ࡱ > ! %` bjbj zf ̟ ̟ ; $ & = = = P = > & " ? 0B 0B 0B 0B C C C t v v v v v v $ h l _I C C _I _I 0B 0B g T T T _I 8 0B 0B T _I t T T Y q 0B ? w = M ʃ , , ő 0 P X X C )E T EF )G 6 C C C S C C C _I _I _I _I & & & D j( $ & & & j( & & &
Reproducing Social Inequality and Unequal Treatment
In the National Health Information Infrastructure:
A Discourse Analysis of IOM Executive Summaries
Lisa J. Trigg, MN, ARNP, BC
School of Nursing; Biomedical & Health Informatics, School of Medicine
University of Washington, Seattle, Washington, USA
Abstract
This paper reports on preliminary data analysis for a larger research project whose purpose is to study how the discourse constituting the currently proposed NHII may reproduce existing social inequality in healthcare. The purpose of this preliminary study is to test the methods planned for the larger study. Textually oriented critical discourse analysis and corpus linguistics methods have been used to compare three executive summaries, the first report of two recent series and one stand alone report from the Institute of Medicine: the Quality Chasm and the Insuring Health series, and the report Unequal Treatment. These methods proved to be an effective way to study the social action of language in use in the Institute of Medicine executive summaries and will be useful in studying a larger corpus of the discourse constituting the NHII. Further research along these lines will provide information required to prevent or mitigate the reproduction of social inequality in healthcare through the proposed NHII.
Keywords: Corpus Linguistics, Critical Theory, Discourse Analysis, Health Information Technology, National Health Information Infrastructure, Social Constructionism, Social Inequality, Social Justice, Value Sensitive Design
Introduction
The National Health Information Infrastructure (NHII) currently exists only as a discursive object in the texts produced by the Institute of Medicine (IOM), regulatory agencies, bipartisan political speeches, health information vendor websites, etc. The NHII has been widely written and talked about but has not yet been built. The purpose of the larger research project is to study how the discourse constituting the currently proposed NHII may reproduce existing unequal access to healthcare. The problematic consequences of social inequality and disparity due to socioeconomic status and racialisation of populations in the United States healthcare system are well described elsewhere ADDIN REFMGR.CITE Byrd2000310An American health dilemmaBook, Whole310An American health dilemmaByrd,W.MichaelClayton,Linda A.2000African AmericansHealthHealth and hygieneHistoryMedical careOfUnited StatesNot in FileNew YorkRoutledge0415924499 (v. 1 : alk. paper)2 v2Hofrichter2003309Health and social justice a reader on the politics, ideology, and inequity in the distribution of diseaseBook, Whole309Health and social justice a reader on the politics, ideology, and inequity in the distribution of diseaseHofrichter,Richard2003Economic statusEqualityHealthHealth aspectsOfPublic HealthPublic PolicySocial aspectsSocial justiceSocial medicineSocial statusSocioeconomic FactorsNot in File1st edSan FranciscoJossey-Bass0787967335 (alk. paper)phttp://www.loc.gov/catdir/bios/wiley046/2003016408.html;http://www.loc.gov/catdir/description/wiley039/2003016408.html;http://www.loc.gov/catdir/toc/wiley032/2003016408.html2Kawachi2002315The health of nations why inequality is harmful to your healthBook, Whole315The health of nations why inequality is harmful to your healthKawachi,IchiråoKennedy,Bruce P.2002EqualityHealthHealth aspectsHealth services accessibilityMedical policyOfSocial aspectsSocial medicineNot in FileNew YorkNew Press156584582X (hc.)viii, 232 p2Marmot1999308Social determinants of healthBook, Whole308Social determinants of healthMarmot,M.G.Wilkinson,Richard G.1999Medical policyOfPublic HealthSocial aspectsSocial medicineNot in FileOxfordOxford University Press0192630695xii, 291 p2Wilkinson1996311Unhealthy societies the afflictions of inequalityBook, Whole311Unhealthy societies the afflictions of inequalityWilkinson,Richard G.1996EqualityHealth aspectsIncome distributionOfSocial medicineNot in FileLondonRoutledge0415092345 (cloth)xi, 255 p2(1-5). The purpose of the research reported here has been to test methods for the larger research project.
The National Committee on Vital and Health Statistics (NCVHS) and the Department of Health and Human Services (DHHS) sponsors a website which contains the materials of two national working conferences held in 2003 and 2004 on the subject of the NHII ADDIN REFMGR.CITE National Committee on Vital & Health Statistics2005304The National Health Information Infrastructure (NHII) 2002-2004Electronic Citation304The National Health Information Infrastructure (NHII) 2002-2004National Committee on Vital & Health Statistics2005Not in FileDepartment of Health & Human Services2005/5/1=01Department of Health & Human Services34(6). According the NCVHS FAQ sheet, the National Health Information Infrastructure is:
An initiative set forth to improve the effectiveness, efficiency and overall quality of health and healthcare in the United States
A comprehensive knowledge-based network of interoperable systems of clinical, public health, and personal health information that would improve decision-making by making health information available when and where it is needed.
