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

Meaning is relational

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

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

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

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

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

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...

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

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

Unpacking HIS schemas:1

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

Meaning is relational

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?

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?

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

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

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?

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