2.6. Empirical research of radiology work
In attempting to understand the relations of work practice, systems use and design I have seen it of utmost importance to immerse in the ‘real world’ communities of work and to study the activities of people in their natural settings. I have carried out a longitudinal empirical investigation of the everyday technology use in actual work and the endogenous procurement, development, implementation and evaluation of technologies in the Clinic of Radiology at Oulu University Hospital. The investigation has consisted of a series of fieldwork phases where several technologically mediated radiology work practices, both with and without computerisation, have been studied.
2.6.1. A longitudinal series of situated fieldwork phases
The empirical work started out in early 1994 as the Department of Information Processing Science was invited to collaborate with the Clinic of Radiology. The clinic had plans for several projects in relation to digital imaging and computer networking, especially teleradiology. The Department saw an opportunity to study radiology work and its technology support which would provide a case study for the corpus of work studies for the COMIC project (Computer-based mechanisms for cooperative work, an ESPRIT 3 project 6225, 1993-1995) in which the department was involved at the time. The collaboration was established by entering into fieldwork to study radiological image interpretation work in order to understand and identify the prospects of technological support of these collaborative work situations with regard to the future distributed network setting (see Table 2, Phase I).
After the fieldwork we learned that two of the planned three projects had either been postponed or cancelled. At this stage, the Department lost interest as the only project to be realised did not fulfil the attempted case study for “distributed, synchronous small group work”. I had, however, got so interested in studying radiology work that I agreed to continue with the experimental Kuusamo-Oulu teleradiology system project (Phase II). This changed the organisational setting of the investigation into a one person undertaking with a few helpful temporary others and without the support from a financed research project.
Furthermore, adjustments to research interest and relationship were required. I had become convinced that the interest could not be based on an agenda of ‘technology possibilities’ (see e.g. Kristoffersen & Ljungberg 1996) which had first been attempted because the clinic of radiology was to make research and technology decisions based on its foremost responsibility in clinical work and the welfare of patients. Consequently, the clinic has been responsible for all the projects and I have studied the actual technology procurement and implementation practices as they have unfolded. At appropriate occasions within these projects I have sought alternative ways to intervene by promoting work practice oriented participatory design. Choosing this kind of approach for empirical work has made it possible for me to engage in research that might not have been possible in other kinds of organisational restrictions and liability relationship settings.
Such a research relationship has meant giving up all kinds of customary control over the research setting. It has required a great deal of adaptation to the range of contingencies that afflict ‘real world’ organisations, thus adjustments in research design and strategy have been made in response and according to the evolving plans and conditions within the clinic of radiology. And, of course, my exploration of the relations of work practice and technology development have been confined to what endogenously has been taking place in the work communities.
On the other hand, research collaboration with the clinic of radiology for the period of four years has offered a rare and exceptionally valuable opportunity to study the naturally occurring radiological work practice as it appears to the members of the work communities and to follow the endogenous processes of technology procurement and implementation with the inherent practical problems. Only by observing several new technology undertakings and clinical trial periods I have come to understand and appreciate the extent and complexity of change to everyday work practice that a new mediating technology introduces.
A longitudinal series of unfolding fieldwork phases.
Phase I: Film-based cooperative image interpretation - May - September 1994 - Juha Pihlaja and Helena Karasti (fieldworkers), Kari Kuutti (research director) - an introductory fieldwork to get acquainted with the staff and to gain an overall understanding of the everyday film-based radiology work practice in the four radiology departments - a focussed study of collaborative image interpretation sessions as image consultations were identified as most likely to directly benefit from computerisation and networking - understanding the nature and requirements of existing cooperative work and communication practices grounded on the use of film and related technologies would inform the design of systems in the future projects |
Phase II: The experimental Kuusamo-Oulu teleradiology system - October 1995 – May 1996 - Sari Tuovila and Helena Karasti (fieldworkers), Kari Kuutti (workshop co-facilitator) - studying the emergent teleradiology work practice during the trial use phase using the experimental system in both locations (from October 1995 to January 1996) - organising two work practice based participatory design workshops (in March and May 1996) - understanding the teleradiology work practice, the transition from film-based traditional work practice to using digitalised images in a computer system |
Phase III: Two areas of radiology work and PACS implementation - June 1997 – January 1998 - Helena Karasti (fieldworker) - studying film-based work practice in relation to two areas of radiology work: post-operational intensive care unit radiology meetings and CT-neuroradiology - following the PACS (Picture Archiving and Communications System) implementation process and organising interventions for education, work practice analysis and system implementation - following a week long PACS trial use phase in the intensive care unit radiology meetings |
Phase IV: A short follow-up study on the teleradiology system - one week in November 1997 (during a quiet period in PACS implementation) - Helena Karasti (fieldworker) - a short follow-up study in relation to an intensive use period of the commercial version of the teleradiology system in clinical work - studying the work practice and system use situations with an interest to changes made in the experimental teleradiology system and whether other implications of workshops could be identified |
In the first fieldwork phase, Juha Pihlaja and I worked together. As a more experienced fieldworker he showed me the ropes, and gradually I became more active in interviewing practitioners, observing and videotaping work activities. Kari Kuutti as the research director was involved in some sessions that bear resemblances to ‘debriefing meetings’ (Hughes et al. 1993), in decision making about how to direct and focus fieldwork and in negotiations with the clinic of radiology.
