How organizations learn to cross technologies boundaries: prototype tacit knowledge

alth care systems are generally understood as organizations whose aim is to deliver a particular service to citizens and patients. This definition proposes a sharp distinction: organizations provide service, patients receive it. We challenge this view proposing a conceptual framework that considers patients as `opaque` and temporary members of the health care system, working (in an unaccounted fashion) for it. This framework emerged as the result of an ongoing project of design of a new technology, Personal Health Record (PHR). A PHR is an “electronic application through which individual can access, manage and share their health information” (AA. VV, 2004). a substitute of existing paper records kept at home. In the rhetoric `information technology society` the PHR is a step towards a more integrated world. There is not a single list of what a PHR should do, but it`s agreed that it must be repository of personal informations (allergies, list of medications, tests) and a part of doctor-patient relation allowing doctors to retrieve data from it (e.g., disease history) and to write notes or prescriptions on it. In a broader perspective, PHR is seen as a patient-centered information hub, allowing on line access to health care system (e.g., lab tests results). Our research considers the PHR as a `technology of accountability` (Suchman et al., 2002), an artifact aimed at building mutually intelligible path of actions between health care systems and patients. In this perspective the PHR is seen as a part of a complex socio-technical system (Berg, 1999) which comprises physicians` work practices, patients` archiving strategies (Moen and Flatley Brennan, 2005), hardware and software, laws and regulations (e.g., privacy), to give a short list. At the same time we consider PHR as a space of a critical transition where different organizations confront themselves as network with different practices and different meanings (Mol and Law 1994). So as a boundaries object PHR offer the opportunity to observe how organization learn from individuals and viceversa in order to understand which kind of potential conflict are latent. As sociologists embedded in a ICT research unit, our specific task has been (and still is) to reflect on the implications of a shift from paper to digital information for patients, doctor and health care system in order to provide information to help building prototypes. As prototypes are yet to be built we have focus on the existing paper records. In this first phase we`ve decided to focus on patients, considering them as our point of access to the health care system and specifically 1. how people collect their medical data (semi-structured interviews); 2. how people manage their (paper) medical information at home, looking for existing strategies to be considered as guidelines in the PHR design (semi-structured interviews, ethnography); 3. the paper records as artifacts-in-use in the building of a shared account between patients and doctors (semi-structured interviews, shadowing), 4. how meaning change their pertinence and relevance when across the boundaries (observations on interactions); The research has brought to the fore the efforts patients have to make in order to interact with doctors. Sometimes relevant medical data is kept by institutions that require a lot of paperwork, doctors use different information systems that do not allow data exchange, storing information in the household and retrieving it before a visit is a time-consuming activity: yet, all these actions are not considered `work`. Without these activities, though, the care could not be given as the health care system relies on them to perform their task. We propose then to consider patient as an unaccounted `health care system worker` whose task is to allow the system`s flexibility, providing some work needed to function. The opaqueness of these work appears to be one of its constitutive features. In this respect we could aspect the PHR t...