Journal of Biomedical Informatics 38 (2005) 26–33
www.elsevier.com/locate/yjbin
Artifacts and collaborative work in healthcare: methodological,
theoretical, and technological implications of the tangible
Yan Xiao*
University of Maryland School of Medicine, 685 W. Baltimore St., MSTF 534, Baltimore, MD 21201, USA
Received 8 October 2004
Available online 30 November 2004
Abstract
Although modeled as knowledge work with emphasis on data flow and decision making, healthcare is delivered in the context of
a highly structured physical environment, with much effort and emphasis placed on physical and spatial arrangement and re-arrangement of workers, patients, and materials. The tangible aspects of highly collaborative healthcare work have profound implications for research and development of information and communication technology (ICT) despite the tendency to model work as
flow of abstract data items. This article reviews field studies in healthcare and other domains on the role of artifacts in collaborative
work and draws implications in three areas: methodological, theoretical, and technological. In regard to methodologies, assessment
of new ICT and development of user requirements should take into account how artifacts are used and exploited to facilitate collaborative work. In regard to theories, the framework of distributed cognition provides a starting point for modeling the contribution and exploitation of physical artifacts in supporting collaborative work. In regard to technology, design and deployment of new
technology should support the functions provided by physical artifacts replaced or disrupted by new technology, and profitable
ways for new technology to support collaborative work by embedding ICT into existing infrastructure of physical artifacts.
Ó 2004 Elsevier Inc. All rights reserved.
Keywords: Artifacts; Computer-supported cooperative work; Distributed cognition
1. Introduction
During the past 20 years, the explosion of information and communication technology (ICT) has changed
dramatically how we work together. ICT creates new
opportunities for collaborative work and is a strong
driving force in reshaping collaborative work. Increasingly, human collaborative activities are mediated by
tools with computing and telecommunication capabilities. Research has been carried out to understand collaborative work in response to the need for optimal design
of ICT to support it. Research results have painted a
complicated picture of collaborative work, both supported and unsupported by ICT [1–3].
*
Correspoding author. Fax: +1 410 706 2550.
E-mail address: [email protected].
1532-0464/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.jbi.2004.11.004
Healthcare has two characteristics that make deployment of ICT challenging as well as potentially highly
beneficial. First, healthcare is a prime example of collaborative work. In hospitals, multiple people provide care
to each patient and bring to bear their expertise and efforts. As pointed out by Bion and Heffner [4], care is
increasingly delivered by highly specialized personnel,
with frequent hand-offs. As conceptualized by Strauss
et al. [5], ‘‘articulation work’’ is necessary to integrate
and coordinate the contributions from individuals over
the course of a patientÕs stay in a hospital. Second, in
contrast to many industrial settings, healthcare work is
often non-routine, so it is difficult to pre-schedule events
and activities. Exceptions, emergencies, and other contingencies are frequent enough to be an obstacle for
standardization of work processes. These two characteristics lead to dependencies on intense information
Y. Xiao / Journal of Biomedical Informatics 38 (2005) 26–33
processing and communication activities to achieve
coordination and lend justification for wide deployment
of ICT to coordinate work. However, introduction of
large-scale ICT has met with resistance and failures
[6,7]. Studies of large-scale ICT, such as computerized
physician order entry systems, have produced insight
into failure factors, such as the mismatch between actual
and assumed information flows in medication processes
[8]. Recently, arguments have been made to incorporate
ideas from the field of computer-supported cooperative
work (CSCW) into health informatics [9]. CSCW has
produced methodologies and conceptual frameworks
for understanding healthcare work that is increasingly
supported by ICT and for designing successful ICT systems. Particularly, the field of CSCW has brought into
focus the importance of studying work activities in their
natural context [10].
