Final Research Analysis and Presentation

Research

Exploring the Effects of Clinical
Exam Room Design o

Communication, Technology
Interaction, and Satisfaction

Zahra Zamani, PhD, EDAC1 , and Esperanza C. Harper, EDAC

Abstrac

Objective: This article evaluates the effects of technology integration and design features in clinical exam
rooms on examination experiences, communication, and satisfaction. Background: Exam room fea-
tures can affect the delivery of patient-centered care and enhance the level of communication, which
has been shown to directly impact clinical outcomes. Although there has been an increasing body of
literature examining design and patient-centered care, little research has evaluated the extent to which
information sharing and electronic health record (EHR) interaction are impacted. Method: The
research randomly allocated 22 patients, 28

caregivers, and 59 clinicians to simulated clinical

encounters in four exam room mock-ups with semi-inclusive, exclusive, and inclusive layouts (12

sessions in 32 scenarios). Video recordings of the simulations were coded for clinician gazing, talking,
and EHR-interaction behaviors. Participants also completed surveys and answered open-ended
questions after experiencing each scenario (N ¼ 362). Results: Semi-inclusive rooms with a trian-
gular arrangement of consultation table, sharable screens, exam table, and caregiver chair were highly
preferred as they supported conversation, gazing, and information sharing. The inclusive layout had highe

durations of EHR interactions and enhanced viewing and sharing of EHR information. However, this
layout was criticized for the lack of clinician-shared information. The exclusive layouts impeded infor-
mation sharing, eye contact, and constrained simultaneous data entry and eye contact for clinicians. The
distance and orientation between chair, exam table, curtain, and door were important for protecting
patient and family comfort and privacy. Conclusion: Characteristics and configurations of design
qualities and strategies have a key role on examination experiences, communication, and satisfaction

Keywords
clinical exam rooms, information sharing, technology integration, patient-centered care, exam room
furniture, eye contact, furniture orientation, satisfaction

Patient-centered treatment can be defined as care

that recognizes the patient’s requirement and

health outcome as the primary influence for

healthcare choices and quality dimensions

(Ajiboye, Dong, Moore, Kallail, & Baughman,

2015; Gorawara-Bhat & Cook, 2011). The quality

1 Design Researcher, EwingCole,

Raleigh, NC, USA

2 Six Sigma Green Belt, Healthcare Planner, EwingCole,

Raleigh, NC, USA

Corresponding Author:

Zahra Zamani, PhD, EDAC, Design Researcher, EwingCole,

8208 Brownleigh Dr #200, Raleigh, NC 27617, USA.

Email: zzamani@ewingcole.com

Health Environments Research
& Design Journal

2019, Vol. 12(4) 99-1

ª The Author(s) 20

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of collaborative, coordinated, and accessible care

is substantial for patient-centered care delivery

and affected by the patient–physician communi-

cation experience (Ajiboye et al., 2015; Lee,

2011). Communication is defined as the act of

transferring information by different means: ver-

bal (talking), nonverbal (gazing), or visualized

(electronic health record [EHR] information

shared and viewed by monitors; Asan, Young,

Chewning, & Montague, 2015; Kazmi, 2014

Recent literature indicates that clinician’s eye

contact (gaze) with patients is a significant pre-

dictor for perceptions of enhanced patient-

centered communication and patient satisfaction

(Gorawara-Bhat & Cook, 2011). Furthermore,

establishing eye contact between the clinician and

patient is linked to patients’ perception of higher

levels of clinician communication, empathy,

attention, and warmth (Asan, Xu, & Montague,

2013; Bonner, Simons, Parker, Yano, & Kirchner,

2010).

The increased integration of the EHR in

healthcare practice suggests the importance of

understanding how technology-mediated clinical

exam rooms impact patient–caregiver–clinician

communication and behavioral dynamics

(Ajiboye et al., 2015; Asan et al., 2013; Asan

et al., 2015; Bonner et al., 2010; Gorawara-Bhat

& Cook, 2011). There is some controversy

regarding the impact of EHR on clinical exami-

nation experiences. Several studies found that

EHR integration inhibits clinician’s continuous

attention on patients, delays communication, and

impairs patient–clinician relationships (Ajiboye

et al., 2015; Asan, D Smith, & Montague, 2014;

Bonner et al., 2010). On the other hand, other

literature suggests that opportunities for EHR

information sharing promotes patient engage-

ment, satisfaction, interaction, and attention for

shared decision-making (Ajiboye et al., 2015;

Almquist et al., 2009; Asan et al., 2013, 2014,

2015; Chen, Ngo, Harrison, & Duong, 2011;

Unruh, Skeels, Civan-Hartzler, & Pratt, 2010).

For example, Ajiboye, Dong, Moore, Kallail,

and Baughman (2015) evaluated a traditional

exam room with an experimental room that pro-

vided equal access to the laptop computer screen.

Findings showed that patients were more likely to

have an excellent encounter and were more

satisfied with the seating position of the physician

in the experimental room versus the traditional

room setup. In the experimental condition,

participants perceived enhanced computer acces-

sibility, interpersonal interaction, provider infor-

mation sharing, and more time engaged in a

conversation with the provider. Asan, Xu, and

Montague (2013) research indicated the

technology-centered rooms with physicians over-

relying on technology had the shortest gaze

between patients and physicians by a significant

margin (p < .05).

Kumarapeli and de Lusignan (2012) classified

consultation room layouts into four categories:

(a) inclusive: Clinicians and patients share com-

puter screens; (b) semi-inclusive patient con-

trolled: Patients have control and can view

screen comfortably; (c) semi-inclusive clinician

controlled: Clinician has control over screen

access, and patients must turn or move, or screen

must be rotated for content sharing; and (d) exclu-

sive: Patients are located at the opposite position

without screen access. Findings showed that a

combination of room layout and the physi-

cians’ actions influenced patients’ gaze towa

the EHR. In the semi-inclusive-clinician-

controlled layouts, screen sharing was not

noticed and clinicians were less likely to look

at the computer versus the semi-inclusive-

patient-controlled layout.

Age and level of clinical experience variations

may also impact perceptions and competence with

the EHR-interaction and patient-centered commu-

nication. For instance, Piper and Hollan (2013)

observational prototype tests indicated that view-

ing charts and images from the EHR improved

communication and data interpretation for older

patients. Literature also suggests that physician

EHR training improves EHR-associated commu-

nication skills, physician–patient relationship, and

provider confidence (Lanier, Cerutti, Dao, Hudel-

son, & Perron, 2018).

Clinical patients spend most of their time and

interaction within the exam room. Therefore, the

physical environment and design of exam rooms

is an important factor for the overall satisfaction

and delivery of care. Typical examination room

layout is clinician centered and mostly lacks

design features for successful patient–physician

100 Health Environments Research & Design Journal 12(4)

communication (Ajiboye et al., 2015; Almquist

et al., 2009). Despite the increasing amount of

research in the wider scope of technology-

integrated exam rooms, there has been litt

exploration of the role of room design and furni-

ture configuration’s impact on communication,

EHR interaction, and satisfaction to inform

design decisions. Therefore, this explorative

study aims to address the following questions:

Q1: Do the exam room’s layout and technology

arrangements affect communication behaviors

and EHR interactions? Q2: What, if any, is the

relationship between satisfaction levels of exam-

ination experience, communication, information

sharing, and exam room features? Do satisfaction

levels vary by user type?

Method

This study deployed an exploratory mixed-

methods approach that included quantified obser-

vation of behaviors, surveys, and qualitative

analysis of open-ended responses. All research

protocols were designed and evaluated for com-

pliance with the institutional review board of the

hospital setting where the research occurred. The

researchers randomly allocated 22 patients, 28

caregivers, and 59 clinicians to simulated clinical

encounters in four exam room architectural

mock-ups. Participation was voluntarily, and

patients, families, and clinicians were recruited

by an e-mail that explained the study purpose,

approach, and data confidentiality.

