Production-Contextual Clinical Information

摘要

There is a widespread health informatics vision of unlimited exchange, understanding and reuse of clinical information. However, it has also been pointed out that to understand clinical information it is to some extent necessary to know the circumstances of its production - the production-contextual clinical information. The purpose of this study was to investigate the nature and significance of production-contextual clinical information in doctors' everyday clinical work in order to asses whether standardization is necessary and possible. The study was performed through observation and focus group interviews at a cardiology department in a midsize Danish hospital. It was found that production-contextual clinical information is complex, extensive, non-quantitative, and that it has an elusive structure. It is concluded that while it may be possible to standardise a limited amount of production-contextual clinical information, a general standardisation may very well be impossible.