The set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, healthcare, and public health.
Voluntary
NOT a centralized database of medical records or a government regulation ADDIN REFMGR.CITE NCVHS Workgroup for the NHII2004131FAQs About NHIIElectronic Citation131FAQs About NHIINCVHS Workgroup for the NHII2004Not in FileNational Committee on Vital and Health StatisticsU.S. Department of Health and Human Services2005/2/4http://aspe.hhs.gov/sp/nhii/FAQ.htmlNational Committee on Vital and Health Statistics34(7).
The NCVHS asserts that a NHII will improve patient safety, improve healthcare quality, enable homeland security (e.g., bioterrorism detection), inform and empower healthcare consumers with respect to their personal health status, and improve understanding of healthcare costs. It should be clear from the NCVHS description of the proposed NHII, especially the third bulleted point above with its emphasis on technologies, standards, systems, values and laws, that this infrastructure has the potential to redefine, reengineer, and reconstitute many if not all aspects of the US healthcare system.
It is difficult to dispute the claim that such an information infrastructure may improve healthcare services as it has so many other industries such as banking, air travel, and the distribution of commercial goods. However, information technologies have also been shown to reproduce bias ADDIN REFMGR.CITE Friedman199743Bias in Computer SystemsBook Chapter43Bias in Computer SystemsFriedman,BatyaNissenbaum,Helen1997HumanOfNot in File2340Human Values in the Design of Computer TechnologyFriedman,Batya1Stanford, CACSLI Publications, Cambridge University Press3(8) and to introduce new apparatuses of inequality and social exclusion ADDIN REFMGR.CITE Norris200158Digital divide : civic engagement, information poverty, and the Internet worldwideBook, Whole58Digital divide : civic engagement, information poverty, and the Internet worldwideNorris,P.2001Digital divide.Internet Political aspects.Internet Social aspects.Political participation Computer network resources.Not in Filexv, 303Cambridge ; New YorkCambridge University Press0521807514 (hb.) 0521002230 (pb.)http://www.loc.gov/catdir/description/cam021/2001025407.html http://www.loc.gov/catdir/toc/cam026/2001025407.html2Warschauer200373Technology and social inclusion : rethinking the digital divideBook, Whole73Technology and social inclusion : rethinking the digital divideWarschauer,M.2003Digital divide.Marginality,Social.Not in Filexii, 260Cambridge, Mass.MIT Press0262232243 (hc. alk. paper)2(9;10). Norris (2001) describes the magnification of existing social inequalities through a digital divide between those who have access to information technology, and those who do not ADDIN REFMGR.CITE Norris200158Digital divide : civic engagement, information poverty, and the Internet worldwideBook, Whole58Digital divide : civic engagement, information poverty, and the Internet worldwideNorris,P.2001Digital divide.Internet Political aspects.Internet Social aspects.Political participation Computer network resources.Not in Filexv, 303Cambridge ; New YorkCambridge University Press0521807514 (hb.) 0521002230 (pb.)http://www.loc.gov/catdir/description/cam021/2001025407.html http://www.loc.gov/catdir/toc/cam026/2001025407.html2(9). This argument can be extended to the divide between those who have access to the inception, design, construction and evaluation processes of information technology, and those who do not. Warschauer (2003) illustrates the social embeddeness of technology by describing the impact of several technology projects on the communities in which they are deployed ADDIN REFMGR.CITE Warschauer200373Technology and social inclusion : rethinking the digital divideBook, Whole73Technology and social inclusion : rethinking the digital divideWarschauer,M.2003Digital divide.Marginality,Social.Not in Filexii, 260Cambridge, Mass.MIT Press0262232243 (hc. alk. paper)2(10). Feenberg (2002) asserts that technology is an ambivalent process of development suspended between different possibilities (p. 15), and that each technological artifact is inscribed with specific values from inception, through design and use ADDIN REFMGR.CITE Feenberg2002124Transforming technology: a critical theory revisitedBook, Whole124Transforming technology: a critical theory revisitedFeenberg,AndrewFeenberg,Andrew2002Critical theoryPhilosophySocial aspectsTechnologyNot in FileNew York, N.YOxford University Press0195146158 (pbk.)xi, 218 p2(11).
Methodology
Critical discourse analysis (CDA) is concerned with how discourses are constructive of and constituted by social institutions and their practices, what constitutes knowledge, how ideology functions in social institutions and how people obtain and maintain power within a given community (p.12) ADDIN REFMGR.CITE Wodak2001302Methods of critical discourse analysisBook, Whole302Methods of critical discourse analysisWodak,RuthMeyer,Michael2001Discourse analysisMethodologymethodsOfNot in FileLondonSAGEIntroducing qualitative methods0761961534viii, 200 p2(12). CDA hypothesizes that certain aspects of language use such as genre, textual surface, authorship, intended audiences, use of modals, etc., are sensitive or to power relations. Textually oriented CDA has been used for this phase of the research ADDIN REFMGR.CITE Fairclough1992320Discourse and Social ChangeBook, Whole320Discourse and Social ChangeFairclough,Norman1992Not in FileMalden, MABlackwell Publishing07456121802(13).