The researchers placed video cameras in unob-

trusive locations in each examination room,

recorded each simulation, and later analyzed

video recordings to determine the duration and

frequency of examination stages, communication

patterns (gazing and talking), and EHR interac-

tion. The observational method followed a

within-subject experimental design in which the

participants were randomly assigned to exam

rooms. Sessions were performed on four consec-

utive days and in eight different time slots. To

address carryover effects, the study employed a

counterbalancing approach in which the orders of

experiencing exam rooms differed in each day

and were randomly distributed. The randomiza-

tion design schedule consisted of four room

orders within four days for each patient type (16

pediatrics or 16 geriatrics), resulting in 32 total

scenarios and 128 session

Participants also completed surveys and

answered open-ended questions after experien-

cing the clinical scenario in each mock-up. The

pilot survey was tested before the actual scenario

and refined. The survey explored levels of satis-

faction in four categories: (a) examination stages,

(b) communication with medical doctor (MD) or

medical assistant (MA), (c) information sharing

and viewing of monitors (visual communication),

and (d) room features. Examples of survey ques-

tions are presented in Table 1. Questions were on

a 7-point Likert-type scale, with anchors at 1 ¼
very dissatisfied, 4 ¼ neither satisfied nor dissa-

tisfied, and 7 ¼ very satisfied. Additionally,

open-ended questions explored participants’ per-

spectives of liked or disliked exam room features.

Demographic characteristics were not col-

lected due to hospital policies; however, gender

information was later retrieved from the videos

(detailed findings are reported in supplementary

Table 1. Example of Survey Questions.

Category Scaled Questions

On a scale of 1–7, with 1 being
very unsatisfied and 7 being very
satisfied, overall how satisfied
were you with:

Examination stages
(6 items)

Intake with medical assistant?
Gowning?
Physical examination?
Prescription of medications?
Tele-visit/consult?
Immunization?

Communication
(4 items)

Communication between the
medical assistant and patient?

Communication between the
doctor and patient?

Information
sharing (2 items)

Sharing of information on the
monitor

Viewing information on the
monitor

Room features
(30 items)

Wall-mounted monitor?
Computer monitor?
Exam table?
Family chairs?
Curtain?

Zamani and Harper 101

files). Participants included patients (n ¼ 11),

patient actors (n ¼ 11), caregivers (n ¼ 12), care-

giver actors (n ¼ 16), MDs (n ¼ 22), and MAs

(n¼ 37). Actors were hospital staff members who

played various roles, defined by the scenario

simulation script in case of patient or family una-

vailability. These role assignments did not impact

the validity of results, as any healthcare staff

member could be or have been a patient or family

in real life.

Setting

Four exam room prototypes were approved and

developed for full-scale construction on a vacated

floor of an existing hospital building. As illu-

strated in Figure 1, each exam room had a differ-

ent taxonomy, configuration, and somewhat

similar furniture. Room A (RA) and Room D

(RD) had a semi-inclusive clinician-controlled

setup, Room B (RB) an exclusive, and Room C

(RC) an inclusive configuration. The exam room

designs were owner/designer preference for this

exploration. Each design was evaluated and

selected based on the owner’s criteria including

but limited to the inclusion of current design stan-

dards, projected budget, designation of clinical

practices to be present in the actual setting, and

current and future EHR technology.

Analysis

The Behavioral Observation Research Interactive

Software (BORIS, version 7.4.2) was implemen-

ted for event logging and video coding of obser-

vations. Behaviors were defined as state events

(with durations) or point events (no duration).

Exported codes included these segments: subject,

examination stage, behavior, and modifier (point

events linked to behaviors). Subjects coded dur-

ing the video analysis included physician (MD)

and MA. Sessions were coded for the following

clinical examination stages of interest: (1) MA

intake: MA initiates questions and enters data in

the computer (excluding blood pressure and

examination); (2) MD information gathering:

physician conversation with patient or family

about the patient’s health status; (3) MD physical

examination: MD starts adjusting the exam table,

performs examination, and rearranges the exam

Figure 1. The four exam room layouts. Floor plans of full-scale mock-ups highlighting various physical features.
Image authorship: author.

102 Health Environments Research & Design Journal 12(4)

table; and (4) MD diagnosis-patient education:

MD enters exam results in EHR system, explains

the examination results, educates the patient, and

discusses future care.

Observed behaviors were classified into the

following categories: (a) gazing: mutual gaze

between the clinician, patients, families, or both

as an indication of attention and communication

(Asan et al., 2014; Montague & Asan, 2014); (b)

EHR interaction: clinician application of key-

board, mouse, or monitor screens to read or enter

data; and (c) talking: the duration of clinician

engaging in a conversation with the patient or

family. Researchers also coded if the patient,

family, or both were the point of focus for clin-

ician gazing or conversation (as a point data

described as a modifier in the BORIS software).

For instance, when the provider (MA or MD) and

patient mutually gazed at each other, the interac-

tion was coded as follows: provider as the subject,

behavior as eye contact, and modifier as patient.

Training in the instrument implementation

occurred to ensure the reliability of findings. The

proportion of agreements and Cohen’s k coeffi-

cients were employed to analyze reliability values

until interrater reliability scores reached .67.

Due to time restraints for coding the entire

videos, sessions were divided into examination

stages, and stages were randomly selected to rep-

resent different patients and exam stage across

rooms. Researchers separately coded the three

defined behaviors within the examination stages,

with the ability to start and stop recording when

the behavior was paused or interrupted for

instance by another person, searching behaviors,

or starting vitals. These pauses created behavioral

segments. That is, if within an examination stage

the observed behavior was stopped, one beha-

vioral segment was created. The total number of

behavioral segments was representative of beha-

vior disconnection.

The resulting sample after data randomization

sampling included nine geriatrics and 12 pediatric

sessions that ranged in different rooms (RA n ¼
16, RB n ¼ 15, RC n ¼ 16, and RD n ¼ 13). The

sample represented the following stages (N ¼
258): MA intake (n ¼ 67, 26%); physician

diagnosis-education referral (n ¼ 73, 28.3%),

physician information gathering (n ¼ 77,

29.8%), and physician physical exam (n ¼ 41,

15.9%). The data included 53.1% (n ¼ 137)

adults and 46.9% (n¼ 121) pediatrics data values

performed by physicians (n ¼ 191, 74%) and

MAs (n ¼ 67, 26.0%).

To evaluate the nature of examination stages

per observed behaviors, codes were structured

into three categories: (a) behavioral duration per

examination stage (BDS): total duration of a

behavior (talking, gazing, or EHR interaction) for

each examination stage; (b) behavioral segments

per examination stage (BSS): Resulting from dis-

continuity of the behavior, this number presented

the total number of behavior segments (start–stop

units) observed in an examination stage; and (c)

total behavior duration per session (TBS): total

duration of the three coded behaviors across the

four examination stages of a session. Addition-

ally, gazing and talking behavior durations were

merged to identify patient–clinician or family–

clinician interactions.

All statistical analysis was conducted using the

SPSS Statistics 24 software. Descriptive statistics

are presented as means and standard deviations

(in parenthesis next to average values) for contin-

uous variables, frequencies, and proportions for

categorical variables. One-way analysis of var-

iance (ANOVA) and post hoc tests analysis were

performed to understand significant differences

between rooms.

The open-ended responses were content ana-

lyzed and audited using standard content analysis

techniques. A minor difference between the

coders was resolved by collective reviewing.

Responses were analyzed to identify perspectives

and underlying reasons for satisfaction ratings on

examination stages, room features, communica-

tion, or information sharing.

Results

Observational Findings

The average duration of the examination sessions,

including MA vital intake, waiting, and gowning

times, was 540.67 s (aggregated data across all

room types). Average duration of all four exam

stages was 377.93 (aggregated data across all

room types). This number excludes MA vital

Zamani and Harper 103

intake, waiting, and gowning times. Average

durations of each exam stage for adult patients

were: MA intake ¼ 91.05 (55.80), MD info gath-

ering ¼ 89.99 (36.90), MD exam ¼ 158.4

(96.41), MD education and referral ¼ 96.4

(14.67), and total ¼ 435.86. For pediatric physi-

cal exam, average durations of examination

stages were as follows: MA intake ¼ 76.75

(35.00), MD info gathering ¼ 56.50 (27.27),

MD exam ¼ 127.52 (50.95), MD education and

referral ¼ 55.75 (35.39), and total ¼ 316.52.

Durations of MD info gathering and MD educa-

tion significantly differed between patient types,

F(1, 22) ¼ 6.39, p ¼ .019, F(1, 21) ¼ 14.17,

p ¼ .001.

