flash ethnography: observations of a doctor’s use of mobile tech with a patient

I took my grandma to the doctors for her annual today. The doctor that we have been with for the last 5 years moved to another office. So today we had a new doctor. I gave the new doctor a brief overview of the last 5 years of my grandma’s medical history. Our new doctor was wonderful, personable, and attentive.

During the entire updating process, the doctor was primarily talking to me because I was translating and I have been the primary overseer of my grandma’s health for the last few years.

I noticed that she was carrying around a new netbook. She was typing my notes in the netbook while constantly referring back to my grandmother’s file that contained her entire medical history being various doctors.

I noticed that the entire time we talked, it was very hard for her to have any direct interaction with my grandma. Her back was faced towards her as the netbook was placed on a stationary built in counter. As she typed the notes, she looked at me and then would periodically turn her entire body around 360 around to smile at my grandma and then immediately turn back to her netbook.

When we were done with the exam, I chatted with the doctor for a few minutes about the netbooks. She said that the office was trialing these netbooks out and had rented them for 6 months. She seemed ambivalent about the netbook, as if it was forced upon her. She said,

“Well I can take it with me everywhere and look up notes on each patient, but the file of the patient’s history still isn’t on the laptop so we still have to pull up files and deal with a lot of papework. It just feels like another thing to carry around and keep track of.”

When I asked her how it affected her interaction with her patients, she said that this was her primary reason for not liking these laptops. She showed me that using the netbook meant that she had to spend more time with her back towards her patients. I asked her if she had tried sitting down and putting it in her lap so that she could face the patient, but she said that was also inconvenient because of all patient history paper file. She then want on to explain that she preferred the stationary big screen desktops on carts at her old office because it was on a table that could face the patient or be moved around within the room.

Post observation thoughts?

spatial layout of material objects matters
I think a big fix in the problem would be the way rooms are designed. Spatial layout of an office/room matters for the introduction of a new technology. Therefore, the reception and usage of a new technology, such as this netbook, will vary across different offices. And it’s cool to think about how even minute furniture and room layouts can make a difference.
In this instance, the only place for the doctor to place her netbook in such way that her physical paper files could also be accessed meant that her face-to-face time with her patient was compromised. Imagine if there was an extra cart in this room with a big computer screen and each doctor could plug in their own netbooks. Or imagine if all the stationary computers in each were networked so doctors didn’t have to keep track of their netbooks. This was a such a great learning moment for me in terms of witnessing how the consideration of spatial layout is especially salient for conducting comparisons in technology usage for a new tool across communities.
This reminds me of the time I spent working in the projects of the South Bronx. I had noticed that the layout of a small apartment that housed 4-8 people would’ve made it impossible for a student to use a desktop computer with broadband the same way as a student in larger apartment or home of middle-high income families.

the extent of digitization of info matters
the mobility of laptops were useful for accessing only recent notes because most of the files had yet to be scanned into computers. For all the promises that mobile tools deliver to professionals in service industries, it’s difficult to take full advantage of these tools when the entire information base of an organization has yet to be digitized. As the doctor had explained, she still had to rely on physical paper files for the patient history. The netbook was only useful for accessing recent visits. I wonder what she would’ve thought about the laptop if ALL patient histories was on it. Would she have sat down and put the netbook in her lap so that she could have more time with the patient?

human connection matters
decreased face-to-face time was the primary issue for the doctor. This was such a great example of when a technology appears to offer more mobility may work to compromise other forms of interactions that may be more valued in a certain social setting.

Mobility as a feature is neutral
There is a lot of excitement across HCI and CSCW for studies on mobilites and how digital tools can complement a more mobile lifestyle. Aside from my observation that most of these studies are on elite Western (usually Anglo) travelers or mobile workers and tend to undervalue informal economy workers who rely just as much on mobility - I think this is such an exciting area of research that has pushed me to bring the concept of mobility closer to lived practices of mobilities.
That being said, I think that it should not be considered a priori that mobility is a “good” or “desired” aspect of X. In the case of the doctor’s office, having a mobile laptop seemed to be novel technology that the doctor was obligated to carry around. Of course it was not an ideal office with patient history files still on paper format and badly designed patient rooms - but that is just the point. Rarely are technologies introduced into ideal or perfect settings. So it’s good to think more critically about the role of mobility for a specified audience and what mobility means to them. In this case, increased mobility of note taking and accessing for doctors compromised personal connections with their patients.

One of the ways I thought about this in the past was trying to think about the other end of mobile cellphones as mobility saviours - so what groups wouldn’t want to be as mobile - what situations would mobility as an option not be valued?

What came to my mind?
• cheating spouses who don’t want to be located
• paraplegics
• people who hate cellphones

yah ok this is a totally lame list - I couldn’t really come up with any other groups because I think my problem is that I live too much in a paradigm where mobility is valued and an absolute! I am one of those working professionals who travels a lot and would stop breathing if I didn’t have my cellphone or my laptop on a work day.

ok so here’s some things questions in conclusion:
• How do new technologies affect work flows?
• How do new technologies affect client/patient interaction?
• What are the compromises that are made for a more mobile lifestyle/interaction?
• How does spatial placement of objects affect technology usage?

Useful Links
• Microsoft Research on Health and Wellbing
Ethnography and Healthcare
• Multi-tasking in practice: Coordinated activities in the computer supported doctor–patient consultation. International Journal of Medical Informatics, Volume 74, Issue 6, Pages 425-436. M.Gibson, K.Jenkings, R.Wilson, I.Purves
• Clinician style and examination room computers: a video ethnography. W Ventres, R Marlin, N Vuckovic, V Stewart - Fam Med, 2005 - stfm.org.
• Mapping the integration of social and ethical issues in health technology assessment.
Lehoux P, Williams-Jones B. Int J Technol Assess Health Care. 2007 Winter;23(1):9-16.
• Making a Case in Medical Work: Implications for the Electronic Medical Record. M Hartswood, R Procter, M Rouncefield, R … - Computer Supported Cooperative Work, 2003 - portal.acm.org