Journal of Risk and Governance ISSN: 1939-5922

Volume 2, Number 1 2011 Nova Science Publishers, Inc.

FROM TALK TO TEXT:

ON ANEW COMPUTER SYSTEM, DISCHARGE
PLANNING AND INSTRUMENTALISM

Roar Stokken1,2 and Felicia Gabrielsson-Jrhult3

1
Regional Patient Education Resource Centre in Mid-Norway,
Mre and Romsdal Hospital Trust, Volda Hospital, 6100 Volda.
2
Department of Industrial Economics and Technology Management,
Norwegian University of Science and Technology, Trondheim, Norway
3
Coordinator at Institute of Gereontology, School of Health Sciences,
Jnkping University, Jnkping, Sweden

ABSTRACT
Because computer systems containing patient information provide the opportunity to
take actions affecting a patient who is absent, these systems move beyond simple
archiving devices. The article investigates how the expansive nature of these systems can
influence care as practiced. The case chosen is discharge planning.We do this from a
collaborative perspective as developed by Science and Technology Studies. To analyze
the system within a framework capable of seeing discharge planning as one process, we
understand it as negotiation between diverse parties within a governance framework.Our
material has been acquired at three hospitals and their surrounding municipalities in
Southern-Sweden. Multi-disciplinary and cross organizational focus group interviews
were conducted prior to and post introduction of the computer system. Findings were
related and adjusted to 27 individual cases.From our investigation, we suggest that the
computer system made professionals mostly occupied with care as a planning process,
rather than care as practice. This shifts the focus in the direction of doing discharge
planning, rather than facilitating good care. A computer system replaces talk with text. In
this case, it moves the focus away from the patient and onto services delivered. Leaving
the daily life behind, strengthening the system. Thus, while discharge planning is
supposed to be an interactive and communicative process, the system insures that it is
not, and as governance process it tends to be limited. Over-reliance on patient
management systems encourages a type of patient care based upon a top-down model
rather than a joint project between those involved. This might pose a threat to both patient
safety and the knowledge base that planning is based upon.

E-mail: roarstokken@me.com
46 Roar Stokken and Felicia Gabrielsson-Jrhult

INTRODUCTION
Our point of departure is an e-mail sent to one of the authors. In this, a patient with
prostate cancer reflects upon being present but still absent in the hospitals computer system:

Just thinking about how at the moment I am floating around on some electronic lists.
Unseen by human beings.As a symbol without any meaning other than being a prostate
cancer.Just one more.One of many. Something one has no feelings for. A statistic. At the
moment I am not a human being but a symbol of an illness. A symbol of a job task that
someone has to be responsible for when the time is right. [] Now it is people I have
never met who meet me on lists and easily transfer me from here to there as it suits them.
Perhaps this is the way it has to be. It has to be effective and there is a production line to
follow and systems for that sort of thing. But it feels strange not being able to follow your
own journey through the system.

This reflection caught our interest because of the wide adaption of computer systems in
modern health care services. To investigate the background of and consequences for people
who meet patients on lists and easily transfer them from here to there, we studied the
introduction of a computer system supposed to facilitate continuous care through
standardization of discharge planning. The system is Meddix, an Internet based system for
exchange and storage of patient information. We investigated the implementation at three
hospitals and their surrounding municipalities in Southern-Sweden.
In particular, we focussed on how traits of technology shape the care provided by giving
caregivers the opportunity to act towards the information in the computer system and not the
patient. We argue that by combining theoretical and empirical approaches, our conclusions
reach beyond the originating context, and speak directly to the challenges experienced when
introducing computer systems. Challenges that not will vanish with time as the system
becomes more familiar and routines are established but rather represent a holistic shift in
the way the patient-carer relationship is structured.

BACKGROUND
In Sweden, discharge planning is legally regulated. The process starts when the hospital
doctor considers a patient ready to leave hospital although she is in need of further care. This
leads to an assessment of the patients community care requirements.
The discharge planning process involves an assessment of medical, psychological,
economic, and social needs, and should aim at the patients total well-being. From this
process should arise agreements concerning patient care, the coordination of services, the
need for support and rehabilitation and the allocation of resources. Still, the most obvious
element of the process is a discharge meeting where health professionals meet the patient,
often together with family members.
Discharge planning concern care. This is a concept that is possible to approach and
assess from various angles and levels. In this case, we do not attempt to evaluate the actual
practice or service delivered, but, rather, to examine the communicative processes that
determine what practices or services should be delivered to the patient after discharge.
 From Talk to Text 47

