This chapter discusses the explorations carried out in this research on how to increase sensitivity towards actual work practice in system design. I have invited into a dialogue the approaches to the integration of work practice and system design introduced in section 2.4 as well as some of their critics, and attempted to give them authentic voices by quoting passages from their writings.
I start by discussing the state of technology use and development in radiology work in section 5.1. The current phase in radiology is a stage of profound transformation and thus the challenges it poses to technology development are equally demanding. Technologies for radiology work practice should be developed with regard to both the transition in the field at large as well as to the local circumstances of endogenous change processes. Therefore, I argue, it is important to take as a starting point for design the study of radiology practice as technologically mediated work in transition.
The discussion is continued on two levels that explore and expose the relations between research(ers), work practice (practitioners) and design(ers). The video-based WPASED workshop is a tool developed for design practice that gravitates system design towards actual work practice and encourages multiparty participation (section 5.2). It is based on reflections on my experiences and location as a fieldworking researcher and it also draws ideas from the techniques and methods of both work analysis and collaborative design.
The relations are further explored through the dimensions of work practice sensitive participatory design which offer generally characteristic analytic categories for thinking about the integration of work practice and participatory design in section 5.3. The three dimensions of interaction describe the interactions of ethnographic studies of work practice and participatory design. Each dimension interweaves the traditions by both appreciating their inherent strengths and questioning some of their fundamental assumptions.
Lastly, in section 5.4 I elaborate on my experiences and location as an interdisciplinary fieldworking researcher, a subject that has remained silenced in the field of system design. These reflections on the changing researcher role have served as a starting point for the exploration of participants’ relations in sensitizing system design towards work practice. They have also led to the suggestion of the role of participant interventionist for work practice-oriented participatory design.
Radiology work is in transition. As the technological mediation of work is being transformed from film to digital imaging, both the everyday work practice as well as the ways in which technologies are acquired have become challenged.
Radiological innovations have consisted of incremental improvements to existing machines and techniques until the 1960s (Bronzino et al. 1990). Radiology work practice has developed along with the gradual acquisition of new examination and imaging equipment. As technologies have been obtained they have been installed and taken into clinical use in radiology work units. The local work communities have accommodated the apparatuses into the existing technological infrastructure and ways of working. As imaging devices are rather isolated pieces of equipment typically having an effect on one examination room, only in infrequent occurrences have they become rejected as they could not be satisfactorily adopted into local work practice.
The technologically mediated ways of radiology work have been developed in close connection with the gradual flow of examination and imaging equipment and as if around the film-based technologies. During fieldwork I observed new technologies, ranging from novel devices of modern imaging modalities to new types of adhesive fastenings for light panels, frequently brought into the departments of radiology. The personnel adopted these technologies into their daily activities as part and parcel of the informal development that takes place in everyday practice. The personnel in the work communities has been able to influence the adoption alongside with carrying out their ordinary productive work. The affordances of film allowed for the development of local ways for organising work which has the advantage of taking into account the situated practicalities of everyday unfolding work practice. The mundane qualities of film and paper have allowed for local innovations of practical methods, procedures and tools, of which the PEF in OUH is an excellent example.
The introduction of new imaging modalities in the 1970’s posed a considerable challenge to radiology work, especially to the interpretive diagnostics but also to the occupational roles and organizational structure (Barley 1986, Barley 1988a, Barley 1990a). Each new computer-based modality (e.g. US, CT and MRI) departed from the traditional radiological practice and represented a disjuncture in radiology’s cumulative knowledge. The imaging technologies brought with them a system of signs, languages of images whose syntax and morphology were well structured, but whose semantics were obscure for those without extensive training in the technology’s use. New imaging modalities created completely new ‘semiotic systems’, new languages of diagnostic signs that radiologists, who hold the interpretive expertise, must master. New modalities and images diverged so radically from the past that large portions of the radiologists’ practical experience failed to generalize to the new situation. (Barley 1988b.)
The current phase of introducing digital imaging coupled with computerisation poses yet a more fundamental challenge to radiology work as a whole. The change in the material and technological mediation from film to electronic media suggests a drastic and thorough-going reorganisation of everyday radiology work practice.
