Actor network theory provides us with a way of explaining the huge
influence that RACGP has had in the adoption of computers and at
first when I started to examine this process it appeared as though ANT
offered little guidance to the analysis and that I should fall back on
diffusion theory. These entities alone show the complexity of
computerization in the study area. I now believe that ANT can also
provide insights on an organization that will be very different from the
usual way that organizations are researched and articulated.
In the above account of how the RACGP went about accelerating
computerisation of general practice I have tried to set the scene for
examination of social arrangements, and in addition outline the
historical progress, and the human and non-human arrangements.
My perceptions as I followed the historical pathway, and interviewed
the players have been very important in identifying who the actors in
this vignette are and in identifying the networks the RACGP created.
In addressing this issue here (that of my perceptions), I feel that I am
exposing the lacuna of ANT but at the same time I know that I am
confirming its strength. In Latour’s (1996) writing he recommends that
you follow the actors and observe the work they do. In doing this the
researcher can trace the network the actor creates.
The actor-world of the RACGP is both varied and diverse in terms of
its constituent actor-networks, and so I feel the best approach to
analysing it is to start from ‘the beginning’, looking at some of the
actor-networks that were both involved, and have subsequently
evolved in the accelerating of the adoption of computers in general
practice. It is obvious that I am not going to explore the total history
of this process but pick it up at its most important point – the decision
to become actively (but not overtly involved in the eye of the general
public) interested in computerization of general practice and actively
promote this occurring
In 1981 the RACGP produced its first formal document advising
standards for computerized medical records systems, ideas for this had
been developing within RACGP since the conference of 1978. The
scene was set, the spotlight on, and the focus (?) on members of the
College some of whom had very little idea of what was about to take
place. It’s likely that the exact rate of adoption was unknown by the
RACGP but they did know that their membership lay unaware in its
torpor. One thing could be relatively certain, though: if
computerization could be shown to be financially beneficial then the
likelihood of adoption was very much increased.
Drawn into the actor-world, and possibly the base actor (along with
the software as a black box entity, encapsulating aspirations, content,
staff, programs, policies) in the world so far, was the computer that
would bring so much change. Whilst this original computer policy
recommended by RACGP was nothing spectacular, it appeared that it
was adequate, and accommodated a certain degree of future growth. It
did not seem to matter that it was based on something from 1974.
Design of the policy was done in-house making use of available staff
within the RACGP and they were required to be no more than
functional, and it managed to do its job in the short-term in guiding
the members towards change. Let’s examine this further –
There were some assumptions that the RACGP had made in their production of the policy and this was about knowledge of the organization and how the council at the time thought change should occur. Kuhn (1996) suggests that knowledge of what a change will do is an unknown in that we have no access to what it is we know, and that the knowledge of how something will effect an organization becomes embedded in the tacit routes or networks that are created in the adoption of the innovation. Kuhn further indicates that instigators of change – technicians, scientists (in this case read
computers, and RACGP goals) are socialised into paradigms and much of the cultural knowledge cannot be transmitted in a codified form by explicit statements. Kuhn acknowledges that this idea is not new.
In a study (Collins (1974) in which a questionnaire was used to identify knowledge clusters, Collins concluded that knowledge is an activity and thus creates the capacity to do something. Furthermore one can only identify groups that had successfully shared tacit knowledge by their activities, in this case building networks and infrastructure to facilitate the adoption of
computers in general practice.
As time progressed, and the policy was implemented it became clear
the first policy was not going to work; it was simply an obligatory
passage point – more and more computer savvy GPs were demanding
a less conservative policy and a policy that offered a real sense of
purpose. The process was stalled because of the political nature of the
RACGP and the conservative nature of the RACGP. It was almost as
though the RACGP had shot itself in the foot. What went wrong? Why
didn’t the policy work?
