The discussion surrounding Koppel et al.  in a recent issue of the Journal [2–6] skirts an important but unmentioned issue in the design and implementation of information technology (IT) in health care—that of the social roles of the primary users of these systems, and their relative disempowerment in healthcare organizations. Nemeth and Cook , and to a lesser extent Horsky  show awareness of it, in their emphasis on naturalistic studies of real users engaged in real work, but it seems important to articulate it explicitly. The reality is that the majority of daily users of most CPOE systems are house officers, not attending physicians or faculty. House officers are in effect, the migrant workers of healthcare. They are transients in organizational life who are obliged, through lack of opportunities and other social constraints, to work under conditions and for compensation that no one else would reasonably accept. Because of their transient, low status role, their voice is not heard in the carpeted corridors where decisions about IT acquisition and implementation are made, nor in the air-conditioned rooms where these systems are designed, implemented, and maintained. In contrast to agriculture migrants, whose oppressed condition is more or less permanent, house officers are co-opted into accepting their role by the certain knowledge that it will eventually end, and by the anticipation of financial rewards after their release. In addition, the well-understood social phenomenon of ‘‘like speaks to like’’  means that house officers discuss CPOE problems only with—other house officers. The combination of these factors results in organizations that are not disposed to listen to house officers (read users ) problems with systems, and house officers (users) who prefer to do ‘‘quiet time’’—to not rock the boat and get out on schedule. Nurses and clerical personnel are the other principal users of IT in healthcare, and are even less well heard than house staff. Front-line nurses, despite their training and formal professional status, are still basically held as hourly, production-line workers by their organizations . Because of this, and probably also the fact that nursing has historically been a ‘‘female profession,’’ nurses have developed their own, back-channel methods of effective working in the organization, but these informal systems are unofficial, unrecorded, and thus often invisible. Clerical personnel, largely female and minority, are even less heard from. The result of these social realties in hospitals and healthcare organizations increases the unintentional compartmentalization of information , and ultimately, leads to loss of important feedback about the realities of these systems in the real, messy world of clinical work. It is no accident that the system Koppel's group studied had been in use for 8 years while all they problems they note continued—the social structure of academic health centers virtually ensured it.
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