This paper reviews a body of literature that highlights
the important role of physical objects in supporting collaborative work. The nuances of work including physical
aspects of a work environment are often unaccounted for
in quantitative studies and work process mapping. Studies of interactions with the physical environment in collaborative work can provide insights into how people
work together [11]. As demonstrated by studies on ways
in which physical and perceptual properties of work
environments are exploited [12–15], much can be learned
about the roles of the tangible. Insights gained in such
studies can guide design of collaborative tools. For
example, paper-based forms perform functions more
than simply conveying information [16]. Ignoring other
functions may have detrimental effects when paper forms
are replaced with computerized forms [17].
Healthcare is delivered in the context of a resource-intensive, physical environment, which is often deliberately
and extensively structured to facilitate collaborative
work. Based on reviews of studies in mostly non-healthcare domains, we wish to draw implications of the
tangible in three areas: methodological, theoretical, and
technological. In particular, with more uses of ICT in
healthcare, cliniciansÕ information space is increasingly
digital and virtual. Bridging the digital with the tangible
may be a driving force for new technology.
2. Collaborative work supported by the tangible
Office automation and the concept of ‘‘paperless office’’ were driven by the advances of desktop computing
[18], although the importance of materiality of coordinative artifacts has been recognized as more and more
office work is automated [19]. In contrast to desktop
computing and office work, healthcare delivery is carried
out in a richer physical environment, which one can
adapt, change, and share. Work objects, such as medication, supplies, laboratory samples, and patients, are
27
physical. A growing body of literature has identified various ways in which the tangible, or physical, aspects of
the workplace can support collaboration.
2.1. Artifacts as mediators of collective work
To illustrate how artifacts are used to support collaborative work, we use the example by Boguslaw and Porter [20] about the ‘‘spindle wheel’’ in the short-order
restaurant industry. The spindle wheel has a number
of hooks on which order checks can be placed. As a simple artifact, it makes the coordination between the waitresses and the cook less effortful and more reliable:
[The wheel] first of all acts as a memory for the cook; he
does not have to remember orders, the wheel does it for
him. The wheel also acts as a buffer drum. The input
rate and output rate need no longer be one-to-one.
Ten waitresses may come to the wheel almost simultaneously, but the cook takes the orders one by one.
The wheel also acts as a double queuing device. Waitresses no longer need to stand in line to put in their
orders; the wheel stands in line for them. Moreover,
the wheel does not get the orders mixed up, but keeps
them in proper queue sequence. Finally, the wheel also
serves as a display of all the information in the system
at a given time. The cooks, by having random access
to the information, are enabled to organize their work
around larger work units, such as the simultaneous
preparation of three or four similar orders. The fact that
the order is recorded on a check, equally available to
waitress and cook to check back upon when an error
has been made, permits feedback and the consequent
elimination of habitual errors (p. 393).
This example and the analysis by Boguslaw and Porter
demonstrate how a physical artifact facilitates the articulation of divided labor and reduces the need for explicit
articulation efforts. In various forms, workers in healthcare ‘‘invented’’ a number of physical artifacts for the
purpose of coordination, from a trivial example of in/
out boxes to a more elaborate example of magnet whiteboards found in many if not most hospitals.
A recent analysis of collaborative work in emergency
response dispatch centers revealed similar beneficial efforts of the tangible, including a large computerized wall
map [21]. In particular, in comparison with desktop
computer systems, physical artifacts afford the economy
of efforts in mediating individual activities and are thus
preferable by workers. Multiple people can easily integrate their contribution through the use of physical artifacts and the shared workspace. When interacting with
physical objects, oneÕs focal attention is visible to coworkers, which is often not the case when work objects
are elements on a desktop computer display.
Air traffic controllersÕ physical paper data strips,
known as ‘‘flight strips,’’ are another example of how
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Y. Xiao / Journal of Biomedical Informatics 38 (2005) 26–33
physical objects facilitate collaboration and why computerized solutions are resisted by users in high-risk settings [22–24]. Flight strips are used to manage air traffic,
primarily as a way to record vital information about a
flight. Because flight strips are in a physical paper form,
controllers can annotate them and handle them physically, such as rearranging how strips relate to each
other. Flights deserving special attention are sometimes
represented by misaligning certain flight strips. A number of benefits of paper flight strips were discovered
[24], which were thought to contribute to the safety of
managing air traffic and may explain air traffic controllersÕ resistance to computerized information systems.