Corpus linguistics (CL) is a methodology used to study patterns of language use in large collections of natural texts which are selected in a systematic or principled way. Historically, CL has been widely used in lexicography, and in the construction of dictionaries based on current language use ADDIN REFMGR.CITE McEnery2003164Corpus linguisticsBook, Whole164Corpus linguisticsMcEnery,TonyWilson,Andrew2003Computational linguisticsData processingDiscourse analysisLinguisticsMethodologyNot in File2ndEdinburghEdinburgh University PressEdinburgh textbooks in empirical linguistics0748608087 (cased)209 p2(14). Modern CL consists of quantitative and qualitative analysis making use of specially designed computer programs for both automatic and interactive analysis ADDIN REFMGR.CITE Biber1998163Corpus linguistics investigating language structure and useBook, Whole163Corpus linguistics investigating language structure and useBiber,DouglasConrad,SusanReppen,Randi1998Computational linguisticsLanguageLinguistic analysis (Linguistics)LinguisticsMethodologyResearchNot in FileCambridgeCambridge University PressCambridge approaches to linguistics0521496225x, 300 phttp://www.loc.gov/catdir/description/cam028/97016560.html;http://www.loc.gov/catdir/toc/cam024/97016560.html2(15). It has recently been combined with critical discourse analysis in projects requiring analysis of large numbers of texts. Fairclough (2000) used this combination to study the social action of the language of the New Labour party ADDIN REFMGR.CITE Fairclough2000305New Labour, new language?Book, Whole305New Labour, new language?Fairclough,Norman20001953-1997-20th centuryBlair,TonyEnglish languageGreat BritainHistoryLanguagePolitical aspectsPolitical oratoryPoliticiansPolitics and governmentSocialismNot in FileNew YorkRoutledge0415218268 (hbk)x, 178 phttp://lcweb.loc.gov/catdir/toc/99046501.html2(16), and Piper (2000) used it to study the use of the expression lifelong learning in the New Labour program ADDIN REFMGR.CITE Piper2000156Some have credit cards and others have giro cheques: 'individuals' and 'people' as lifelong learners in late modernityJournal156Some have credit cards and others have giro cheques: 'individuals' and 'people' as lifelong learners in late modernityPiper,Alison2000/10/1CultureLanguageRiskNot in File515542Discourse Society114http://das.sagepub.com/cgi/content/abstract/11/4/515Discourse Society1(17).
Methods
Preliminary analysis was conducted to test these methods on the executive summaries of the first report of both the Quality Chasm and the Consequences of Uninsurance series, as well as the opening summary of the stand alone report Unequal Treatment. The IOM is one of the National Academies of Science, and each report can be read free online at the National Academies Press website ADDIN REFMGR.CITE National Academy of Science2005299History of the National AcademiesElectronic Citation299History of the National AcademiesNational Academy of Science2005OfNot in FileNational Academy of Science2005/5/1http://www.nationalacademies.org/about/history.htmlNational Academy of Science34(18). For this research each executive summary was purchased in book and digital format from the National Academies Press (NAP) website. The PDF documents were converted to text documents to enable processing via WordSmithTM 4.0. WordSmithTM enables corpus based analysis through the use of keyword searches, concordancing, collocation, etc., and was used for keyword searches in this analysis ADDIN REFMGR.CITE Oxford University Press2005312Oxford Word Smith ToolsElectronic Citation312Oxford Word Smith ToolsOxford University Press2005Not in FileOxford University PressOxford University Press2005/9/25http://www.oup.com/elt/catalogue/guidance_articles/ws_form?cc=globalOxford University Press34(19).
Data Selection Because corpus linguistics analysis requires a principled approach to corpus selection, an explanation for the choice of texts is provided here.