Aggregated data across all room types showed

talking duration (M ¼ 104.7), and eye contact

(M ¼ 83.39) were longer than EHR interaction

(M ¼ 35.59), and this difference was significant,

F(2, 136) ¼ 18.078, p < .001. The ANOVA indi-

cated significant difference between room types

and average BDS, F(3, 251)¼ 3.44, p¼ .017, RA

M ¼ 37.75 (28.79); RB M ¼ 39.75 (29.98); RC

M ¼ 53.79 (36.43); RD M ¼ 37.55 (33.38). RC

had significantly higher duration of behaviors

than RA and RD (p < .05). There were no signif-

icant variations across rooms in the average BSS

or TBS values. The results showed no significant

difference comparing the average BDS, BSS, and

TBS values for the two patient types in rooms.

Rooms did not significantly differ in the

average TBS or BSS for talking, gazing, or

EHR-interaction values. Average BDS values for

talking or gazing were not significantly different

across rooms. However, statistical analysis

showed significant variations among BDS values

for EHR interaction across rooms F(3, 55) ¼
4.80, p ¼ .005, RA M ¼ 18.37 (13.17); RB

M ¼ 22.46 (13.58); RC M ¼ 49.84 (49.32); RD

M ¼ 16.95, (15.25). Tukey HSD comparisons

indicated that RC had longer EHR-interaction

BDS than RA, RB, and RD (p < .05).

Data analysis explored BDS values for talking,

gazing, and EHR interaction per the four exam-

ination stages across rooms. ANOVA indicated

no significant difference across rooms, except the

average duration of EHR interaction during MA

intake, F(3, 17)¼ 5.034, p¼ .01. Tukey HSD test

indicated that RC had significantly longer EHR

interactions during MA intake, in comparison to

RA and RB (p < .05). Descriptive results showed

that clinician interactions occurred mainly with

patients, subsequently patient–caregiver, and

then caregiver (59.6%, n ¼ 115; 21.24%, n ¼
41; 19.17%, n ¼ 37, respectively). BDS and BSS

values during interactions were not significantly

different across rooms.

Survey Findings

Average time for survey completion was 15 min

and 13 s (MD n ¼ 123, 34.0%; MA n ¼ 89,

24.6%; family n ¼ 89; 24.6%; and patient n ¼
61, 16.8%, N ¼ 362). Overall satisfaction with

examination stages and communication levels

was high (5 and above), with no significant dif-

ference between rooms.

The findings show that satisfaction with mon-

itor sharing and viewing information on the

monitor significantly differed across rooms:

monitor-sharing RA M ¼ 4.03 (2.83); RB M ¼
2.66 (2.5); RC M ¼ 4.96 (2.47); RD M ¼ 4.22

(2.86); F(3, 348) ¼ 14.19, p > .001; viewing

information on monitor RA M ¼ 4.95 (2.6); RB

M ¼ 3.54 (2.7); RC M ¼ 4.84 (2.44); RD M ¼
4.76 (2.68); F(3, 346) ¼ 6.58, p > .001. Tukey’s

test showed that RB had significantly the lowest

ratings for sharing and viewing information on

the monitor (p < .001).

Satisfaction ratings for MA or MD communi-

cation with patient or family were not signifi-

cantly different across rooms. Table 2 displays

significant predictors of satisfaction with commu-

nication between MD, patient, and family mem-

bers across rooms. As displayed, satisfaction with

the MD examination was affected by perception

of communication level and exam room features

such as the MD workstation, wall monitor, and

computer monitor.

Table 3 displays room features with significant

satisfaction ratings. Tukey’s analysis indicated

that average ratings for the computer monitor in

RB were significantly lower compared to RA

(p ¼ .002) and RD (p ¼ .001). Also, RC repre-

sented significantly lower ratings for computer

monitor, compared to RA (p < .001) and RD

(p < .001). RB had significantly lower mean

ratings for satisfaction with the wall monitor

104 Health Environments Research & Design Journal 12(4)

(p < .001) and exam table (p < .05), compared to

other rooms. Post hoc tests showed that RD rep-

resented the highest satisfaction ratings for the

physician workstation table, compared to other

rooms (p < .01). Satisfaction with the curtain con-

figuration ranged significantly in exam rooms.

RD had significantly higher ratings for the

curtain configuration compared to other

rooms (p < .05). Further RA had significantly

lower curtain configuration ratings compared

to RB or RD (p < .05).

Table 4 displays descriptive values for vari-

ables that significantly differed across rooms by

user type for examination stages, communication,

information sharing, and room features. (For this

study, only relevant features are disused.) For

MDs, the following attributes significantly dif-

fered: RC and RB the least favored for the com-

puter monitor and wall-mounted monitors,

respectively, compared to other rooms. MD

workstation in RD was more favored than in

RC. The curtain configuration in RD was rated

higher than in RA and RC.

For MAs, the computer monitor configuration

in RB had lower ratings than in RA and RD. RB

was the least favored for wall-monitor

configuration, compared to other rooms. For fam-

ily members, RC had higher ratings than RB for

information sharing on monitor, with RB the least

favored across all rooms for information viewing,

wall-monitor configuration, and exam table. The

curtain in RD was rated more satisfactory than in

RA. For patients, RB was the least favored for

information sharing, information viewing, com-

puter monitor, wall-mounted monitor, and exam

table across all rooms. Also, patients favored RD

more than RA for curtain configuration and the

MD workstation. Overall, all participants had

higher satisfaction with RD and low satisfaction

ratings for RB.

Open-Ended Findings

Table 5 presents examples of liked or disliked

physical features, associated attributes, and possi-

ble outcomes. Table 6 displays total frequency of

negative or positive comments based on room type

and associated outcomes. Figures 2 and 3 display

findings based on room type, physical features,

and associated outcomes (Figures 2 and 3).

The triangular setup in RA and RD was the

most preferred because it supported eye contact,

communication, and monitor information-sharing

opportunities. Physicians favored the ability to

maintain eye contact while entering EHR informa-

tion in RA and RD. The clinicians favored the

shape of the MD workstation and its orientation

toward the exam table that provided minimal dis-

tance between the provider and patient, facilitating

conversation and monitor sharing. The exam table

position was the most favored feature in RB, as it

provided adequate room for examination, was near

the caregiver chair, and afforded eye-contact

opportunities when the provider entered the room.

The triangular setup in RA and RD was

the most preferred because it supported

eye contact, communication, and monitor

information-sharing opportunities.

In RC, the multiple wall-mounted monitors

were a preferred feature. Comments inferred that

information sharing was enhanced by the

“readable fonts.” Additionally, the monitors were

considered a positive distraction in the exam

Table 2. Analysis of Variance Results of Significant
Predictors for MD Communication With Patients or
Family.

b F

Satisfaction With MD Communication With Patient
RB MD workstation 0.30** 7.91**
RC Wall-mounted monitor 0.29* 11.68***

Sharing information on
monitor

0.27*

RD MD workstation 0.51*** 23.39***
Viewing information on

monitor
0.32**

Satisfaction With MD Communication With Family
RA Sharing information on

monitor
0.23* 4.28*

RC Wall-mounted monitor 0.29** 9.73***
MD workstation 0.26*

RD Physician workstation 0.54*** 22.04***
Viewing information on the

monitor
0.24**

Note. MD ¼ medical doctor; RA ¼ Room A; RB ¼ Room B;
RC ¼ Room C; RD ¼ Room D.
* indicates p < .05; ** indicates p < .01; *** indicates p < .001

Zamani and Harper 105

room. Conversely, some participants disliked the

wall-mounted monitor information sharing in

RC who perceived it as “overwhelming,”

“expensive,” or “unnecessary.” The clinicians

were concerned about liability issues for sharing

sensitive information and violating Health Insur-

ance Portability and Accountability Act of 1996

(HIPPA) policies (n ¼ 10). Physicians also

favored the mobile workstation and wireless

keyboard in RC that enhanced maneuvering and

flexibility during EHR entry.

The inadequate distance between clinician

workstation and exam table in RA resulted in the

most negative comments on furniture positioning,

indicating that it resulted in uncomfortable man-

euvering, tripping hazards, furniture movements,

and inefficiency. The exclusive layout of RB had

the highest number of negative comments on

face-to-face communication, information shar-

ing, and patient comfort. Participants criticized

the location of provider workstation in RC in

relation to the monitors. Providers needed to

Table 3. One-Way Analysis of Variance on Satisfaction With Exam Room Features.

