Citizen-centric view of health and wellbeing

A view to
Citizen centric information systems
Abstractions in different levels
Pekka Muukkonen 24.11.2009
Tämä teos, jonka tekijä on
Pekka Muukkonen, on
Lisensoitu Creative Commons
Nimeä-JaaSamoin 4.0
Kansainvälinen –lisenssillä.

A short story in three steps
•  MyWellbeing project
•  Finnish e-service trajectories
– Context areas of
•  healthcare and wellbeing
•  General e-society development
•  A view I have on technology
– Adopted influences

MyWellbeing - Involved parties
•  TEKES FinnWell-program project 3/2008-3/2010
•  Åbo Akademi
•  University of Turku
•  University of Kuopio
•  University of Tampere
•  Helsinki University of Technology
•  University of Applied Sciences – Savonia (Kuopio)
•  Funding partners: Itella, Logica, Mediconsult, Cel’Amanzi, The city
of Turku – health care, Duodecim
•  Funding total: 1,3M€
•  http://omahyvinvointi.utu.fi

MyWellbeing value promise
•  Develop a ”Citizen-centric service concept” that
supports and supplements
–  different customer centric development plans and
systems implemented by the service providers
–  projects of public administration to enhance service
processes and the furtherance of the increase in
citizen’s self initiative
–  Organizational implementation and mobilization of e-
information channels in various institutions in
communal and national level

Aims of the MyWellbeing project
•  Formulate a general perspective on the subject of
eElämänhallinta (e-’kontroll över livet’, eLivskompetens.
eLivs-kompetens)
•  To support the citizen in the centre of service production as a
competent (beslutsmässig) and active actor – empowerment
•  To provide an opportunity to gain a meaningful and holistic view on
the situation and state of one’s health and wellbeing – to supply
tools to enhance the management of wellbeing
•  To enhance the ability to set goals and increase action possibilities
in multidimensional service network – develop tools for a citizen to
become an active actor

Focus areas of the involved parties
•  Åbo Akademi (futurologists, Corporate Foresight Institute)
–  future scenarios from organizational and societal level
•  University of Turku (Information system researchers)
–  Wrapping up the concept description(s)
–  Target group of ’people retiring from work’
•  Moving away from the service relationship of occupational health care
•  University of Kuopio (Computer science, IS and Health Informatics
researchers)
–  Arhcitecture and information infrastructure in Health Care
•  University of Tampere (Information system researchers)
–  Process evaluation
•  Helsinki University of Technology (System engineers)
–  Architecture and information infrastructure as Service Business
•  University of Applied Sciences – Savonia (Kuopio) (Nurses and
Nursing Informatics researchers, Anthropologist)
–  Target group of ’families having a baby’

The promise and purpose of the
concept of Coper
•  4 basic properties
•  3 level integration support

From general aims to
features of the Coper
•  Personal life record
–  ”Dual system architecture” – Citizens/customers IS
–  Access to different person registers
–  Self produced entries and notes
–  A document based representation?
–  Possibilities to link discrete data elements into different representations
•  Ability to have additional information based on a personal profile
•  Personal activity navigation
–  Decision support
–  Process descriptions (clinical care paths and ”
Patientversionerna av God medicinsk praxis –rekommendationerna”)
–  A calendar (upcoming events)
•  Service relationship management (consumer2business)
–  Information exhange
–  Choice management
•  Service directory
•  Quality-/cost comparisons
•  Peer group support (citizen2citizen)
–  Social media
•  An emancipated citizen as a result?
–  From regulatory and restriction politics to independent decision ability and authority?

Personal life record
•  Solution suggestion to the problem of location:
•  ’Dual system’ (double entry bookkeeping)
–  Total solution: I receive a copy from all the entries that concern me to my own personal system
–  Probably a sufficient solution: I receive information about all the entries concerning me – what has been
saved where (metadata) and ability to access and retrieve information in the time of need
Primary health care
Masseuse
Nutrition
specialist
Pharmacy
Occupational health care
Maternity clinic
Secondary health care
FPA
- e-prescription
- e-archive
WellnessDiary
- And the like
Peer group
forums
Pekka Muukkonen, on lisensoitu
Creative Commons Nimeä-JaaSamoin
4.0 Kansainvälinen -lisenssillä

Case example – my godchild
•  Action needs emerged from the life situation
–  Visits to maternity clinic
–  Birth-giving trainings
–  Filling up the ’maternity card’
–  Filling up the form of ’birth giver’
–  Explication of inherited diseases - family bound risks (e.g. Celiac disease)
–  Internalization of birth anamnesis and follow-up plan
–  Reading information about general baby caretaking
–  Informing the child to population register
–  Forms for the district registry (magistrat)
–  Following and providing the information about the birth-related diabetes –
recording and transmission the values of blood sugar level to nurse on a weekly
basis
–  Reseersättninggar åt FPA (need for further clarifications – delivery of
certifications of services for example from the hospital)
–  New rental agreement
–  Aquiring the husbands last year tax income
–  Updating the forms of housing allowance (FPA)
–  Initiating a process for having föräldrapenning
•  A report of income from the past year and so on.