Due to the changing conditions of life, care must always be re-evaluated in light of the
patients improvements and set-backs, and a care team has to attend to new twists, turns,
problems, frictions and complications (Mol, 2008). This means that quality of care often is
about discretion and the tacit dimension (Polanyi, 1967) rather than the systemized and
explicit. If we follow the logic of Nss (2004), this means that provided help, that is
operationalized needs can be quality assured and managed, while care cannot due to ever-
changing conditions, tacitness and need for discretion.
Despite the challenges, conveying discharge planning in an efficient manner has become
increasingly important recently, due to rising demands for efficiency in health care, both
within primary and secondary care. This entail that patients now are being discharged more
rapidly than before, leaving primary care with complex medical cases; and less time to handle
them (Birmingham, 1993; Coffey, 2006; Dunnionand Kelly, 2005; Tierney andCloss, 1993).
Meddix is designed to convey continuous care between hospital, primary care and
community care. The goal is increased patient safety in general and information safety in
particular.The system replaces telefax, phone calls and ordinary mail, which were judged to
be inefficient, time-consuming and obstructive to continuous care, with one single, integrated
system.
The actual content of the system concerns medical and occupational status, various needs
including those of rehabilitation, distribution of medicine, need for nursing, and contact
information. The information is characterized by consisting of practicalities from the
perspective of health care and social services. Patients and families have no access to the
system, and receive no information from it. Central users of the system are discharge
planners, district nurses, occupational therapists and nurses at hospital. Other professions like
doctors and physiotherapists also contribute information, but tend to do this through proxies
rather than by themselves.
The introduction of Meddix throughout Sweden in 2005 was meant to both increase
efficiency and quality, and making information exchange safer. Meddix is supposed to do this
by providing information to involved actors and by consolidating information for
administrative purposes. The latter is important due to unit pricing of care.
Since Meddix is supposed to support discharge planning, the system aims to bridge the
gap between what Glouberman and Mintzberg (GloubermanandMintzberg, 2001) define as
the world of public control, the world of acute care and the world of community care.
Regarding discharge planning, public control concerns social workers in their role as
discharge planners, acute care mainly concerns nurses at hospitals, and community care is
first and foremost represented by district nurses and district occupational therapists. Bridging
the gaps between these is demanding due to different sets of activities, different ways of
organizing, and unreconciled mindsets. The gaps are, according to Mintzberg and
Glouberman (MintzbergandGlouberman, 2001) the main managerial challenge within the
health care of today.
Systems like Meddix, storing information about patients in terms of patient records, have
been introduced in various settings and formats during the latest decades. While
implementation among general practitioners tends to be rather smooth and promising,
implementation at the hospital level tends to be more complicated; due to hospitals being
more complicated organizations than those within general practice. This makes both
coordination of use and implementation harder (EllingsenandMonteiro, 2003; Lium, Tjora,
andFaxvaag, 2008; TjoraandScambler, 2008). Because of this, there is reason to believe that
48 Roar Stokken and Felicia Gabrielsson-Jrhult

implementation of Meddixbecomes even harder, because the system is taxed with bridging
the gap between the worlds of public control, acute care and community care. In order to
analyze the implementation of Meddix within a framework capable of seeing the three worlds
as one, we understand discharge planning as negotiation of care-as-practiced within a
governance framework.
In literature, the term governance is used in a variety of ways, but there is baseline
agreement that it refers to blurred boundaries within public sector and between sectors and
their surroundings. While government refer to formal institutional structures and authoritative
decision-making like ministries, agencies, municipalities and counties; governance is about
organisations working together in partnership. We understand discharge planning across the
three worlds of Glouberman and Mintzberg (GloubermanandMintzberg, 2001) as this kind of
partnership, and continuous care as the governance project. Our theoretical foundation
(Amdam, 2009; Friedmann, 1992; Habermas, 1984) denotes that partnership between the
three worlds is understood as joint effort to empower each other. The goal is to take on tasks
in a better way through the communicative action that negotiation of care is. Before we look
closer at how Meddix influences discharge planning in practice, we ought to elaborate upon
Meddix as technology.

