The many faces of the computer: An analysis of clinical software in the primary care consultation

Background: Almost all general practitioners in Australia now use a computer for some part of the consultation, and mostly use one of eight clinical software applications. There has been little research into the impact of clinical software on the clinical consultation. Clinical software broadly functions in two ways: it replaces the paper record of the patient's history of health and clinical contacts within the general practice, and it communicates directly to the doctor in various ways about outstanding clinical actions. Aim: This paper draws on Goffman's notion of "face" to explore the way in which the actions, visual presentation, and interactions between general practitioners, patients and the computer can imbue the software with its own "face" in the consultation. Methods: Analysis of 141 consultations by 20 doctors (13 men, 7 women), who used one of four medical software applications commonly used in Australian general practice. Consultations were videotaped, tagged, analysed using a hermeneutic framework. Results: All four software packages replicated constitutive elements of the paper health record, such as medical history, current medications, and the patient's social history, but also introduced other content not present in a paper system. They differed in their use of communicative strategies. This necessitated differing interactions between the software and the doctor. The differences in communicative work of each software package led to their different "faces", along a gradient from a relatively passive mode that provided context dependent information in an unobtrusive way, to a relatively active mode that interrupted to provide information and to demand responses. We conclude that the more active the mode of presence of the computer in the consultation, the more patients and doctors may have to adapt their communicative styles in response.