”Personal Information Repository, 2005”
Jaakko Lähteenmäki, VTT (Affärsverksamhet av teknologi)
Clinical visits
Distant health care
Prescriptions
Guided excercise
Personal entries
Personal information repository
Information sources:
Quick access to information
Linking and combination of
data, analyses for personal
use
-> follow-up
-> motivation
Anonym utilization of
information in research
-> drug research
-> public health care
Excercise entries
Vaccinations
X-ray &
soft
tissue
graphs
Diet regime
Weight
Medical certificats
and epicrises
Medication
Care
guidelines

Personal life record
•  Where should this record recide?
–  PC, Cloud, kommun, nation, EU, UN?
–  Itella – ePost  - ’secure document database’ – with tagging properties, free storage for 6 years/document (taxation purposes)
•  Solution suggestion for the entries: Standard terms (open schema)
–  Information is recorded according to unified classification schema
–  Must maintain an ability to add and use personally defined classes (personal tagging)
–  Conversion of self produced entries to interchageable - acceptable also to others
•  E.g. different measurement equipment (Continua Health Alliance – open industry group)
•  Solution suggestion for the information presentation (visualization): Linked
data
–  Data must also be received in ’raw’ format, not only as documents (ref. eView)
–  Life events can be re-constructed for example in a time-line highlighting various aspects while, preserving their internal
relationships
•  A possibility to create differents kinds of views. For example to the care of diabetes - in
a same view the blood clugose levels, nutrition values, used medicine, excercise
routines - and their development trends
–  You could also posit a question: ”how much has the treatment of the diabetes cost over the past 5 years” –
and even get an answer (stuff of Deep Thought)
http://www.ted.com/index.php/talks/tim_berners_lee_on_the_next_web.html
•  Realization of previous points enables the decision support
•  ”God medicinsk praxis – rekommendationerna” as the basis on virtual check-ups
(Duodecim)
–  Recommended medications?
–  Risk indications and preferred vaccinations
•  Self initiated check-up of treatment, receiving treatment recommendations based on a
profile and an incentive to seek care

Example – document management

Feature 2. Personal activity navigation
•  A need to know how for example the treatment of certain
illness will be arranged – or the process of ’having a
baby’
–  What will be done in what order
•  Also plausible questions
–  Why it is done
–  What will it cost, who pays
–  How to prepare for future events/arrangements and adjustment needed to the daily living
•  A general case of explicating ’intentional activity’
–  ’a project’
–  Process articulation
•  E.g.. Care paths (VSSHP)
•  What are the parties that participate to activity
•  Who deals with what part – and when
–  What are the information needs of distinct actors
–  Event-articulation
•  E.g. Call for operation (Itella ”ärandehanteringservice” – B2C-pro-project, surgery)
–  Guides
–  Maps
–  Forms of preliminary data (self provided anamnesis)
–  A possibility to produce an organized view to the caledar (or to a map – if wanted)

Feature 3. Service relationship management
•  Besides oneself for the sake of self-monitoring, gathered data
might be useful to somebody else as well – and this might be
even more common than bury oneself to own data...
–  How to provide information to others in a usable format for them?
–  How to make this as convenient as possible for oneself
•  …pre-filled forms
•  Message channel to care personnel (nurses and doctors)
•  Knowledge about what services I’m entitled to – by law and
contracts (e.g. Insurance coverage)
•  Dealing with payments and benefits
•  Where to find a service provider and what kind of contract
relationship is purposeful
–  Service directory and its usability (SADe 2009-2012, Suomi.fi)
–  Quality and price comparisons between different service providers
(Palveluvaaka – service scale, 2011)
–  Is this essential – doesn’t care guidance work ’properly’ and well enough
already?

Feature 3. Service relationship management
•  General national guidelines in seeking care and ’increasing the
possibilities of customer and patient’
–  ’e-appointment booking’s are commonplace - in a private sector
•  Systems not synchronizable to any other calendar software in use on phones/
computers 
•  Need to provide some other means than e-mail in treatment related
communication
•  Care and other services provided by neighbouring municipalities and
beyond
•  An ongoing kommunsammanslagsprogram
•  ICT-servicecenter (SITRA kommunprogram 2009-2013)
•  (e)Service-sedlar being in development (Palvelusetelilaki voimaan 1.6.2009)
–  The management of excess (how much you have to pay yourself) and customer
invoices is changing
•  Aspirations to provide EU-wide care network/martket area
–  Dealing with different kinds of persmissions and health insurances

Feature 4. peer-to-peer support
•  Support, knowledge and comfort is also
available from other than ’authorized
information producers’
•  An ability to engage in the activity of a
peer-group that deals with a self
determined interest area
–  Social media services

Not to make it too difficult;
Citizen’s actions in service relationships
•  Home monitoring
–  Entry recording
–  Result transmission
•  Examination of personal health records
–  Patient documents
–  Laboratory results
•  Appointment bookings
•  Information exhange
–  QA service
–  Pre-anamnesis (forms of previous conditions and current status)
•  Locating the service
•  Management of payment methods and conditions
•  Retrieval and understanding the general information

The usefulness of the concept from
activity-support and mental wellbeing
points of view
•  Service situation awareness
–  Service relationship management
–  Intentional wholes of errand handling ’ärandehantering’ formulated together with
service producers
–  Project/process follow-up
•  Personal situation awarenss
–  The value and meaning of relevant things of measurements
–  The trend of values
•  Easiness of operation
–  All the needed documents(/information) are easily available and in a format that
can be sent/given an access to relevant parties
•  Sense of closeness
–  Both social peer-networks and possible personalized services in different phases
of ”service production conveyor-belt/assembly line” provide a sense that I and the
situation I’m in is cared for

Summa summarum:
the concept of Coper
•  As a concept of ”metaservice” gathers up different
visions and concepts from multiple services, systems,
tools and actors
•  Provides an integration platform to combine distinct
information and services, which serves
–  The Citizen (situational awareness and easiness of errand handling)
–  Actors in the health care (extensive information in one place and ability to receive it at once –
no need for further clarifications)
–  (in the future) Researchers (data not available previously)

Coper as a technical service
(rendered from the SAAS perspective)
Platform services
Core of ”Coper”
Personal
information repository
Core
functionalities
User interfaces
Presentation
services
Added value
services
Information
source
services
Provider
collaboration
Community
Knowledge
Personal
Personal
health device
Service
provider
Information
management
Communication
User
managemet
Scanning