DIGITAL REPRESENTATIONS
Computer systems like Meddix are more than information sources. By providing
opportunity to act towards the patient even thought the patient herself might be absent, these
systems contain digital representations of the patients (Tjora, 2004). This provides health
professionals with the opportunity to act independently of the patient, through acting towards
an object that represents the patient. Not all objects exist in Euclidian space, even though we
can act towards them.
Objects can be stuff and things, and ideas, stories and memories, as well as those things
that have both physical and cultural aspects, like tools, artefacts and techniques. Some objects
are even solely abstract entities that only exist in the world of ideas, like democracy and the
object idea itself. Of special interest in the forthcoming text is the difference between the
real patient and the patient that is stored in Meddix. This is what our patient in the
introduction speaks of when he says: Now it is people I have never met who meet me on lists
and easily transfer me from here to there as it suits them. Our patient here refers to the
possibility of acting towards him without him being present at the site of action.He accepts
that it has to be that way, although it feels strange.
In terms of Habermas (Habermas, 1997), legitimacy is obtained through accordance
between system and lifeworld. Lifeworld is our public and private spheres that cannot be
known; it is our background and our horizon. As such, it is the framework within which
culture; social integration and personality are produced and sustained. Consequently, it cannot
be questioned as a whole, although elements can be communicated and scrutinized and
ultimately stored in computer systems as objects.
Those objects stored within Meddix belong to the system, and must thereby be in
accordance with the lifeworld to be legitimate. This denotes that to obtain legitimacy, they
must be regarded as representing the world in a truthful way through accordance with the
lifeworld. Those judging this accordance are health professionals (See (Stokken, 2009) for
 From Talk to Text 49

elaboration of health professionals lifeworldly presence within health care). As long as only
health professionals use the system, it is only the lifeworld of health professionals with which
Meddixmust correspond.
To understand how Meddix influences discharge planning, we turn to theories from
Science and Technology Studies (STS), an interdisciplinary research area concerned with
how scientific research and technological innovation affect society, politics, and culture. This
technology-in-practice perspective is unlike the perspective of those occupied with either
technological determinism that interprets technology as a force too strong to influence upon,
or social essentialism interpreting technology as a passive device (Timmermansand Berg,
2003).
Within STS, both humans and technology are understood as actors with agency that
shapes human action by promoting or impeding certain ways of acting. Madeleine Akrich
(1992) compares this agency with the way a film-script defines the framework within which
the actors operate.
Meddix is an object that shapes action by being of various natures and by being
understood in various ways. Law and Singleton (2005) argue that objects can keep their shape
in four different ways: By acting as volumes, as stable network configurations, as gentle
relational reorderings, and as patterns of absent presences. They label these four ways
volume, network, fluid and fire, and states that one object can render itself in more than one
of these ways.
Of special interest in the forthcoming analysis is how Meddix itself, and the information
stored therein poses challenges to quality of care. We therefore investigate how the computer
system influences the division of power and labour by acting as volumes, network, fluid and
fire objects.

VOLUME OBJECTS
A volume object is something present in Euclidian space, and hence something you can
throw at someone, put in your pocket or give a hug.
When volumes are shared as in the model above, interaction between person A and
person B concerning an object O could be understood in a naturalistic or behaviouristic sense,
where the A and B share O as a physical object, and that is all there is to it. An example
illustrating this way of sharing objects could be two nurses (A and B) working in tandem to
move a patient (O) from bed to wheelchair, or it could be a nurse (A) working in tandem with
a patient (B) to switch from bed to wheelchair (O).
It is important to observe that Meddix, and the information stored therein, are shared in a
much more complex way than in this example.

A O B

Figure 1.Shared Volume Object.

50 Roar Stokken and Felicia Gabrielsson-Jrhult

NETWORK OBJECTS
A network object manifest relations between actors and is a representation that can be
moved around. The term was worked up by Latour(1987)as a tool for thinking about the work
that goes into moving scientific facts around. Latour call these stabile and movable objects
Immutable mobiles. These are produced by inscription in one way or another. A map is a
perfect example. It is mobile while the actual land is not. The same goes for patient records.
The record is mobile independent upon the patient. A subtler example is the vessels of the
British Empire. These held the empire together as they moved from Lisbon to Calicut and
back again. As volumes, they included hulls, sails, winds, sailors, etc. But because they are
also inscriptions of the empire, the vessels also helped maintain British hegemony.

A AO O BO B

Figure 2. Shared Network Object.