For example, the physical activities associated with handling flight strips provide visual cues to neighboring
controllers. Even in control centers where computerized
systems were installed, Mackay [24] found that various
paper artifacts were used. She concluded that ‘‘attempts
to radically change work practices that have successfully
evolved over the past 50 years will almost certainly fail
to account for all the embedded, intangible safety factors and are likely to result in dangerous, perhaps fatal,
situations’’ (p. 337).
In a study on workflow technology used in print
shops [25], an important distinction was made on
whether workflow technology is internal or external to
work objects. In typical office work, the objects of work
are often files on computers on which workflow technology resides (internal). In the print shops described by
Bowers et al. [25], a litho-machine and heterogeneous
computerized printing machines were not connected to
workflow technology (external). Consequently, smooth
flow of work was achieved through direct observations
of physical work objects (e.g., noise patterns from machines and paper stocks remaining) without the benefit
of workflow technology. In fact, Bowers and associates
found that work flow technology disrupted smooth flow
of work by imposition of inefficient procedures.
In healthcare, collaborative work is usually mediated
through physical objects not linked to any computer systems. For example, one person may lay out ampules of
medication on a drug cart to support anticipated use by
another, as during preparation for anesthesia induction.
The drug cart is part of the shared workspace between
the two workers. The number and types of ampules prepared are communicated by direct access to the shared
workspace. No separate communication is needed. As
another example, one crew (nurses) may set up an operating room for another crew (surgeons). The physical
work environment (operating room) thus becomes a
medium for mediating activities of different workers.
2.2. Close physical proximity and implicit communication
When people work in close physical proximity, such
as pilots in airplane cockpits, non-verbal communica-
tions may become vital and efficient ways of exchanging
information. Segal [13] observed that pilots use direct visual access to check the status of the tasks carried out by
the other pilot. His findings demonstrate the importance
of information implicitly exchanged in a face-to-face setting. For example, a redesign was considered that would
disrupt pilotsÕ direct visual access to each otherÕs activities, although explicit communication (voice) was supported. Such redesign would increase explicit
communication workload and make coordination more
difficult.
Heath et al. [26] observed that a small group in close
physical proximity made use of peripheral monitoring
to maintain an awareness of othersÕ work status. Such
monitoring could, for example, allow one to detect the
‘‘boundary’’ of othersÕ activities so that necessary interruptions could be made with the least detrimental effects.
Coordination was simplified due to the fact that everyone
in the group was aware of each otherÕs activities. Bellotti
and Bly [27] found that the members on a design team
took advantage of being co-located by walking to colleaguesÕ workstations. They concluded that co-presence
and mutual awareness provided opportunity for implicit
communication, whereas current technology tends to
support only explicit communication.
2.3. Public displays
An important class of mediating artifacts is respresented by the public display boards found in many workplaces. These boards are used to represent task, material,
personnel, and scheduling and status information. Public
displays provide awareness information about staff, patients, and resources in a hospital environment. Fig. 1
is an example of a ‘‘grease’’ board on which information
about new patient admissions to a trauma center is written after receiving calls from prehospital care providers.
Historically, the board was an economical way of broadcasting time-sensitive information, but people must come
to the board to see the information. Some public display
boards have been replaced by individual computer terminals. Presumably the goal of communicating to a large
audience is now achieved through individual access.
Studies of public display boards have demonstrated
the importance of shared access in collaborative work.