The role of the Coper –
a civil servant in the digital age
•  Navigator
•  Ombudsman (spokesperson in the
bureaucracy jungle)
•  Personal trainer
•  Technological ”palm reader” (genes,
measurement information, statistical
comparison)
•  e-Integrator (visual, semantic, process)

Coper in relation to existing
services
•  Levels of integration
–  Level 1 – platform
•  Single sign-on
–  UID & pwd management
•  Visual outlook of different services (standard ’look and feel’)
–  Level 2 – data
•  Data in raw format – ability to combine data from different
sources for different purposes
–  Level 3 – process management
•  Ability to create and deal with processes that cross many
organizational boundaries
–  E.g. a treatment process transforms into insurance claim
process seamlessly
–  The whole flow of operations and related information under a
domain of a single ”ärandehantering”

The design process
•  People moving away from the occupational
health services (20 persons)
–  Gathering the existing health records
•  Providing a ’simple’ tool to organize the records
–  Construction of personas (4)
–  Building action scenarios and their refinement (4)
–  Consolidation of data and generalization of services
•  Families having a baby
–  Ethnographic methods applied to the examination of
the adoption of a tool of ’social media’ in a cohort
•  Facebook 4 families with new born babies

Action scenarios
•  4 different ’archetypes’
–  Diabetes - Management of long-term/chronic disease
•  Illustrating the process of continuous (but periodical) record
keeping, data transmission, plan renewing
–  Knee operation – One time major event
•  Illustrating the information exhange and life adjustment
needs in multi-organizational service process
–  Swim excercise – aquiring a wellbeing service
•  Illustrating the service selection, travel planning and
utilization of social relations
–  Swineflu – receiving a public health recommendation
and acting on it
•  Illustrating the case of receiving a profile-based
(”personalized”) process recommendation

THE EXISTING
•  Have we implemented anything yet?
–  No – well, yes.
•  A software to store and tag scanned health records (Åbo)
•  Savonia ’Social networking tool for families’
•  At the moment implementation in progress
–  Transmission medical record data directly to the Itella NetPost
(secure mailbox)
•  Do we have any systems to analyze in order to
have feedback and validation of ’news value’on
our ideas?
–  Yes

PHIM/PHRs implemented in
Finland
•  TEKES (Finnish Funding Agency for Technology
and Innovation) FinnWell programme 2004-2009
–  GoodCare-group (HyväHoito-kokonaisuus)
•  Esbo - Egenvård
•  Åbo – Diabetes management system
•  UleåBorg - Egenvård
•  EteläSavo sjukvårddistrikt (OmaHyvis)
– MyWellbeing (& FeelGood)

OmaOulu & Oulun OmaHoito
EgenUleåborg & EgenVård
•  Active development since 2004->

Uleåborg EgenVård – two layers of
realization
•  1 - General information gathered
– Under a single user interface http://www.oulunomahoito.fi/
•  Background information services – Coronaria ”information
portal service package” of Tervemedia (HealthMedia)
–  Helistin.fi
–  Poliklinikka.fi
–  Tohtori.fi
–  Verkkoklinikka.fi
•  Other integrated information sources
–  Drug Information Centre (Pharma Industry Finland)
–  HealthLibrary (Duodecim)

EgenVård – two layers of realization
Layer 2 – Personal HealthFolder (old picture – laboratory results are
missing)
Active self-care (ProWellness) – partially redundant properties

EgenVård - Requirements (re)definition
in progress (...ready any day soon now...)
•  What was also thought but was not
implemented in the pilot system
–  Connection to patient record system used by the professionals
(Effica) – referrals and epicrises
–  Connection to national eArchive – e.g. Prescription information
–  Invoice management in primary health care
–  SMS-notifications from new events
–  and so on...

Egenvård in relation to Coper
•  Many thoughts already implemented
•  Refinements provided by MyWellbeing
–  Personal records not grouped (tagged) to concern a certain situation
•  E.g. Laboratory results, care messages, diagnoses, prescriptions, measurement
records and appointments are scattered around
•  = difficult to form a view on the overall situation
–  Few options to utilize the collected information
•  Possible to grant an access to collected data
•  NOT possible to send anything for example as pre-anamnesis/linked to care messages
•  NOT possible to use for example in pre-filling of e-forms – Jorvi
–  Multiorganizational errand handling wholes N/A
•  Next – appointment bookings to secondary health care
•  Next – referral management
–  Service guidance
•  Much is done over the phone
•  = need for formulating and articulation of the care process plan

A citizen-centric pilot system
implemented and ”use tested” in
Uleåborg
•  City owned platform
–  What will happen in the case of moving to another
location?
•  Concretizes some features of the first sphere of
e-service management
–  The situation of the person is more complicated
•  = a good start, a demonstration that systems of
this kind are realizable (a proof of concept -
partially), but...

The domains of the Coper

Service system network from the
point of view of en anhörigvårdare

The ’Big Boys’, act 1
•  Google Health
•  Microsoft HealthVault
•  Continua Health Alliance
•  Not applicable at the moment in everyday health
and wellbeing management – in a Finnish
setting

The national setting
•  The service and information infrastructure
in which the Coper must find it’s way in
– Much talk in political arenas must take place
before that

Information infrastructure – level 1
Local area health information systems (Datorstött patientsystem)
•  Two main vendors in the primary public health care (PHC)
–  Tieto (Effica)
–  Logica (Pegasos)
•  A couple of other vendors and systems also in use in PHC
–  Mediconsult (Mediatri)
–  ? (ESKO)
•  Private sector is an open field systemwise
–  Terveystalo
–  MedOne
–  Pulssi
–  ...
•  Secondary health care (hospitals) is a chaos systemswise (TYKS –
over 60 different systems in use)
•  Pharmacy systems are also divided mainly by two vendors