In this model, A and B still share an object O, but there are two different contexts. This
diversity can, for example, be rendered by diverse locations, roles and/or professional
backgrounds. These two ways of understanding object O are in the model labelled AO and BO.
Hence, we have one single object and two diverse contexts/cognitive representations. An
example could be an oncologist, a radiologist and a surgeon working together on the same
patient at diverse times to diagnose cancer.
It could make sense to understand patient records in this way. Still we argue that to fully
understand the consequences of computer systems like Meddix, we ought to apply a more
intricate understanding of what is shared. We therefore now turn to fluid and fire objects.

FLUID OBJECTS
A fluid object is an unstable object that lack clear-cut boundaries in an ontological sense.
It is like fluids, it changes shape, and is absorbed in other objects (De LaetandMol, 2000).
These objects are of concern as actors. (O being shaped in same way as the two human actors
in the model illustrates this.) This perspective is in addition to Science and Technology
Studies (i.e. Bijkerand Law, 1992; Latour, 1987, 2005; Star andGriesemer, 1989), for instance
to be found inSituated Learning (i.e. Hutchins, 1995; Lave and Wenger, 1991)and Activity
theory (i.e. Engestrm, 1987).

A AO OA O OB BO B

Figure 3. Shared Fluid Object.

 From Talk to Text 51

A fluid object is shaped differently depending on who is using it. Hence, there is not only
a situational/cognitive representation of O connected to the persons. There is also a social
property connected to the object, dependent upon the actors utilizing it. Star and Griesemer
(1989) have developed one of the most influential contributions to understanding interaction
this way. Here fluid/plastic objects shared between diverse social worlds are
labelledboundary objects. Scholars in various fields have embraced the term, due to its view
of objects as enablers of negotiations and transactions between diverse social worlds.
The key feature of a boundary object is its ability to facilitate communication by being
plastic and thereby reducing complexity of what communicated. This is done in various ways.
Star distinguishes between four different kinds of boundary objects: Repositories, idealtypes,
coincidentboundaries, and standardizedforms (Star, 1989; Star andGriesemer, 1989). The
common denominator is that such objects have diverse meaning to diverse actors.
Being understood as diverse makes boundary objects feasible when it comes to
facilitating connection of work in diverse social worlds. But it is also a disadvantage when it
comes to stabilization (Fujimara, 1992), for boundary objects support heterogeneity, and are
therefore not enablers in homogenization and stabilization processes. This is because they
carry their own context that actors in diverse social worlds can relate to, allowing for neglect
of the context at the other side of the boundary in favour of the context provided by the
boundary object.
In the following text, the fluidity of objects and how they support heterogeneity is
important in explaining the role of Meddix and the information stored therein.

FIRE OBJECTS
A fire object is an object that manifests itself differently in a multiple ontological sense
by being either in one or in another way. Fire objects manifest themselves differently, and are
not merely understood differently. This is what our patient is speaking of when he writes:
Now it is people I have never met who meet me on lists and easily transfer me from here to
there as it suits them. For it is obvious that it is not the patient made of flesh and blood that is
moved. This view is elaborated by for instance De Laet (De LaetandMol, 2000), Annemarie
Mol (2002) and Law and Singleton (2005). Their focus upon practices makes objects come
in to being and disappear through the practices in which they are manipulated.

A AO OA

OB BO B

Figure 4. Shared Fire Object.

Hence in the model, OA and OB are different entities in different practices that make up
the totality of O as object. This denotes that what is shared is not a single, but a multiple
object where the diversity within might be huge and the combined appearance messy.
52 Roar Stokken and Felicia Gabrielsson-Jrhult

Typically, the messiness induced by this kind of objects is understood as a matter of different
perspectives. In Body multiple (Mol, 2002: p 5), Annemarie Mol argues differently,
recommending the difference is to be understood ontologically. This means that difference is
no longer a matter of different perspectives of a single object but the enactment of different
objects in different sets of relations, contexts and practices.
Mols example is atherosclerosis, and in a clever way she demonstrates how this disease
is different to patient, general practitioner, and diverse groups at the hospital, not only
understood differently. It is these diverse representations that are atherosclerosis as whole.
Heldal (2008) also demonstrates how different health professionals tend not only to view
diseases differently, but also produce the disease through representations that may or may
not be complementary. He shows that radiologists and cytologists produced different
measurements and understandings of the same anticipated cancer lump dependent upon
knowledge and tools utilized.
With these four different ways that objects manifest themselves, we are ready to head on
to Meddix and how the system shape care in four diverse ways dependent upon what kind of
object it enacts.

