment area. The Consultant Psychiatrist then makes
another formulation of a patient disposal state, saying “we wouldn’t keep him here
– this is an acute ward”.
At this point, the consultant is willing to broker a deal: the Consultant Psychi-
atrist will call Moorhouse and attempt to swap the patient with another: he calls
Moorhouse and states that there is a need to “look after him with special nurses,
if (you) have problems then swap him with (patient name), that’s Simon’s deal”.
This does not lead to a deal, and the Consultant Psychiatrist formulates the gist
of the reply saying “so you want me to try Strombank then?” The Consultant
proceeds to characterise the patient in a manner that will gain admission to the
hospital, stating that the patient is “a potential threat, rather than an actual threat”
and noting “he hasn’t threatened any of the nurses”. Of course, this is in marked
contrast to the Consultant’s characterisation of the patient on his first telephone call
to Moorhouse. The call ends with the Consultant noting that “we’re busy here too,
(we) have fourteen overdoses to see, and this chap to sort out.”
Calling Strombank, the Consultant Psychiatrist gives a history of the patient,
pointing out that “the medics are happy, he’s not having fits at the moment, he’s not
attacked the nursing staff but has the propensity to do so”. As Strombank respond,
the Consultant says “thanks for your help, thanks for not saying ‘we just can’t
take him’ ”. The Consultant again offers a candidate formulation of the patient’s
state: “(we) have avoided sedating him. (we’re) just using muscle at the moment,
there’s two burly guards sitting next to him. I’m happy to sedate him if you want
me to”. It is notable that in characterising the state of the patient, the Consultant
now states that the guards are sitting next to the patient as opposed to on him – this
would appear to be consistent with the characterisation of the patient as a potential

MAKING A CASE IN MEDICAL WORK 253
threat, a characterisation that appears to have enabled the patient to be disposed of
to Strombank.
In this case we can see the ways in which the Consultant Psychiatrist attempts to
find the patient a bed through the judicious selection of membership categorisations
and the ways in which he formulates the case to various recipients. It is instructive
for our purposes to see how the characterisations made are different and how the
Consultant can make different selections from a universe of descriptors even when
talking to the same hospital. The Consultant’s utterances are recipient designed
to dispose of the patient to either hospital yet we should not be heard to suggest
that any formulation will do as the psychiatric assessment team are concerned with
maintaining their ‘professional ace’ in that they attempt to avoid what are called
‘poor’ referrals – that is to say they are concerned not to be seen to be seeking
admission for a patient ‘inappropriately’ or ‘too often’, and there is a concern to
maintain some order within their admissions that fits with the established rule set
for admissions.7
The role of recipient design can be further seen in the following example: the
Consultant Psychiatrist interviews a patient who has a history of alcohol abuse
admitted to the toxicology ward following an overdose and subsequently attempts
to arrange for admission to the local psychiatric hospital. During the interview, the
Consultant asks the patient about the circumstances of the overdose: she notes that
“I knew there wasn’t enough to kill myself – it was just a buzz”. When calling
the psychiatric hospital the Consultant formulates the case as follows: “the patient
had been drinking for the last three years, had an alcohol-related seizure on Friday
and was beaten up on Monday – probably when drunk”, in his next utterance he
goes on to say “the overdose was with some suicidal intent (though) not very
clearly formed”. This case instantiates the way in which the case is formulated
to gain admission to appropriate services for the patient. The Consultant accounts
for the patient’s claim to have taken the tablets ‘for a buzz’ saying that the patient
is unable to articulate clearly or unaware of her actions. The Consultant formulates
the patient’s intentions as suicidal in order to get her admitted to the hospital.