In the second fieldwork phase I was accompanied by Sari Tuovila who completed her course on research apprenticeship through participating in fieldwork. She helped with audio and video recording in situ and stimulated recall interviews, actual instances of teleradiology work and the workshops. After a day in the field we would also discuss our experiences, observations and interpretations. Kari Kuutti participated as a co-facilitator in the workshops and as he had not been involved in fieldwork, his ‘voice’ was more of a outside designer. In the last two phases of fieldwork I have been employed by the clinic of radiology and have worked alone.
The four fieldwork phases have provided an abundance of possibilities to study the relations of actual technology use and development in the clinic of radiology. The project in which an experimental teleradiology system was developed, implemented, evaluated and redesigned (Phase II) will be described in more detail below as it has provided the concrete setting for exploring the relations between practitioners, researchers and designers. Research carried out in other phases has contributed to the maturing of my thought in relation to the issues addressed in this work.
2.6.2. Studying the co-existing ways of working mediated with different technologies
This special time in the development of radiology when technologies from different periods co-reside both temporally and spatially within radiology departments allows to study two differently mediated ways of working simultaneously. The traditional technologies and equipment, i.e. conventional radiological imaging devices, films, light panels and autoalternators co-exist with new imaging modality devices, digitised images, computer monitors and workstations.
Barley who has conducted a set of outstanding studies on the use of CT scanners in radiology has described the situation: “a prior social order continues to exist side by side with what has come since and with what is likely to come in the near future. When living traces of a former order reside along side vestiges of a new, it is possible to compare the two simultaneously” (Barley 1990b, p. 223). Though his studies were carried out already in the 1980s, the words accurately describe the still ongoing period of technical and social transition within radiology work practice.
Furthermore, this phase in the history of radiology allows to follow the transition taking place in the endogenous technology procurement and development processes. In the past and current practice the clinic of radiology has procured new imaging technologies, both conventional and computerised modalities, at a steady phase in keeping up with the rapidly developing field of radiological examinations. On the other hand, the clinic has little experience with the acquisition and development of information systems. The in-house developed RIS (Radiology Information System), called X-RAY, implemented in the beginning of 1990’s, has remained the only widely used computer system in the clinic. The undertakings of the experimental teleradiology system and PACS have been the first major involvements in system design projects.
2.6.2.1. The traditional film-based work practice
The everyday work practice in the clinic of radiology is technology intensive and thoroughly film-mediated. Practically all work in the departments of radiology relates to film at some point and most tasks are intimately mediated by film. In current practice all images are printed on film though increasing numbers of examinations are produced with computerised imaging modalities. All interpretation is done with films mounted on light panels, only MRI and CT scans are preliminarily viewed on monitors. Film is not only used in examining, producing, interpreting and storing images but also for co-ordinating and scheduling work as well as creating an awareness of the overall situation.
The following example attempts to illustrate some of the most fundamental qualities of film-mediated everyday radiology work practice, i.e. procedures and methods, collaboration of specialised occupations and situated co-ordination, as they are lived and enacted in the everyday work of CT-neurology examinations. It makes visible how the technical infrastructure and the mundane tools that have been developed around the use of film are used by the practitioners in their mundane activities and interactions as taken-for-granted aspects of the ordinary film-based work practice.
‘Doing heads’, as CT-neurology examinations are called in the local parlance, is carried out in one of the examination rooms that houses the technological apparatuses for this particular kind of examination and imaging (see Figure 1, Point 3, on page 56). Admitted patients are examined, images are produced and consultations are provided in form of image interpretation reports (see on page 57 Table 3, Picture C in which a radiologist interprets images and dictates a report) and regular demonstrations organised for the tending neurologists and neurosurgeons (Table 3, Picture F in which another radiologist is holding an image demonstration). In the following paragraphs Points 1-7 refer to Figure 1 on page 56 and Pictures A-F to Table 3 on page 57.