METHOD
This study is part of a research project conducted at three hospitals in Southern-Sweden
and their surrounding municipalities. The main material is multi-disciplinary and cross-
organizational focus group interviews (n=6) carried out in 2005-06 and making up a total of 9
hours. Interviews were conducted prior to and approximately 6 months after Meddix was
introduced. Approximately 50% of participants (total n=46) participated in both pre- and post
implementation interviews. Focus group interviews were taped and transcribed. At one
hospital, focus group interviews were broadened with eight individual interviews making up a
total of 5 hours.
Data was analyzed in a theoretically informed inductive approach inspired by grounded
theory (Glaser and Strauss, 1967). To increase reliability and assure validity, findings were
related to and adjusted by a body of individual discharge planning investigations (N=27).
This body is made up of video- or tape recorded discharge meetings, individual interviews
(27 older patients, 25 family members and 19 professionals), medical and social records and
other documents related to the cases as well as national regulations describing discharge
planning, local routines etc. 23 cases were conducted prior to and four cases after introduction
of Meddix.
The theoretical framework discussed earlier guided the analysis. The study was approved
by the Ethics Committee at the Faculty of Health Sciences, Linkping University, Sweden
(Dnr M87-05). Written consent was obtained from participants who decided whether the
researcher could videotape, audiotape or merely participate as observer and notetaker during
meeting. In most cases, the participants were informed at the medical ward one day ahead of
discharge meeting, allowing time for consideration. If relatives rejected to participate, patients
were excluded from study. Health care professionals involved as informants received both
oral and written information.
 From Talk to Text 53

MEDDIXAS VOLUME OBJECT

A volume object is present in Euclidian space, and hence something you can throw at
someone, put in your pocket or give a hug. Even though Meddix is software and not present
in Euclidian space in a strict sense, it renders itself just as real to users as the chair they sit on.
When we investigate Meddix in this way, we attune ourselves to how the system shapes
practice by being an infrastructure diverse from those it replaced -archives, faxes, phone calls
and postal mail. Relating to the model of shared volume objects, we map Meddix as
infrastructure into O and think of A and B as respectively a discharge planner and a district
nurse.

A O B

Figure 5.Shared Volume Object.

The usability of Meddix is in general considered to be good and information safety is

now judged to be good enough; this was not the case before. Still, some challenges remain.
One example is that users argue that Meddix is more time consuming and less effective than
expected:
We had not thought that it could possibly take more time than it had taken earlier.It took
time to sort faxes and other documents but this has taken even more.
As with all systems, knowledge is a limiting factor. Concerning Meddix, this is
particularly a challenge due to the relatively high turnover among the patient care
coordinators. High turn-over combined with the fact that Meddix was designed for specialists
and thus has no user guidance or security check, makes system knowledge an especially
vulnerable area.One user puts it:

Actually, I believe that the computer should ask questions like are you sure? [] after
all we are only human and not superhuman, you know.

At care facilities where Superman is not on staff, users can create problems in the system
that lead to difficulties of many kinds when attempted implemented. Further, even though
Meddix is supposed to convey the discharge process, processes also take place in parallel-
systems, for example by phone. This denotes that the system does not reflect reality. This is a
problem since Meddix is programmed for conveying discharge planning, and not simply
being an infrastructure for information transfer. This creates extra work for discharge
planners, since they ought to act as quality assurance personnel:

One must have eagle eyes and ensure that a discharge document really has been written.If
this hasnt been done, the patient is still technically admitted.And if he is in another
department, the system locks up.

The lack of participation from staff in wards is common, and even district nurses tend to
be more absent than appreciated in the process. Also, participation from physicians
54 Roar Stokken and Felicia Gabrielsson-Jrhult

initiating the discharge planning process is said to be very limited. This lack of involvement
from diverse actors contrasts with the ideal of discharge planning asa rather complicated,
dynamic and iterative process that normally should involve many and diverse actors at
various stages. This was also the case prior to introduction of Meddix, but the introduction of
the system has made it even easier to act on limited knowledge.
Still, the most striking change that has taken place is replacement of talk with text. Prior
to the introduction of Meddix, actors spoke, and things could be communicated informally.
This is harder now, and while communication prior to Meddix was between peers, it now is to
a stronger degree between humans and a computer system. The absence of the principle
actors is the norm, and ways are now found to conduct processes without beneficial
knowledge that is rendered unavailable.
Caregivers have simultaneously too little information of the kind usually gleaned from
person to person interaction and too much of the written one. One informant expressed
satisfaction with Meddix like this:

Information is at hand. We never had access to see and read like this before. [...] So far, I
think it is better forus.