There are many sources of texts on the subject of the NHII. The Quality Chasm series of reports, also known as the patient safety reports published by the IOM, is of particular interest because deployment of health information technology is a key recommendation for improving safety in many of these reports, which are widely cited in health informatics literature ADDIN REFMGR.CITE Institute of Medicine2005148Crossing the Quality Chasm: The IOM Health Care Quality InitiativeElectronic Citation148Crossing the Quality Chasm: The IOM Health Care Quality InitiativeInstitute of MedicineBoard on Health Care Services2005Not in FileInstitute of Medicinehttp://www.iom.edu/focuson.asp?id=8089Institute of Medicine34(20). The final report in that series, Patient Safety, is a policy level requirements specification for the NHII ADDIN REFMGR.CITE Aspden2004298Patient safety achieving a new standard for careBook, Whole298Patient safety achieving a new standard for careAspden,PhilipCorrigan,Janet M.Wolcott,JulieErickson,ShariInstitute of MedicineCommittee on Data Standards for Patient Safety2004Data processingHealth PolicyInformation ServicesMedical errorsMedical InformaticsMedical recordsPatient Carepatient safetyPolicy Makingprevention & controlRisk ManagementSafety ManagementStandardsUnited StatesNot in FileWashington, D.CNational Academies Press0309090776 (hardcover)xx, 528 phttp://www.loc.gov/catdir/toc/ecip0414/2004001869.html2(21). The IOM has also published another report series concerned with the so called uninsurance problem ADDIN REFMGR.CITE Institute of Medicine2004123Consequences of Uninsurance ProjectElectronic Citation123Consequences of Uninsurance ProjectInstitute of MedicineCommittee on the Consequences of Uninsurance2004Not in FileInstitute of Medicine2005/2/3http://www.iom.edu/project.asp?id=4660http://www.iom.edu/project.asp?id=4660Institute of Medicine34(22), as well as a stand alone report on unequal treatment of racialized populastions in United States healthcare ADDIN REFMGR.CITE Smedley2003296Unequal treatment confronting racial and ethnic disparities in health careBook, Whole296Unequal treatment confronting racial and ethnic disparities in health careSmedley,Brian D.Stith,Adrienne Y.Nelson,Alan R.Institute of MedicineCommittee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care2003Cross-cultural studiesDiscrimination in medical careEthnic GroupsHealth services accessibilityMedical careMinoritiesMinority GroupsOfQuality of Health CareRace discriminationRacismSocial medicineUnited StatesNot in FileWashington, D.CNational Academy Press030908265X (hardcover)xvi, 764 p2(23). These reports were all published contemporaneously between 2000 and 2005 resulting in a large naturally occurring corpus of textual data from which to study the stated research problem. Texts from the first report of the two report series were selected in order to represent the beginnings of those two projects, and there was only one summary option for the stand alone report Unequal Treatment. Comparing these executive summaries enables sampling of three quite different IOM report/series while still limiting the data for the scope of this project of testing these methods. Finally, these three executive summaries offer a unique opportunity to study social action in the discourse of a single American institution which has broad influence on US healthcare policy.
Analysis
In this section only, the titles of the executive summaries selected as data are abbreviated as follows: TEH = To Err is Human, CM = Coverage Matters, and UT = Unequal Treatment.
Genre Bazerman (1997) describes genres as frames for social action, environments for learning, and sites of meaning construction which shape our thoughts and communication ADDIN REFMGR.CITE Bazerman1997319The life of genre, the life in the classroomBook Chapter319The life of genre, the life in the classroomBazerman,C.1997Academic writingEnglish languageInterdisciplinary approach in educationLiterary formOfRhetoricStudy and teachingNot in FileGenre and writing issues, arguments, alternativesBishop,WendyOstrom,Hans A.Portsmouth, NHBoynton/Cook-Heinemann0867094214 (acid-free paper)xv, 311 p3(24). These data texts are representative of at least two and perhaps three genresthe executive summary, a policy recommendation report from the IOM, as well as a sample of writing from three report series topic subgenres.
An executive summary is typically understood to be a high level synopsis of a longer report or proposal. The word executive in the title suggests that the report is summarized for the executive reader who may be pressed for time by executive duties, but must become familiar with, and possibly act on the contents of the longer report. This reading of executive summary implies consideration of the time resources of the reader by the author. Another interpretation of the title word executive might be that the whole report has been summarized by an executive of the committee, board or institution, or at her direction. Either reading of executive summary supports the interpretation that the text contains the authors intended must read or take home points of the overall report, and may foreground views the authors wish to emphasize.
These texts are also executive summaries of reports issued by the Institute of Medicine, which is a policy institution, chartered to advise the federal US government on matters pertaining to medicine and healthcare ADDIN REFMGR.CITE National Academies Press2005313More About the Institute of MedicineElectronic Citation313More About the Institute of MedicineNational Academies Press2005Not in FileNational Academies Press2005/9/25http://www.iom.edu/subpage.asp?id=4091National Academies Press34(25). These reports aim to synthesize current best evidence in healthcare and are used to guide federal and state legislature, regulatory practices, and set standards of care across disciplines, professions and institutions, with the stated overall goal of improving healthcare in the US.
While each sample represents an aspect of healthcare quality, each of these is a sample of a distinct IOM discoursethe quality/safety, the uninsurance/insuring health and the unequal treatment discourses.
Textual Surface In the PDF format, each text is visually quite similar when viewed from the first page. Each bears a standard cover page identifying the document as a product of the National Academies Press (NAP), and providing information about how to make further use of NAP resources. This cover page in the electronic version appears to brand each document as a NAP publication. Both TEH and UT are available in hardback book format as well as PDF, while CM is available only in paperback and PDF formats. Only UT is available in all three formats. The hardback book form of TEH and UT seems much more substantial both physically and visually than the paperback edition of CM.
