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Murdoch J, Paparini S, Papoutsi C, James H, Greenhalgh T, Shaw SE. Mobilising context as complex and dynamic in evaluations of complex health interventions. BMC Health Serv Res 2023; 23:1430. [PMID: 38110918 PMCID: PMC10726627 DOI: 10.1186/s12913-023-10354-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/20/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND The relationship between healthcare interventions and context is widely conceived as involving complex and dynamic interactions over time. However, evaluations of complex health interventions frequently fail to mobilise such complexity, reporting context and interventions as reified and demarcated categories. This raises questions about practices shaping knowledge about context, with implications for who and what we make visible in our research. Viewed through the lens of case study research, we draw on data collected for the Triple C study (focused on Case study, Context and Complex interventions), to critique these practices, and call for system-wide changes in how notions of context are operationalised in evaluations of complex health interventions. METHODS The Triple C study was funded by the Medical Research Council to develop case study guidance and reporting principles taking account of context and complexity. As part of this study, a one-day workshop with 58 participants and nine interviews were conducted with those involved in researching, evaluating, publishing, funding and developing policy and practice from case study research. Discussions focused on how to conceptualise and operationalise context within case study evaluations of complex health interventions. Analysis focused on different constructions and connections of context in relation to complex interventions and the wider social forces structuring participant's accounts. RESULTS We found knowledge-making practices about context shaped by epistemic and political forces, manifesting as: tensions between articulating complexity and clarity of description; ontological (in)coherence between conceptualisations of context and methods used; and reified versions of context being privileged when communicating with funders, journals, policymakers and publics. CONCLUSION We argue that evaluations of complex health interventions urgently requires wide-scale critical reflection on how context is mobilised - by funders, health services researchers, journal editors and policymakers. Connecting with how scholars approach complexity and context across disciplines provides opportunities for creatively expanding the field in which health evaluations are conducted, enabling a critical standpoint to long-established traditions and opening up possibilities for innovating the design of evaluations of complex health interventions.
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Affiliation(s)
- Jamie Murdoch
- School of Life Course and Population Sciences, King's College London, London, UK.
| | - Sara Paparini
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hannah James
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sara E Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Golembiewski EH, Espinoza Suarez NR, Maraboto Escarria AP, Yang AX, Kunneman M, Hassett LC, Montori VM. Video-based observation research: A systematic review of studies in outpatient health care settings. PATIENT EDUCATION AND COUNSELING 2023; 106:42-67. [PMID: 36207219 DOI: 10.1016/j.pec.2022.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 09/13/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To examine the use of video-based observation research in outpatient health care encounter research. METHODS We conducted a systematic search of MEDLINE, Scopus, Cochrane and other databases from database inception to October 2020 for reports of studies that used video recording to investigate ambulatory patient-clinician interactions. Two authors independently reviewed all studies for eligibility and extracted information related to study setting and purpose, participant recruitment and consent processes, data collection procedures, method of analysis, and participant sample characteristics. RESULTS 175 articles were included. Most studies (65%) took place in a primary care or family practice setting. Study objectives were overwhelmingly focused on patient-clinician communication (81%). Reporting of key study elements was inconsistent across included studies. CONCLUSION Video recording has been used as a research method in outpatient health care in a limited number and scope of clinical contexts and research domains. In addition, reporting of study design, methodological characteristics, and ethical considerations needs improvement. PRACTICE IMPLICATIONS Video recording as a method has been relatively underutilized within many clinical and research contexts. This review will serve as a practical resource for health care researchers as they plan and execute future video-based studies.
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Affiliation(s)
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Department of Family Medicine and Emergency Medicine Laval University Quebec, Canada.
| | - Andrea P Maraboto Escarria
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Department of Obstetrics and Gynecology Hospital Angeles Lomas Mexico City, Mexico.
| | - Andrew X Yang
- Mayo Clinic Alix School of Medicine Rochester, MN, USA.
| | - Marleen Kunneman
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Medical Decision Making, Department of Biomedical Data Sciences Leiden University Medical Center Leiden, the Netherlands.
| | - Leslie C Hassett
- Division of Endocrinology, Diabetes, Metabolism and Nutrition Department of Medicine Mayo Clinic, Rochester, MN, USA.
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Mayo Clinic Libraries Mayo Clinic, Rochester, MN, USA.
