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ICT in Health Care: Sociotechnical Approaches
Article in Methods of Information in Medicine · February 2003
DOI: 10.1267/METH03040297 · Source: PubMed
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Methods Inf Med 4/2003
297
ICT in Health Care: Sociotechnical Approaches
M. Berg1
, J. Aarts1
, J. van der Lei2
1
Institute of Health Policy and Management, Erasmus University Medical Center,
Rotterdam, The Netherlands
2
Institute of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
What Are Sociotechnical
Approaches?
Within medical informatics, and within the
broader fields of informatics and informa-
tion systems, the importance of incorpo-
rating insights from the social sciences is
increasingly recognized [1, 2]. As informa-
tion systems require interaction with
people and thereby inevitably affect them,
understanding information systems re-
quires a focus on the interrelation between
technology and its social environment.
‘Sociotechnical approaches’ aim to do just
this: increase our understanding of how
information systems or novel electronic
communication techniques are developed,
introduced and become a part of social
practices.With this aim comes a concurrent
ambition to improve these systems. When
insights from the social sciences can help us
better understand these phenomena, after
all, they may also help us to make better
systems – or to make systems function
better.
There is no such thing as ‘the’ sociotech-
nical approach. The term has several
roots. Within information systems design,
Mumford and co-workers introduced a
‘sociotechnical approach’ some thirty years
ago. Their specific aim was to ensure that
developments in Information and Commu-
nication Technology (ICT) would go hand
in hand with a central focus on users’ skills,
job satisfaction, and good working rela-
tionships. The ‘social’ aspects of system
development, in other words, had to be
balanced with the ‘technical’ aspects [3, 4].
Independently, researchers in the field of
science and technology studies recognized
how in any in-depth study of the func-
tioning or development of a ‘technology’,
‘social aspects’ abounded – and vice versa.
To understand the successes or failures in
Summary
The importance of the social sciences for medical infor-
matics is increasingly recognized. As ICT requires inter-
action with people and thereby inevitably affects
them, understanding ICT requires a focus on the inter-
relation between technology and its social environ-
ment. Sociotechnical approaches increase our under-
standing of how ICT applications are developed, intro-
duced and become a part of social practices. Socio-
technical approaches share several starting points:
1) they see health care work as a social, ‘real life’
phenomenon, which may seem ‘messy’ at first, but
which is guided by a practical rationality that can only
be overlooked at a high price (i.e. failed systems).
2) They see technological innovation as a social
process, in which organizations are deeply affected.
3) Through in-depth, formative evaluation, they can
help improve system design and implementation.
Methods Inf Med 2003; 42: 297–301
Editorial

3. the history of bicycle design, for example,
one had to include diverse issues such as
gender, 19th century culture, or industry
strategies. Similarly, to understand the
development of 20th century towns one
cannot overlook how the impact of tech-
nologies such as the car resulted in a
‘spreading out’ of cities over new geograph-
ical spaces. To highlight this intertwine-
ment, they also coined the term ‘sociotech-
nical’ [5, 6]. A similar understanding of the
interdependency of ‘social’ and ‘technical’
elements is reflected in the use of the term
‘sociotechnical systems’ by authors investi-
gating errors in ‘high risk’ environments
such as airplanes or hospitals [7-9].
‘Sociotechnical’ analyses also originate
from fields such as Computer Supported
Cooperative Work, where social scientists
and computer scientists cooperate in order
to make tools to support group decision
making, collaborative writing, virtual
meetings, and so forth [10, 11]. Or from
Participatory Design, where – quite similar
to Mumford’s design principles – users are
given the lead in design in order to ensure
that the tools developed support their
needs and positions better [12, 13]. Finally,
many of these issues come to play in the
field of Information Systems Research
[14, 15]. Building upon these diverse back-
grounds, the ‘sociotechnical approach’ has
also found its way in medical informatics
[16-18]. The different traditions all bring
their own specific interests to the fore, and
importantly so: the manifold ways in which
the interrelation of ‘social’ and ‘technical’
aspects presents itself cannot be captured
in one simple model or theory.