The fieldworker asked the Consultant Psychiatrist about his formulation of
suicidal intent. The Consultant replied that he felt he had phrased his formulation
badly and that he should have stressed the self-harm intention. The Consultant
noted that “(we) don’t judge on what (the patients) say alone – she took rather a lot
– (we) also judge on how they behave (...) that’s just me wriggling out of the accus-
ation that I exaggerated to get her in there. There’s probably some truth in that”. It
should be noted that we are not accusing the psychiatric assessment team of making
grand guignol formulations in order to get patients admitted – rather we want to
attend to the flexibilities of ordinary language and the ways in which the psychiatric
assessment team formulate patients as candidates for this or that service while still
providing professionally adequate descriptions of conditions with which patients
present. The psychiatric assessment team’s task as we see it is to maintain respect
for the professionalism of their diagnoses while getting the patients admitted under

254 MARK HARTSWOOD ET AL.
conditions wherein one is attempting to place patients with healthcare services that
are most appropriate for the patient – and to ensure that the system keeps moving,
admitting and disposing of patients in the most professionally adequate manner.
Another dimension that requires consideration is the often sceptical attitude
of healthcare services who may be suspicious that an admission has been made
or attempted ‘inappropriately’. Some of the best examples of this are admissions
made to the toxicology ward itself from A&E. The toxicology ward deals with
patients who have taken drug overdoses, but not cases where the overdose is clearly
recreational. In particular, if a patient is admitted insensible through alcohol intox-
ication then they should be referred to one of the other medical assessment wards to
‘sleep it off’. Occasionally, members will describe admissions as ‘inappropriate’,
suspecting that the admitting doctor in A&E has framed the case as involving
suicidal intent in order simply to quickly deal with (or offload) a difficult patient
during a busy admissions period.
There can also be pressure to make a particular disposal where acceptance
criteria are not fully met, even where the healthcare worker does not believe that
the disposal is necessarily the most appropriate course of action. This typically
occurs in the toxicology ward when issues of professional accountability arise. A
particular and potent example of this is suicide. If a patient maintains that they
are intent on suicide then a member may be ‘constrained’ to attempt a psychiatric
admission even if they do not believe that the patient is sincere. This is because
if the patient does complete suicide on discharge then the member who dealt with
the case may subsequently be held responsible as the ‘last professional contact’. In
cases such as this the member might say that they “have their hands tied.” In other
circumstances there is intense debate as to what ‘counts’ as an overdose.
The following summarised transcript is of a discussion between medical
students and the Consultant Psychiatrist about “what counts as an overdose?”
This was prompted by A&E having referred to the toxicology ward a “drunk and
unmanageable” patient who had taken two thoridazine tablets.
Consultant Psychiatrist: “If they are time pressured at A&E then anything might
count as an overdose – even two thoridazine tablets.”
Medical student: “But that could be an overdose if not usually taken.”
Consultant Psychiatrist: “Yes, but then you would have to define any street drugs
taken as an overdose; there has to be intent too. ... There are two ways you
can do it. Look at the amount they have taken and how serious that is, or look
at their intent. Usually is an uneasy mix of the two. If A&E are busy and the
patient is disruptive then two thoridazine would be an overdose ... if they have
time and the doctor is interested, they might find another disposal route.”
Overall, the psychiatric assessment team displays some sensitivity to the possible
reasons for ‘inappropriate’ referrals from A&E. They are aware of the circum-
stances in which their colleagues in A&E may find themselves. This enables them
to respond sympathetically by suggesting, as in the case above, that patients have

MAKING A CASE IN MEDICAL WORK 255
been referred because it might have been busy in A&E. On other occasions, the
psychiatric assessment team commented that the admitting doctor might not be
fully aware of the procedure or that the patient was prescribed an unusually high
dose of some medication that could be misread as being an overdose.
This raises the issue of the view one service might form of another where there
is a regular relationship between them in terms of referrals. One aspect of the
work in the toxicology ward is that a number of patients requesting admission
to psychiatric services in particular are denied access. Thus, in an extended sense,
toxicology ward staff act as gatekeepers for other healthcare services and it may not
be appreciated by the admitting service that a significant number of ‘inappropriate’
admissions are prevented in this way. All the admitting service ‘see’ are the patients
who are actually referred. This potential for a ‘one sided’ view of those requesting
admissions is mitigated somewhat by the rotation of Senior House Officers and
Registrars through different psychiatric services enabling learning with respect to
the difficulties and contingencies faced elsewhere. Thus, there is a sense that the
healthcare workers in different services share an awareness of working together
towards a common aim, and that there is tension between this, and allegiances and
responsibilities they have toward the service to which they (currently) belong.