For example, in emergency resource centers, several
types of public displays are used to indicate status information and facilitate discussions (e.g., a flip chart)
among many people [28]. Similarly, in a news editorial
office [29], web pages are printed out and placed on a
large wall surface to facilitate collaborative efforts in
reviewing and editing web page content. In a train control rooms, the wall display of train track status not only
supports individual controllersÕ information needs but
also enables the controllers to refer to and discuss the
information [30]. In evaluating a computerized patient
Y. Xiao / Journal of Biomedical Informatics 38 (2005) 26–33
29
Fig. 1. Use of the ‘‘Doe Board,’’ a display board in a trauma resuscitation unit, which ‘‘stores’’ and ‘‘displays’’ incoming trauma patients for the
purpose of coordination.
scheduling system, Bardram [17] found that users maintained a whiteboard to re-represent the information in
the computer system so that it was publicly shared and
manipulated.
Public displays, as opposed to private displays, support synchronous communication among collaborating
workers in face-to-face settings. Previously cited studies
in emergency resource centers [28], editorial offices [29],
and train control rooms [30] all demonstrated the role of
public displays in supporting group discussions. Other
roles of public displays have been noted in previous
studies. When public displays can store information
for later access, one can essentially communicate across
time [31], although shared use of such asynchronous
capabilities has not been emphasized. Getting everyone
‘‘on the same page’’ is another role of public displays.
Bellotti and Rogers [29], for example, noticed that the
public display of assignments provides a way for individuals or teams to visualize current team activities
and resource availability, so that everyone knows what
everyone else knows about resource status.
In our own research, the use of a large ‘‘communal’’
display (the magnetic whiteboard shown in Fig. 2) in
managing a six-room trauma operating suite was studied [32]. The display is located in a convenient gathering
point, yet access is restricted to staff. The public nature
of the board encourages communal management of
activities in the operating rooms, with workers voluntarily updating the whiteboard with information to which
they have easy or special access, such as staffing schedules or surgery progress [33]. Negotiations and joint
assessment of situations are supported by manipulating
and referencing objects on the whiteboard.
2.4. Customization and tailoring of the work environment
Physical objects often afford flexible configuration
and tailoring, perhaps due to the ease with which phys-
ical objects can be rearranged and new objects introduced. In the study described earlier on a whiteboard
used in operating room management [32], staff members
on a continual basis adapt and invent uses of physical
objects placed on the whiteboard. They also exploit different arrangements of objects to convey changes in status (often subtle) in response to the changing
environment, such as staffing shortages or patient volume increases.
A field study at a Stockholm underground control
room [34] uncovered how the same technological artifacts are being used by operators in different ways during day- and night-shift operations. A comparison
between the shifts revealed that the available computer
support systems were not flexible enough to capture
the different operational needs. Idiosyncratic customizations, undertaken by the operators, and their adaptations of the provided systems made it possible to
organize work in such a way as to properly address
the dynamic nature of tasks.
The amount of effort devoted to customization and
tailoring workplaces is best represented by surgical operations, where an extensive amount of preparatory work
is carried out. Hazelhurst et al. [35], through an ethnographic study, examined how the physical layout of
instruments and tools as well as nursesÕ ‘‘cheat sheets’’
and other memory aids are used as cognitive artifacts.
They discovered that the interaction with the tangible
was maintained through formal and informal practices.
Through these practices, the customization and tailoring
work was carried out to dynamically achieve a balance
between planning as preparation to follow a specified
path to an intended outcome and planning as preparation for unanticipated circumstances and events. In surgery, it is essential to have the right tools for the job in
the right place at the right time in order to achieve desired outcomes, even in the face of unforeseen circumstances and events.
30
Y. Xiao / Journal of Biomedical Informatics 38 (2005) 26–33
Fig. 2. Public whiteboard for managing operating rooms at a trauma
center.
Reorganizing work and tailoring work environments
are often needed in healthcare owing to the variability of
patient conditions and the demand for autonomy by
care providers. The studies reviewed here indicate a preference by workers for tangible objects in complex, dynamic environments, perhaps because of a perceived
ease in working with physical objects and of a perceived
simplicity of physical objects.