The change in the mediation of work practice and the traditional work practice based on the use of films have, however, not been an issue in the development of technologies based on digital imaging. On the contrary, the development has been technology driven with an interest on the problems in the derided film-based work practice to be improved with new technology (e.g. Wendler et al. 1997). For instance, the traditional film-based work practice has a routine problem of the unique copies being someplace else than where they are needed as duplicates of images are rarely produced and the increasing amounts of radiological examinations and expanding film storages pose growing demands to the management of film logistics. In the development of technologies based on the potentials of digital imaging one of the leading arguments has been to cure the problem of ‘missing films’ by allowing for the simultaneous use of the same radiological images in multiple locations.
The promised and awaited increase in the availability and accessibility of digital images is not, however, a straight-forward issue from the point of view of everyday work practice. The electronic media has a drawback of being totally dependent on the technological infrastructure. Thereby, any kind of use of radiological images or textual patient documents is confined to the data networks and computer workstations. Whereas film, as the above elaborations on the PEF have exemplified (e.g. sections 2.2.2, 2.6.2.1 and 3.2.2), is flexibly accessible to varied uses by different occupational groups who have their tasks to carry out at different phases and places across the patient examination trajectory. The contents of PEF can be instantly tailored to the specific needs of the use situation, e.g. what materials need to be consulted, in what order do they become relevant or is it just enough to see the PEF located in a specific place with certain pieces of patient materials in it. The PEF also allows for the unexpected uses of materials and deviations from the typical ways of working should such situations occur. Systems based on digital imaging undermine the malleability and local flexible access of the film and PEF as digital imaging is confined to the technological infrastructure whereas they do allow for the simultaneous access and shareability of images in various locations of medical work that are equipped with appropriate devices.
The multifarious ways in which the PEF is used in the organisation and co-ordination of everyday radiology work practice are intimately intertwined with and resilient to the inherent qualities of film. The very materiality and tangibility of the medium makes the PEF observable and visible to the practitioners. The PEFs are consulted for their ‘information substance’, i.e. patient materials of various sorts, but they also ‘impart implicit information’, i.e. the spatial location and the physical appearance of PEFs, the ‘filmtrails’ and ‘pools’ over which the practitioners gather an overall at-a-glance awareness of what is going on in local work practice and through which they communicate and co-ordinate the ongoing organisation of unfolding work practice. For example, the PEFs form an essential medium and tool for making visible and accountable the progress of each case through the patient examination trajectory.
The visibility and tangibility of film are examples of affordances of the traditional material mediation which are essential in the organisation and co-ordination of everyday work practice and which will disappear with the digitalisation of images and computerisation. Their meanings to the practitioners and the fluent flow of everyday practice need to be accounted for and compensated in the digital technologies and computer systems. The question is not about the digital alternatives mimicking the properties of film but rather about finding alternatives to provide for the affordances of mundane technologies (cf. Sellen & Harper 1997, Harper & Sellen 1995). This, however, is not an uncomplicated task and it requires an understanding of the intricate nature of mundane technologies and the complexly intertwined consequences. My argument is that radiology work should be studied as technologically mediated work practice in order to understand the essential meanings of film to the mediation, communication, organisation and co-ordination of everyday collaborative work. Though there is a handful of accomplished studies of radiology work in relation to computerisation and system design (e.g. Aas et al. 1993, Sørgaard & Holmes 1993, Kjær & Halskov Madsen 1995, Lundberg & Tellioglu forthcoming, Tellioglu & Wagner forthcoming), none of them has studied radiology with a special interest in the material and technological mediation.
A further problem with the development of information systems for radiology work is that they have been designed for and from the point of view of the radiologist holding the expert medical knowledge whereas the supportive film and paper work are typically considered only as something to be automated. In the teleradiology and PACS (Picture Archiving and Communication System) literature the tasks related to film work are discussed in terms of routines and quantifiable knowledge, e.g. ‘automated prefetch mechanism’, ‘intelligent prefetch strategy’, and ‘knowledge-based image retrieval’. An outline for future PACS puts forward an idea of automating supportive work for the convenience of expert work: “These systems will build a higher level of intelligence into the workstation software ... These workstations will be able to ‘remember’ the working habits of each radiologist, as a good film librarian [a film developer in OUH]; might, and they will anticipate which images will be required and how the radiologist prefers to view them.” (Siegel 1997, p. 66.)