The fieldwork examples above show that although referrals may be made
unproblematically and as a matter of routine, that equally they may present
members with ‘normal natural troubles’ – i.e., expectable and anticipated diffi-
culties in matters of referral that it is within their competence as liaison psychiat-
rists with working knowledges of local healthcare services to deal with. Achieving
an admission can often be a matter of human ingenuity involving finding work-
arounds and improvising compromise solutions based upon working understand-
ings of where services and the people within them are likely to be flexible, and
where they are not.
Collectively, the fieldwork examples indicate some of the subtleties consequent
upon everyday ‘organisational transparency’; the understanding of a service’s
internal mechanisms and the leverage this provides for improvising workarounds.
Service integration through technology at this level presumes the ordered, formal-
isable, trouble-free working of inter-service co-operation that can be embedded
in a computer-based system. In practice, the rules governing the relationships
between various collaborating services are members’ achievements, reconstituted
on a referral-by-referral basis, rather than a set of givens from within which
members can unproblematically undertake their work. While this might seem to
be a ‘straw man’ argument, its purpose is draw attention to the basis for deciding
what systems might be most effectively developed to support inter-service working.
We pick up this point again in the conclusions.

256 MARK HARTSWOOD ET AL.
5. Discussion
The focus of this paper is on how toxicology ward staff go about the task of working
up shared, inter-service understandings about a given self-harm incident. The
empirical evidence shows this being achieved through the psychiatric assessment
team’s exercise of mundane, interactional competencies and ordinary language use.
In other words, for the purposes of “making a case” to someone in another service,
the psychiatric assessment team give ‘readings’ of the patient record, rather than
just ‘reading out the facts’. However, this is not to imply the unimportance of the
patient record for the work of the toxicology ward. A feature of this work is the
routine completion, processing and duplication of the various components of the
paper-based patient record, and the routine completion of the patient record consti-
tutes an integral part of the work. Such paperwork is not simply the production
of paper documents but of ‘records’, ‘forms’, ‘letters’, and so on, to use labels
which denote the social context of their use (Hughes and King, 1993; King and
Hughes, 1994; Brown and Duguid, 1996) and the amount and nature of paperwork
is linked to other issues of accountability and blame. This emphasis on paper, as
it is in so many other organisations, is closely linked to the need for an audit trail
and to questions of accountability should these arise. The ‘completeness’ of the
paper record enables it to act as an audit trail, providing an outline, rationalisation
and justification for administrative decisions. This trail is valuable not simply or
merely for the attribution of blame but through its ‘procedural implicativeness’ –
informing and guiding the actions of others – an activity assisted by its ‘at a glance’
visibility. Our study of the work within the toxicology ward has identified a number
of social features of paper records (Hartswood, Procter, Rouncefield and Slack
in preparation). What these are intended to emphasise is that paper records have
their place within some organisational setting and its activities. Paper records are
‘shared objects’ and for those who know how to use them can constitute a means of
making the activities of the organisation accountable and available in various ways.
We suggest that electronic patient records should afford organisational knowledge
in a similar, though not necessarily identical, way. Looking at the EMR should
enable a Consultant Psychiatrist, for example, to see, ‘at a glance’, the status of
a patient and calculate whereabouts in the organisational and temporal cycle of
events surrounding a patient’s ‘illness trajectory’ that particular patient might be.