Information infrastructure – level 2
Sjukvårdsområdena (20)
•  ”Area information systems”
–  Link data within one area
•  Personnel have an access to data recorded in
other municipality
•  Concerns only public health care
–  Two different system providers
•  Area Effica
–  Tieto (-Enator)
•  Fiale
–  Itella
–  Logica (WM-data)
•  Underutilized in everyday practice
–  Slow
–  Messy
–  inconsistent data recording practices

National eArchive - KanTa
(implemented by the Folkpensionsanstalten)
•  In the year 2007 EU commission announced a recommendation
K(2008) 3282 which is aimed at
cross-border interoperability of electronic health record systems for
the EU citizen by the year 2015 in order to have single European market
also in cross-border patient treatment.
•  Finland as a model pupil adopted this guideline rather immediately –
Ministry of Social Affairs and Health (Social- och hälsovårdsministeriet)
formulated a law, according which public health care organizations must be
connected to national archive (eArchive & eReceipt service) by 30.03 2011
•  3 part functionality
–  ePrescription
–  eArchice
–  eView
•  Flunked research applications – seemingly no interest to evaluate the
implications for the citizens – nor the professionals (!) (restricted access to
cabinet meetings...)

Services for the Citizen - eView
•  Access to personal eArchive for over the age of
consent (myndig)via internet
•  Requires e-identification
–  E-banking codes
•  Available information
–  e-prescriptions and the delivery information
–  service events in health care
–  Referrals (remiss), epicrises, medical certificates
(läkarutlåtanden)
–  Förklaringar av samtycke, log events
–  In the future: appointments and research results
(laboratory and imaging results)

KanTa – what is expected from the
Citizen?
•  1st the ePrescription (and eView to that)
–  Activity in finding out the rights, responsibilities and adjusting
oneself (accommodation) to the new practices
•  Sign away the needed permissions in prescribing and delivery
situations
•  Using the e-prescription when aquiring the medicine
•  Following the status of remaining doses in prescription
•  Renewing the e-prescription
–  Using the right to view own information
•  Requests must be done in writing
–  Viewing the log events
•  Must be requested separately from the FPA either orally or in
written format
–  Using eView
•  Makes possible to do above mentioned things as a self-service

Problem of gathering the personal
records
•  What should be the system that is
connected to citizen?
– Direct link to professional systems?
– Area system?
– National DB?
•  How to gather and integrate other health
related infromation for personal use?
– And where does it come from?

Network actors of Health
Information
•  National actors
–  Institutet för Hälsa och välvård
–  Social- och hälsovårdsministriet
–  Läkemedelsvärket
–  Läkemedelinfo
–  Terveyskirjasto.fi (Duodecim/SITRA)
–  Osv.
•  Sjukområdena,
–  t.ex. Egentliga Finlands sjukvårdsdistrikt
•  Kommun
–  T.ex. Åbo hälsovården
•  Private clinics
•  3rd sector organizations – e.g. Heart diseases, cancer, etc.
•  Commercial information producers
–  T. Ex. Tervemedia.fi
•  Personal record keeping
–  Monitoring devices etc.
•  Social media
•  Internet as such
•  HOW TO INTEGRATE THESE IN PURPOSEFUL MANNER?

A view of the Citizen
to the information infrasructure
•  What is available
–  General information and guidelines – widely distribited
–  Basic e-services (e.g. Åbo: appointments, laboratory results,
messaging) in scattered areas in unmanaged manner
•  eView – ”coming soon...”
•  Pharmacy services – drug interaction check-up’s as part
of loyal customer services (no personal access to own
information)
•  What is needed? Personalized services.

Govermental definition of (e-)policy
Vanhanen’s 2. regeringsprogram
•  ”Inability to maintain the current service-level of affluent society (välfärdssamälle) as
too expensive” –> need to increase self-services and independent initiative
(företagsamhet)
•  Strategies for e-democracy – SADe
–  bruktagningen av medborgarnas elektroniska
ärendehanteringskonto samt omvandlandet av Suomi.fi till en
interaktiv ärendehanteringsportal är de första stegen inom
elektronisk ärendehantering.
•  Realized systems for e-gov
–  Failed e-voting system
–  Vero.fi
–  Muuttoilmoitus.fi
–  Kela.fi
–  ...
–  Many other piloted initiatives via KuntaIT(KommunIT) directed by the Ministry of Finance (involved in the
development community since 2007->)
•  For example e-samservicekontoren
•  The result: citizen having a plethora of different ”accounts” to interact in govermental issues

Service promise of the
”ärendehanteringskonto”
•  “Root definition”: Ärandehanteringskonto offers one centralized and
customer-centric place where an individual or a company can
“ingångsätta sin” errand, by locating and initiating the service
provided by the authority (myndighet), receive and send errand
related material, ask from the authority, follow the progress of
handling and keep up contact information (e-mail and cellular phone
number).
•  Interpretation: the value to the user comes from the ability to use a
single system to launch a ”service process”. However, this falls short
on the ideal of creating a holistic view on the ”ärandet med alla olika
punkter som måste handlas”.
•  It is also implied that there may be many different service platforms
and the notion of ”service guide” remains vague.
–  a need for an ombudsman to find the way in the bureaucratic labyrinth.
–  and where all the ”related material” is stored/where it can be found?