Firstly there had been little consultation with the members of the
college. Secondly the “new” policy in 1981 was based on a policy that
addressed the needs of a manual system, and thirdly there had been no
real effort to diffuse the policy beyond the immediate members
involved in its development. In terms of ANT this policy was doomed
from the start – it would never have assisted in accelerating the
process of adoption. The process that had been started was
underpinned by cultural factors and contextual aspects that had not
been accounted for. There had been very little consultation with
members whose characteristics were age 40 to 60, predominantly male
and graduating from a time when general practice was “seen” as the
poor cousin in medicine. In this case the GPs knowledge about them
was indeed a social construct (a contextual entity)
The lack of consultation with members led to the way that the policy
was viewed – it was not owned by the members and so they did not
have to do anything about it. Their assistance in supporting it had not
been sought – in ANT terms they were not enlisted in the mutual
achievement of goals. Most of these GPs would have claimed to have a
computer in their business at this time but the things that it was used
for were most likely not within the business. The acquisition of the
computer at this time was simply a tax write off for most of them. The
idea of computer use by general practitioners had been accepted but
not the use of them.
This points out another fault in the first policy – it had not addressed
the knowledge that the GPs had, it was simply imposed from the top
and resulted in being a black box that was destined never to be
opened. The translation of the policy to working guidelines never
happened. No heterogeneous element was apparent; there was no real
network of like minded doctors, no acceptance of the statements in the
policy, and very little understanding of the potential for the use of
computers. Thus the knowledge in the policy was a technical
construction not a socio-technical construction.
The political nature of the RACGP cannot be underestimated in the
adoption of computers in general practice. Unlike virtually any other
member based organization at the time, in response to the rejection of
the first attempt the proponents of computerization became a tight-knit
community between those who were starting to use computers and
devising their own software and those that were showing success in
developing the technology. The computer buffs would regularly
participate in discussions, and even help out with technical problems
some users had with their computers. By interacting regularly with (at
least part of) their member base, they were able to shape the direction
of their new community, subtly (yet surely) and much later, translating
a very diverse group of actors into the supporters of computerization
in general practice.
This is what happened next: In 1985 the RACGP joined up with Medrecord. The relative success of the alliance between Medrecord demonstrated by the launching of the Computer Assistance Practice Project and their community can be characterized by the following quote: “He who is able to translate others’ interests into his own language carries the day… But interests, like everything else, can be constructed.” (Latour, 1996) It wasn’t simply enough for the College to be interested in computerizing it had to be shown to work.
By creating a community of supporters for computerization, the
RACGP was creating interest in further upgrading the technology and
providing access to it though the Computer Assistance Practice
Project. It was slowly but surely getting everyone on board –enlisting
them in the common cause. More importantly for the future success of
the goal, they had set the scene for the most important proof that
computers were worthwhile – they had shown that there were financial
rewards in adopting computers by instigating the computer assistance
practice program.
Further to this by using a delivery style of helping/assistance they
were creating a predisposition to adopting the technology for there is
nothing a GP likes to more than to help. Such a style could be seen to
be both professional, part of the Hippocratic Oath – “pass on thy
trade”, and innovative. Thus actors both human and non-human were
simultaneously translated into networks that would begin to work
toward the common goal of computerization of general practice.
Like any successful actor-network (or world, even), the RACGP is a stabilized investment of form, one that has well and truly formed its social, physical, and professional forms. Taking a step inward and exploring the subsistent actor-networks, it can be seen that “…there was no essential distinction between trying computers in your practice under the assistance program and the consumption of the idea that this would be a good thing. The two took shape and adjusted to one another in the same movement.” (Callon and Law 1994). As both a generator and organizer of information, the RACGP were creating and constructing various ways of communicating ideas, opinions, and beliefs.
The actual policies in regard to computerization are essentially formalism; “This is because, like all formalisms, it connects and defines the relations between a set of terms” (Law and Mol, (2002) or in this case a network. Along with the assistance program the RACGP instigated the position of computer fellow and with this the college began the process of standardizing
the connections and definitions of the formalism for virtually every member. The RACGP spelt out the way that computers were to be used. The
membership group had been engineered into a heterogeneous identity and the smaller networks can now be enlarged upon. As an aside at this time it is important to comment that while this is a political process it is done with the risk of litigation high in the mind of the college.