3. Methodological and theoretical implications
ICT, because of its roots in computation and desktop
document processing, has contributed to the tendency to
model work processes in terms of abstract data elements. Along with the flow of the tangible in work processes is the flow of information, which relies
increasingly on ICT as opposed to paper. Healthcare
workers are interacting more frequently with virtual objects in the digital world. However, the tangible nature
of health care delivery creates a challenge in bridging
the gap between the tangible and the virtual. Based on
the studies reviewed here, I will first draw implications
in methodologies and theories in understanding the
challenge. In the subsequent section, I will draw implications related to technological development in meeting
the challenge.
Ethnographic methodologies have been used in the
field of CSCW to reveal how work is actually carried
out, through a combination of direct observation, interviews, and detailed analysis of audiovideo records. In
the case of healthcare work, much can be learned about
the mediating functions of physical artifacts in articulating individual activities. Ethnographic studies often uncover flexible, multiple methods or processes used in
response to contingencies and contextual factors
[12,25]. In particular, the division of labor is often flexible, as work organization could be made easily, in part
mediated by the physical environment. For example, the
study of a print shop showed that line-of-sight access to
other workers and the noise from machines allow workers to help each other [25].
The grounded theory approach [36] is a qualitative
research methodology that emphasizes the iterative nature of discovery, especially in the study of complex human activities with rich social context. The essence of
the grounded theory approach is generative as opposed
to confirmative. Because of this nature, it is applicable
to studies of phenomena that are not yet well defined.
The grounded theory approach, as outlined by Strauss
and Corbin [36], provides procedural guidance to qualitative analytic methodologies. The procedure is driven
by general research questions as opposed to specific
well-defined questions.
Several theoretical frameworks are relevant in understanding the key roles of the physical aspects of a workplace. One framework is distributed cognition, and the
other is display-based cognition.
The term ‘‘distributed cognition’’ is used to describe
the nature of problem solving when information processing is distributed in the environment (external representation) and in the problem solverÕs head (internal
representation). Distributed cognition emphasizes the
integral role of external representations and the collaborative nature in human cognition [37,38]. This approach
stresses the importance of including representational
artifacts in the study of human behavior. Onboard a naval vessel, Hutchins [12] observed that artifacts such as
maps, rulers, and pointers functioned as external reference pointers for intra-crew communications and as
markers of intermediate knowledge. The collaborative
nature in healthcare provides a strong incentive to study
in detail how work is organized across different workers
through the use of artifacts. Instead of viewing information processing as activities carried out only inside oneÕs
head, we should examine how information processing
occurs in a system of workers and their work environment, including representation and manipulation afforded by the physical characteristics of the work
environment. ICT can be considered as components of
the system, as opposed to a separate system. Workers
will tailor ICT so that it fits into the work environment.
For example, schedules stored by ICT are frequently
printed so they can be posted where access is needed,
such as near telephones. As another example, clinicians
often use printed lists of patients under their care to
write notes and reminders. Such activities represent
methods of bridging the digital world and the physical
worlds. The distributed cognition framework provides
a guide for us to examine the cognitive contribution of
physical objects.
A related approach in modelling the contribution of
the tangible to human cognitive activities is displaybased cognition. Larkin [39] commented that ‘‘problem
Y. Xiao / Journal of Biomedical Informatics 38 (2005) 26–33
solving is often done in the context of an external display. Often there are the physical objects that are part
of a problem situation. Alternatively the solver may
construct equations and diagrams as an aid to solving
the problem’’ (p. 319). By having external representation, humans can solve problems by leveraging perceptual capabilities. Larkin noted several features of such
‘‘display-based’’ problem solving: (1) the process is easy,
(2) it is largely error free, (3) it is not degraded by interruption, (4) the steps are performed in a variety of orders, and (5) the process is easily modified. The
contribution of external representation was verified in
an experimental effort [37]. Zhang and Norman [37]
summarized how external representation helps problem
solving: (1) external representations can provide memory aids and (2) external representations can provide directly perceivable information (such as constraints and
options).
