Organizing visions for data-centric management: how Norwegian policy documents construe the use of data in health organizations

PURPOSE

Norway, like other welfare states, seeks to leverage data to transform its pressured public healthcare system. While managers will be central to doing so, we lack knowledge about how specifically they would do so and what constraints and expectations they operate under. Public sources, like the Norwegian policy documents investigated here, provide important backdrops against which such managerial work emerges. This article therefore aims to analyze how key Norwegian policy documents construe data use in health management.

DESIGN/METHODOLOGY/APPROACH

We analyzed five notable policy documents using a "practice-oriented" framework, considering these as arenas for "organizing visions" (OVs) about managerial use of data in healthcare organizations. This framework considers documents as not just texts that comment on a topic but as discursive tools that formulate, negotiate and shape issues of national importance, such as expectations about data use in health management.

FINDINGS

The OVs we identify anticipate a bold future for health management, where data use is supported through interconnected information systems that provide relevant information on demand. These OVs are similar to discourse on "evidence-based management," but differ in important ways. Managers are consistently framed as key stakeholders that can benefit from using secondary data, but this requires better data integration across the health system. Despite forward-looking OVs, we find considerable ambiguity regarding the practical, social and epistemic dimensions of data use in health management. Our analysis calls for a reframing, by moving away from the hype of "data-driven" health management toward an empirically-oriented, "data-centric" approach that recognizes the situated and relational nature of managerial work on secondary data.

ORIGINALITY/VALUE

By exploring OVs in the Norwegian health policy landscape, this study adds to our growing understanding of expectations towards healthcare managers' use of data. Given Norway's highly digitized health system, our analysis has relevance for health services in other countries.

Data driven or data informed? How general practitioners use data to evaluate their own and colleagues' clinical work in clusters

In contemporary policy discourses, data are presented as key assets for improving health-care quality: policymakers want health care to become 'data driven'. In this article, we focus on a particular example of this ambition, namely a new Danish national quality development program for general practitioners (GPs) where doctors are placed in so-called 'clusters'. In these clusters, GPs are obliged to assess their own and colleagues' clinical quality with data derived from their own clinics-using comparisons, averages and benchmarks. Based on semi-structured interviews with Danish GPs and drawing on Science and Technology Studies, we explore how GPs understand these data, and what makes them trust-or question-a data analysis. The GPs describe how they change clinical practices based on these discussions of data. So, when and how do data for quality assurance come to influence their perceptions of quality? By exploring these issues, we carve out a role for a sociological engagement with evidence in everyday medical practices. In conclusion, we suggest a need to move from the aim of being data driven to one of being data informed.

Data work and practices in healthcare: A scoping review

CONTEXT

In healthcare, digitization has been widespread and profound, entailing a deluge of data. This has spurred ambitions for healthcare to become data-driven to improve efficiency and quality, and within medicine itself to improve diagnosing and treating diseases. The generation and processing of data requires human intervention and work, though this is often not acknowledged.

PURPOSE

The paper investigates who, where, by which means, and for which purposes data work is conducted which is crucial for healthcare managers and policy makers if ambitions to become data-driven are to succeed. To guide further research, it also provides an overview of existing research on data work and practices.

METHODS

We conducted a scoping review based on a search for papers including the terms healthcare or health care combined with at least one of the following terms: data work, data worker*, data practice*, data practitioner* in Scopus and Web of Science. 74 papers on data work or practices in healthcare were included.

ANALYSIS

The 74 papers were coded and analyzed regarding the following themes: the kind of data workers and practitioners, organizational settings, involved technologies, purposes, data work tasks, theories and concepts, and definitions of data work and practice.

RESULTS

Data work is pervasive in healthcare and conducted by various professions and people and in various contexts. The field researching data work and practices is emerging, with publications spread across multiple venues. and there is a need for more precise definitions of data work. Further, data work and practices are useful concepts that have enabled the exploration of those efforts and tasks in detail.

CONCLUSION

The research on data work and practices in healthcare is emerging and promising. We call for more research to consolidate the field and to better understand and support the work needed for healthcare to become data-driven.