Satisfaction Rating RA Mean (SD) RB Mean (SD) RC Mean (SD) RD Mean (SD) F

Monitor sharing 4.03 (2.83) 2.66 (2.5) 4.96 (2.47) 4.22 (2.86) 14.19***
Monitor information viewing 4.95 (2.6) 3.54 (2.7) 4.84 (2.44) 4.76 (2.68) 6.58***
Computer monitors 5.72 (1.61) 4.90 (2.13) 4.35 (2.59) 5.86 (1.49) 10.16***
Wall-mounted monitor 4.58 (2.7) 0.63 (1.8) 4.81 (2.42) 4.71 (2.73) 76.48***
Exam table 4.83 (2.16) 4.30 (2.1) 5.61 (1.60) 5.65 (1.52) 12.13***
Physician workstation 4.48 (2.36) 4.50 (2.14) 4.31 (2.39) 5.60 (1.83) 6.61***

Note. RA ¼ Room A; RB ¼ Room B; RC ¼ Room C; RD ¼ Room D.
***p < .001.

Table 4. Significant Satisfaction Average (M) and Standard Deviation (SD) Variations Across Rooms by User
Type.

A B C D
FM (SD) M (SD) M (SD) M (SD)

MD Computer monitor 6.10 (1.03) 5.33 (1.69) 3.81 (2.39) 6.32 (0.77) 14.91***
Wall-mounted monitor 4.29 (3.04) 0.39 (1.41) 5.03 (2.01) 4.93 (2.56) 28.78***
Physician workstation 5.29 (2.04) 4.94 (1.87) 4.55 (1.86) 6.07 (1.04) 3.87*
Curtain 1.48 (2.13) 3.00 (2.87) 1.68 (2.27) 4.07 (2.65) 6.94***

MA Computer monitor 5.91 (1.28) 5.37 (2.11) 4.16 (2.41) 5.77 (1.57) 4.24**
Wall-mounted monitor 4.05 (2.79) 1.00 (2.13) 3.60 (2.63) 3.59 (3.00) 5.35**
Curtain 2.22 (2.61) 2.26 (2.88) 2.38 (2.84) 5.73 (1.67) 10.07***

Family Sharing information on monitor 4.00 (2.76) 2.20 (2.21) 5.50 (2.47) 3.75 (3.06) 5.73**
Viewing information on monitor 4.90 (2.57) 1.90 (1.74) 5.80 (2.38) 4.63 (2.77) 10.49***
Wall-mounted monitor 5.68 (1.39) 0.41 (1.53) 5.48 (2.40) 4.95 (2.48) 34.18***
Curtain 2.23 (2.56) 3.73 (2.57) 2.64 (2.63) 4.45 (2.21) 3.50*
Exam table 5.14 (2.38) 3.10 (1.87) 5.84 (1.70) 5.70 (2.05) 8.61***

Patient Sharing information on monitor 4.15 (2.91) 1.50 (1.91) 5.75 (1.95) 4.53 (2.85) 7.84***
Viewing information on monitor 5.15 (2.64) 1.64 (1.98) 5.75 (1.95) 5.12 (2.71) 9.12***
Computer monitor 6.21 (0.89) 3.29 (2.27) 5.63 (2.31) 5.82 (1.85) 6.72**
Wall-mounted monitor 5.69 (1.89) 0 5.69 (2.15) 5.82 (2.30) 33.57***
Curtain 2.29 (2.46) 4.07 (2.76) 3.06 (2.74) 5.00 (2.32) 3.28*
Physician workstation 3.21 (2.15) 4.57 (1.16) 4.38 (2.78) 5.94 (1.78) 4.53**
Exam table 6.14 (1.35) 4.14 (2.11) 5.81 (1.52) 6.41 (1.12) 6.35**

Note. MD ¼ medical doctor; MA ¼ medical assistant.
* indicates p < .05; ** indicates p < .01; *** indicates p < .001

106 Health Environments Research & Design Journal 12(4)

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(R

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l
(R

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lik

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p
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ck

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ro

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m

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ve

ry
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ry

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ry

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am

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lo
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d
e

ch
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rs
.

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h
ey

se
em

in
th

e
w

ay
o
ft

h
e

p
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n
;t

ig
h
t

o
n

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se
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to
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am
ch

ai
r

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d

o
th

er
ch

ai
rs

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m
ily

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ot

e.
M

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¼

m
ed

ic
al

d
o
ct

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r;

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¼

m
ed

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al

as
si

st
an

t;
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A
¼

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o
m

A
;
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B
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m

B
;
R

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¼

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m

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;
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D
¼

R
o
o
m

D
.

107

Table 6. Total Frequency of Negative and Positive Open-Ended Comments Based on Room Type and Associated
Outcomes.

Position Flow
Patient

Comfort Gazing
Info

Sharing
Staff Safety
Comfort

Total frequency of positive comments
Room A 128 44 28 2 1

Room B 102 9 32 40 9 6
Room C 110 36 36 16 11 26
Room D 94 30 42 6 3

Total frequency of negative comments
Room A 128 44 28 2 1 0
Room B 102 9 32 40 9 6
Room C 110 36 36 16 11 26
Room D 94 30 42 6 3 12

31.00

0.00

1.00

11.00

6.00

30.00

17.00
21.00

8.00 7.00

16.00

6.00 7.00

2.00

6.00

28
31.00

27.00

10.00

7.00

1.00

11.00

1.00

3.00

1.00 2.00

4.00

1.00

5.00

5
2.00

4.00

15.00

18.00

13.00

2.00

5.00

4.00

5.00

5.00 4.00

14 18.00

13.00

1.00

11.00

3.00

2.00

3.00

4.00

2.00

1.00

18.00

7 4.00

3.00

11.00

4.00

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

Ex
am

T
ab

M
D

W
or

ks
ta

�o
n

Ch
ai

W
al

l M
on

ito
r

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m

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r M
on

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r

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am

T
ab

M
D

W
or

ks
ta

�o
n

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ai

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nk

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rt

ai
n

Ex
am

T
ab

M
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W
or

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ta

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ai

W
al

l M
on

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ed

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al

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qu

ip
m

en
t

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am

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ab

M
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W
or

ks
ta

�o
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ai

W
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on

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r

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m

pu
te

r M
on

ito
r/

Ke
yb

oa
rd

W
in

do
w

RA RB RC RD

Frequency of Posi�ve Comments on Exam Room Physical
Features and Percevied Outcomes

Posi�on Impac�ng Flow Pa�ent Safety-Comfort Face-to-Face Communica�on Info Sharing

Figure 2. Open-ended comments content analysis results. The diagram displays frequency of positive comments
on exam room features and associated outcomes. Image authorship: author.

108 Health Environments Research & Design Journal 12(4)

continually turn around to read the screens. Fur-

ther, providers found that facing the wall-

mounted monitors was an “inconvenience.”

RC was also disliked for the caregiver chair

location as it was uncomfortably close to the

door, curtain, and exam table. Its location also

restricted eye contact opportunities with clini-

cians during the examination. RD had the high-

est frequency of negative comments impacting

patient safety and comfort due to the opposite

positioning of caregiver chairs in relation to the

exam table, which was criticized for impeding

patient privacy and safety.

Discussion

This article underscores the salience of physical

attributes of exam rooms in supporting patient-

centered care by impacting communication, EHR

interaction, and satisfaction outcomes. Total

behavior duration of EHR interaction was less

than talking or gazing. This may be due to

19 15

22
15

31 27

2
7

16
11

8
18 16 18 14 18

8
3

5
5

8
9

14
8

4 2

5
4

1 2

3 7

1
3

7 3

2 1

100

120
Co

m
pu

te
r T

ab
le

Cu
rt

ai
n

Di
ag

no
s�

c
Se

Ex
am

T
ab

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ai

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m

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te

r/
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oa

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pu
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r T
ab

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rt

ai
n

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ag

no
s�

c
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am

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ab

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ai

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ab

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ag

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am

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ab

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w

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ai

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ab

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ag

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Ex
am

T
ab

Si
nk

W
in

do
w

ROOM A Room B Room C RD

Frequency of Nega�ve Comments on Exam Room
Physical Features and Percevied Outcomes

Posi�on Impac�ng Flow Pa�ent Safety-Comfort

Face-to-Face Communica�on Info Sharing Staff Safety-Comfort

Figure 3. Open-ended comments content analysis results. The diagram displays frequency of negative comments
on exam room features and associated outcomes. Image authorship: author.