Nature of Health Care Work
A few core common denominators are
shared by all these approaches. First of all,
sociotechnical approaches focus on the
nature of health care work, including
working with information technologies,as a
social process. Health care work involves
simultaneously dealing with sick individu-
als, with varying needs and problems, and
with other health care professionals and
organizational units. Standard organiza-
tional‘solutions’ never wholly fit a patient’s
individual problem; and where a standard
solution would be appropriate, chances are
that it is not available as such. As a
result, health care workers are constantly
‘matching’ one to the other, matching
‘problem’ to ‘solution’, constantly handling
contingencies that require ad hoc and
pragmatic responses [19].
Seeing medical work as the social,
real-life practice that it is transforms our
views of many of the constituents of health
care work – large and small. What it is to
place an order, for example, or to report a
result of a test. At first glance, it seems
obvious that a doctor conceives of an order,
writes it down, and that a nurse sub-
sequently executes it. Variations in who
gives and who executes the order are
possible – but the basic syntax remains the
same. Yet studies of ‘orders’ in real-life
medical work show a more complicated
picture. ‘Orders’ are often not simply
‘given’ by one person to another: they arise
out of a collective discussion, for example,
in which different doctors and nurses
participate [20]. Or they are written down
by a doctor who was subtly informed by an
experienced nurse about the ‘proper thing
to do’ [21]. Similarly, what counts as a
proper, high quality ‘result’ also depends
on the context: in acute situations, first
impressions of an X-ray can have to form
the basis for far reaching decisions, while in
other settings, the ‘standard’ X-ray quality
(resolution, detail in radiologist’s report)
may be far from sufficient [22]. What
is a ‘good’ or ‘high quality’ image, or a
‘proper response’ to a question is always
relative to the purpose for which the
result or response was elicited [23].
This same issue affects the coding of
clinical data. ‘Codes’ should not be con-
ceived as the standardized, universal labels
that stand for the‘essence’ of (a part of) the
medical consultation. In this view, ‘coded’
text is more scientific than ‘uncoded’ text,
and the way to ‘free’ medical information
from its‘paper prison’ lies in proper coding.
‘Coding’, however, should always also be
done only when a clear purpose is expli-
cated. If not, the coding becomes a source
of frustration to the clinicians [24], and
results in data aggregates of less than no
value [25]. In addition, the work of coding
should be more clearly recognized, and
health care professionals’ desire to‘localize
codes’ to their own daily working needs
should be properly supported rather than
seen as a ‘tainting’ of the original coding
exercise [26].
This detailed focus on the real-life,
‘messy’ reality of work-in-action aligns with
those who study cognition in practice. Such
studies show how what we traditionally
conceive as ‘individual’ thinking processes
are in fact heavily structured by the social
and material context in which these
‘thinking’ processes take place [27]. When
physicians handle patients, they use many
material cues to help them organize and
structure their work – from ‘reading’ the
status of the patient off the ‘thickness’ of
the record to ordering their records in
specific ways [28, 29]. Such practices are
not only crucial for the ongoing work itself:
they simultaneously (re-)sustain social
relations between professionals. In the
interactional handling of records, for exam-
ple,the building of mutual trust is as impor-
tant as the transferring of information [30].
With these examples, we immediately
touch upon how health care ICT should be
designed to fit the specific nature of health
care work – or of professional work more in
general. Many of the current Physician
Order Entry (POE) systems, for example,
are based upon the ‘standard’ image of
‘placing orders’. As a result, they cleanly
separate ‘order giving’ – conceived as an
individual activity – from ‘order receiving’
– conceived as the clear-cut reception of
‘the result’. Non-structured communica-
tion between ‘giver’ and ‘sender’ is poor-
ly supported, and the importance of ‘com-
pleteness’ of the data entered is stressed as
a good in and of itself [20, 31, 32]. From a
sociotechnical perspective, design is cru-
cially about finding the synergy between
the specific particularities of health
care work, and the informating properties
of ICT [33]. It is about designing interac-
tions not from the view of the technology,
but from the agents that work with that
technology, and the practices in which it
will become embedded [34].