The problems that the psychiatric assessment team face routinely in gaining
access to patient information may seem to typify the problems of fragmented,
service-centred record keeping and to be tailor made for demonstrating the afford-
ances of the EMR. Our findings suggest, however, that assumptions about the
capacity of the EMR to transform this significantly need careful scrutiny. It is
certainly the case that the toxicology ward’s local patient record system exhibits
many of the drawbacks of paper-based records, but looking closely at the wider
information gathering work of the psychiatric assessment team, we find that rarely
does the effort expended reflect a desire to obtain access to patient records held
elsewhere. Rather, it reflects a desire to get a ‘reading’ of the record, preferably

MAKING A CASE IN MEDICAL WORK 257
from its author. It is commonly stated by the psychiatric assessment team that
“talking to someone” is better than “having a letter”, which is in turn preferable
to being read notes over the phone (although the latter is preferable to having
“nothing at all”). Here, the ability of someone who knows the patient to summarise
and make a relevant selection from the corpus of the record is key. Rather than
this mediated access being perceived as a problem by the psychiatric assessment
team, it is actually welcome. It might be argued that this preference for “talking to
someone” is specific – and self-evidently due – to the nature of liaison psychiatry
work. However, the fact that similar observations have been made in studies of
other kinds of medical work suggests that it may well be a feature of medical work
as a whole (see e.g., Coiera and Tombs, 1998; Symons et al., 1996).
While the inter-service sharing of information is central to the work of the
toxicology ward, its accomplishment has little to do with the formal structure or
content of the patient record. Instead, various features of the mundane, interactional
competences of those involved are routinely observed to play an important part
in the work, such as knowing how to preface, repair, produce formulations, tell
stories, develop scenarios and so on. So, for example, formulation provides the
psychiatric assessment team with an opportunity to present their understanding of
the patient or institutional interaction that just took place, and the implicativeness
of that interaction. In this case, it generally involves formulations about whether
someone fits the criteria and what help can be offered. The formulations produced
here are put forward to propose particular views of both ‘how things are’ and ‘how
they came to be that way’. They include instances of the kind of working up of
a presumed sense of shared experience, knowing how to make a story of self-
harm relevant and to project its significance in some way. In these conversations,
various membership categories and category predicates are produced, oriented to,
accepted or rejected as part of the work of negotiating patient identity, treatment,
responsibility and procedure. Knowing how to build a recognisable and coherent
scenario draws upon assumed sets of common-sense understandings about ‘how
we do this kind of work’; and ‘how we resolve this position’. Furthermore, much
of the inter-service contact is about rather more than merely ‘sharing information’
but rather providing opportunities for discovering the ‘current state of play’; the
circumstances each service is facing; how they are likely to respond to future
requests; what view they have of the referring service and so on. Such liaison
work enables the building and maintenance of important professional relationships
and an opportunity to represent the ‘state of play’ in the referring service. This
underlines the relevance of our findings to medical – and, indeed, to collaborative
– work in general.
In all the examples of referral work outlined earlier, the psychiatric assessment
team are not simply reading the record to a third party, but are involved in ‘inter-
pretive work’ with the aim of translating the circumstances of the patient into an
appropriate medical formulation. Data and information provided by the psychiatric
assessment team in their telephone conversations with various admitting units are

258 MARK HARTSWOOD ET AL.
not produced to create a complete image of any patient. Instead the work is directed
at resolving a paramount egological problem of organisational life, the “practical
problem par excellence: ‘What to do next?’ ” (Garfinkel, 1967). the psychiatric
assessment team do not attempt to create ‘true’ images, instead they attempt to
create a meaningful difference, to construct a case, for the purpose at hand – a result
sufficient to direct the immediate course of action in terms of admitting patients.
The apparent solidity and objectivity of medical information and diagnosis can
then continually be challenged as new data come to the fore, for example, where the
‘suicidal’ patient becomes a mere drunk. Understanding of the record is facilitated
through reconstructing the available information, that A&E was busy, for example,
and a prominent feature of these reconstructions is that there are no types of data
that always prevail when they clash with others. Readings of data are ‘defeas-
ible’, capable of being re-interpreted to fit with new items of information and
presented to different audiences. All data can be, and are, reconstructed, providing
fluid resources for the actors involved, who actively orient to the data in order to
accomplish the practical task at hand. As Garfinkel suggests:
For the practical decider the ‘actual occasion’ as a phenomenon in its own
right exercised overwhelming priority of relevance to which ‘decision rules’ or
theories of decision making were without exception subordinated (Garfinkel,
1967).