Zamani and Harper 109

participants entering scenario-scripted informa-

tion in computers, whereas in real-life instances

more focus, experience with EHR technology,

and attention are required to enter data and

prevent possible errors (Kazmi, 2014). Clini-

cians had to continually look back-and-forth

between the EHR screen and the patient and

caregiver, resulting in longer BDS durations

in RC. Further, the lack of dedicated computer

monitors was an obstacle toward simultaneous

eye contact and EHR entry, reducing satisfac-

tion and efficiency.

The results of this study indicate the active

role of computer monitors, and more specifi-

cally wall-mounted screens, in information shar-

ing and decision-making during clinical visits.

RA and RD were highly favored for the posi-

tioning of the wall monitor, clinician worksta-

tion, and the exam table. This triangular

arrangement promoted face-to-face communica-

tion, active information sharing, and simulta-

neous

EHR entry. It also enabled concurrent

data entry and eye contact for the

clinician.

This triangular arrangement promoted

face-to-face communication, active

information sharing, and simultaneous

EHR entry. It also enabled concurrent

data entry and eye contact for the

clinician.

Similar to previous studies (Ajiboye et al.,

2015; Almquist et al., 2009; Asan et al., 2015;

Kumarapeli & de Lusignan, 2012; Unruh et al.,

2010), the inclusive layout of RC was highly pre-

ferred for information sharing and interaction

facilitated by the size and quantity of wall moni-

tors in the room. Nevertheless, clinicians were

concerned about inability to control what infor-

mation is shared on the monitors, which could

jeopardize patient privacy, as found in prior stud-

ies (Asan et al., 2015; Bonner et al., 2010; Dow-

ell, Stubbe, Scott-Dowell, Macdonald, & Dew,

2013; Margalit, Roter, Dunevant, Larson, & Reis,

2006). Consistent with prior studies on exclusive

layouts (Asan et al., 2015; Milne et al., 2016;

Unruh et al., 2010), the lack of wall monitors for

information sharing with patients and families in

RB resulted in promoted passive patients and was

highly disliked by all participants.

. . . the inclusive layout of RC was highly

preferred for information sharing and

interaction facilitated by the size and

quantity of wall monitors in the room.

Sharing and viewing information on monitors,

as well as the orientation of MD workstation and

wall monitors, were predictors for communication

between MD, patient, and families. The findings

showed that across all rooms, designing opportuni-

ties for patient interactions through room layout

should be prioritized for achieving a patient-

centered experience. Studies show that physician

gaze highly impacts patient gaze, and thus focusing

on EHR information decreases potential eye con-

tact with patients (Almquist et al., 2009; Asan et al.,

2013; Montague & Asan, 2014). When clinicians in

RB focused on EHR entry with their back toward

the patient, eye contact was reduced. This exclusive

layout was identified as “impersonal” as it discour-

aged patient-centered communication, eye contact,

and information sharing. This corroborates previ-

ous literature (Gorawara-Bhat & Cook, 2011;

Kazmi, 2014; Kumarapeli & de Lusignan, 2012;

Milne et al., 2016; Montague & Asan, 2014).

Sharing and viewing information on

monitors, as well as the orientation of MD

workstation and wall monitors, were

predictors for communication between MD,

patient, and families.

In RC, computer screens were defined as dis-

tractions. In contrast, the semi-inclusive rooms

(RA and RD) were highly preferred as they facili-

tated provider–computer–patient–family commu-

nication and information sharing. In this room,

the clinician controlled the extent of data sharing

displayed on the wall monitor and could position

their keyboard workstation in various ways for

data entry. In RA, some participants, especially

patients, mentioned that the close distance

between workstation and exam table felt uncom-

fortable during the examination. In RC, the work-

station was portable but not positioned for

optimum wall-monitor viewing, and in RB, the

110 Health Environments Research & Design Journal 12(4)

workstation was at the corner of room limiting

EHR sharing and eye contact. This result shows

the importance of the workstation orientation for

enhanced gazing and monitor sharing.

Satisfaction with exam tables has been linked

to satisfaction with the facility, perceived quality

of care, and approach behaviors (Lee, 2011). The

results of this study offer new empirical insight

on how the orientation and usability of exam

tables also had major impacts on satisfaction. In

RA, participants were dissatisfied about the posi-

tioning of the exam table in the midsection of the

wall as it resulted in space redundancies. Further,

the exam table located at the front of the consult

table yielded a tight space for maneuvering dur-

ing examination thus reduced throughput. For

families and patients, the exam table in RB was

the least favored, compared to other rooms.

Reflecting on usability issues, families of pedia-

tric patients and older patients complained about

the difficulty of getting onto the exam table due to

its high positioning. Participants were unable to

alter the exam table configuration, and in RB, the

exam table was armless with manual adjustments.

Also, during pelvic exams, the stirrups were too

close to family chairs. The orientation in relation

to MD workstation impeded eye contact between

providers and patients and was unfavorable.

Integrating positive distractions in healthcare

environments is associated with enhancing

patient mood and satisfaction, as well as reducing

anxiety, pain, and the perception of waiting time

(Nanda et al., 2012; Schneider, Ellis, Coombs,

Shonkwiler, & Folsom, 2003). In line with prior

literature (Corsano, Majorano, Vignola, Guidotti,

& Izzi, 2015; Schneider et al., 2003), participants

mentioned that multiple monitors in RC facilitated

“the passing of time” and provided a “positive dis-

traction.” This underlines the importance of incor-

porating dynamic, interactive, and informative

technology components as a positive distraction.

During the clinical exam, triangulation

changes as patients, family, and clinicians move

through different stages. Figure 4 demonstrates

Figure 4. Triangulation diagram. This diagram shows the change in triangulation angles at start and information
sharing stages of the exam visit. Image authorship: author.

Figure 5. Ideal exam room layout. This diagram dis-
plays a revised configuration of Room D based on the
empirical findings. Image authorship: author.

Zamani and Harper 111

the how triangulation in each room is altered from

the starting stage of the exam (handwashing upon

clinician’s entry) to information gathering.

Rooms that maintain the relative angles between

the participants and between stages support tran-

sition as the clinician moves in the room and help

to keep the

continuity of the conversation, by

minimizing the disruption of repositioning. The

qualitative findings highlighted the importance of

furniture distances and adjacencies in exam

rooms to enhance performance and comfort. For

instance, participants in RD criticized that the

“too close” distance of furniture produces trip-

ping hazards for participants. Having the chair

at the corner of RD made some caregivers feel

“left out” of the examination process. Patients in

RC favored sitting next to caregivers while obser-

ving the wall-monitor information. However, the

location of caregiver chairs was the least favored

as it was proximate to the door swing, curtain, and

exam table and impacted flow and comfort.

Rooms that maintain the relative angles

between the participants and between

stages support transition as the clinician

moves in the room and help to keep the

continuity of the conversation, by

minimizing the disruption of

repositioning.

Adjustable and flexible furniture was an

important consideration for achieving satisfac-

tory evaluation. The fixed consult table in RD

was not favored and was perceived as a limitation

for monitor sharing and communication. How-

ever, being able to readjust computer monitors

using adjustable swivels diminished this barrier,

as suggested by prior studies (Chen et al., 2011).

RD had higher satisfaction ratings for the posi-

tioning of the curtain. RD’s curtain location

effectively separated the patient zone from family

or clinician zones and did not interfere with any

room furnishings. RA’s curtain had the lowest

rating across all participants as the family and

patient zone were on the same side forcing the

family to walk next to the door during the exam.

RA was perceived as not protecting patient pri-

vacy as patients were not shielded from the door

by a curtain.

Limitations and Directions for
Future Research

This study has limitations. In response to client

contracts, researchers were not able to test a semi-

inclusive patient-controlled layout. Further, due

to a lack of resources, researchers were unable

to code all the collected videos, so randomization

was employed to retrieve an acceptable sample.

Demographic data were not retrieved to ensure

Figure 6. Ideal exam room layout and triangulation. This diagram displays the revised configuration of Room D
clinical exam room that supports eye contact and information sharing by triangulating exam table, medical
doctor’s workstation, and family chairs, and wall-mounted monitor. Image authorship: author.