As all radiology work also the everyday practice of ‘doing heads’ relies on a number of work procedures and customary routines that have been formed collaboratively over a period of time and are known to all members of the work community. One of the most essential standard method in the clinic of radiology is the use of ‘patient examination folders’. A PEF is formed for each patient in the registration (see Point 1 and Picture A in which a receptionist receives patient materials to establish a PEF). The ‘practical rationale’ of PEF is to collect and keep together patient materials during ‘patient examination trajectory’ (cf. Strauss et al. 1985, 8-39) which is the entire process of taking a patient case through the consultation. A typical examination trajectory depicted in the groundplan (Points 1-7, 56) shows how its sequentially organising and technologically bound tasks take place in the close proximity of appropriate devices. As each patient case proceeds along the patient examination trajectory the assemblage of heterogeneous patient materials in the PEF change correspondingly. The progress of each patient as well as the overall work situation can be perceived through the very material and observable ‘film trails’.
Figure 1. A groundplan for the radiology department in OUH depicts the most relevant work spaces, devices and tools used in the CT-neurology examinations.
Film-based work practice of neurological CT examinations.
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| Picture A. In reception Sanna, a department secretary, receives materials from a patient to be examined (Point 1 in Figure 1, p. 56). | Picture B. Taina, a film developer (on the right) takes a film from a printer to a technical inspection on a near-by light panel (Point 4 in Figure 1, p. 56). |
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| Picture C. Amidst own duties Asta, a film developer, and Ulla, a radiologist, engage in a brief exchange about a patient (Point 5 in Figure 1, p. 56). | Picture D. Marja and Pirjo, department secretaries, type out dictated reports and insert them in patient record files (Point 6 in Figure 1, p. 56). |
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| Picture E. Alternator magazines, PEFs, film files and lists of patient cases in preparation for image demonstrations (Point 7 in Figure 1, p. 56). | Picture F. Eero, a radiologist, is holding an image demonstration regularly organised for neurosurgeons (Point 7 in Figure 1, p. 56). |
Specialised occupations take care of different phases of the patient examination trajectory. For instance, an appropriate CT examination procedure is chosen for each patient case by a radiologist (Point 2, p. 56), a team of roentgen nurses together with a radiologist performs the examination (Point 3), a film developer takes care of technical image check (Point 4 and Picture B), selects and assembles relevant patient materials and mounts films on alternator light panels (Point 5 and Picture C), a radiologist interprets the images and dictates a report (Point 5 and Picture C) which is typed out by a department secretary (Point 6 and Picture D), if the case is to be discussed in an image demonstration meeting a film developer takes care of the arrangements (Point 7 and Picture E) otherwise the patient materials are returned to appropriate locations.
The successful completion of ‘doing heads’ is achieved through a high degree of collaboration in the unfolding process that takes place during a relatively short time period and in quite close spatial proximity. On one hand, the personnel can anticipate the activities of other workers and depend on the pre-set division of tasks and responsibilities of the specialised occupational groups. On the other hand, continuous co-ordination of collaboration is required to bring to meet the specialised practitioners and volatile technological resources with the more or less steady flow of patients for examinations.
The use of PEFs, face-to-face communication and local awareness constitute major aspects of the practical achievement of situated co-ordination. The use of PEFs is an organising element in the sequential work tasks and changes in turns between individual practitioners and/or occupational groups. The activity at each state is to receive a folder partially completed, add documents to the folder by assessing certain resources or completing certain tasks, and take the folder to the next stage in the trajectory. As the folder is handed over or passed along it alerts the person(s) responsible for the next phase to proceed. These exchanges provide natural occasions for brief face-to-face encounters. Furthermore, working in close proximity within departments offers possibilities for desultory communication and situated negotiations for scheduling and organising work (Pictures B, C and D, p. 57). The physical and spatial layout of the departments supports an awareness of others and their activities. For instance, in Picture B, a film developer engaged in her duties on the right can overhear her colleagues discussing a case of missing films on the other side of the light panel counter and stay aware of the overall situation of the ongoing ‘film work’. The practitioners are accustomed to reading their environment, being continuously and peripherally aware of the PEFs and the ‘film trails’.
