Placing HISP in Context

1. Placing HISP in Context A relational look at meaning generation in a health information system Mark Thompson Geoff Walsham

2. Meaning is relational

3. Structure of talk • HISP in Cape Town • Context: (re)introducing Blackler’s 5 categories of knowledge • Contextual analysis: a useful practical approach?

4. Political computing - a ‘new deal’ • Decentralisation • Vertical and horizontal data flows support local empowerment • Standard MS Office software across application layers • Open source distribution • Participative prototyping • Geared to local capture, validation, and use

5. Data collection & use Indicators, procedures & datasets: International IS National Inf. Systems Community District Provincial Information Systems Province District Information Systems National International Community Information Systems

6. Is HIS Working? • DoH endorsement; Phase 2 rollout, national & international • Positive feedback from nationwide HIS users • First minimum health dataset on African continent

7. HISP: Ongoing problems • HISs collect only clinical information, often out of context • Data sometimes captured/interpreted by inappropriate people • Meaning often lost as data becomes progressively abstracted from original context • Data collection forms and software support only explicit, ‘representational’ knowledge forms

8. Revisiting Blackler • Knowing as mediated, situated, provisional, pragmatic, and contested • Context as embrained, embodied, encultured, embedded and encoded • Blackler ‘replaces’ quantitative categories with qualitative attributes - but need both...

9. Why is this useful? • Growing recognition of limitations of representationalist conceptions of ‘knowledge’ • Increasing interest in ‘relational’ approaches focusing on process (e.g. activity theory) BUT • Limited focus on low-level sensemaking within any particular schema

10. Contextual analysis • Examine interrelationships between various elements of context, within a schema • Do they appear to support one another? • Suited to iterative IS development approaches, and to ‘fine tuning’ existing IS

11. Unpacking HIS schemas:1

12. HIS Totalled RMR Weekly Total 1 Weekly Total 2 Weekly Total 3 Weekly Total 4 Tally Sheets TB STDs Maternal Trauma THC PAM Pharmacist Other HIV Child Mental “Community” Unpacking HIS schemas:2 Clinic Environ

13. Meaning is relational

14. Example 1: Child Health • Do practitioners have ‘embodied’ evaluative skills (hunch) so vital to effective diagnosis? • How do overlapping ‘encultured’ schemas relationally complement one another, affecting final ‘encoded’ data? • Are ‘embedded’ routines (forms, RMR, software) optimised to support ‘embodied’, ‘encultured’, and ‘encoded’ aspects of schema? • Are ‘encoded’ data categories sensitive enough to address ‘embodied’, experience-based hunches? Do they address ‘encultured’ social expectations?

15. Example 2: Entering RMR data • Numeracy/ ‘embrained’ aptitude? • Access to practitioner in order to activate ‘hunch’, embodied judgements re questionable figures? • Do final figures accurately reflect relational contribution of overlapping ‘encultured’ schemas, or over-focus on, say, clinical? • Are forms of ‘embedded’ software best aligned to elicit this judgement? • Is ‘encoded’ data being used in a relational manner to generate meaning? Meaning loss attendant on progressive abstraction of ‘encoded’ data from other forms of context?

16. Contextual analysis for HISs:1 Benefits: • Generates vital questions that relate to issues deeply embedded in catchment area, both clinical & non-clinical • Retains focus on accuracy, fairness and usefulness of selected indicators • Allows ‘calibration’ of a HIS to its organisational & social context & hence its usefulness to users • Introduces ethical emphasis on ‘truth value’, significance and meaning • Heavily practical & suited to field use

17. Contextual analysis for HISs: 2 Issues: • Low-level, granular approach is resource-heavy & potentially expensive • Limitations on ability of analyst to identify appropriate relational balance • May raise issues of a political nature which prove difficult to resolve

18. Practice-based approaches: theoretical questions Current theories of practice are: • not especially good at approaching issues of power • heavily schema-oriented, with a danger of reverting to an equilibrium model • inadequate in theorising ‘between-schema’ co-ordination by biographical individuals …a role for contextual analysis in addressing this?

19. Perhaps… • Practice-based conceptions of experience are phenomenal • Therefore comprise both shared & non-shared context • As vital components to meaning, interrelationships between all contextual types deserve detailed attention • ‘Contextual analysis’ may represent a practicable way of achieving this