112 Health Environments Research & Design Journal 12(4)

patient, caregiver, and clinician privacy. It would

be interesting to explore the impact of age, gen-

der, and ethnicity in satisfaction and communica-

tion outcomes in relation to room layouts.

Although observer reliability was at an accepta-

ble level, modifying the methodology and coding

descriptions may enhance reliability in future

studies. In real-time clinic visits, interruptions

and distractions may impact examination and

behavioral durations or segmentation. Addition-

ally, clinicians from different areas of expertise

may use different examination methods from

those we explored. More research is needed to

explore different communication and satisfaction

outcomes in various medical specialty contexts

and with diverse layouts affected by design fea-

tures in exam rooms. In future research, diverse

patient types and demographics should be

explored. It would also be interesting to validate

the results obtained in this research through pre-

occupancy and postoccupancy assessments

through the design of new clinical exam rooms.

Conclusion

Exam room layout modification provides a great

capacity to increase communication, EHR inter-

action, and satisfaction in clinical exam rooms.

Semi-inclusive physician-controlled configura-

tions increased eye contact and encouraged

patient–caregiver involvement in discussions.

The computer in this layout was appreciated as

it supported patient privacy during information

sharing. Inclusive layouts promoted interactions

between clinicians, patient, and technology.

However, participants emphasized the value of

a balanced and effective technology integration

that is not overwhelming for the patients and pro-

tects patient privacy. The lack of opportunities for

viewing and sharing information in the exclusive

layout negatively affected the clinician’s capabil-

ity to establish eye contact and attentiveness

toward them.

In terms of furniture arrangement, the results

show that triangular configurations for the exam

table, clinician table, and caregiver chairs were

highly preferred. This orientation contributed to

comfortable encounters, efficiency, eye contact,

and effective information sharing. Patients

reflected the need for proper orientation of exam

table in relation to family chairs, curtains, or

doors to enhance perceptions of privacy and com-

fort. These findings suggest the importance of

comfortable and acceptable distance between fur-

niture (especially MD workstation, exam table,

and chairs) to reduce flow disruptions and

enhance comfort. The results of this study suggest

that RD had the best layout configuration for

patient-centered outcomes. Figure 5 suggests

changes to RD in response to the participant com-

ments. In the edited RD exam room, repositioning

the sink in the circulation path of the clinicians

promotes hand hygiene. An additional monitor

placed 90� from each other supports a triangular

relationship between patients, family, and clin-

icians as well as ease of maintaining eye contact

during information sharing (Figure 6). Further,

the revised position of the curtain and family

seating supports privacy and comfort. Overall,

this research contributes to the body of knowl-

edge and adds new perspectives regarding beha-

viors and preferences impacted by different

exam room layouts.

Implications for Practice

� Locate shared monitors directly in front of

patients, caregivers, and physician to

enhance information sharing, patient–fam-

ily engagement, and comfort.

� Configure appropriate distance for room

furniture positioning for comfortable man-

euvering, comfortable access to equipment,

and visibility of shared information.

� Triangular configuration of exam table,

caregiver chairs, and physician workstation

facilities eye contact, engagement, and

productivity.

� Providers prefer semi-inclusive exam room

configurations that include private and control-

lable computer screens on portable tables for

comfortable information sharing, simulta-

neous data entry, and enhanced face-to-face

communication.

� Exam table location, angle, and attributes are

essential factors for supporting patient pri-

vacy and comfort. Placing the exam table at

Zamani and Harper 113

the room corner with a 45� angle and reason-

able reach from provider chairs and curtain is

preferable.

Acknowledgment

The completion of this research could not have

been possible without the collaboration and assis-

tance of so many people. The authors sincerely

appreciate the inisght and contributions of Dr.

Nicholas Watkins and Alice Gittler.

Declaration of Conflicting Interests

The authors declared no potential conflicts of

interest with respect to the research, authorship,

and/or publication of this article.

Funding

The authors disclosed receipt of the following

financial support for the research, authorship,

and/or publication of this article: The authors

would like to thank EwingCole for funding this

research article.

ORCID iD

Zahra Zamani, PhD, EDAC https://orcid.org/

0000-0003-0536-245X

Supplemental Material

Supplemental material for this article is available

online.

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Mucahid Emre Kahraman

Research Analysis Practice

Mucahid Emre Kahraman

Professor Silvia Muller

2023SP – SOCIAL INFORMATICS 5:40 ASSIGNMENT

February 19, 2023

What is the exact statement in which the authors of your study describe what they were testing. (Hint: This information may be provided in the article as a hypothesis or a research question(s). Include quotation marks around the exact wording and indicate page number(s).

‘Exploring the Effects of Clinical Exam Room Design on Communication, Technology Interaction, and Satisfaction’ Page 99

Describe the purpose of the study in your own words.

This study aims to investigate the impact of technology integration and design features in clinical exam rooms on patient examination experiences, communication, and satisfaction. The study aims to determine whether integrating technology, such as electronic medical records, digital imaging, or patient portals and design features, such as ergonomic furniture and ambient lighting, can enhance the overall quality of clinical examinations. The study also seeks to examine the influence of these factors on patient communication with healthcare providers and their overall satisfaction with the healthcare experience. By analyzing the effects of technology and design features on patient outcomes, the study aims to provide insights into how healthcare facilities can optimize their clinical exam rooms to improve patient care and satisfaction.

What was the gap in the research that the authors were trying to fill by doing their study? How many sources do the authors cite?

In their article “Exploring the Effects of Clinical Exam Room Design on Communication, Technology Interaction, and Satisfaction,” the authors addressed a research gap regarding the relationship between the clinical exam room design and patient outcomes. Although previous studies have explored the impact of the physical environment on healthcare outcomes, few studies have specifically examined the effect of clinical exam room design and technology integration on patient outcomes such as communication and satisfaction. To address this gap, the authors reviewed a diverse set of 21 sources, including peer-reviewed research articles and books related to healthcare design, patient communication, and technology integration in healthcare settings. Considering a broad range of literature, the authors provided a comprehensive overview of the current research on this topic and identified areas that require further exploration.

What are some of the authors’ major conclusions or findings in the article? Include quotation marks wherever you are quoting from the article and indicate page numbers.

Firstly, the authors found that the design of clinical exam rooms can significantly impact communication and technology interaction, which can affect patient satisfaction. The authors state, “Rooms that maintain the relative angles between the participants and between stages support transition as the clinician moves in the room and help to keep the continuity of the conversation by minimizing the disruption of repositioning.” (p. 112). That indicates that the physical environment of a clinical exam room, including its layout, lighting, and furniture, can affect the way healthcare providers and patients interact and communicate during clinical examinations. The authors also found that a well-designed clinical exam room can positively influence a patient’s emotional and physical well-being, leading to better health outcomes. The authors note, “Adjustable and flexible furniture was an important consideration for achieving satisfactory evaluation” (p. 112). That suggests that patients are more likely to feel at ease and comfortable in a clinical exam room designed with their needs in mind, which can lead to better outcomes regarding their overall health and well-being.

Moreover, the authors found that technology integration can enhance communication between healthcare providers and patients. They note that ” The fixed consult table in RD was not favored and was perceived as a limitation for monitor sharing and communication. However, being able to readjust computer monitors using adjustable swivels diminished this barrier…,” (p. 112). That suggests that technology, such as electronic medical records, digital imaging, or patient portals, can improve the flow of information and communication between patients and healthcare providers during clinical examinations.

What is your understanding of these findings in your own words?

According to the article, the design of clinical exam rooms and technology integration has a notable effect on patient outcomes, including communication, satisfaction, and overall well-being. A well-designed clinical exam room can create a more comfortable and relaxed environment for patients, leading to improved health outcomes. Furthermore, technology integration can facilitate communication between patients and healthcare providers, resulting in more effective care. These findings suggest that healthcare providers should consider patient-centered approaches when designing clinical exam rooms and integrating technology to enhance the quality of care and patient experience in clinical settings.

Briefly summarize the main steps or measurements the authors used in their methods. Explain these methods in your own words as much as possible.

The study used a mixed-methods approach to examine the impact of clinical exam room design and technology integration on patient outcomes. The authors surveyed 22 patients, observed four exam room mock-ups, and conducted in-depth interviews with healthcare providers. They analyzed the data using descriptive statistics and content analysis. Overall, the authors employed a comprehensive approach to gather and analyze data on the impact of clinical exam room design and technology integration on patient satisfaction, communication, and overall health outcomes.