2.6.2.2. The emergent digitally mediated experimental teleradiology work
In the Kuusamo-Oulu teleradiology project (for an overview see Karasti et al. 1998) an experimental system based on personal computers suitable for primary care centers with X-ray services was developed first (see Figure 2, p. 59)[1]. The system was designed to enable radiological consultation through asynchronous transfer of digitized images with combined electronical requests and reports. The design had started out as a collaboration between the designers from two hardware and software companies together with radiologists and physicists from the OUH, later on representatives from Kuusamo Primary Care Center were invited. A set of requirements based on previous research (Reponen et al. 1995) was fixed by the design team and the emphasis in design was placed on the technical performance of the system.
We[2] entered the field when the pilot system was taken into trial clinical use for consultations between the two radiology work communities. During fieldwork we studied the entire emergent teleradiology work practice introduced by the experimental system. We observed the actually occurring activities in making the new teleradiology service work in both locations and conducted in situ interviews with the involved personnel. Instances of teleradiology system use were videotaped for further analysis and to be used in stimulated recall interviews. Though our emphasis was on studying the actual use of the new teleradiology system we also conducted interviews with the members of the design team to delineate what had taken place in the preceding design phase when we had not yet been present in the field and with occupational groups not involved with the everyday direct use of the system, e.g. clinicians in Kuusamo and some administrative personnel in both ends of the link.
The teleradiology service was seen to ideally work as a simple workflow system (see the chain of tasks in Figure 3, originally presented in Karasti et al. (1998)). After a patient’s radiological examination and initial interpretation of the images the tending physician in Kuusamo would decide whether an expert consultation is necessary in which case s/he dictates a request. A roentgen nurse or a primary care center assistant would scan the films, enter the patient information and type the request into the system and then send them to the University Hospital (see Table 4, Pictures A and B, p. 61). The teleradiologist on duty at Oulu University Hospital would check once a day whether images to be interpreted had been received. The radiologist then would interpret the images of each patient case on a computer screen and dictate reports (Picture C). S/he would hand over the tape to the departmental secretary to type the report into the system and to send the file back to Kuusamo Primary Care Centre (Picture D). In Kuusamo the reports would be received and printed out to be delivered to the tending physicians.
As we studied the emergent work practice we found that the teleradiology service was more complex than the workflow view let believe (cf. Bowers et al. 1995). The system introduced an entirely new kind of work relationship and way of collaboration between the radiology communities that required articulation work (Strauss et al. 1985, Gerson & Star 1986, Suchman 1996b) on behalf of all involved practitioners to maintain the service as a running operation (see the articulation work of both individual tasks and cooperation in picture 17). The teleradiology service brought about new work tasks in Kuusamo Primary Care Center (depicted in Figure 3 by the nurse’s/assistant’s responsibilities in Kuusamo). Radiologists in OUH carried out clinical monitor interpretation for the first time as only electronic records and digital images were exchanged.
Instances of everyday teleradiology work practice.
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| Picture A. Maija in Kuusamo Primary Care Center scans the films to be transferred to Oulu University Hospital. | Picture B. Maija prepares relevant patient materials and types in the necessary information into the system. |
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| Picture C. Kari, a radiologist, interprets the images of the transferred patient case and simultaneously dictates a report. | Picture D. Marjatta, a department secretary in the clinic of radiology, types out the dictated report and sends it to Kuusamo. |
The experimental system was successful in the sense that images and requests for consultation were transferred and reports obtained. However, a closer look into the actual use situations disclosed a set of problems manifest in problems, work-arounds, extra work, unease, uncertainty and dissatisfaction with the system. More detailed descriptions of teleradiology work can be found in Karasti (1997a), publication I, that especially makes visible the supportive work that goes into providing for the everyday teleradiology service and in Karasti et al. (1998) that focuses on image interpretation.
After the clinical trial period two workshops were organised (and videotaped for further analysis, see Figure 4, p. 62). Our interest was to provide to the until then technologically focussed system development an alternative in form of work practice-based, participatory interventions. The idea was that the fieldwork findings and the experiences of participants could be taken into account in the evaluation and redesign of the experimental system as well as in the further development of teleradiology work practice before moving on to product design. The specific themes of the workshops included the new collaboration between two radiology units that had previously worked separately, distributed supportive work and the radiologists’ image interpretation work. Chapter 4 and Karasti (1997c), publication III in this thesis, spell out in detail the development of the more specific ideas for the workshops, their organisation, experiences gained and initial interpretation of the elements contributing to the gravitation on work practice.