Governmental infrastructure
- ” ärendehanteringskonto” as the citizen’s service channel –
konkurrensutsättas 2009
Kansallisetperustietovarannot
Hallinnon
tietojärjestelmä
Viestien välitys
Hallinnon palvelualustat
- itsepalvelut
Asiointitili
Asiakkaan
tietojärjestelmä
Palveluun ohjaus (portaalit)
ja haku
Tukipalvelut
Tunnistaminen
Yksilöinti- ja
tavoitettavuustiedot
Valtuutusten
hallinta
Aikaleimat
Otteiden ja aika-
leimojen validointi
Salaus
Maksaminen
(kansalaiset)
Allekirjoitus
Kertakirjautuminen
Maksaminen
(yritykset)
Suostumusten
hallinta
= valmis
= suunnitteilla tai osittain valmis
= ei yhteisiä toimenpiteitä
VTJ
Yritys- ja yhteisö-
tiedot
KTJ
AKE
KELA
VERO
Paikkatiedot
DIGIROAD
= tärkeimmät kehittämiskohteet

The ’Big Boys’, act 1
•  Major SW/”service” companies have also
seen the potential in governance systems
– Microsoft ”Citizen service platform”
•  Product promotion also in Sweden
– IBM Goverment Industry Framework
•  From the the citizen’s point of view the
logic of designing the service platform is
up-side down...

Tools aready available – sources
for inspiration & rip-off

Cognitive aids - PIMs
•  Concepts
–  MemEx (Vannevar Bush, ”As We may Think”, 1945)
–  Dynabook (Alan Kay 1968)
–  WorldBox (Nicolas Calder, ”Technopolis”, 1970?)
–  Knowledge Navigator (John Sculley, ”Odyssey”, 1987)
–  MyLifeBits (Microsoft Research, 2002->)
–  LifeLogging & True Recall (Gordon Bell, ”Total Recall”, 2009)
–  e-Me (2004->)
•  Products available
–  ”Google cloud” (platform ”independent”)
–  MS skydrive, Live Mesh etc.
–  Evernote (multiplatform)
–  Calendars
–  RSS/PodCasts/all other ”push online”- feed services
–  Wiki’s
–  Online databases of many kinds
–  ...

Social aids – social media
•  Products available
–  IRC/IM
–  Twitter
–  Blogs
–  Facebook
•  Borås museum biljettsäljare – more fun to use FB than stare
at the security monitors...
•  Also ’govermental’ services are moving into FB – Police in
Finland, SITRA...
–  Skype
•  Tools already very ingrained in our daily living...

Private sector service relationship
aids
•  The explosion of e-portals to single
services
– Phone & network companies
– Electricity providers
•  Also ”2nd generation” services are becoming
available – e.g. www.elskling.se
– Banking
– Bonus card conglomerates (central
corporations, in Finland S-group & KESKO)
– You name it...

The situation seen through
theoretical lenses

The ground -
Theories and basic assuptions
•  Conception of the spheres of living
Environmental
Societal
Physical Mental
Social
SexualSpiritual
Emotional

Outer spheres - Environmental
•  A global disussion on climate change
– the age of ecological concern (”the age of Stupid”)
– Popularization of concepts like ”miljövänlig &
klimatsmart” in everyday discussion and
product marketing
•  ”Small is Beautiful – a study of Economics As If
People Mattered”, E.F. Schumacher, 1973
–  The idea of decentralization and the ”production by the
masses” -> ”Intermediate Technology”

Outer spheres - Societal
•  A transition from post- to transmodern?
”We have never been modern” B. Latour 1993
–  Movement towards the the ”Age of dialogical culture”
•  Post: the destruction of ”totalitarian” grand narratives and
development of micro-level epistemology and teleology
–  ultra-individualistic notions of knowledge, truth, faith etc.
–  in short: everybody may develop a plausible personal
worldview which is as good as any other = no objective truths
exist, hence represents a relativistic ideal (Lyotard, Baudrillard,
Virilio bl.a.)
•  Trans: acceptance and preservation of individual (personal)
plurality of truths but an effort to understand the other –
learning to care
–  Dialogue: an ”Intersubjective signification process”
–  Also the ” Age of challenging the viability of affluent
society (välfärdssamhälle)”

The ground
Environmental
Societal
Physical Mental
Social
SexualSpiritual
Emotional

Inner sphere – Mentality
”The individual perception cycle”
•  Cognitive schema model
(”Cognition and Reality, Principles and implications of cognitive Psychology”, U. Neisser,1976)

”The individual perception cycle”
•  Perception cycle remodelled by Muukkonen (2003) – illustrating the teleology and self-producing ”intentionality” of
perception
–  Refining and implicating more clearly the recursive and ”autopoietic” aspect of perceptive activity and schema functioning flavored
with concepts from phenomenology defined by E. Husserl (for autopoiesis see e.g. Maturana & Varela ”Realization of the living” &
”Tree of Knowledge”)
•  A direct implication: e.g. Affordance (in HCI e.g. D. Norman, 1990, ”The Design of Everyday things”) is not a
property of an object/artefact but it is defined by the internalized schema/biological functioning...
•  From Husserl to Heidegger – ”The question concerning technology” 1954/1977 - techne "the name not only for
the activities and skills of the craftsman but also for the arts of the
mind and the fine arts" (Angst and authentic existence)
Perceptual
orientation
Perceptual
interpretation
modifies
”reveals itself”,
becomes apparent to
Directs
attention
directs
Schem
a
noema
Noumenon –
Transscendent
”core” or ”essence”
Hyle -
perceivable
phenomenon
Extramental
object
Intramental
object
Immanent
”principle”
Noesis (intuitive – non-rational activity, insight
imagination, intelligence, ”tacit knowledge”,
”feeling of the impression”)
Dianoia (rational and discursive thinking)

”Trapped in our own perceptions”
•  recursion and emergence – ”self-creation”
•  Heidegger: poiesis ”bringing-forth”
M.C. Echer 1948

Inner sphere - social
•  Information and COMMUNICATION technology is by definition
social tehchnology
•  Pretty self-explaining, but...
–  the social acceptance of certain tools is somewhat unpredictable
•  How to influence the trend-setters?
–  ”social pressure” to adopt the use of comm. technologies is evident
•  ”I must have one because ’all’ others do” – in order to stay ”connected”
–  You can’t stop the waves but you can learn to surf
•  Applicable to research - Diffusion of Innovation (Rogers, 1968)
•  To maintain a social relation a tool must be possessed...
–  techno outcasts, neo-luddites etc.
•  Point to consider: ”a simple way of life” – technology is too difficult
•  Feeling a loss of ”authenticity” in machine mediated action