Personal data store ecosystems in health and social care

This paper considers how the development of personal data store ecosystems in health and social care may offer one person-centered approach to improving the ways in which individual generated and gathered data-e.g., from wearables and other personal monitoring and tracking devices-can be used for wellbeing, individual care, and research. Personal data stores aim to provide safe and secure digital spaces that enable people to self-manage, use, and share personal data with others in a way that aligns with their individual needs and preferences. A key motivation for personal data stores is to give an individual more access and meaningful control over their personal data, and greater visibility over how it is used by others. This commentary discusses meanings and motivations behind the personal data store concept-examples are provided to illustrate the opportunities such ecosystems can offer in health and social care, and associated research and implementation challenges are also examined.

Reconciling healthism and techno-solutionism: An observational study of a digital mental health trial

In a growing trend in digital psychiatry, algorithmic systems are used to determine correlations between data that is collected using wearable devices and self-reports of mood. They then offer recommendations for behaviour modification for improved mood. The present study consists of observations of the development of one of these systems. Descriptions of the trial emphasise the powerful role of the intrinsically motivated, responsible participant on one hand and the empowering machine learning (ML)-based technology on the other. This conceptualisation is shown to extend the neoliberal paradox of a freedom that, to be maintained, must be continually adjusted through discipline. Because of the paradoxical nature of this formulation, laboratory members disagree about the balance of agency between the objective machine learning system and the empowered participant. The guides who help participants interpret ML outputs and implement system recommendations are ascribed a replaceable role in formal accounts. Observations of this guidance practice make clear not only the important role played by guides but also how their work is relegated to the technological side of the broader formulation of the trial and further how this conceptualisation affects the way they conduct their work.

The Trouble of Stigma in the Age of Datafication: Screening for Mental Health Issues in a Refugee Camp in Jordan

Drawing on ethnographic fieldwork in a refugee camp in Jordan, this article investigates how datafication through digital screening technologies helps shape mental health issues in the face of widespread uneasiness about the subject, especially among the intended beneficiaries. We argue that the refugees and their health care providers face a dilemma: on the one hand, the desire to make mental health issues visible and clinically actionable through datafication and, on the other hand, the wish to keep mental health issues out of public view to avoid potential stigma.

Data as symptom: Doctors' responses to patient-provided data in general practice

People are increasingly able to generate their own health data through new technologies such as wearables and online symptom checkers. However, generating data is one thing, interpreting them another. General practitioners (GPs) are likely to be the first to help with interpretations. Policymakers in the European Union are investing heavily in infrastructures to provide GPs access to patient measurements. But there may be a disconnect between policy ambitions and the everyday practices of GPs. To investigate this, we conducted semi-structured interviews with 23 Danish GPs. According to the GPs, patients relatively rarely bring data to them. GPs mostly remember three types of patient-generated data that patients bring to them for interpretation: heart and sleep measurements from wearables and results from online symptom checkers. However, they also spoke extensively about data work with patient queries concerning measurements from the GPs' own online Patient Reported Outcome system and online access to laboratory results. We juxtapose GP reflections on these five data types and between policy ambitions and everyday practices. These data require substantial recontextualization work before the GPs ascribe them evidential value and act on them. Even when they perceived as actionable, patient-provided data are not approached as measurements, as suggested by policy frameworks. Rather, GPs treat them as analogous to symptoms-that is to say, GPs treat patient-provided data as subjective evidence rather than authoritative measures. Drawing on Science and Technology Studies (STS) literature,we suggest that GPs must be part of the conversation with policy makers and digital entrepreneurs around when and how to integrate patient-generated data into healthcare infrastructures.

Facilitators and barriers to access hospital medical specialty telemedicine consultations during the COVID-19 pandemic: Systematic Review

BACKGROUND

COVID-19 pandemic accelerated the digital transition in healthcare, which required a rapid adaptation of stakeholders. Telemedicine has emerged as an ideal tool to ensure continuity of care by allowing remote access to specialized medical services. However, its rapid implementation has exacerbated disparities in healthcare access, especially for the most vulnerable populations.