Berg et al.
298
Methods Inf Med 4/2003

4. Nature of Technological
Innovation
In addition to this focus on the nature of
health care work, sociotechnical approach-
es also emphasize the fact that health
care practices are social settings like any
other: structured by hierarchies, rivalries,
institutional histories, and so forth. As any
technology, information technologies affect
the contexts in which they are introduced –
in many different ways, and more deeply
than is often expected [5,35].In subtle ways
(that may make the difference between
‘success’ and ‘failure’), new forms of com-
munication invariably affect the relations
between those communicating.This issue is,
for example, often painfully overlooked in
telemedicine projects. Introducing cameras
for first aid teams in emergency medicine
(to let a remote doctor overlook the
accident scene) invoked a whole series of
unexpected issues of control, responsibility,
whose interests take precedence, and
so forth [36, 37]. In ‘ordinary’ hospital
information systems or electronic records,
feelings of ‘surveillance’ and the issue of
who gets to see whose data can create great
organizational havoc [38].
As information technologies ascribe
novel ‘roles’ to the health care pro-
fessionals that work with them, they also
invariably affect the patient. This touches
upon many more issues than ‘patient
satisfaction’; it is, for example, about how
‘informed consent’ is made operational in
an electronic patient record [39]. Similarly,
the different attempts to regulate patient
information on the internet, to signal what
counts as ‘reliable’ and what does not,
touches upon fundamental issues such as
whether we see patients as independent
consumers or as potential prey for money-
hungry quacks – or as something again
wholly different [40].
These social ‘impacts’ invariably affect
the further development of the technology.
New authorization protocols are made in
order to deal with visibility issues [41],
new uses for technologies emerge [37], and
requirements for new versions of the
application are updated in order to further
align it to the organization's emerging
working patterns [42]. In addition, more
‘meso’ or ‘macro’ developments leave their
mark as well: ICT developments are
equally structured by institutional mergers,
national ICT politics, hypes in health care
policy, and so forth [43]. Technological
development,therefore,cannot be seen as a
merely ‘technical’, linear process. Actors
will seize upon or obstruct a specific devel-
opment depending on how they perceive it
to extend their interests [44, 45]. As an
extended process of negotiations, whose
course can never be fully predicted, the
‘technology’ and the practice in which it is
put to work transform each other – often in
unexpected ways [46].
Here as well,these insights can be drawn
upon to improve these technologies, and
the processes through which they are
developed. In part, the contingencies
structuring technological development can
be so overwhelming and multi-layered that
any attempt to ‘improve’ such a develop-
ment seems fatally flawed from the outset.
Indeed, one might become pessimistic
when one realizes that the introduction of
an EPR may be crucially affected by the
vendor's longevity, the financial status of
the health care organization (and, thus, by
national health politics), by the personality
of the project leader, by organizational
culture – to name just a few of the lesser
‘malleable’ aspects [43, 47].
Yet one need not become so pessimistic.
When one realizes how information
technologies impact the settings in which
they are put to work, it becomes relevant
to investigate whether the social ‘roles’
inscribed in the system are at all feasible
for that practice. Too often, health care
institutions buy applications developed in
another country, only to find out that the
other country’s patient handling routines,
billing practices, inter-professional rela-
tions and so forth are so thoroughly built
into the software that major reprogram-
ming is necessary [38].
Likewise, the process of developing the
technology is important. Sociotechnical
approaches favor a central role of the user
throughout the development process. Too
many databases have become ‘data grave-
yards’ because those who had to fill and
draw upon the databases were not taken
seriously enough during the information
system design [48].How to truly involve the
user, however, is not easy [41, 49]. There is
much rhetoric here – who would nowadays
argue that the user should not be involved?