The documents from both TEH and CM are both titled Executive Summary. UTs executive summary is actually titled Summary, but this text refers to itself as the Executive Summary near the bottom of the third page. The UT title Summary seems inclusive of non-executive readers.
All three texts make use of headings and subheadings for organization of background, themes, and arguments. The executive summaries of both TEH and UT include Recommendations which are numbered and printed in bold text, and which immediately draw the readers eye. These recommendations are culled from the full reports, and including them in the executive summaries gives the impression that enough is known about the problems outlined in the reports that solid, evidence based recommendations can be made and consequently evidence based actions can be taken. UT also isolates a feature called Findings in the same way, and follows each finding with a recommendation. The use of the word findings has an authoritarian tone, suggestive of legal or medical findings. The executive summary from CM makes no prominent display of findings and makes no recommendations. Unlike the other two reports, the CM text specifically outlines the next five reports to appear in this series. This gives CM a much more tentative feel than either TEH or UT, giving the impression that far less is known about uninsurance than either quality/safety or unequal treatment based on race or ethnicity. While both UT and TEH encourage the executive reader to act based on the respective reports, CM seems to caution the executive reader to wait for the upcoming five reports before taking action.
Intended Audience The intended audience of any given text affects author choices in such things as vocabulary, evidence, and publication venues. Given that the Institute of Medicine is charged with the responsibility to advise the US government on matters relating to healthcare and medicine, the primary intended reader of these texts is the government of the US, or at least federal policy makers. Inasmuch as these are executive summaries, it may be assumed that persons with positions of high level executorial authority are another intended audience of these texts. Since these recommendations may be used by policy makers to set funding priorities, these reports are also read and integrated into grant applications and scholarly research by graduate students, researchers and grant seekers. TEH quality/safety reports are widely quoted in biomedical informatics literature, because of the recommendations for the deployment of information technology for purposes of improving patient safety in healthcare. Any of these intended readers may be considered elites in comparison to the vast majority of consumers of American healthcare.
References and Reference Lists Swales (1990) refers to the use of citations or references in academic writing as a means of creating a research space or territory ADDIN REFMGR.CITE Swales1990303Genre analysis: English in academic and research settingsBook, Whole303Genre analysis: English in academic and research settingsSwales,John1990English languageForeign speakersInterdisciplinary approach in educationResearchStudy and teaching (Higher)Not in FileCambridge EnglandCambridge University PressThe Cambridge applied linguistics series0521328691xi, 260 phttp://www.loc.gov/catdir/description/cam024/90002464.html2(26). All three executive summaries make use of references to research and other texts to support the framing of the problems, recommendations, and solutions contained in the summaries. The citation format of TEH is numbers, while the other two texts use author last names and publication dates. However, while both TEH and UT have reference lists at the end of the executive summary, CM makes use of one long reference list at the end of the report. As a result, a person skimming the executive summary of CM is unable to skim the references used in the executive summary without turning to the back of the book and viewing the reference list for the entire book. This increases the reading burden for the reader who is not already familiar with the literature in this area. This weakens the authority and obscures the research space or territory of the executive summary of CM in comparison to the other two texts.
TEH cites 18 outside sources in the executive summary, while the reference list for UT has 88 entries. If considered in terms of a ratio of references to tokens or words, TEH 5139/18 and UT 7729/88, then TEH uses an average of one reference per 286 tokens, while UT uses an average of one reference per 88 tokens. This may imply that the UT executive summary is much better grounded in supporting evidence than is TEH, but can also be interpreted to mean that the authors of UT perceive a more pressing need to demonstrate the strong evidence supporting their project than do the authors of TEH. The absence of a reference list at the end of the CM executive summary renders comparison of its references to those of the other texts a tedious process requiring extraction of the CM citations from the executive summary text and is beyond the scope of this paper.
There is no overlap between the references in the executive summaries of UT and TEHhowever UT does refer to the second report in the Quality Chasm series ADDIN REFMGR.CITE Institute of Medicine2001266Crossing the Quality Chasm: A New Health System for the 21st CenturyBook, Whole266Crossing the Quality Chasm: A New Health System for the 21st CenturyInstitute of Medicine2001Not in FileCommittee on Quality Health Care in AmericaWashington D.C.National Academy Press2(27).
Table 1. Keyword ComparisonKeywordsCMTEHUTaccess10222disparit*3072inequality002inequit*001information01813insurance9317quality41325safety11060system*05330unequal001uninsurance1300uninsured7700Table SEQ Table \* ARABIC 1. Comparison of keywords selected by the author from the titles and descriptive materials of the reports.
