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The Challenges of Clinical Governance: ‘Informationalising’ as Socio-Technical Literacy

Of principal interest to health information experts are accuracy, confidentiality, and relevance of the data and information processes that they are in charge of (Hovenga and Lloyd 2002). What these criteria mean in relation to how data and information are (re)constituted in practice is of course highly stakeholder-specific; what constitutes accuracy or relevance for one person does not necessarily do so for someone else. But if what health information experts do is generate, process and interpret data to facilitate decisionmaking at multiple levels of the healthcare organisation, then people at these different levels will also have views on what accuracy, confidentiality and relevance mean for them in their practices. Policy makers have an interest in the demographics and overall health outcomes of, for example, mental health care and cancer care. Hospital managers require insight into more ‘local’ patterns, to do with patient throughput in their organisation, resource usage, staff deployment and the like. Clinicians’ expectations are different again, and are likely to be significantly more ‘local’ still; they want to know about the effectiveness of their treatments for specific patients. These differences have direct implications for health information experts; the potential lack of common ground among stakeholders translates directly into contestation over the profile of the codes and the structure of the language within which to frame and communicate health data and information. Not surprisingly, such differences in views and expectations about what counts as useful data and information are not just making life hard for health information experts, but for everyone working in the healthcare system. Unfortunately perhaps, these are problems for which there are no technical solutions, because they reach back to people’s different ways of seeing the world. And we know that our ways of seeing are equally ways of not seeing (Cooper 1997), which means that the ways in which we make meaning about the world always run the risk of ‘muting’ others and their meanings. Our ways of framing the world are indicative of how we define, and where we draw boundaries around, our interests and concerns. Undeniably, however, these interests and concerns are intimately tied up with our self-identity. When naming and framing the world, therefore, we don’t just promote particular codings and classifications because they suit us. Rather, we do so because we genuinely feel that things just could not be categorised differently. Put differently, we don’t just utilise codings and classifications to differentiate things for pragmatic reasons, we embody them as a way of ‘making sense’ of things. And because they enable us to sense the world, we find ourselves in alien territory when we step outside of them, and have the feeling of being unable (or less able) to find meaning. It is at the interstice between self and emerging information and communication technologies (ICTs) in particular, that those interested in ‘informating’ healthcare are confronted with the most serious challenges but also the greatest opportunities. First, ICTs create networks across sites, stakeholders, systems of practices and rituals of meaning-making like never before (Bowker and Star 1999). ICTs have little respect for traditional boundaries, codes, classifications or identities; anything that can connect, will connect, and will change things on contact. For any frontiers to stay in place they need to be increasingly intensely policed. Second, because these digital networks are continuously changing and expanding, ICTs do not just make do with once-off new codings and classifications; they require these to be continuously revised and updated, and this occurs at an increasingly rapid rate (Timmermans et al. 1998). It is not the case therefore that, once in place, the new codes and designs that ICTs require to function will forever stay in place. On the contrary, because of the increasing ubiquity of ICTs and the rapidly transforming networks that they entrain, we are both enabled and expected to digitally represent as well as rerepresent more and more facets of our social and working lives. We constantly re-represent these things as part of our effort to keep up with technological, organisational, social, cultural and political changes going on around us. We have entered an age where we are constantly having to recode and redesign our work, our working environments, as well as our selves (Iedema and Scheeres 2003)! Think of how often we hear about lifelong learning and continuous improvement while at work, or career ‘resiliencing’ and multiskilling as we move through different domains of work. For some, this constant re-representation of what we do and are is a prominent feature of contemporary working life, and points to the close connection between ‘informationalising’ (devising classifications and analytical procedures to produce information about something), communicating, and being in the world: ‘today labour and society have to informationalise, become intelligent, become communicative, become affective’ (Hardt and Negri 2004: 109). For others, this means that we ourselves are faced with having to ‘flexibilise’ our self-identity (Grey and Garsten 2001). All this is because we’re now living and working in an ‘information network society’ (Castells 1990), which means we do not merely ‘shadow’ what people do and say and transform that into information, only to leave them subsequently alone. On the contrary, this new information network society and the informationalising that is at the heart of it require that we continually communicate, negotiate and resolve decisions and differences to do with how and what we informationalise. As Hardt and Negri’s point above makes clear, central to informationalising is that we become communicative and affective. More challenging is that informationalising entails enabling people to absorb different ways of being and seeing themselves. What do these developments mean for healthcare employees, and what do they mean for those who informationalise healthcare work? First, informationalisThe challenges of clinical governance: ‘informationalising’ as socio-technical literacy