Do the authors suggest any problems with their methods? Do you see any problems or limitations with their methodology?

The study’s small sample size, with only 22 patients and a limited number of healthcare providers, limits the generalizability of the findings. Additionally, the study only considered patient and healthcare provider perspectives, overlooking organizational and environmental factors that could affect patient outcomes. Lastly, the study was conducted in a mock-up setting, which may not accurately reflect real clinical settings. While these limitations exist, the methodology still provides useful insights into the impact of clinical exam room design and technology integration on patient outcomes.

How did the authors analyze their data? Describe their tests in your own words.

The authors used both quantitative and qualitative data analysis methods to analyze their data. They used descriptive statistics to analyze the survey data about communication, satisfaction, and technology use in clinical exam rooms. The authors also conducted content analysis on the qualitative data from the observations and interviews to identify common themes and patterns. They used a standardized observation tool to collect data on the design features and technology used during the observations of the mock-up exam rooms. For the in-depth interviews with healthcare providers, the authors transcribed the interviews and conducted a content analysis to identify common themes and patterns in the healthcare providers’ responses regarding the impact of the design features and technology integration on clinical care.

Do the authors suggest any problems with the study that could lead to unreliable results?

The study has limitations that could affect the reliability of its results. These include being unable to check/inspect a semi-inclusive patient-controlled layout due to client contracts, not coding all collected videos, lack of demographic data, and the need to discover many different communication results in different medical specialty contexts and with multiple patient types and demographics. Additionally, observer reliability was acceptable but could be improved in future studies. Interruptions and distractions during real-time clinic visits may lead to examination and behavioral separations. Future research should also explore validating the results obtained from pre-occupancy and post-occupancy assessments of room designs.

Do the conclusions about the nature of the study results discussed by the authors make sense to you? Do the claims seem in proportion to the size or the nature of the study?

The conclusions need to be clarified for me due to the proportion in size. Twenty-two patients are a lower figure for any meaningful study that seeks to refer to a significantly larger population.

Based on the accuracy of the methodology and the reliability of the results, do you think the conclusions can be believed?

Not entirely, the conclusion is inconclusive, and more studies must be conducted.

Based on what you have discussed in this exercise, how could the findings of your study be applied in new software development or implementation of existing tools?

I could use the study findings to improve patient experience and health outcomes by integrating technology into clinical exam rooms. To make care more effective, software or tools could include features that promote communication and patient comfort. A mixed-methods approach can provide a comprehensive understanding of design features and technology integration’s impact on patient outcomes. It could be used to evaluate the new software or tools. The study offers insights that can be used to develop and implement more patient-centered technologies in clinical exam rooms.

Reference

Zamani, Z., & Harper, E. C. (2019). Exploring the Effects of Clinical Exam Room Design on Communication, Technology Interaction, and Satisfaction.
HERD: Health Environments Research &Amp; Design Journal,
12(4), 99–115. https://doi.org/10.1177/1937586719826055

Bottom of Form

For this assignment, you will submit a final draft of your earlier assignment answering questions about your Class Meeting group’s research study.

In addition to this final draft, you are also required to produce a presentation of your analysis to the class.

Essentially a presentation is a different way to present data in support of an argument. The essential pattern for all the research study presentations is the same:

· State the title of the study with a full, correct, and legible APA citation for the assigned research study on the first slide in large type.

· Summarize the purpose and hypothesis of the study,

· What were the major findings of the study?

· How did the author(s) test their hypotheses?

· Are the results likely to be reliable and accurate?

· How would Kling see this study as fitting into (or, possibly, not fitting into) his argument for why the research in the field of Social Informatics? How is this research connected to Kling’s argument?

Although you should feel free to discuss your work with other members of the group, each person is responsible for posting a video presenting their answers to these questions in which they speak and their language is their own. The discussion thread for posting these videos is available here.

For an example of a previous student’s video presentation, see:

Links to an external site.

After the videos are posted on or before Wednesday, March 8th, individually, each student is required to watch

at least four other assigned students’
videos and post review and questions for each presentation. Assignments and a rubric will be provided and reviewed in the class meeting. Feedback is due before 11:59 pm, Friday March 10th.

A few tips for creating your presentation:

· These presentations will be done online using videos. Ultimately, it doesn’t matter which software tool you opt to use to create this video, so long as the material is clear and the focus remains on the content, not on the film-making. A screen capture tool such as Kaltura or Screencast-o-matic are both OK options, but I would use any tool that can output to .mp4.

·
You will need to upload your video work to a streaming service (YouTube or Vimeo works well)
and embed your finished video in a posting to the discussion in Canvas. The revised Analysis document is submitted for this assignment.

· I’m not going to impose a specific time limit for these presentations since we’re working online instead of in a class meeting. I would recommend that 6-8 minutes is a good time to aim for. Running very short or very long is a strong indication that you either haven’t done a good job analyzing the study or you haven’t decided what the best materials to present are.

· You shouldn’t need to cite any sources for either the analysis essay or the video except the assigned research study itself. If you do choose to cite other work in the video, please use APA format on the slides that contain specific data points or quotes. (this can be in smaller type than the rest of the body text)

· Glitz isn’t exactly the enemy of sound reasoning and fact in presentations, but it’s not your friend either. Keep your presentation simple and consistent and be prepared to cut anything that doesn’t move your points forward in a clear fashion.

Grading for this assignment is 50% on the revised analysis document, 30% the presentation (your interpretation of the article you were assigned as well as the presentation design including citations, spelling, grammar and APA citations on the slides), and 20% your completion of the feedback for other students’ work.
In particular I am looking for you to respond to my requests for clarification from the earlier assignment analyzing the study which are listed in the Speedgrader feedback.

As always, please be sure to email me with questions and follow up for this assignment!

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The Information Society, 23:

205

–220, 2007
ISSN: 0197-2243 print / 1087-6537 online
DOI: 10.1080/01972240701441556

What Is Social Informatics and Why Does It Matter?

Rob Kling

School of Library and Information Science, Indiana University, Bloomington, Indiana, USA

Originally published in D-Lib Magazine, January,
1999. Available at http://www.dlib.org/dlib/january99/kling/
01kling.html. Reprinted with permission.

1. INTRODUCTION

A serviceable working conception of “social informatics”
is that it identifies a body of research that examines the
social aspects of computerization. A more formal defi-
nition is “the interdisciplinary study of the design, uses
and consequences of information technologies that takes
into account their interaction with institutional and cultural
contexts.”

It is a field that is defined by its topic (and fundamen-
tal questions about it) rather than by a family of methods,
much like urban studies or gerontology. Social informat-
ics has been a subject of systematic analytical and critical
research for the last 25 years. This body of research has
developed theories and findings that are pertinent to un-
derstanding the design, development, and operation of us-
able information systems, including intranets, electronic
forums, digital libraries, and electronic journals.

Unfortunately, social informatics studies are scattered
in the journals of several different fields, including com-
puter science, information systems, information science,
and some social sciences. Each of these fields uses some-
what different nomenclature. This diversity of communi-
cation outlets and specialized terminologies makes it hard
for many nonspecialists (and even specialists) to locate
important studies. It was one impetus for coining a new
term—social informatics—to help make these ideas ac-
cessible to nonspecialists, as well as to strengthen commu-
nication among specialists, and to strengthen the dialogs
between communities of designers and social analysts.

This article discusses some key ideas from social in-
formatics research and ends with a brief discussion of the
character of the field today. Readers who wish to under-
stand social informatics by learning about its origins and
influences may wish to start in that later section and then
return to the beginning for a more substantive focus. This
article serves as a brief introduction to social informatics
for information technology professionals and researchers,

and includes numerous references to help interested read-
ers readily locate more comprehensive resources.

2. PUNDITRY ABOUT INFORMATION
TECHNOLOGIES AND SOCIAL CHANGE

There are alternatives to systematic research about infor-
mation technologies and social change. Wired Magazine’s
articles often illustrate one popular alternative—vivid pun-
ditry. In the January 1998 issue, journalist George Gilder
wrote about the way that computing power has increased
a hundred millionfold since the 1950s. Computer scientist
Danny Hillis wrote about the ways that computerization
is leading to a transformation of a new civilization in a
few paragraphs and with high spirits. This kind of opin-
ionated journalism is very readable. Wired is colorful, both
in its prose as well as its typography, and it lends itself to
new sound bites. Unfortunately, it doesn’t lead to the kind
of deep understanding that many information technology
professionals need.

