Placing HISP in ContextA relational look at meaning generation in a health information system

Mark Thompson

Geoff Walsham

Meaning is relational

Structure of talk

• HISP in Cape Town

• Context: (re)introducing Blackler’s 5 categories of

knowledge

• Contextual analysis: a useful practical approach?

Political computing - a ‘new deal’

• Decentralisation

• Vertical and horizontal data flows support local

empowerment

• Standard MS Office software across application layers

• Open source distribution

• Participative prototyping

• Geared to local capture, validation, and use

Data collection & use

Community Information Systems

District Information Systems

Provincial Information Systems

National Inf. Systems

International ISIndicators,procedures& datasets:

Community

District

Province

National

International

Is HIS Working?

• DoH endorsement; Phase 2 rollout, national & international

• Positive feedback from nationwide HIS users

• First minimum health dataset on African continent

HISP: Ongoing problems

• HISs collect only clinical information, often out of context

• Data sometimes captured/interpreted by inappropriate people

• Meaning often lost as data becomes progressively abstracted from original context

• Data collection forms and software support only explicit, ‘representational’ knowledge forms

Revisiting Blackler

• Knowing as mediated, situated, provisional,

pragmatic, and contested

• Context as embrained, embodied, encultured,

embedded and encoded

• Blackler ‘replaces’ quantitative categories with

qualitative attributes - but need both...

Why is this useful?

• Growing recognition of limitations of representationalist conceptions of ‘knowledge’

• Increasing interest in ‘relational’ approaches focusing on process (e.g. activity theory)

BUT• Limited focus on low-level sensemaking within

any particular schema

Contextual analysis

• Examine interrelationships between various elements of context, within a schema

• Do they appear to support one another?

• Suited to iterative IS development approaches, and to ‘fine tuning’ existing IS

Unpacking HIS schemas:1

Unpacking HIS schemas:2

ClinicEnviron

THC

TB

HIV

STDs

Child

Maternal

Mental

Trauma

PAMPharmacist

Other

“Community”

HIS

Totalled RMR

TallySheets

WeeklyTotal 1

WeeklyTotal 2

WeeklyTotal 3

WeeklyTotal 4

Meaning is relational

Example 1: Child Health• Do practitioners have ‘embodied’ evaluative skills (hunch)

so vital to effective diagnosis?

• How do overlapping ‘encultured’ schemas relationally complement one another, affecting final ‘encoded’ data?

• Are ‘embedded’ routines (forms, RMR, software) optimised to support ‘embodied’, ‘encultured’, and ‘encoded’ aspects of schema?

• Are ‘encoded’ data categories sensitive enough to address ‘embodied’, experience-based hunches? Do they address ‘encultured’ social expectations?

Example 2: Entering RMR data• Numeracy/ ‘embrained’ aptitude?

• Access to practitioner in order to activate ‘hunch’, embodied judgements re questionable figures?

• Do final figures accurately reflect relational contribution of overlapping ‘encultured’ schemas, or over-focus on, say, clinical?

• Are forms of ‘embedded’ software best aligned to elicit this judgement?

• Is ‘encoded’ data being used in a relational manner to generate meaning? Meaning loss attendant on progressive abstraction of ‘encoded’ data from other forms of context?

Contextual analysis for HISs:1

Benefits:

• Generates vital questions that relate to issues deeply embedded in catchment area, both clinical & non-clinical

• Retains focus on accuracy, fairness and usefulness of selected indicators

• Allows ‘calibration’ of a HIS to its organisational & social context & hence its usefulness to users

• Introduces ethical emphasis on ‘truth value’, significance and meaning

• Heavily practical & suited to field use

Contextual analysis for HISs: 2

Issues:• Low-level, granular approach is resource-heavy &

potentially expensive

• Limitations on ability of analyst to identify appropriate

relational balance

• May raise issues of a political nature which prove difficult to resolve

Practice-based approaches: theoretical questions

Current theories of practice are:

• not especially good at approaching issues of power

• heavily schema-oriented, with a danger of reverting to an

equilibrium model

• inadequate in theorising ‘between-schema’ co-ordination by

biographical individuals

…a role for contextual analysis in addressing this?

Perhaps…

• Practice-based conceptions of experience are phenomenal

• Therefore comprise both shared & non-shared context

• As vital components to meaning, interrelationships

between all contextual types deserve detailed attention

• ‘Contextual analysis’ may represent a practicable way of

achieving this