New routines and more bureaucratization allows the carer to act independent of human
interaction. Routines now compensate for the lack of participation. These routines are of
different kinds and natures, but they focus upon text. One example is expressed by a
discharge planner:

We will attempt to have all the nurses write short notes, to make it easy, so that we know
which professions should be a part of the planning [] then we could perhaps call the
secretary and tell them when we are coming.Everyone would win if we worked in such a
way.

There is reason to believe that challenges induced by Meddix as infrastructure might

diminish over time as these textual routines become more deeply established. Hence,
understood as volume object, Meddix do its task quite well, and practice seems to have
gained from the introduction.

MEDDIX AS NETWORK OBJECT

A network object manifest relations between actors and is a representation that can be
moved around. When Meddix is understood in this way, we look at how the information
shared via the infrastructure shapes thoughts.

A AO O BO B

Figure 6. Shared Network Object.

 From Talk to Text 55

In this model, O is information stored in Meddix, and Meddix as volume object is now
found as the lines connecting O to its surroundings. A and B still are discharge planner and
a district nurse. AO and BO are cognitive representations that reflect differences between how
discharge planner (A) and a district nurse (B) understand Meddix (O). Here, challenges are
induced through the way information within Meddix is produced and maintained.
Discharge planners rely on negative feedback from their surroundings. If they do not get
any feedback, they assume that their job is done satisfactorily. When asked explicitly about
feedback practices, they are convinced that feedback from unsuccessful events would be
provided through existing meeting places:

We receive a lot of feedback when we attend discharge planner meetings from other
discharge planners whether there have been many mishaps or none.There are not many
mishaps.

From our knowledge of organizational structure and practices, we doubt that knowledge
of mishaps in general are conveyed to the patient care coordinators responsible. Another
problem concerning knowledge of care as practiced is that discharge planners, by relying
upon negative feedback, do not get any feedback when things go well. A third problem is that
routines for receiving and handling written feedback is lacking hence also the total benefit
might be questioned:

I think that there are benefits to knowing what is going on with patients.At the same time,
it means more work.If you receive reports, they ought to be properly archived [] and
what is the total benefit?

Another problem is that the aim of discharge planning, which is to provide care that is
good enough. This is aggregated by job segmentation in combination with the limited time
available to the carer and a narrow time horizon. An informant states that due to this, she does
not feel that she needs to know how the planning turned out in practice:

I make judgements based upon what I know now.And these decisions are good for 14
days.One must simply believe that one makes the best plans for the patient.

Further, users are only allowed to access the records of patients they are currently in
charge of. When planning is done, they are no longer in charge of the patient. Thus checking
how something went becomes a violation of rules and not a practice the organization can
endorse. In actuality, the demand for information safety has therefore turned into information
secrecy concerning the care provided, making it hard to acquire information. It is like one of
the planners put it:

It is hard to know who I should ask and who I should seek out to ensure that things
continue to go well

As network object, Meddixfulfil its role less well than as volume object. Crucial to this is
the low level of integration between parties. It could be argued that over time, common
interpretive practice will be developed. But we argue differently because nothing in the
56 Roar Stokken and Felicia Gabrielsson-Jrhult

system allows carers to examine the outcome of the care once the plans have been set into
practice.

In principle, I forget Greta when I leave the gates; she is forgotten.Because when I come
back, there are five new ones waiting for me.

MEDDIX AS FLUID OBJECT

A fluid object is an unstable object that lack clear-cut boundaries in an ontological sense.
It is like fluids; it changes shape, and is absorbed in other objects. When Meddix is
understood in this way, we can sense how the boundary nature of Meddix shapes information
and the use of it.

A AO OA O OB BO B

Figure 7. Shared Fluid Object.

This model is similar to the one concerning network object - exempt the middle part
where the sum of information is to be found in O while OA and OB is the social properties
connected to A and B that shape the rendering of O. It is this shaping we look into here,
wherein boundary objects are important entities.
Use of boundary objects serves to reduce complexity and integration. This is
demonstrated by how tasks are defined and kept apart at the boundary between the worlds of
public control, acute care and community care where Meddix act as a repository. These are
built to deal with problems of heterogeneity by being possible to utilize differently dependent
upon context. While discharge planners within the world of public control first and foremost
appreciate Meddix as a means to increase economic control, staff within the world of acute
care see it as a way to remove bed-blockers, while the district nurses within the world of
community care respond to Meddix as a way to acquire knowledge of patients for whom they
will care.
This diversity between agendas in combination with boundary objects reduces the need
for integration. Another aspect is that the discharge planners should not be superintendants.
Community care acts towards patients, and discharge planners ought to trust those working
there:

I believe that you must simply trust that others do their work.