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Drogt J, Milota M, Vos S, Bredenoord A, Jongsma K. Integrating artificial intelligence in pathology: a qualitative interview study of users' experiences and expectations. Mod Pathol 2022; 35:1540-1550. [PMID: 35927490 PMCID: PMC9596368 DOI: 10.1038/s41379-022-01123-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022]
Abstract
Recent progress in the development of artificial intelligence (AI) has sparked enthusiasm for its potential use in pathology. As pathology labs are currently starting to shift their focus towards AI implementation, a better understanding how AI tools can be optimally aligned with the medical and social context of pathology daily practice is urgently needed. Strikingly, studies often fail to mention the ways in which AI tools should be integrated in the decision-making processes of pathologists, nor do they address how this can be achieved in an ethically sound way. Moreover, the perspectives of pathologists and other professionals within pathology concerning the integration of AI within pathology remains an underreported topic. This article aims to fill this gap in the literature and presents the first in-depth interview study in which professionals' perspectives on the possibilities, conditions and prerequisites of AI integration in pathology are explicated. The results of this study have led to the formulation of three concrete recommendations to support AI integration, namely: (1) foster a pragmatic attitude toward AI development, (2) provide task-sensitive information and training to health care professionals working in pathology departments and (3) take time to reflect upon users' changing roles and responsibilities.
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Affiliation(s)
- Jojanneke Drogt
- Department of Medical Humanities, University Medical Center, Utrecht, The Netherlands.
| | - Megan Milota
- grid.7692.a0000000090126352Department of Medical Humanities, University Medical Center, Utrecht, The Netherlands
| | - Shoko Vos
- grid.10417.330000 0004 0444 9382Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annelien Bredenoord
- grid.7692.a0000000090126352Department of Medical Humanities, University Medical Center, Utrecht, The Netherlands
| | - Karin Jongsma
- grid.7692.a0000000090126352Department of Medical Humanities, University Medical Center, Utrecht, The Netherlands
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Papoutsi C, Wherton J, Shaw S, Morrison C, Greenhalgh T. Putting the social back into sociotechnical: Case studies of co-design in digital health. J Am Med Inform Assoc 2021; 28:284-293. [PMID: 33043359 PMCID: PMC7883972 DOI: 10.1093/jamia/ocaa197] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 08/01/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE We sought to examine co-design in 3 contrasting case studies of technology-supported change in health care and explain its role in influencing project success. MATERIALS AND METHODS Longitudinal case studies of a seizure detection and reporting technology for epilepsy (Southern England, 2018-2019), a telehealth service for heart failure (7 UK sites, 2016-2018), and a remote video consultation service (Scotland-wide, 2019-2020). We carried out interviews with 158 participants and collected more than 200 pages of field notes from observations. Within- and cross-case analysis was informed by sociotechnical theory. RESULTS In the epilepsy case, co-design prioritized patient-facing features and focused closely around a specific clinic, which led to challenges with sustainability and mainstreaming. In the heart failure case, patient-focused co-design produced an accessible and usable patient portal but resulted in variation in uptake between clinical sites. Successful scale-up of video consultations was explained by a co-design process involving not only the technical interface, but also careful reshaping of work practices. DISCUSSION A shift is needed from co-designing with technology users to co-designing with patients as service users, and with healthcare staff as professionals. Good co-design needs to involve users, including those who engage with the technology-supported service bothdirectly and indirectly. It requires sensitivity to emergence and unpredictability in complex systems. Healthcare staff need to be supported to accommodate iterative change in the service. Adequate resourcing and infrastructures for systems-focused co-design are essential. CONCLUSIONS If co-design focuses narrowly on the technology, opportunities will be missed to coevolve technologies alongside clinical practices and organizational routines.
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Affiliation(s)
- Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Joseph Wherton
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Sara Shaw
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Clare Morrison
- Technology Enabled Care Programme, Scottish Government, Edinburgh, United Kingdom
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
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Wiljer D, Charow R, Costin H, Sequeira L, Anderson M, Strudwick G, Tripp T, Crawford A. Defining compassion in the digital health age: protocol for a scoping review. BMJ Open 2019; 9:e026338. [PMID: 30772865 PMCID: PMC6398782 DOI: 10.1136/bmjopen-2018-026338] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION The notion of compassion and compassionate care is playing an increasingly important role in health professional education and in the delivery of high-quality healthcare. Digital contexts, however, are not considered in the conceptualisation of compassionate care, nor is there guidance on how compassionate care is to be exercised while using digital health technologies. The widespread diffusion of digital health technologies provides new contexts for compassionate care, with both opportunities for new forms and instantiations of compassion as well as new challenges. How compassion is both understood and enacted within this evolving, digital realm has not been synthesised. METHODS AND ANALYSIS This scoping review protocol follows Arksey and O'Malley's methodology to examine dimensions of compassionate professional practice when digital technologies are integrated into clinical care. Relevant peer-reviewed literature will be identified using a search strategy developed by medical librarians, which applies to six databases of medical, computer and information systems disciplines. Eligibility of articles will be determined using the two-stage screening process consisting of (1) title and abstract scan, and (2) full-text review. Screening, abstracting and charting will be conducted by two independent reviewers, with a third reviewer available for resolution when consensus is not achieved. In order to look at the range of current research in this area, extracted data will be thematically analysed and validated by content experts. Descriptive statistics will be calculated where necessary. ETHICS AND DISSEMINATION Research ethics approval and consent to participate is not required for this scoping review. The results of the review will inform resource development and strategy for Associated Medical Services (AMS) Healthcare, a Canadian charitable organisation at the forefront of advancing research and leadership development in health and humanities, as part of the AMS Phoenix Project: A Call to Caring, particularly for digital professionalism frameworks so that they are inclusive of a compassion competency.