Keyword Comparison It is not possible to make a true keyword analysis between the three texts without a large corpus to use for comparison to ordinary, policy, medical or some other specialty language usage. However, Table 1 contains a limited comparison of key words selected by the author of this paper from the title and descriptive material of each of the three texts. As shown in the table, there is very little overlap across all three texts in the use of these keywords. The only three words which appear in all three texts are access, insurance and quality, and these words are used somewhat differently in the texts. For instance, in TEH access refers to access to information, where access in the other two texts refers to access to healthcare. Even in cases of overlap, the word appears predominantly in one text over the others by a factor of at least 100%. The authors of CM or UT make minimal use of the word safety. While the word information is used 18 and 13 times in TEH and UT respectively, it doesnt appear at all in CM. Even the words inequality and inequity appear only three times in any of the texts!
Modality Fairclough (2000) defines modality as a reflection of the level of commitment to the truth claims a writer makes and/or the obligation to respond which is expressed to the reader ADDIN REFMGR.CITE Fairclough2000305New Labour, new language?Book, Whole305New Labour, new language?Fairclough,Norman20001953-1997-20th centuryBlair,TonyEnglish languageGreat BritainHistoryLanguagePolitical aspectsPolitical oratoryPoliticiansPolitics and governmentSocialismNot in FileNew YorkRoutledge0415218268 (hbk)x, 178 phttp://lcweb.loc.gov/catdir/toc/99046501.html2(16). Words such as could, should, can, and might reflect modality The word could appears only once in both TEH and UT and not at all in CM, while should appears 47 times in TEH, once in CM, and 20 times in UT. In TEH could is used on the first page, at the end of the second paragraph: ...adverse events resulted from medical errors which could have been prevented (p. 1). The use of could so early the TEH strongly promotes the central thesis of this reportthat medical errors are widespread, causing injuries which could be prevented as well as the implication that the reader should feel obligated to do something about this egregious problem.
In UT, the word could appears much later in the text and has much less impact on the mode of the text: To achieve this [disclosure of health plans clinical protocolsLJT], private accrediting entities and state regulatory bodies could require that health plans publish their clinical practice protocols, along with supporting evidence, thereby opening these protocols (p.16). The use of could here instead of should weakens the suggestion being made by the author that clinical protocols (which might contain evidence of systematic exclusory practices targeting ethnic minorities) ought to be available for public scrutiny. This is curious given the political project of the report which is to expose institutional and systematic exclusionary practices which lead to inequity in healthcare.
The low incidence of the modals could and should in CM is curious given that this is the beginning report of a policy series outlining the consequences of uninsurance, with the presumed purpose of persuading readers that this is an important problem.
Opening paragraphs It is beyond the scope of this venue to present a detailed comparison of the language in use in these three texts. However, an examination of the opening paragraphs demonstrates some striking stylistic differences between the three texts. The references from these text samples do not appear in the reference list of this paper.
TEH (p.2):
The knowledgeable health reporter for the Boston Globe, Betsy Lehman, died from an overdose during chemotherapy. Willie King had the wrong leg amputated. Ben Kolb was eight years old when he died during minor surgery due to a drug mix-up.1
UT (p.1):
Looking gaunt but determined, 59-year-old Robert Tools was introduced on August 21, 2001, as a medical miraclethe first surviving recipient of a fully implantable artificial heart. At a news conference, Tools spoke with emotion about his second chance at life and the quality of his care. His physicians looked on with obvious affection, grateful and honored to have extended Tools life. Mr. Tools has since lost his battle for life, but will be remembered as a hero for undergoing an experimental technology and paving the way for other patients to undergo the procedure. Moreover, the fact that Tools was African American and his doctors were white seemed, for most Americans, to symbolize the irrelevance of race in 2001. According to two recent polls, a significant majority of Americans believe that blacks like Tools receive the same quality of healthcare as whites (Lillie-Blanton et al., 2000; Morin, 2001).
CM (p.1):
Healthcare increasingly affects our personal lives and the national economy as its benefits to our health, longevity and quality of life grow. Over the past quarter of a century, clinical medicine has become more sophisticated, technological advances have become more commonplace, and the range of healthcare interventions has been much expanded. Yet over the same period, the numbers of persons without health insurance to help them purchase health services has increased by about one million per yearfaster than the rate of overall population growth. The total number of uninsured Americans grew even during years of economic prosperity (Holahan and Kim, 2000).
The opening paragraphs of TEH and UT both make use of active agency, expressing a sense of immediacy through the use of dramatic and emotional narrative stories of specifically named persons who have suffered adversity in healthcare. In TEH the adversity is death or maiming due to tragic medical errors, and is by far the more dramatic of the two. In UT, Mr. Tool is depicted as an heroic African American recipient of the latest in cardiac technologyan implantable artificial heart. TEH uses this approach to imply that any American is in danger when she receives medical care in the US. The strong use of the modal word could follows in the second paragraph of TEH (not shown in the excerpts above), where the authors of the text state that these errors could have been prevented. UT goes on in the second paragraph (not shown in the excerpts above) to state that the story of Mr. Tool is somewhat misleading, that his case is not the norm, and that it represents an isolated case of an African American receiving cutting edge treatment in healthcare. Most readers can relate the circumstances depicted in these two paragraphs on the level of feeling endangered by or deprived of a healthcare good.