One particular trouble in coordinating medical work is that patient records can
be read in different and irreconcilable ways, either as a strict medico-legal docu-
ment or as a practical document that involves various ‘sense making’ activities
(Garfinkel, 1967). Such activities include: knowledge of the patient; knowledge of
the people who have contributed to the record; knowledge of the clinic’s organisa-
tion and operating procedures; knowledge of a mutual history with other persons –
patients and clinic members; and knowledge of clinic procedures. In this case, the
toxicology ward, as a ‘disposing’ rather than ‘treatment’ unit, requires that staff
have knowledge, an ‘awareness’, of numerous separate and formally independent
services. Observations in the toxicology ward indicate that much of the ‘organisa-
tional knowledge’ regularly utilised by its staff in coordinating work in the ward
is not of a kind that is transparently visible in procedures or simply facilitated by
reference to the patient record. Providing computer-based support for such knowl-
edge work, in all its contingent aspects, requires that system designers necessarily
pay attention to the occasioned character of activities. Knowledge is a matter of
organisational relevance; of understanding the context in which things are known.
If the aim is to embed knowledge properties in systems then it needs to be captured
and managed not only in a way that will make it accurate, available, accessible and
effective but, most importantly, usable. Such a task is hardly a matter of simply
computerising existing patient record systems, but raises complex conceptual and
empirical issues that need to be understood:

MAKING A CASE IN MEDICAL WORK 259
For shared databases and the like to be more than repositories or archives, and
for contributions to be appropriate for some practical purpose ... the entries
have to be tailored for the demands, or ‘designed’ for their recipients and
sensitive to their circumstances (Heath and Luff, 1996b, p. 362).
Even as a medico-legal document – what Suchman (1993) calls ‘technologies of
accountability’, “systems aimed at the inscription and documentation of actions
to which parties are accountable” – the EMR cannot be simply implemented. As
we have emphasised, such technologies of accountability need to be understood
organisationally and inter-organisationally as they are technologies for organisa-
tional ordering and, in consequence, their introduction can conflict with existing
ways of organising work. Finally, our study reinforces some of the points made
by Berg (1997) that question the impact of formal tools, such as the EMR, on
everyday work and practice. In the case of the toxicology ward, the decision to
admit a patient is the ‘total net effect’ of varied interacting networks where the
patient record, and ‘readings of the record’ become a resource that is mundanely
called upon in the regulation of activity. This is not, as Berg suggests, “to sail a
risky course between either granting too much power and self-sufficiency to the
tool ... or overly stressing the versatile and creative skill of the human workers”.
Instead it is an attempt to present an instantiation of a more subtle, nuanced way of
appreciating the use and possible impact of the EMR where, “we witness a fragile,
never static, equilibrium, characterised by never ending frictions, loose ends and
unforeseen consequences.” The work performed by toxicology ward staff and its
formal rendering in the patient record are the outcome of varied historical and real
time processes. In everyday work the difference between the merely drunk and
the suicidal, between the violent and the suicidal is produced by the balancing
and careful and complex articulation of various interrelated tasks. In the process,
the patient record is ‘brought to life’ to present a particular and organisationally
adequate representation of the current state of affairs.