Loss of authencity - ”Not about the skillfulness and artisty of
the weaver but the skill and art of engineer and data
programmer”

Inner sphere – Social
”Trapped in our own relations”
•  recursion and emergence – ”self-creation”
in sustaining created relationships
•  Heidegger: poiesis ”bringing-forth” the
connection and interaction pattern(s)
M.C. Echer 1948

Between Inner/outer spheres –
Mental/social/emotional etc. & societal boundary?
•  A. Giddens (1984) Structuration theory
•  -> IS and other artefacts ”carry structures” and hence act as
”boundary objects” in the intersubjective communication process (CSCW,
S.L. Star)
Agency (praxis)
Structure

The ghost in the machine – pt1
•  ”Spirit” in AST (DeSanctis & Poole, 1994)

Phasing out into Self-productive systems?
•  In IS context on a personal level:
–  1st gen. -> task automation
–  2nd gen. -> process engineering
–  3rd gwn. -> (community) user driven development for self determined activities?
•  Systems that define their own communication, power and sanction routines...

Luhmann – social systems theory
•  ”Ecological communication”, 1986
–  Systems theory
–  Communication theory
–  Evolution theory
•  A partly reified set of institutions form our modern societies – they
can be seen as self sustaining and ”auto-referential” systems in a
networked equilibrium - with only acts of microadjusting
–  Politics
–  Economy
–  Education
–  Law
–  Media
–  Religion
–  Science
•  The challenge is not to keep the systems reflexive but self-reflective
and self correcting
–  If they fail to accommodate to new situations/assimilate new areas of
operation a disturbance is bound to emerge

Habermas – communicative theory
•  The existence of disturbances and
conflicts are triggers for learning
– Double binds – conflict of intentions

You can learn from everything…
- Everything’s got moral, if only you
can find it.
---
- ”The game seems to be going on
rather better now,” she said.
- ”’Tis so,” said the Dutchess: ”And the
moral of it is – ’Oh, ’tis love, ’tis love
that makes the world go round!’
- ”Somebody said,” whispered Alice,
”that it’s done by everybody minding
their own business!”
- ”Ah, well! It means much the same
thing,” said the Duchess --

The challenge of changing
•  ”3” levels of learning
–  questioning processes – ”what is challenged” (”Steps to an
ecology of mind”, Gregory Bateson, 1972)
•  Single- , double and triple loop learning
•  Ref.
–  ”motivation, goal, condition” (Kuutti, 1995),
–  ”vision, strategy, technique”,
–  ”activity, action, operation”,
–  ”purpose, process, task”
–  etc.
Principles
and values
Triple-loop learning

Personal & Interpersonal schemas as restriction
devices
– a systemic not(at)ion
•  Stripped away from any particular context – ”pure” abstract model –
Engeström and Cultural Historical Activity Theory (1987 ->)
•  System interpreted as a value creation device
•  An interpretation of the tool/instrument as an ”embedded system”
–  Rules
–  Division of labor

Rules (and
contracts)
(how – and
how much)
Division of
Labor
(who and
when)
Tools
(with what)

Rules
(how – and
how much)
Division of
Labor
(who and
when)
Tools
(with what)
Values
(why?)

Rules
(how – and
how much)
Division of
Labor
(who and
when)
Tools
(with what)
Values
(why?)
Outcome
(benefit
according the
value promise)

Rules
(how – and
how much)
Division of
Labor
(who and
when)
Tools
(with what)
Subject
(an individual)
Values
(why?)
Motivation
Outcome
(benefit
according the
value promise)

Rules
(how – and
how much)
Division of
Labor
(who and
when)
Tools
(with what)
Subject
(an individual)
Values
(why?)
Motivation
Outcome
(benefit
according the
value promise)
Object
(target of
operation)

Rules
(how – and
how much)
Division of
Labor
(who and
when)
Tools
(with what)
Subject
(an individual)
Values
(why?)
Motivation
Outcome
(benefit
according the
value promise)
Object
(target of
operation)
Community
(who else)

The ghost in the machine – pt2
”Embedded structures”
•  No technological ”spirit” – just integrated and embedded institutionalized(/reified) structures in the artefacts
(”Social construction of reality”, Berger & Luckmann, 1967)...
•  IT artefacts carry (multiple) meanings that influence/restrict the operator by embedding the fuctionality and
defining assumed use intentions
•  A somewhat similar trick was pulled through by Annita Fjuk in 1997 or so...
•  An implication: since the elements of rules and DOL are being interwoven into the instruments, it becomes rather
difficult to change the operation of the whole system if the adopted infrastructure has become institutionalized - let
alone reified (and this embedding actually drives forward these processes... Rules and DOL becomesunarticulated
as such and they are only implied but reproduced without conscious awareness)
Subject Object
Community
Instruments that
embed rules and
division of labor
(structures)

Mental & societal embedded
”Trapped in our own devices”
•  recursion and emergence – ”self-creation” of embedded structures
in tech use
•  Heidegger: poiesis ”bringing-forth” the preprogrammed pattern of the
socially legitimated ”spetsmaskin”
M.C. Echer 1948
Subject
Community
Instruments that
embed rules and
division of labor
Object

Embedded stuctures are not
inevitably a bad thing to have
•  ...they can be seen as obstacles only when you
want to raise the level of quality

Systemic networks
- hinder & slow down the change possibilities

Challenge of changing –
3 level challenging revisited
•  Bateson applied to CHAT
•  Double binds (conflicts) located in the
systemic framework and pinpointing the
”locus of innovation”