Not only is Meddix a boundary object, but the information stored within it is also one.
This information is stored in standardized forms. These are mutually understood and
standardized methods of communication that facilitate distributed collaborative work by
providing standards that can be communicated between diverse social worlds. The downside
is that when a complex reality is put into standardized forms, uncertainties concerning how to
fill in the form vanish, since a very limited part of the reality is communicated. The
 From Talk to Text 57

consequence is that both Meddix and the information stored therein, is both shaped differently
and understood differently depending upon actors.

MEDDIX AS FIRE OBJECT

A fire object is an object that manifests itself differently in ontological sense; by being
either in one way or in another. When Meddix is understood this way, we can perceive how
Meddix shapes the patient. This is what our patient in the introduction refers to as: floating
around on some electronic lists [where] people I never have met [] easily transfer me from
here to there as it suits them.

A AO OA

OB BO B

Figure 8. Shared Fire Object.

When we understand Meddix as fire object, O is the patient and the connecting lines (i.e.
the one between AO and OA) the information stored in Meddix. This alters the model
completely, for then we put the discharge planning process, as conveyed by Meddix, as A and
a district nurse as B. B could also be any other care personnel, the patient herself or a family
member of the patient. Then AO is how the process understands the person as patient and OA
how it renders the person within Meddix. Correspondently BO is how the district nurse
understands the person as patient, and OB how he renders the person as patient when
providing care.
It is obvious that accordance between OA and OB would be preferable. But as we have
seen, the information provided by Meddix is of various quality, and the patient of flesh and
blood might even be somewhere else than the patient within the system. This means acting
towards the patient within the system poses risks.We can see the risks in the following
sequence of actual events:

According to Meddix, the patient had been admitted, but luckily the district nurse had not
checked Meddix and simply had gone home to the patient, and the patient was there.And
possibly needed insulin or something [] If the district nurse had been attentive and
checked Meddix, she would have been told that the patient was admitted to hospital.Then
she would not have gone to the patients home.

Even though the system does not reflect reality, another informant expressed that she
thought information and discharge management was better coordinated and easier to organize
due to the use of Meddix. This could pose risks since provision of incorrect knowledge could
give health professionals a sense of coping with a situation beyond control. Some times this
58 Roar Stokken and Felicia Gabrielsson-Jrhult

becomes evident enough to be seen, like in the citation below, but we argue that the same also
happens without the actors seeing it due to limited contact with care as practiced.

Every now and then, one thinks that one operates from very thin information.It has been
my hope that we could perhaps go deeper and read more about the planning process.A bit
more about discussions so we could put some meat on the bones.

The most important effect of Meddix is that more actors can relate to patients without
meeting them as persons. In this way, the introduction of Meddix has made the lack of actor
participation a less visible problem since the system provides information concerning the case
independent of collaboration. But since the information is thin, patient care coordinators using
Meddix rather than patient consultation decouples the multiple ontologies that normally
should make up the patient. The result is one patient of flesh and blood and one patient in the
system; where the latter is the one relevant to the patient care coordinators conducting
discharge planning. This leaves the discharge planning process with two diverse objects
instead of one object that is multiple in ontological sense.

DISCUSSION
The introduction of Meddix throughout Sweden in 2005 intended to both increase
efficiency and quality of discharge planning, and make exchange of information safer. In
plain words this means that the implementers wanted to enhance quality by making the
process more coordinated and transparent.
As infrastructure and volume object, Meddix works quite well. The introduction
increased information safety and standardized the discharge planning process. Still, some
challenges remain. Meddix is more time consuming than expected and since knowledge of the
system among users is a limiting factor, we found the system posing challenges of different
kinds in practice. Still this kind of challenges might become less important over time, when
competence among users increase, better routines are established and/or high turnover among
planners is reduced.
Still, the most important change brought by Meddix as volume object is the replacement
of talk with text. Text is free from human actors, their time and their location. This is
positive in that information can be provided when it suits the contributor. Prior to
introduction, however, partakers in the planning process talked more with one another, giving
more room for both richer and more informal communication, and hence better knowledge of
both patient and one another.
The downside of textual communication is that the discharge planning process becomes
reliant upon sparse knowledge of patient, those providing care, and the environment for the
provision. We further observe that these challenges aggregate at organizational level, causing
Meddix toconceal the lack of involvement from actors rather than encouraging the actors to
take part. This happens due to the reduced complexity of information exchanged and a
reduced scope for negotiation between acute and community care concerning whether a
patient is suited for discharge or not.
As source of knowledge and network object, Meddix also conceals challenges. Beyond
their own organizations, discharge planners rely on negative feedback. This is a problem
 From Talk to Text 59