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Affiliation(s)
- David Wiljer
- UHN Digital, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- The Wilson Centre, University Health Network, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Rebecca Charow
- UHN Digital, University Health Network, Toronto, Ontario, Canada
| | - Helen Costin
- The Wilson Centre, University Health Network, Toronto, Ontario, Canada
- Medical Psychiatry Alliance, University of Toronto, Toronto, Ontario, Canada
| | - Lydia Sequeira
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Melanie Anderson
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Gillian Strudwick
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Tim Tripp
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Allison Crawford
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Medical Psychiatry Alliance, University of Toronto, Toronto, Ontario, Canada
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When 'yes' means 'no': why the small details of clinical interactions matter. Br J Gen Pract 2018; 68:410-411. [PMID: 30166372 DOI: 10.3399/bjgp18x698441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Shapiro J. "Violence" in medicine: necessary and unnecessary, intentional and unintentional. Philos Ethics Humanit Med 2018; 13:7. [PMID: 29890993 PMCID: PMC5994834 DOI: 10.1186/s13010-018-0059-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/13/2018] [Indexed: 06/08/2023] Open
Abstract
We are more used to thinking of medicine in relation to the ways that it alleviates the effects of violence. Yet an important thread in the academic literature acknowledges that medicine can also be responsible for perpetuating violence, albeit unintentionally, against the very individuals it intends to help. In this essay, I discuss definitions of violence, emphasizing the importance of understanding the term not only as a physical perpetration but as an act of power of one person over another. I next explore the paradox of a healing profession that is permeated with violence sometimes necessary, often unintentional, and almost always unrecognized. Identifying the construct of "physician arrogance" as contributory to violence, I go on to identify different manifestations of violence in a medical context, including violence to the body; structural violence; metaphoric violence; and the practice of speaking to or about patients (and others in the healthcare system in ways that minimize or disrespect their full humanity. I further suggest possible explanations for the origins of these kinds of violence in physicians, including the fear of suffering and death in relation to vicarious trauma and the consequent concept of "killing suffering"; as well as why patients might be willing to accept such violence directed toward them. I conclude with brief recommendations for attending to root causes of violence, both within societal and institutional structures, and within ourselves, offering the model of the wounded healer.
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Affiliation(s)
- Johanna Shapiro
- Department of Family Medicine, UC Irvine School of Medicine, Rte 81, Bldg 200, Ste 835; 101 City Dr. South, Orange, CA, 92651, USA.
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Schoeb V, Hiller A. The impact of documentation on communication during patient-physiotherapist interactions: A qualitative observational study. Physiother Theory Pract 2018; 34:861-871. [DOI: 10.1080/09593985.2018.1429036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Veronika Schoeb
- Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, China
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), Lausanne, Switzerland
| | - Amy Hiller
- Department of Physiotherapy, University of Melbourne, Melbourne, Australia
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Juggling confidentiality and safety: a qualitative study of how general practice clinicians document domestic violence in families with children. Br J Gen Pract 2017; 67:e437-e444. [PMID: 28137783 PMCID: PMC5442959 DOI: 10.3399/bjgp17x689353] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/19/2016] [Indexed: 11/24/2022] Open
Abstract
Background Domestic violence and abuse (DVA) and child safeguarding are interlinked problems, impacting on all family members. Documenting in electronic patient records (EPRs) is an important part of managing these families. Current evidence and guidance, however, treats DVA and child safeguarding separately. This does not reflect the complexity clinicians face when documenting both issues in one family. Aim To explore how and why general practice clinicians document DVA in families with children. Design and setting A qualitative interview study using vignettes with GPs and practice nurses (PNs) in England. Method Semi-structured telephone interviews with 54 clinicians (42 GPs and 12 PNs) were conducted across six sites in England. Data were analysed thematically using a coding frame incorporating concepts from the literature and emerging themes. Results Most clinicians recognised DVA and its impact on child safeguarding, but struggled to work out the best way to document it. They described tensions among the different roles of the EPR: a legal document; providing continuity of care; information sharing to improve safety; and a patient-owned record. This led to strategies to hide information, so that it was only available to other clinicians. Conclusion Managing DVA in families with children is complex and challenging for general practice clinicians. National integrated guidance is urgently needed regarding how clinicians should manage the competing roles of the EPR, while maintaining safety of the whole family, especially in the context of online EPRs and patient access.