6. Summary and Conclusions
Our ethnographic study of the work of the toxicology ward reveals several signifi-
cant characteristics about the nature of routine interactions between ward staff and
the various healthcare services to which they refer patients. We suggest that these
practices may have a range of important implications for the design of systems to
support collaborative work in general, and for the EMR and inter-service medical
work, in particular. The arguments for the EMR as a technology for promoting
healthcare service integration stress information accessibility as the key problem,
presupposing an agreement between the parties as to what that information actually
means. In practice, however, we find that the ‘normal, natural troubles’ of inter-
service working concern reaching agreement, not the accessibility of information
per se. Further, this agreement has little to do with the formal structure or content
of the patient record, but, instead, is achieved in vivo and seems to turn on the

260 MARK HARTSWOOD ET AL.
flexibility of ordinary language formulations used by the psychiatric assessment
team for the purpose of getting their patients admitted to the most appropriate
service. It is our contention, therefore, that the introduction of the EMR in liaison
psychiatry work is unlikely to have a major impact on service integration issues
within this healthcare sector. To be sure, as we have seen, an EMR system could
record the characterisations made and agreed by the members, but this would
constitute a record of formulations that have been successful in gaining admission
for patients to services. The rules for referral are open ended and situated – this
does not mean that anything goes, but that any account of the activity of referral
has to take into account the knowledge of, inter alia, people and resources, as
well as the more usual knowledge of patients’ presentation and needs. In short, the
everyday fabric of practical reasoning in medical settings must be understood if
the EMR is to provide real benefits. Narrow sets of rules and attendant categories
will not afford the realities of work practice and practical reasoning, as we explain
below.
Our study suggests that it would be a mistake to assume that healthcare service
integration would follow in any simple way by the integration of patient record
systems. To pursue the goals of service integration it is necessary to look beyond
such simple ‘technical fixes’ and to examine what it is that inter-service work
consists of, and, on that basis, to explore what tools that may be devised to
further the goals of closer inter-service collaboration. It may be necessary to scru-
tinise more closely what ‘service integration’ is actually attempting to achieve
and what it may turn upon. In doing this we find that rather than it being a
problem amenable to a single technical solution, inter-service working consists
of a series of ‘practical problems’ that might be addressed in an individual and
specific manner. In summary, inter-service working depends on members’ use of
practical competencies to achieve mutual understandings and alignments between
different organisations in order to enmesh their separate operations. It is unlikely
that technology can provide shortcuts to these processes and likely that patient
record integration would have to be predicated on healthcare service integration,
rather than the other way around.
6.1. MEMBERSHIP CATEGORISATION AND RECIPIENT DESIGN
The sorts of practical negotiation undertaken between the psychiatric assessment
team and care providers is a matter of arriving at some shared sense of the signifi-
cance of the matter under discussion and a shared sense of its implicativeness
for future courses of action. It is about arriving at shared understandings – does
this person qualify as a possible client for a particular healthcare service? It is
this candidate patient status that is important to us, the manner in which it is
recipient designed using a range of membership categorisation devices in order
to get the patient admitted. For example, we saw earlier the ways in which the
Consultant Psychiatrist characterises the same patient range from someone who

MAKING A CASE IN MEDICAL WORK 261
has smashed up his parents’ home with an axe through someone who is violent
and in need of guards ‘sitting’ on him through to his being ‘potentially’, but not
‘actually’, violent. Neither in this case, nor in our observations generally, do we
find a unified representation of a patient, rather a series of representations-for-a-
purpose, reflecting medical professionals’ routine requirement for meaning (the
implicativeness of a particular patient’s presentation for their service) rather than
merely for information.
The elasticity of potential descriptors represents both a resource for the psychi-
atric assessment team and a potential trouble for the EMR. It suggests that if this
feature of the work is not taken into account in the way that the EMR is deployed,
such that affordances for ‘negotiating’ the patient are reduced, then the EMR
could actually hinder inter-service working. The categorical order and membership
categorisations, upon which professionally adequate, accountable patient disposal
depends, are locally contingent, thoroughgoingly practical, interactional achieve-
ments of ordinary language use. The record elides this work, placing in its stead a
descriptor of just what this occasion of doing disposal came to (c.f. the ‘potter’s
object’ in Garfinkel et al., 1981). The work is not totally lost; it is, of course,
subject to the documentary method of interpretation precisely as a part of doing
recognisably professional disposal work. The work of doing disposal therefore has
to be read into the record as opposed to being read from it.