when the information exchanged now is sparser and there now is less integration between
parties. This creates the opportunity for divergent readings of the information available.
Another problem is that discharge planners do not get feedback when things go exceptionally
well. This quality is reinforced by routines that make written feedback a challenge to handle.
Further, legislation is a challenge to experiential learning due to privacy concerns. All in all,
this means that the concept of care tends to vanish in favour of the concept of discharge
planning.
As fluid object that shapes information, Meddix also poses challenges. The utilization of
boundary objects and the boundary nature of discharge planning reduce both complexity and
integration between actors. Not only is Meddix a boundary object, so is also the information
stored therein. The challenge is that when a complex reality is put into standardized forms,
local uncertainties are deleted, and a very limited part of the reality is communicated. The
consequence is that both Meddix and the information stored therein, is shaped very different
dependent upon the actors point of departure.
As fire object and contributor to the patients multiple ontology, Meddix does not work
well. Of special concern is the possibility of the system providing incorrect information,
allowing for the patient to be in another condition or location from that given by the system.
The result is one patient of flesh and blood and one patient in the system; where the latter is
the one relevant to the patient care coordinators conducting discharge planning. When the
system allows for acting towards patients without attuning to them as persons, this leaves
health care and social services with two diverse patients instead of one patient and a
reflection of her.
To health care as delivery, this is very problematic since decoupling between these two
patients conceals problems more than solves them. One example that can illustrate this point
iswhat happens in evaluation meetings where managers rely on information from Meddix.At
these meetings Meddix is used to assess how money is spent on care; those spending less
money are the ones doing the best job within the world of public control. Without feedback
from care as practiced, problematic consequences the way money is spent might be neglected.
It is therefore important that information of a more informal nature still is communicated
by other means, such as by phone. On the other hand, this contradicts with the idea of Meddix
as conveyor of the process. Hence to take advantage of parallel systems, the goal of Meddix
might have to be redefined from conveying the process to reflecting it.

CONCLUSION
Computer systems like Meddix replace talk with text. This has many facets, but one of
the most important is a move away from the patient and her life to services and goals
originating from the system. This poses challenges to care as practiced, since the only
lifeworld that the system ought to be judged against to achieve legitimacy is the one of health
workers.
Another aspect contributing to alienation of patients is Meddix distancing the patient
from the process as a result of bureaucratization and internal quality assurance procedures.
This entails a less informed patient who is, therefore, undemanding, unempowered and
potentially at risk.
60 Roar Stokken and Felicia Gabrielsson-Jrhult

The most intriguing effect of Meddix therefore might be moving processes away from
patients and families. This contradicts the underlying idea of empowering patients as active
collaborators in modern health care and of discharge planning as an interactive
and communicative process.
We conclude that implementation of Meddix has made discharge planning more of a top-
down initiative from the world of public control rather than a joint project between
those involved. This might pose a threat to both patient safety and the knowledge base upon
which discharge planningoperates.This development poses risks by concealing what going on
rather than promoting transparency.

ACKNOWLEDGMENT
First of all, a debt of gratitude goes to our informants, who have generously shared their
lifeworld and knowledge. Thanks are also owed to those who have read the text and passed
on their comments mostly as a lifeworldly gift. A special gratitude goes to FrodeHeldal that
through many and fruitful discussions have given major contributions to the theoretical part.
Another gratitude goes to Annemarie Mol for a small but significant contribution by
answering: Remember: even object categories is objects of diverse nature when asked
whether she thought that the categorization was apt. Finally we want to thank Central Norway
Regional Health Authority and the Institute for Gerontology, School of Health Sciences at
Jnkping University for financing. At the latter institution a special gratitude goes to Stig
Berg and Bo Malmberg for providing support not only through medias coined in the system,
but also through medias coined in the lifeworld.

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