One could argue that the contribution of the tangible
to collaborative work is more significant than that to
individual work. The importance of being aware of
activities of others in a collaborative environment is easily understood, yet how such awareness is achieved is
not [9,40]. As healthcare becomes more fragmented,
resulting in more hand-offs, achieving awareness is even
more critical for patient safety and efficiency. The tangible aspects of a workplace are exploited by workers to
achieve awareness, as shown in the previous selected review of studies. In our own work, the concept of joint
display-based cognition was proposed to denote how
the physical aspects of a workplace serve as an integral
part of cognitive functions, keeping co-workers informed of events, activities, and status [32].
4. Technological implications
Recent advances in ICT have the potential to blur the
boundary between the tangible and the digital information world [41]. The integration of networked devices
with physical workplaces has provided new exciting
directions for supporting collaborative work in healthcare [42]. For example, widely used whiteboards may
be driven, in part, by networked computers, as in the
case of the eWhiteboard for coordinating activities in
a cardiac catheterization laboratory [43]. With ICT,
information on a whiteboard can be captured and then
displayed at a remote location [44]. Networked information can be embedded onto physical surfaces, such as
through projecting computer images [45]. Sensor technology such as radio frequency identification (RFID)
has the potential to connect the tangible to the digital.
These exciting developments bode especially well for
healthcare in terms of leveraging the advantages of
ICT. Collaborative work is usually mediated by physical
objects, and failures of ICT are not well tolerated. In the
31
air traffic control domain reviewed above, experimental
systems were developed to take advantage of paper
flight strips. One system used closed circuit television
with cameras aimed at flight strips to provide distributed
access to them [22]. Through the system, air traffic controllers can maintain an awareness of neighboring traffic
regions by peripherally monitoring the strips of other
controllers, even when they are not side by side. Another
system was based on the concept of ‘‘augmented reality’’
[46] and on the assumption that computing technology
does not exclude the use of paper-based artifacts. Physical flight strips were connected with computer data
through sensors and projected images.
Described as the next generation of user interfaces,
tangible interaction [47–49] promises another way to
bridge the gap between the physical and the digital
worlds. A large and growing body of research has focused on physical-world modalities of interaction, largely built upon research themes related to ubiquitous
computing, augmented reality, mixed reality, and wearable computing. The technical capabilities of using physical artifacts as representations and controls for digital
information have been demonstrated repeatedly in the
development of tangible user interfaces [49].
5. Conclusions
Healthcare delivery is full of examples of the articulation of individual activities. This articulation is often
mediated by the physical environment containing work
objects such that work flow is smooth and explicit
coordination efforts are minimal. The physical environment also mediates information flow to maintain
awareness of other peopleÕs activities and general status
of the workplace. Desktop computing provide a starting point for CSCW, but recent advances in ICT have
made it possible to embed advanced ICT into the
workplace.
To harness the potential of ICT in supporting collaborative work in healthcare, and to guide development of CSCW systems, we should direct our
attention to the tangible in modeling, designing, and
supporting workflow. In terms of methodologies, detailed studies using ethnographic methods should be
carried out to understand how cognitive artifacts are
used for safety and efficiency of healthcare delivery
and to appreciate difficulties in incorporating large
ICT systems that fundamentally change collaborative
work. In terms of theories, distributed cognition approaches can be used to understand the contribution
of the tangible to individual and collective performance. In terms of technology, efforts toward hybrid
user interfaces and embedding information (both access
and input) within physical work objects can further
leverage ICT in healthcare.
32
Y. Xiao / Journal of Biomedical Informatics 38 (2005) 26–33
Acknowledgments
This material is based on work supported by the National Science Foundation under Grant No. 0325087.
Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author
and do not necessarily reflect the views of the National
Science Foundation. The paper benefitted from contributions from current and previous members of the Human Factors and Technology Group at the University
of Maryland, including Jake Seagull, Peter Hu, Anne
Miller, Jackie Moss, Cheryl Plaster, Jos de Visser, and
Colin Mackenzie.
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