Our findings also demonstrate that the intelligibility of the patient record cannot
simply be assumed across professional and/or care boundaries. This problematises
the possibility of realising the transparent sharing of information through the EMR,
but also suggests at least one way in which the EMR might be adapted to fit
more closely with the realities of the work. This would be to support recipient
design, perhaps by the inclusion of free-form ‘narratives’ or ‘stories’ that can be
written for specific audiences in much the same way as discharge and referral letters
serve currently as the shared, or bridging, components of different medical record
corpuses. To similar ends, processes of ‘obtaining a reading’ could be facilitated by
documenting means of establishing contact with the ‘writer(s)’ of the record. There
is no shortcut to the intersubjective constitution of meaning through stipulating
categories within an EMR: intersubjectively meaningful categories will only come
from members talking together and establishing a lingua franca as a thoroughgo-
ingly practical matter. This is not to stipulate meaning but to interactively realise it
in and through the processes of inter-service communication.
6.2. AFFORDING ORGANISATIONAL TRANSPARENCY
Our findings document the way in which the everyday, routine work of the
psychiatric assessment team involves various forms of awareness, relationship and
‘liaising’ work that get interleaved into the processes of obtaining and presenting
information. In part, this reflects the changing nature of the services with which
they deal. Though their continuing contacts with various services, the psychiatric

262 MARK HARTSWOOD ET AL.
assessment team can be thought of as engaged in an ongoing process of estab-
lishing what an ‘admissible’ patient currently consists of and which healthcare
services are the most appropriate disposal routes in the light of changing organ-
isational contingencies. More often than not, the accessibility problems that the
psychiatric assessment team are concerned with solving are to do with talking
to the ‘right people’ – where ‘right’ is a practical and situated achievement of
a working division of labour in doing professionally adequate and accountable
disposal of the patient to a service able to offer appropriate treatment – in a timely
fashion, and being aware of and understanding organisational procedures, and the
contexts in which they apply. Thus, inter-service working does not only consist of
negotiating meanings, but in the practical matters associated with mobilising organ-
isational resources by those outside of the service to particular ends. Various ways
of delivering practical assistance in these matters are possible, for example, the
sharing of online internal telephone directories and documents concerning organ-
isational procedures. Again, simply sharing such information would not necessarily
make transparent their implicativeness for particular referring services in particular
circumstances, since what is possible or appropriate is not always inherent in, or
exhaustively encapsulated by, what is officially proscribed. Thus, such a resource
could be further tailored to allow annotation based on members’ actual experiences
of using the various services – detailing, for example, approaches that have been
successful, who is the best contact in what circumstances, and various ‘work-
arounds’ that have been discovered in practice. In this way it would be possible
to support organisational memory and learning.
Our study indicates some obvious difficulties and complexities in moving
towards even basic computer-based support for patient referrals. Whilst this might
be easy to visualise – e.g., technically, it is easy to conceive of details about bed
availability in other healthcare services being accessed remotely by the psychi-
atric assessment team, and beds being booked ‘on-line’ – such a proposal elides
the complexities attendant on achieving an admission when things do not run so
smoothly, and the flexibilities and compromises that medical workers attempt to
obtain and are willing to give in order to make the system of referrals workable.
It is also certain that such a change in procedure would require a significant re-
negotiation of professional responsibilities for liaison work. In turn, this makes
it hard to conceive that re-engineering liaison work could happen without being
accompanied by major changes in the cultures of the services involved (Hanseth
and Monteiro, 1998). Furthermore, it is likely that the issues of negotiated meaning
and organisational transparency would re-emerge in different guises.
6.3. BEYOND ETHNOGRAPHY FOR DESIGN:DESIGN IN USE
Regardless of how the EMR and other integrative technologies are to be deployed,
the argument that designers of such systems should spend some time examining
the work practice of members in such settings seems clear:

MAKING A CASE IN MEDICAL WORK 263
... the detailed examination of documentary practices, particularly the infer-
ences individuals commonly utilise for their production and for their recogni-
tion may provide a resource for assessing the shortcomings and possibilities for
new technologies.” (Heath and Luff, 1996b, p. 362)
Members will have a knowledge and awareness of the social organisation, the
social circumstances of healthcare; circumstances which, as Sacks (1972) points
out, may be of some significance for the introduction of new technologies such as
the EMR, which are made “at home in the world that has whatever organisation it
already has”.