OBJECTIVE

To characterize the determinants factors (facilitators and barriers) of access to hospital medical specialty telemedicine consultations during the COVID-19 pandemic; to identify the main opportunities and challenges (technological, ethical, legal and/or social) generated by the use of telemedicine in the context of the COVID-19 pandemic.

METHODS

A systematic review was conducted according to PRISMA guidelines. Four databases (Scopus, Web of Science, PubMed and Cochrane COVID-19 Study Register) were searched for empirical studies published between January 3rd, 2020, and December 31st, 2021, using established criteria. The protocol of this review was registered and published in PROSPERO (CRD42022302825). A methodological quality assessment was performed, and results were integrated into a thematic synthesis. The identification of main opportunities and challenges was done by interpreting and aggregating the thematic synthesis results.

RESULTS

Of the 106 studies identified, 9 met the inclusion criteria and the intended quality characteristics. All studies were originally from the United States of America (USA). The following facilitating factors of telemedicine use were identified: health insurance coverage; prevention of SARS-CoV-2 infection; access to Internet services; access to technological devices; better management of work-life balance; and savings in travel costs. We identified the following barriers to telemedicine use: lack of access to Internet services; lack of access to technological devices; racial and ethnic disparities; low digital literacy; low income; age; language barriers; health insurance coverage; concerns about data privacy and confidentiality; geographic disparities; and need for complementary diagnostic tests or for the delivery of test results.

CONCLUSIONS

The facilitating factors and barriers identified in this systematic review present different opportunities and challenges, including those of technological nature (access to technological devices and internet services, level of digital literacy), sociocultural and demographic nature (ethnic and racial disparities, geographical disparities, language barriers, age), socioeconomic nature (income level and health insurance coverage), and ethical and legal nature (data privacy and confidentiality). To expand telemedicine access to hospital-based specialty medical consultations and provide high-quality care to all, including the most vulnerable communities, the challenges identified must be thoroughly researched and addressed with informed and dedicated responses.

CLINICALTRIAL

Coding for quality? Accountability work in standardised cancer patient pathways (CPPs)

A vital part of standardised care pathways is the possibility to measure performance through different indicators - for example, codes. In this article, based on interviews with health personnel in a project evaluating the introduction of standardised cancer patient pathways (CPPs) in Norway, we explore the specific types of work involved when health personnel produce codes as (intended) signifiers of quality. All the types of work are dimensions of what we define as accountability work - work health personnel do to make the codes signifiers of quality of care in the CPP.Codes and coding practices raise questions of what quality of care represents and how it could and should be measured. Informants in our study advocate for coding as important work for the patient more than for 'the system'. This shows how organising for quality becomes a crucial part of professional work, expanding what it means to perform high quality care.

Exploring the challenges of and solutions to sharing personal genomic data for use in healthcare

Boosted by the COVID-19 pandemic, as well as the tightened General Data Protection Regulation (GDPR) legislation within the European Union (EU), individuals have become increasingly concerned about privacy. This is also reflected in how willing individuals are to consent to sharing personal data, including their health data. To understand this behaviour better, this study focuses on willingness to consent in relation to genomic data. The study explores how the provision of educational information relates to willingness to consent, as well as differences in privacy concerns, information sensitivity and the perceived trade-off value between individuals willing versus unwilling to consent to sharing their genomic data. Of the respondents, 65% were initially willing to consent, but after educational information 89% were willing to consent and only 11% remained unwilling to consent. Educating individuals about potential health benefits can thus help to correct the beliefs that originally led to the unwillingness to share genomic data.

Of Numbers and Moods: Screening for Mental Health Issues in a Rohingya Refugee Camp in Bangladesh

Screening refugees for mental health issues, medical assistants use a digital tool that produces a numerical score but also, importantly, attunes to the moods of their clients and the atmospheres of their homes. In this article, we propose the concept of numeration-attunement as helpful for medical anthropology. Drawing on ethnographic fieldwork conducted among medical assistants working in the Kutapalong refugee camp in Bangladesh, we explore their assessment of the mental health of the refugees: its numeration-attunement. To develop the notion of numeration-attunement, we draw on numeration research as well as phenomenology. Comprehending how medical assistants assess the mental health of refugees requires attention both to numeration and datafication by way of a screening tool as well as the revelatory character of attunement to moods.

