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Inscription, prescription, sanction : les " entre-faire " d'une norme dans le processus d'informatisation du dossier de soin

Abstract : Inscription, instruction, sanction: The 'in-between' doing of a norm in the process of medical record computerization In this communication, we focus on the practical and agency of the norm rather than on the institutional dimensions by which it is usually studied. In doing so, we propose to question the norm's specificities that makes it a source of what Latour (1994, 2000) names the 'making-do' [le faire-faire]. As such, the norm is both the object of people's agency - what they act upon - and an agent that makes people act - what they deal with. The term of 'making-do' suggested by Latour underlines this dialectic dimension of agency. Following Souriau, we propose therefore to explore the 'in-between' of the doing of a norm, identifying the way it acts and the way people act under and possibly upon the norm.This communication is issued from a collective research program between two research teams, namely CERTOP - ECORSE in Toulouse, and ComSanté, in Montréal. The norm under study was enacted by the French National Healthcare Authority (Haute Autorité de Santé, hereafter HAS). This norm is nowadays the basis for the certification of French healthcare establishments, whose activities depend on this agreement. This communication is based on a longitudinal long-term case study, engaged in 2008, in a French hospital (and more specifically wards dedicated to oncology), involved in the process of computerization of medical records. Our observations began six months before the first implementation, that took place step by step, wards after wards, during nearly a year, with a follow up since then. For this paper, we will focus on an in-depth interview with a head nurse involved in the project team. This hour-and-a-half filmed interview has as main subject the evolution of clinical records, from the previous paper records and related practices to the current electronic ones, with demonstration and specific focus on main transformations all along the overall process of computerization. This process considered as a whole took place during more than ten years.Based on a discourse analysis, we have chosen to follow up the manifestation of one of the HAS' norms, that is the medico-legal reporting. With the computerization of medical records, the norm and its enactment have gained a renewed materiality that gives rise to an improved agency. To question this evolution, we rely on the notion of inscription as developed firstly in Science and Technology Studies, and mobilized thereafter in Organizational Studies (Akrich, 1992; Joerges & Czarniawska, 1998; Latour, 1993; Verbeek, 2006, Taylor & Van Every, 2000, 2011). We will focus more precisely on the forms of textualization of the norm that take place in the electronic medical records. The notion of inscription is useful here for analyzing the way the norm is textualized (or even more, in this case, instrumentalized) in the electronic medical records; this focus highlights the writing practices (who writes, when, where, how) involved in the medical record computerization as well as the authoring issues that the HAS' norm puts forward.The norm as textualized in/by the toolThe HAS advice specified in its certification handbook and followed up by the experts in charge of auditing provided the main arguments for medical record computerization. These arguments refer to an 'ideal' way of producing information, with great emphasis on a single registration of information, and on the continuity and control of data flows. According to this, the paperless wards and the computerization extended to the totality of the activities was seen as guarantying a good information treatment (Harper & al., 1997; Sellen & al., 2001). The medicolegal norm is put forward to legitimate the computerization, with a related argument concerning the potential legalization of the patient-practitioner relationship. A law published in France on March 2002 has strengthened the possibility for the patients to get access to their medical record. The patient is thus one of the quoted figures to legitimate the implementation of the electronic tool. The underlined quality of the tool is its capacity of strictly registering who wrote a specific information, who is the author and therefore the responsible for the medical act; so doing, the tool enables to decide who accounts for and who is accountable for.Because of the renewed materiality of the norm, of its inscription in the form of the computerized medical record, the norm's agency appears to be less visible, it seems more neutral, its origin is decontextualized, its authority is blurred. The apparently main agent is neither the norm nor the accreditation process, it is a supposed-to-be-neutral entity - that is to say, the technology - that is meant to treat the information efficiently and insure the accurate follow up of the patients. The enrolled norm is formally detached from its author; it is hidden behind the computerization process.Meanwhile, this norm gives form to the tool, setting up the framework of the dedicated software and databases, designed and operationalized according to the legal definition of employee territories and of tracking requirements. The related objective of the tool deals with being able to account for responsibilities through inscriptions. The incorporated norm prescribes the territories of agencies, their relations, and the people who are held responsible. So doing, it renews a traditional and legal hierarchy according to which the physicians are the writing masters.Writing practices and authoring issuesIn the hospital we studied, the computerization process is seen as an opportunity for the staff and the project team to select the authorized practices, to sustain the 'best' ones, and to bring back each employee to his/her authorized professional territory. Physicians are legally the exclusive authors of medical decisions. When implementing electronic medical records, the project team took this opportunity to specify who is authorized to write according to the type of documents and information that is required for the patient's follow-up. This writing practice in the electronic medical record strongly links an author/authority and a domain of information. Access codes and parameters play as filters to reallocate the roles and authorized practices to employees according to legal texts and registered protocols.In so doing, the link is strengthened between the norm, responsibility and potential sanction. The equipped norm helps specifying the practiced territories and related authorities. It aims at countering the inscriptions that were previously crossing the barriers, setting up forms of inter-relation and translation. Such translations and relations are set up to facilitate cure and care practices through the reconstruction of patient stories. However, part of these practices was infringing the legal rules. With the electronic tool, such practices are not possible anymore. This is more specifically the case of an element of the paper medical record that has been excluded from the electronic version.Conclusion: From authoring traces to de-authored texts... a broken promise of the power of the norm?The computerization of medical record has been stated as a guarantee against gaps between legal authority and daily practices. It was supposed to supply a continuous tracking of activities in the case of potential sanction through identifying responsibilities.It was supposed to be a magic and powerful tool, capable to tell who does what, where and when. However, effective practices partly escape from this close-meshed net. The problem the tool was supposed to solve reoccurs somewhere else. Moreover, the main issue deals with sense making, with the meaning of the global text and its accuracy for care and cure.The produced text is made of a diversity of locally registered and signed writings. Taken as a whole, it can be seen as a de-authoredtext (Taylor & Van Every, 2011), the product of a collective writing (Callon, 2002), where authoring/authority is distributed and sometimes blurred in the mechanics of the computerization process. In the electronic tool design, a great concern as been devoted in identifying the local inscriptions and their authors. Yet the question of the overall sense making of the patient stories stays unanswered, as well as the plots discussed during the passing on (Boudes & al., 2005; Browning, 1992). With the focus dedicated to reallocating each employee in the limits of his legal territory, it seems that there is no possibility left to related stories, discussed plots, and translations. These plots and related stories give way to new forms of writing, which are non-authorized ones; they are also shared in conversations. Therefore, they escape from the tool and weaken the tracing project, the very reason for equipping the norm through a supposed to be omnipotent tool.
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  • HAL Id : hal-00835843, version 2

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Anne Mayère, Consuelo Vásquez, Isabelle Bazet, Angélique Roux. Inscription, prescription, sanction : les " entre-faire " d'une norme dans le processus d'informatisation du dossier de soin. Communiquer dans un monde de normes. L'information et la communication dans les enjeux contemporains de la " mondialisation "., Mar 2012, France. pp.147. ⟨hal-00835843v2⟩

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