Yet the reality of most design practices is
more often than not that 'users' are consult-
ed only a few times, in meetings whose set-
up mitigate against any real involvement of
users, or any real openness of the designers
[50]. Successful user involvement requires
stamina, a stubborn organizational focus
from day one on, and, most of all, a realiza-
tion that technology ‘implementation’ is
first and foremost a process of organiza-
tional change [42].
In addition, sociotechnical approaches
emphasize the need for an iterative, incre-
mental change process. At every new step,
the (often unpredictable) lessons learned
from the previous step should be properly
integrated and acted upon. The non-linear
nature of technology development should
not be ‘quenched’ with an overdose of
project management tools – it should
rather be embraced and‘nourished’,so that
the potential of organizational learning and
the chance of finding synergy is maximized
[51-53]. Rather than worrying about how
such a ‘messy’ design process will affect the
‘overall’ integration of the information
systems or the purity of the architecture,we
should realize that a ‘patchwork’ of only
partially integrated systems may in fact be
much more robust,much more flexible,and
much more ‘sensitive’ to the multiple
information needs of complex organiza-
tions [54, 55].
From Evaluating Failure to
Evaluating to Prevent Failure
This issue is full of accounts of information
system failure, or poor use of information
system functionalities.Failures are reputed-
ly underreported [56], and this special issue
balances the accounts somewhat. This
special issue of Methods of Information in
Medicine was not intended to deal with
system failures – nor did any of the contrib-
utors start out with the desire to study a
ICT in Health Care: Sociotechnical Approaches
299
Methods Inf Med 4/2003

5. ‘failed system’.Then why so many partial or
complete failure cases? The main differ-
ence with other journal issues in medical
informatics is that the majority of authors
that contributed to this issue were research-
ers without a stake in the tools reported
upon. The only reason that there are so
many failures reported here, then, is prob-
ably because so many systems fail. Moreover,
the stories collected here illustrate why so
many systems fail. Not because of hard- or
software problems, or of fundamental limi-
tations to the technologies being used.
Rather, systems fail because they are build
upon the wrong assumptions [37, 48], they
incorporate problematic models of medical
work [38, 45], or they fail to see ‘implemen-
tation’ as organizational change [41,53,57].
One additional important reason for
system failure is the omission of evaluation
studies during system development. If
we want to optimize the opportunities for
organizational learning, we will have to
carefully monitor the reactions to the im-
plemented technology – the complaints,the
use rates, the horror stories, the shifting
inter-professional relationships. Only in
this way can the development process ‘stay
in tune’ with the technology's impact and
vice versa [58]. As this special issue illus-
trates, qualitative research methods are
often the method of choice for such ques-
tions; they can give us insight in the nature
of the changing sociotechnical relations,the
reasons of failure, and the particularities
of specific working routines [59].
Drawing upon these insights, we believe
we can increase our aims: to develop pa-
tient care information systems that not
only ‘not fail’, but that actually help to
restructure our traditional ways of ‘doing’
the primary care process.This might be the
largest challenge for the sociotechnical
approach: finding out just how to interre-
late the nature of health care work with
the characteristics of formal tools. So that
we can move from better understanding
why information systems failed to demon-
strate how to find synergy between health
care work and information technology [33].
Acknowledgments
The papers in this issue are a selection of papers
first presented at the conference ICT in Health
Care: Sociotechnical Approaches, held 6-7 Sep-
tember 2001, in Rotterdam. We thank Samantha
Adams, Barbara Blank, Marlies Hellendoorn,
Marleen de Mul and Brit Ross-Winthereik for
their work to make this conference happen.
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Correspondence to:
Marc Berg, MA, MD, PhD
Institute of Health Policy and Management
Erasmus University Medical Center
P.O. Box. 1738
3000 DR Rotterdam
The Netherlands
E-mail: m.berg@bmg.eur.nl
ICT in Health Care: Sociotechnical Approaches
301
Methods Inf Med 4/2003
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