'Is this something I should be worried about?': A study of nurses' recontextualisation work when making clinical decisions based on patient reported outcome data

As clinical care practices are becoming more digitalised, information about patients is increasingly being encoded as quantified data, and the processes of sorting data are often supported by algorithmic computations. One such practice becoming more prevalent across Western countries is the clinical use of Patient Reported Outcome (PRO) data. Drawing on ethnographic fieldwork carried out in a Danish setting among nurses managing PRO-based breast cancer follow-up, we examine how clinical decisions are made on the basis of PRO-data and what this requires from the nurses. By applying the concept of recontextualisation work as an analytical perspective, we shed light on the efforts of nurses when mobilising complementary information about patients in order to recontextualise the otherwise decontextualised data, thereby giving data practical value in clinical decision-making. Recontextualisation work, we show, is shaped by organisational structure, available resources, and nurses' professional capacity. Drawing analytical attention to the work of recontextualisation allows for a nuanced understanding of the efforts required to make data workable and hence what it takes to carry out clinical decisions in today's datafied healthcare system.

Tracking towards care: Relational affordances of self-tracking in gym culture

In the past few years, self-tracking technologies have been celebrated for the possibilities they offer to 'optimize' fitness and wellbeing, yet also criticized for being rigid and isolating. In this article, we identify complex tracking arrangements that consist of a variety of data and multiple modalities of tracking emplaced within arrangements of actors and objects (digital/analog tracking devices and data output). We inquire into how these arrangements afford care. Based on our ethnographic research of gym culture in Denmark, we find that individuals make the technologies 'work' for them in ways that shield them from bodily or emotional distress. Fitness practitioners combine digital tracking technologies with analog methods and enrol other human actors in recording, interpreting, questioning and tinkering with their data; in other words, they perform data work in ways that mend or prevent ruptures and brokenness and thus afford 'care'. We highlight the role of the personal trainer, who often complements or salvages the outputs of digital technologies. We argue that tracking has the capacity to afford care and wellness when it is emplaced within socialities and when actors are able to exercise their capacities and knowledge in ways that mitigate the data outputs.

Tensions in Representing Behavioral Data in an Electronic Health Record

Taking an action research approach, we engaged in fieldwork with school-based behavioral health care teams to: observe record keeping practices, design and deploy a prototype system addressing key challenges, and reflect on its use. We describe the challenges of capturing behavioral data using both paper and electronic records. Creating records of behaviors requires direct observation, and as a result the record keeping responsibility is challenging to distribute across a care team. Behavioral data on paper must be transferred and prepared for reporting, both inside the organization and to stakeholders outside of the organization. In prototyping a computerized working record, we targeted user needs for capturing details of a behavioral incident in the moment. Challenges persisted through the transition from paper to our prototype, and based on these empirical findings over two years of fieldwork, we present five tensions in representing behavioral data in an electronic health record. These tensions reflect the differences between entering behavioral data into the record for intraorganizational use versus interorganizational use.

Constraints in Clinical Cardiology and Personalized Medicine: Interrelated Concepts in Clinical Cardiology

Systems biology is established as an integrative computational analysis methodology with practical and theoretical applications in clinical cardiology. The integration of genetic and molecular components of a disease produces interacting networks, modules and phenotypes with clinical applications in complex cardiovascular entities. With the holistic principle of systems biology, some of the features of complexity and natural progression of cardiac diseases are approached and explained. Two important interrelated holistic concepts of systems biology are described; the emerging field of personalized medicine and the constraint-based thinking with downward causation. Constraints in cardiovascular diseases embrace three scientific fields related to clinical cardiology: biological and medical constraints; constraints due to limitations of current technology; and constraints of general resources for better medical coverage. Systems healthcare and personalized medicine are connected to the related scientific fields of: ethics and legal status; data integration; taxonomic revisions; policy decisions; and organization of human genomic data.