An alternative to the rather straight-forward approach of seeing supportive work as identifiable, structurable tasks to be automated, would be to study the practical organisation of everyday radiology work with an interest on the experience, skill, and expertise of film articulation work. The elaborations on the film developers’ work above (section 3.2.2) have revealed that their mundane work of handling the film logistics also accounts for the organisation of everyday work practice in which they draw on their local tacit knowledge and lived experience of radiology work. This unarticulated aspect of supportive work would rather suggest for developing information systems to support their work than attempting to automate it.
Radiological examination and imaging technologies have typically been ‘off the shelf’ devices, ready to be installed and taken into use. With the procurement of information technologies that by nature are more flexible the accustomed ways of obtaining technologies and managing the change processes have become challenged in radiology. New kinds of knowledge and expertise have become seriously needed because the procurement of computer-based systems involves engagement at least in tailoring, implementing and possibly even developing the system. The two information system undertakings that I studied, namely teleradiology system and PACS, were quite different from one another with regard to extent and complexity of issues involved and therefore posed dissimilar demands to the clinic.
In connection to the teleradiology system, the clinic of radiology had a possibility to influence the design and development of the technology. Selected practitioner groups had already participated in the initial design team’s activities and the workshops organised after the trial phase offered a possibility for an extended practitioner participation. The participants engaged in developing both work practice and teleradiology system by sharing experiences of the trial phase, analysing work practice, evaluating the experimental system in use and envisioning images of the improved system. As the commercial version of the system, in which the critique and ideas put forward in the workshop have been taken into account, has been taken into clinical practice, the designers have continued to collect user feedback for the system’s further development.
Teleradiology services constitute relatively independent forms of radiology work. They typically introduce a new way of collaboration between geographically separate radiology units. Thus, they do not have to face all the problematics involved with compensating for the existing film-based work practice. The personnel can cope with the new technology related change and emergent work practice through adaptation and local innovation. For example, in the Kuusamo-Oulu teleradiology service the system had to comply with the existing work practice to an extent because the radiologist needed to be able to carry out interpretive diagnostics in the digital environment. However, the system did not need to strive to replace or substitute current ways of working more comprehensively as, in fact, another major challenge of the trial phase was to create a new way of collaboration between the previously separate radiology units.
The implementation of PACS into an existing radiology work practice, on the other hand, is an undertaking of a different magnitude requiring a profound transition in the operation of the entire radiology clinic and collaborating medical units. The reported success of PACS has hitherto been limited (e.g. Bick & Lenzen 1999, Carrino et al. 1998, Siegel et al. 2000).
In the OUH the extensive nature of the PACS implementation phase and complexity of related problematics astounded the clinic of radiology. On one hand, the dilemmas came down to such basic essentials as the integration of the PACS with all digital imaging devices in use and the existing Radiology Information System (RIS) coupled with the Hospital Information System (HIS), and the possibilities of tailoring the PACS developed for a health care system that uses different kinds of patient records to be compatible with the local records and ways of working. On the other hand, the clinic-wide PACS would also have required a simultaneous and more intentional co-development of technology and work practice.
In the PACS phase both the importance and difficulty of participation in the technology development increased. As the PACS addresses the mediation of the entire radiology work practice with a new pervasive technology, it would require a purposeful engagement of the entire work organisation in the simultaneous development of work and technology. On the other hand, as the PACS typically are developed by multinational companies, having influence on the system becomes more difficult. In this case the system was developed by a foreign company and the local representatives acted as go-betweens. The incompatibility of the system with the local ways of working became apparent, but the possibilities of having a meaningful effect on the system were restricted. Furthermore, with imaging devices the radiology practitioners were able to fit the new device in the technological infrastructure and ways of working of an examination room from within their situated views of work practice, whereas an implementation of a clinic-wide information system would require a more systematic approach.
Developing work practice and system intervention within such a framework by mere organisation of workshops would obviously be an inadequate way to proceed. However, my contention is that the thoughts for sensitizing system design towards work practice that have been put forward in this work would be of benefit also in undertakings of a more comprehensive nature, provided that there were sufficient resources and the information system development and project management methods would be flexible enough to accommodate them.