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Emmerich N, Swinglehurst D, Maybin J, Park S, Quilligan S. Caring for quality of care: symbolic violence and the bureaucracies of audit. BMC Med Ethics 2015; 16:23. [PMID: 25952931 PMCID: PMC4493962 DOI: 10.1186/s12910-015-0006-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 02/16/2015] [Indexed: 11/16/2022] Open
Abstract
Background This article considers the moral notion of care in the context of Quality of Care discourses. Whilst care has clear normative implications for the delivery of health care it is less clear how Quality of Care, something that is centrally involved in the governance of UK health care, relates to practice. Discussion This paper presents a social and ethical analysis of Quality of Care in the light of the moral notion of care and Bourdieu’s conception of symbolic violence. We argue that Quality of Care bureaucracies show significant potential for symbolic violence or the domination of practice and health care professionals. This generates problematic, and unintended, consequences that can displace the goals of practice. Summary Quality of Care bureaucracies may have unintended consequences for the practice of health care. Consistent with feminist conceptions of care, Quality of Care ‘audits’ should be reconfigured so as to offer a more nuanced and responsive form of evaluation.
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Affiliation(s)
- Nathan Emmerich
- School of Politics, International Studies and Philosophy, Queen's University Belfast, Belfast, UK.
| | - Deborah Swinglehurst
- Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, UK.
| | | | - Sophie Park
- Research Department of Primary Care and Population Health, UCL Medical School, London, UK.
| | - Sally Quilligan
- University of Cambridge, School of Clinical Medicine, Cambridge, UK.
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Swinglehurst D, Greenhalgh T. Caring for the patient, caring for the record: an ethnographic study of 'back office' work in upholding quality of care in general practice. BMC Health Serv Res 2015; 15:177. [PMID: 25907436 PMCID: PMC4408578 DOI: 10.1186/s12913-015-0774-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 02/27/2015] [Indexed: 11/28/2022] Open
Abstract
Background The quality of information recorded about patient care is considered key to improving the overall quality, safety and efficiency of patient care. Assigning codes to patients’ records is an important aspect of this documentation. Current interest in large datasets in which individual patient data are collated (e.g. proposed NHS care.data project) pays little attention to the details of how ‘data’ get onto the record. This paper explores the work of summarising and coding records, focusing on ‘back office’ practices, identifying contributors and barriers to quality of care. Methods Ethnographic observation (187 hours) of clinical, management and administrative staff in two UK general practices with contrasting organisational characteristics. This involved observation of working practices, including shadowing, recording detailed field notes, naturalistic interviews and analysis of key documents relating to summarising and coding. Ethnographic analysis drew on key sensitizing concepts to build a ‘thick description’ of coding practices, drawing these together in a narrative synthesis. Results Coding and summarising electronic patient records is complex work. It depends crucially on nuanced judgements made by administrators who combine their understanding of: clinical diagnostics; classification systems; how healthcare is organised; particular working practices of individual colleagues; current health policy. Working with imperfect classification systems, diagnostic uncertainty and a range of local practical constraints, they manage a moral tension between their idealised aspiration of a ‘gold standard’ record and a pragmatic recognition that this is rarely achievable in practice. Adopting a range of practical workarounds, administrators position themselves as both formally accountable to their employers (general practitioners), and informally accountability to individual patients, in a coding process which is shaped not only by the ‘facts’ of the case, but by ongoing working relationships which are co-constructed alongside the patient’s summary. Conclusion Data coding is usually conceptualised as either a technical task, or as mundane, routine work, and usually remains invisible. This study offers a characterisation of coding as a socially complex site of moral work through which new lines of accountability are enacted in the workplace, and casts new light on the meaning of coded data as conceptualised in the ‘quality of care’ discourse. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0774-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Deborah Swinglehurst
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
| | - Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
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