The opening paragraph in CM makes no reference to specific persons who have suffered adversity due to lack of health insurance, though the need for a series on uninsurance/insuring health implies that there must be many such cases. The absence of personal narrative is striking in comparison to the other two reports. Instead CM begins with a broad, general description of the importance of healthcare and how it has evolved over a quarter of a century. As a result the CM opening paragraph seems much more global, less personal, and may hold less interest for the reader, especially given that the intended readers for this text are predominantly elites who likely have high quality health insurance as a benefit of employment.
Discussion
This has been an analysis of three different executive summaries from three different IOM policy recommendation reports. Because of the limited corpus used to test these methods, only modest claims can be made based on this research, and these relate predominantly to the methodology. Textual studies such as discourse analysis and corpus linguistics are intrinsically data intensive, and analysis is predominantly narrative in nature. The page limit of this publication venue places severe restrictions on the amount of data and analysis that can be presented; however, the author believes that enough has been presented to demonstrate the usefulness of this approach for further research.
The data analysis reveals discursive partitioning between three major healthcare quality problems, as well as the potential reproduction of inequality in US healthcare in the IOM discourse surrounding the NHII. Second, these results can be used to inform the design of a large scale study of this problem using the combination of critical discourse analysis and corpus linguistics. The lack of overlap between the three texts of either references or key words suggests minimal intersection of the research space of these three report/series, even though all three are considered important enough to American healthcare quality to warrant either a series or large stand alone report. The absence of the word information in CM is of particular interest and warrants further study in the larger project. This may simply indicate differences of vocabulary and problem sets of the discourses reflected in the three texts. However, it may also reflect the values and ideologies which are inscribed in these discourses, as well as discursive partitioning between quality problems outlined in these three different report series. If this lack of overlap in research space pervades the entire corpus of all reports from both series and the stand alone report, this almost certainly means that the IOM literature supporting the NHII does not include consideration of the reproduction of social inequity in healthcare through the NHII.
The genre analysis and study of the intended audience reveals texts written by a group of elites for another group of elite peers. Most consumers of American healthcare are excluded from this problem definition and decision and policy making discursive space. This exclusion is somewhat mitigated by the fact that all IOM reports and those of the other National Academies can at least be read in their entirety on the World Wide Web. However, this requires a computer and web access with sufficient bandwidth to comfortably read the pages because the pages can only be downloaded one at a time. It does nothing to provide a voice for participation for non-elite, non-specialist consumers, or ensure that the vocabulary is accessible for non-specialized readers. The analysis of textual surfaces and modality overwhelmingly illuminates a tentative voice with weak commitment to action in Coverage Matters while To Err is Human and Unequal Treatment boldly offer definite findings and strong recommendations in the executive summaries. This weakens the engagement and exhortation to action in Coverage Matters. The comparison of opening paragraphs revealed similarities and differences in the strategies of persuasion and engagement used by the authors of these executive summaries. To Err is Human and Unequal Treatment both make strong active efforts to exhort and engage the reader on the level of human interest, while Coverage Matters lacks the element of personal narrative and seems almost blas about the report topic. This is surprising given that so called uninsurance is such a profoundly distinctive American problem that there is a popular movie starring Denzel Washington as an underinsured working father who takes a hospital hostage in order to procure a heart transplant for his ailing son ADDIN REFMGR.CITE New Line Productions2002307John Q.Electronic Citation307John Q.New Line Productions2002Not in FileNew Line ProductionsNew Line Productions2005/9/26http://www.iamjohnq.com/New Line Productions34(28).
Conclusion
Textually oriented critical discourse analysis combined with corpus linguistics is an effective way to study the social action of the IOM texts. Further research using larger a larger corpus and more discourse analysis and corpus linguistics analysis methods will provide information required to prevent or mitigate the reproduction of social inequality in healthcare through the proposed NHII.
Acknowledgements
Many thanks to the NLM training grant # T15 LM07442, Gail Stygall, Carole Schroeder, David Allen, Sherrilynne Fuller.
Contact Info Lisa Trigg HYPERLINK "mailto:trigger@u.washington.edu" trigger@u.washington.edu ADDIN REFMGR.REFLIST
References
[1] Byrd WM, Clayton LA. An American Health Dilemma, Vol 1,2.. New York: Routledge, 2000.
[2] Hofrichter R. Health and social justice a reader on the politics, ideology, and inequity in the distribution of disease. 1st ed ed. San Francisco: Jossey-Bass, 2003.
[3] Kawachi I, Kennedy BP. The health of nations why inequality is harmful to your health. New York: New Press, 2002.
