2.1. Research setting in clinical radiology

I have carried out empirical work in the field of clinical radiology[1]. Radiology is a branch of medicine (see e.g. Standertskjöld-Nordenstam et al. 1998, Sutton 1988) that started in 1895 when Professor W. C. Roentgen discovered X-rays (Blume 1992). Ever since, radiology has been concerned with the use of radiant energy in the diagnosis and treatment of disease. The basic purpose of medical radiology is the demonstration of human internal anatomy, physiology and, above all, pathology (Sutton 1988). Radiologi­cal imaging produces such information in pictorial form that cannot be acquired by any other non-invasive medical means. Therefore it has been said that radiology has revolut­ion­ized medical diagnosis by enabling a look into the human body previously accessible only during surgery (Barley 1990a).

Radiology as a diagnostic field had to have a role created within the medical system in order for it to become a part of the diagnostic routine. The diagnostic value of the roentgenograph had first to be appreciated, and this was itself a complex and protracted process as Pasveer shows in a study of how images were introduced and made sense of in interpretation and medical thinking around the turn of the century. (Pasveer 1989.) Simultaneously professionalisation within the field took steps towards specialisation. Physician-radiologists became to secure an exclusive license to interpret images and the ‘productive’ and ‘interpretive’ expertise within radiological labour became segregated (Blume 1992). Currently, the occupations in radiology units, naturally, are a great deal more varied.

In the early days of radiology, X-ray machines had to be placed in the hospitals as they were too expensive and cumbersome for the local doctor"s clinic. Separate departments of radiology were established, and the influence of their activities spread to almost every other department of medicine. (Bronzino et al. 1990.) Within hospitals, centralised departments of radiology are still built enveloping the high cost technologies and the special medical expertise of the personnel to produce services within medical institutions. For example, the Clinic of Radiology with its five specialised departments provides radiological examinations and consultations to other medical units within the Oulu University Hospital and the hospital region. As OUH, with a staff of 3000 and all medical specialities, is the northernmost of the five university hospitals, the Clinic of Radiology is the consultancy center for an area covering half of Finland (Karasti et al. 1998).

Unlike most medical specialities, the development of radiology has always been inextricably bound to technical innovation (Barley 1988a). The development of non-invasive tools for visualizing anatomical structures and disease processes while posing minimal risk to the patient has been given a high priority (Bronzino et al. 1990). In the early years most technical change came to radiology as incremental improvements to existing machines and techniques, but in the 1970’s a stream of new computerised imaging modalities began to infiltrate radiological work, e.g. ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI)[2].

At this time the field of radiology is going through an intensive period of transition. Interpretive diagnostics have been changing since the 1970’s requiring radiologists to master new languages of diagnostics because new imaging modalities depart radically from the conventional radiology of X-rays (Barley 1988c). Recently, the entire radiology work practice has been challenged by the notion of ‘filmless radiology’ (e.g. Siegel 1997, Bick & Lenzen 1999) promoted by the increasing digital imaging and technology driven computerisation in the field. The awaited filmless radiology (cf. paperless office), i.e. fully digitalised radiological services, has been realised only in few radiology units world wide whereas the use of film for printing, interpretation and storage has largely remained in the everyday radiology work.

I have encountered the clinic of radiology in Oulu University Hospital (OUH) in similar circumstances. The specialised roentgen departments house all modern imaging modalities and the number of examinations with computer-based modalities had steadily increased. However, observation of everyday radiology work only served to confirm that all examinations in all roentgen departments were still printed on film and the most pervasive, ubiquitous material used was film.

During the years of my fieldwork the clinic began – besides the conventional use of film – to experiment with computerised systems based on digital imaging, first with teleradiology[3] and then with Picture Archiving and Communication System (PACS)[4]. In this thesis I draw especially on the experimental teleradiology project. The project was significant as it was the first occasion of clinical work that broke away from using film. During the trial only digital images were transferred for consultation from Kuusamo Primary Care Center and the teleradiologists in OUH performed image interpretation using solely digital images displayed on computer screens. After the trial period multiparty workshops were organised that attempted to combine analysis of actual work practice, evaluation of experimental system-in-use situations and redesign of the experime­n­tal system.

The workshops gave the professional designers the first opportunity to familiarise themselves with the everyday radiology work practice although the initial design for the pilot system had been somewhat participatory in nature, i.e. the design team had consisted of radiologists, technical and management personnel in addition to professional designers. Two of the designers described their comprehension of radiological image interpretation: “I’ve never seen” and “I suppose too little”. These comments are by no means unique, rather they tell about the more general dilemma of the invisibility of work that predominates in the field of information system design.