Single-loop and Solution innovation
•  Single loop learning – or questioning
•  Focus: Tools, Rules, DOL – well, at least the ”rules” of using the tools
–  More efficient manipulating techniques and ”rationalization”
–  Are the tools good enough/has there been enough practice?
•  Learning characteristics: Changes in existing organizational rules largely at program levels; general
tightening and improvement in current procedures.
•  As a result: routinization
•  Learning discussion’s main topic: productivity and efficiency (optimization of the existing)
http://www.infed.org/thinkers/argyris.htm

Double-loop and Process-innovation
•  Double questioning
–  Norms, practices and all other conventions that define the object of manipulation
–  Does the upheld habit have any value creating properties in achieving the outcome/result?
•  Focus: Insight – reframing the order of doing things & dropping out unnecessary ones
•  Learning characteristics: Re-thinking of existing rules according to why things are being done;
involves understanding reasons for applied strategies
•  As a result: inventing new means and ways in achieving the result
•  Learning discussion’s main topics: meaningfulness
http://www.infed.org/thinkers/argyris.htm

Triple-loop and System innovation
•  Triple questioning
–  Challenge the meaningfulness of the activity in it’s entirety – including the outcome
–  ”Does this thing that we do have any sense/meaning at all?”
–  ”let’s cjamge a theory” (ref. Copernican revolution/quantum mechanics/personal importance structure – a change in the ethos of activity
•  Focus: Principles
•  Learning characteristics: Questioning the rationale for the organization as a whole, particularly the mixture of internal desires and identity,
and the relationships with the external environment.
•  As a result: what is anyone supposed to do here?
•  Topic of the learning discussion: motivation, capability
Triple-loop learning
Principles
and values

Yet another set of three elements:
The nature of activity…
•  Systems Theoretical
–  By definition: processes
–  Operational logic according to a predetermined plan
•  Socio-Technical
–  Handling of error situations
–  Need for situational action (restricted by the technical system)
–  Area of responsibility
•  Humanistic
–  Expertise, crafmanship and professional skill
–  Situational activity
–  Development and improvement of activity
•  Refer also ”Plans and Situated Actions: the problem of human-machine communication”, Lucy Suchman, 1987

…defines the nature of learning
(och kunskap). Know how to...
•  Systems Theoretical – kunskap diskurs: efficiency and productivity
–  follow instructions – ”predetermined plan - process”
–  ask from more wise if a problem arises
•  Socio-Technical – kunskap diskurs: meaningfulness (vettighet) and co-
operation
–  devise a path back to the instructions if an error situation arises - which makes
you to diverge from the path (some independent resourcefulness, please)
–  do and know whatever it is that one is supposed to do (and also know a little
what others are ought to do – Alice:...if only everyone dealt with their own
businesses...)
•  Humanistic – kunskap diskurs: capability, skillfulness (skicklighet) and
autonomy
–  Learn the basics of the line of industry/activity (preferably from somebody who
knows his/her stuff well)
–  Invent things to do
–  Invent (alternative) ways and tools to conduct activity
–  Invent better things to do
•  do ”co-configurations” and be a skillful bricoleur
•  These definitions are very nice in a organizational and work environment
–  applicabilty in a personal life in an evolving society/environment?

A collected view on an IT artefact
•  Intermediate technology
–  Which provides an opportunity to use it as a
production device for self determined purposes
•  That does not pass as a subject (or an actor/
actant) on its own
•  But which inevitably binds certain collectively
constructed structures be they consciosly or
unconsciously applied
•  And that may be used as a tool for increasing
situation and task awareness by being a...

The object of construction:
”ideal” IT artefact
•  A cognitive expansion kit
–  give information and consequently control over our environment: increase the ability to
understand causality, support better decision making and help to manipulate the
environment (but not to automate our living – the danger of an ”automated man”)
–  Support the basic cognitive processes: extending memory (in three levels: sensory, work &
long term – episodic & semantic associations), provide reason to make better judgements
and solve problems
•  A social mediator
–  Support in leveraging social awareness and facilities - you can relate better to your fellow
beings (area of ”social intelligence”, e.g. Daniel Goleman, 2006)
•  A societal integrator
–  Support in purposeful action and engagement in institutionalized practices (area of ”
systems intelligence”, Hämäläinen & Saarinen, 2004-2008)
•  In short: increases transparency and fluent operation in different domains
•  Missed sectors:
–  spiritual, sexual, physical & emotional 
–  Environmental
•  So actually the ideal IT artefact should also lead you to enlightenment, cause tingling sensations and
stimulate proper glands to have desired endocrinological effects, increase stamina & strength, have an
option to select different moods and be recyclable/constructed from organic materials and produce its
own operating power and reduce the ecological footprint of the bearer...

The real Object of construction –
the ”ideal” beneficiary of ”ideal” IT artefact
•  A man as a ”artisan of his own life”
•  Self-creative in intentions, actions and tools
–  Imaginative, proactive + capable and equipped in defining own needs
•  Sensible and sensitive to others
–  In immediate social relations
–  In situational society defined instututional relationships
•  Aware (att ha känssla av situationen) and prepared (att vara
”driftsäker”) all the time
•  In short: empowered emancipated free man
•  How do you create such a Golem?
–  More precisely – how do you support such a Golem to emerge?

Implications for ISD
•  ”Transmodernistic” encounters for ISD
practice
•  Scandinavian (scholarly) utopia
– Involve the concerned
– Co-construction in a dialogical process
•  What should be talked about?
– Dialogue ”intersubjective signification
process”
•  What is signified and in what kind of process?