[4] Marmot MG, Wilkinson RG. Social determinants of health. Oxford: Oxford University Press, 1999.
[5] Wilkinson RG. Unhealthy societies the afflictions of inequality. London: Routledge, 1996.
[6] National Committee on Vital & Health Statistics (2005). The National Health Information Infrastructure (NHII) 2002-2004. Department of Health & Human Services [On-line] Available HYPERLINK "http://aspe.hhs.gov/sp/nhii/" http://aspe.hhs.gov/sp/nhii/ accessed 9/25/2005.
[7] NCVHS Workgroup for the NHII (2004). FAQs About NHII. National Committee on Vital and Health Statistics [On-line]. Available: HYPERLINK "http://aspe.hhs.gov/sp/nhii/FAQ.html" http://aspe.hhs.gov/sp/nhii/FAQ.html accessed 9/25/2005.
[8] Friedman B, Nissenbaum H. Bias in Computer Systems. In: Friedman B, editor. Human Values in the Design of Computer Technology. Stanford, CA: CSLI Publications, Cambridge University Press, 1997: 23-40.
[9] Norris P. Digital divide : civic engagement, information poverty, and the Internet worldwide. Cambridge ; New York: Cambridge University Press, 2001.
[10] Warschauer M. Technology and social inclusion : rethinking the digital divide. Cambridge, Mass.: MIT Press, 2003.
[11] Feenberg A, Feenberg A. Transforming technology: a critical theory revisited. New York, N.Y: Oxford University Press, 2002.
[12] Wodak R, Meyer M. Methods of critical discourse analysis. London: SAGE, 2001.
[13] McEnery T, Wilson A. Corpus linguistics. 2nd ed. Edinburgh: Edinburgh University Press, 2003.
[14] Biber D, Conrad S, Reppen R. Corpus linguistics investigating language structure and use. Cambridge: Cambridge University Press, 1998.
[15] Fairclough N. New Labour, new language? New York: Routledge, 2000.
[16] Piper A. Some have credit cards and others have giro cheques: 'individuals' and 'people' as lifelong learners in late modernity. Discourse & Society 2000; 11(4):515-542.
[17] National Academy of Science (2005). History of the National Academies. National Academy of Science [On-line]. Available: HYPERLINK "http://www.nationalacademies.org/about/history.html" http://www.nationalacademies.org/about/history.html accessed 9/25/2005.
[18] Oxford University Press (2005). Oxford Word Smith Tools. Oxford University Press [On-line]. Available: HYPERLINK "http://www.oup.com/elt/catalogue/guidance_articles/ws_form?cc=global" http://www.oup.com/elt/catalogue/guidance_articles/ws_form?cc=global accessed 9/25/2005.
[19] Institute of Medicine and Board on Healthcare Services (2005). Crossing the Quality Chasm: The IOM Healthcare Quality Initiative. Institute of Medicine [On-line]. Available: HYPERLINK "http://www.iom.edu/focuson.asp?id=8089" http://www.iom.edu/focuson.asp?id=8089 accessed 9/25/2005.
[20] Aspden P, Corrigan JM, Wolcott J, Erickson S, Institute of Medicine, Committee on Data Standards for Patient Safety. Patient safety achieving a new standard for care. Washington, D.C: National Academies Press, 2004.
[21] Institute of Medicine and Committee on the Consequences of Uninsurance (2004). Consequences of Uninsurance Project. Institute of Medicine [On-line]. Available: HYPERLINK "http://www.iom.edu/project.asp?id=4660" http://www.iom.edu/project.asp?id=4660 accessed 9/25/2005.
[22] Smedley BD, Stith AY, Nelson AR, Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Healthcare. Unequal treatment confronting racial and ethnic disparities in healthcare. Washington, D.C: National Academy Press, 2003.
[23] Bazerman C. The life of genre, the life in the classroom. In: Bishop W., Ostrom HA, editors. Genre and writing issues, arguments, alternatives. Portsmouth, NH: Boynton/Cook-Heinemann, 1997.
[24] National Academies Press (2005). More About the Institute of Medicine. National Academies Press [On-line]. Available: HYPERLINK "http://www.iom.edu/subpage.asp?id=4091" http://www.iom.edu/subpage.asp?id=4091 accessed 9/25/2005.
[25] Swales J. Genre analysis: English in academic and research settings. Cambridge England: Cambridge University Press, 1990.
[26] Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington D.C.: National Academy Press, 2001.
[27] New Line Productions (2002). John Q. New Line Productions [On-line]. Available: HYPERLINK "http://www.iamjohnq.com/" http://www.iamjohnq.com/ accessed 9/25/2005.
Methods testing study # 1
Accepted to NI2006 9th International Congress in Nursing Informatics
To be presented June 14, 2006 in Seoul, Korea
Q j k 1 2 3 4 < = ̢̫}t[B 0hZX h- CJ OJ QJ ^J aJ mH nHsH tH 0hZX h