Beyond the issue of sensitising aprioridesign to the work practices and settings
of use, however, is the fact that the effects of introducing new technologies are
often unpredictable and can only be determined in use. Over time, users may adapt
to, adapt and even re-invent technologies as they explore their possibilities for
practical purposes (Berg et al., 1998; Berg, 1999). As IT systems and artefacts
become ubiquitous at work and design becomes more entwined with the awesome
complexities of organisational working, so the challenges facing systems designers
correspondingly increase. The ‘design problem’ becomes not so much concerned
with the simple creation of new technical artefacts or the ‘computerisation’ and
replacement of work practices, as it is with the effective integration of computer
systems with existing, localised work practices, while allowing space for the
development of new ones. This effectively takes the ‘design problem’ beyond the
conventional design phase to implementation and deployment, where users must
try and apply any new system to their work practice. It is commonly suggested that
in order to make systems ‘work’, actual working practices have to be ‘disciplined’
to fit the requirements of the system. Systems such as the EMR, however, need
to be adapted to local circumstances in various ways. Implementing new systems
changes both the practices and, in an iterative process, the system itself. Similarly,
users are forced to adapt, to use ‘ad hoc’ practices and, in so doing, the work also
changes. Socio-technical systems are thus mutually constituting and adaptive as
organisations and activities constantly evolve, presenting what might be regarded
as the classic CSCW issue – what to automate and what to leave to human skill and
ingenuity. In the suggestions we have made above for tools to support healthcare
service integration, we have assumed that the relationships between services are not
static, but rather are subject to change depending on a host of contingent factors
(not least the availability of funding and changes in strategies for provision, as
well as is in day to day changes in service availability). Thus tools that support the
inter-working of such services have to be either sensitive to these contingencies
and/or be subject to ongoing re-design. We argue that for technologies like the
EMR to deliver the maximum benefit, design and development methodologies must
actively support these user-led processes of adaptation and, elsewhere (Hartswood
et al., 2000, 2002), we report on our experiences of putting just such a user-led
methodology into practice within a healthcare setting.

264 MARK HARTSWOOD ET AL.
Acknowledgements
We would like to thank staff from the toxicology ward, North British Hospital,
for their help with this project. This work is funded by the UK Engineering and
Physical Sciences Research Council, grant number GR/M52786.
Notes
1. In some cases there has been some attention to the sequential nature of language, but our
intention here is to focus, e.g., on the ways in which categories are used (in sequence) and
the implications that these have for both the work and the design of EMR systems.
2. Also referred to as the electronic patient record (EPR) and electronic health record (EHR). These
terms are used sometimes to distinguish between the record of periodic care held by a single
provider (EPR) and the fully integrated record of the patient’s complete medical history (EHR)
(Royal College of GPs, 2000).
3. People and place names that appear in the fieldwork transcripts have been anonymised.
4. This is not in the sense of a labelling process but a process wherein persons become bearers
of a particular categorisation for the practical purposes of getting them treatment. Such labels
may not adhere to the patient for long in a public sense (the patient may not be regarded as
‘psychotic’ or labelled as such by doctors and others) but they are important for design – the
central question is what is one to call this or that condition with which the patient presents as an
object for designers.
5. For example, the patient might have a history with that hospital; the consultant’s preference
might be for different patients (often expressed as a view about what the service provided is for
and how it should be used); and there may be disputes as to whose responsibility the patient
actually is depending on age, location and so on.
6. Of course, the diagnosis is in part achieved through the pairing doctor-patient wherein the doctor
has the right to categorise the patient in a manner that lay members do not.
7. We take this up below.
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