Ways of seeing the whole (or
ways to get stuck)...
Actant
Direction of
knowledge
transfer
Actant
Prime motive
of action
Social action
type
World view
Perspective
on IS Paradigmatic
notion of
designer
Tools, techniques,
methods
(Habermas) (Pepper) (Nurminen)
Customer Designer
Examination
of existing
social systems
Communicative Contextualism Humanistic
Social therapist,
labor partisan
Ethnographies,
contextual inquiry,
workplace studies
etc.
Customer Designer
Design of
work,
Enhancing
business
operations
Discoursive &
strategic
Formism
Sosio-
technical
Facilitator,
emancipator
BPR, RUP, future
workshops,
exploratory and
experimental
prototyping etc.
Customer Designer
Design of a
technical
system
instrumental Mechanism
Systems
theoretical
Systems expert
OOA/OOD, ER-
descriptions, DFD
etc.

negotiations
design
implementation
utilizationThe ISD process
what is here?
a hollow centre?

From boundary crossings...
Designers
Managers /
sponsors
Coders /
implementers
End users /
Operational
workers
boundary zone
IS representations
as mediative
boundary objects
Modus of communication: negotiations (discoursive & strategic)
Sharing and interpretation of knowledge
distinct beneficiaries

An open
dialogue
Creation of
understanding
Coders / implementers
Facilitators
Managers / sponsors
End users /
operational workers
Communication tools
- shared and mutual objects
Designers in
participatory design:
all
Awareness of:
Habituational influences
Institutionalized patterns
Reified thinking
Inscription, codification
De-scription, interpretation
accountabilities
Modus of communication: dialogue (communicative)
(explicable, understandable
- unfolded)
...to a creation of shared meaning
Dialogue a core process (of ISD)

•  Bricolage
•  co-everything
–  Design
–  Creation
–  Realization
–  Configuration
•  Situated development - ”hacking” on social level?
•  Real life restrictions:
–  Co-everything is not possible (not even desirable)
•  All the depicted roles are not usually present and involved together all the
time...
•  Iterations are needed in the configurations
–  Trial – error, still the most effective way to learn
–  ”Idea-implementation” cycles are inevitable
–  The need for a deliverable
•  ...proper rigour in the process handling is needed – RUP and the like & project-
management routines have their own important role...
The ”ideal” design process

CHAT’s impression of professional
development
•  Towards a dialogical production system
Yrjö Engeström (2004),
” New forms of learning in co-configuration work”

Transmodernistic encounters
- enter the Dialogue
•  Dialogue as defined by
– David Bohm
– Mikhail Bakhtin
– Martin Buber
•  ...as applied by William Isaacs, etc.
•  Dialogue and Innovation must have
something to do together (10M+ Google
hits)

Descriptions of dialogue
”Buber used the term ”dialogue” in 1914 to describe a mode of exchange among
human beings in which there is a true turning to one another in a full appreciation of
another not as an object in a social function, but a genuine being” (Smith, 1998, p.119).
4
”Dialogue proposes to explore current beliefs and thinking… dialogue is a mutual
inquiry, which is different from discussion, whose root is the same as percussion and
concussion. We believe that dialogue can be a method for discovering paradigm
assumptions in understanding the collective wisdom. Dialogue is uncovering the group
mind, discovering shared meaning…” (ibid).
”Dialogue is referred to here, not in the ordinary sense of a conversation
between two people, but in a specific sense, defined by the late physicist David
Bohm, which uses particular methods by which a group can ”participate in a pool of
common meaning which is capable of constant development and change”… There
is no predetermined output, no agenda, no structure… Difference is
valued.” (Varney, 1996, p. 31). 6
”Dialogue can lead to the emergence of the true ”mind of the organization”
– a collective intelligence that transcends the limited capacity of individual
managers... Transcendence of personal limitations releases individual minds from
deep cultural conditioning and enables higher level learning to take place”(ibid.).7

Descriptions of dialogue continued
”Dialogue is a process of allowing issues to be raised, discussed and questioned. It is
also a process of sharing attitudes, feelings, reactions and discomforts with others to
uncover a common disposition” (O’Donovan, B. & Roode, D., 2002, pp. 32-33). 8
”Dialogue’s purpose is to overcome incoherence, fragmentation, and polarities” (Ibid.
p. 33). 9
”The degree of mutual understanding between the communicating persons and their
individual and united ability and will to communicate their understanding in an
individualized development process.”
(Kunøe, 1998, siv. 1127). 10
”Mead (1927/67) says that, ”The development of communication is not simply a
matter of abstract ideas, but a process of putting one’s self in the place of the other
person’s attitude, communicating through significant symbols. Mead is not explicitly
discussing dialogue, but is pointing to the common world of symbols the
communicating parties have to share if they are to be able to communicate at all.
Bråten (1987) defines “dialogue communication” a “symmetrical
conversation between communicating participants based on self reflective
terms”” (ibid.).

Dialogue
•  A state of interaction where we enter to
different loops of learning in supportive
and non-judgemental atmosphere
•  The future (of HCI) lies in realizing that
what we can build is more limited by our
imagination, our ability to discover, and
our ability to envision than by our system
development limitations.(Arias et al., 2000)

Theory-Praxis
•  Is the world really such as it was depicted
by different theories?
– Do these ideas reveal themselves in the
actual living at the moment?
•  ...and if so – so what?
•  What truly lies in the ”Zone of proximal
development” (CHAT)?

SIGNS OF THE TIMES
•  Attempts to realize a semantic network
–  the utopia of universal lexicon – e.g. Leibniz ”
Characteristica universalis”
–  Problem = ref. Wittgenstein & language games
•  (Almost) All encompassing network existists nonetheless
•  PIM & Social media artefacts are becoming more
sophisticated (=usable)
•  Myndighet serviceplatforms are blooming (e-governance)
•  UCD and UID practices are gaining larger acceptance
–  > co-design and co-constructive efforts are promoted for (and
even desired in some cases ;)

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