title: Choose and Book: a sociological analysis of 'resistance' to an expert system.
abstract: In 2004, the English Department of Health introduced a technology (Choose and Book) designed to help general practitioners and patients book hospital outpatient appointments. It was anticipated that remote booking would become standard practice once technical challenges were overcome. But despite political pressure and financial incentives, Choose and Book remained unpopular and was generally used reluctantly if at all. Policymakers framed this as a problem of 'clinician resistance'. We considered Choose and Book from a sociological perspective. Our dataset, drawn from a qualitative study of computer use in general practice, comprised background documents, field notes, interviews, clinical consultations (directly observed and videotaped) and naturally occurring talk relating to referral to hospital in four general practices. We used strong structuration theory, Giddens' conceptualisation of expert systems, and sensitivity to other sociological perspectives on technology, institutions and professional values to examine the relationship between the external environment, the evolving technology and actions of human agents (GPs, administrators, managers and patients). Choose and Book had the characteristics of an expert system. It served to 'empty out' the content of the consultation as the abstract knowledge it contained was assumed to have universal validity and to over-ride the clinician's application of local knowledge and practical wisdom. Sick patients were incorrectly assumed to behave as rational choosers, able and willing to decide between potential options using abstracted codified information. Our analysis revealed four foci of resistance: to the policy of choice that Choose and Book symbolised and purported to deliver; to accommodating the technology's socio-material constraints; to interference with doctors' contextual judgements; and to adjusting to the altered social relations consequent on its use. We conclude that 'resistance' is a complex phenomenon with socio-material and normative components; it is unlikely to be overcome using the behaviourist techniques recommended in some health informatics and policy literature.
authors.affiliation: Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, UK. Electronic address: p.greenhalgh@qmul.ac.uk.
authors.forename: Trisha
authors.initials: T
authors.lastname: Greenhalgh
authors.affiliation: School of Social Sciences and Psychology, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia.
authors.forename: Rob
authors.initials: R
authors.lastname: Stones
authors.affiliation: Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, UK.
authors.forename: Deborah
authors.initials: D
authors.lastname: Swinglehurst
mesh_terms: D001071:Appointments and Schedules; D002755:Choice Behavior; D005103:Expert Systems; D058006:General Practice / Q000458:organization & administration*; D058005:General Practitioners / Q000523:psychology*; D006291:Health Policy; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D036301:Qualitative Research; D012961:Sociology; D013222:State Medicine; D006113:United Kingdom
keywords: Electronic patent records; Expert systems; Referral; Resistance; Structuration theory; United Kingdom; e-Health