Wired exemplifies the magazines that offer energetic
prose, but information technology pundits, such as Esther
Dyson, communicate in many other forums as well, such
as their own books and conference talks. Pundits play in-
teresting social roles. The best pundits are entertaining,
provocative, and timely. If an issue arises this week, they
can rapidly formulate an articulate opinion, and perhaps
even a sound bite. In simplifying, they often oversimplify
and polarize issues. Unfortunately, the typical pundit re-
lies upon anecdotes and bold assertions, rather than using
them as entry points for analysis. Pundits usually rely upon
their own experience as a basis for expertise and don’t en-
courage serious and systematic research into information
technology and social life (see Nimmo & Combs, 1992).

Professionals are sometimes involved in very prosaic
work in designing information systems, selecting and
configuring equipment and developing policies and prac-
tices about the use of the resulting systems (i.e., which
data to collect and archive, how to identify authorized
users, how to organize training and consulting). The de-
tails of this development work differs substantially for

205

206 R. KLING

systems as varied as claims management for an insur-
ance company, a litigation support system for a law firm,
and a public-access online library of self-help medical
bulletins supported by a public health agency. However,
social informatics researchers have developed some fun-
damental ideas that can help improve professional prac-
tice and that pertain to a diverse array of information
systems.

The design and configuration of information systems
that work well for people and help support their work,
rather than make it more complicated, is a subtle craft.
Good application design ideas are neither obvious nor
effective when they are based on technological consid-
erations alone. Their formulation requires understanding
how people work and what kind of organizational prac-
tices obtain. However, many managers and professionals
often advance simple criteria to help guide computeriza-
tion strategies, such as:

1. Use more advanced technology (whether it is faster
or easier to use);

2. Use “better technologies,” (though there are differ-
ent criteria for “better” such as less expensive or
compatible with other equipment); or

3. Organize systems so that they are more efficient.

There are other guidelines, such as replacing repetitive
human activity with computer systems or devising com-
puter systems to leverage an organization’s value chain.
These kinds of context-free guidelines have not been good
enough to help information technology professionals de-
sign or implement effective systems.

Their limitations will be illustrated by the examples that
I develop in the following sections. Before I launch into
a discussion of some interesting ideas from social infor-
matics research, I will discuss one important phenomenon
that helps sets the stage for the importance of social in-
formatics for information technology professionals—“the
productivity paradox.”

3. THE PRODUCTIVITY PARADOX

Between 1960 and 1980, computer use and productivity
gains were linked together—in the writings of economists,
in the advertisements for new computer systems, and even
in the expectations of many working people who feared
that widespread computerization could lead to a society
with massive unemployment. As the costs of acquiring
computers rapidly declined, many North American orga-
nizations, public and private, increased their investments
in computerized systems. In the late 1980s, U.S. firms
were spending approximately half of their capital funds
on computers and telecommunications. Economists no-
ticed that national statistics for labor productivity were
not steadily increasing, and some managers noticed that

large investments in PCs did not seem to translate into
major productivity boosts.

Since the late 1980s, the U.S. business press has trum-
peted the expectations that computerization would soon
lead to productivity spurts and also published stories that
dash such hopes. A set of stories from Business Week il-
lustrates the conflicting themes in the business press. In
February 1994, Business Week published two short articles
by Gene Koretz: “Computers May Really Be Paying Off:
Effect of Automation on Productivity in the Workplace”
and “And They’re Giving the U.S. a Nice Competitive
Edge.” In January 1995, Business Week published a short
article by Dean Foust, “Is the Computer Boost That Big?
Computers Do Not Enhance Productivity Very Much.”

Economists also differed in their beliefs about the
relationship between computerization and productivity
growth. Many believed that technological innovation was
a major factor in national productivity and assumed that
investments in information technology would be reflected
in national statistics; when the cumulative capital stock
of computer systems was large enough, they would re-
sult in improved productivity statistics. Some economists
coined the term “productivity paradox,” after Nobel lau-
reate economist Robert Solow (1987) wrote, “You can see
the computer age everywhere but in the productivity statis-
tics.” Solow’s assertion counters the common assumption
that computerization would directly and dramatically im-
prove productivity. Economists were divided in their ex-
planations of the productivity paradox. Some believed that
their ways of measuring productivity were inadequate; oth-
ers argued that the capital stock of information technology
was still too small to have meaningful consequences in na-
tional economic statistics; and still others argued that lag
effects were being underestimated. Still others believed
that mismanagement was a root cause of the productivity
paradox.

The “productivity paradox” is also an important so-
cial phenomenon. Unfortunately, it is ignored in the
technophillic press, such as Wired Magazine, and is
glossed by most of the pundits. Within the United States,
annual economic productivity has been growing at a much
slower rate in the mid-1970s through the 1990s than in the
1960s. For example, labor productivity in nonfarm busi-
ness grew by 2.8% from 1960 to 1973 but grew by only
1.1% from 1973 to 1996 (Webb, 1998). While the spe-
cific rates of growth of labor productivity vary with the
years counted, and do vary within economic sectors, the
general pattern of reductions in measured labor productiv-
ity growth rates in the last two decades is well accepted
among economists.

Certainly many things have changed in industrial soci-
eties between the first 20-year period after World War II
and the most recent 20-year period. One set of changes
is the proliferation of, and the very deep investment in,

WHAT IS SOCIAL INFORMATICS AND WHY DOES IT MATTER? 207

computer and telecommunication systems. Since the late
1980s, private firms in the U.S. have been investing about
half of their capital in information and communication
technologies. That investment includes telephone systems
and voice mail as well as computers. Still, it is a large frac-
tion, and it has been sustained since the “PC revolution.”
There has been a fairly intensive purchasing campaign, and
an increasing computerization campaign in major firms,
and it is beginning to show up in cumulative technology
investments on a significant scale.

This is the very period in which productivity gains are
not going up by a factor of a hundred million—the num-
ber that Gilder (1998) likes to give as the gain in comput-
ing value since the 1950s. In the U.S., labor productivity
has grown 2–4% per year in this period. Many people
have assumed that computerization should directly and
dramatically improve productivity. Newer computer and
telecommunication systems may offer many advantages
over traditional media or even older computerized systems.
However productivity gains may be hard to achieve with
the low-volume high-variety computer applications that
many professionals use. These may be called “productivity
tools,” but they may do more to help improve the appear-
ance of documents and presentations, to deepen analysis,
and to improve control over one’s work relationships—
especially with reduced secretarial support. These are
valuable gains, but they may not translate into “throughput
productivity.”

Some economists are concerned about these matters
and believe that the productivity paradox is primarily “not
real.” It will be resolved by improved ways to measure
productivity and actually a larger investment in computer
systems. There is a lively debate between economists and
organizational analysts (see Kling, 1996b). Organizational
analysts suggest explanations that range from “We haven’t
learned how to use computers well enough at an organiza-
tional and social scale” (King, 1996), through describing
many organizational processes and work practices that re-
duce productivity in practice (Attewell, 1996). Such work
practices include managers generating more numerous,
fine-grained reports from information systems, authors
making numerous interim drafts of manuscripts, people
fiddling with malfunctioning computer systems, and so
on. The managerial reports may help managers feel more
confident in taking certain actions, the incrementally re-
vised manuscripts may be improved, and so on. But these
practices don’t increase “throughput productivity.”

There are several social explanations for the produc-
tivity paradox: (a) Many organizations develop systems
in ways that lead to a large fraction of implementation
failures; or (b) few organizations design systems that ef-
fectively facilitate people’s work; or (c) we significantly
underestimate how much skilled work is required to ex-
tract value from computerized systems. Taken together,

these observations suggest that many organizations lose
potential value from the ways that they computerize.

Some recent studies indicate that information technol-
ogy investments have improved the productivity of some
organizations and national economies in the 1990s (Bryn-
jolfsson & Hitt, 1998; Dewan & Kraemer, 1998). However,
the firm-level data show substantial variation across firms
(Brynjolfsson & Hitt, 1998, p. 52). The evidence is accu-
mulating that organizations that computerize intensively
with appropriate organizational practices are more pro-
ductive than the average, while those that do not organize
appropriately lag behind the firms that do not computerize
intensively. Brynjolfsson and Hitt (1998, p. 54) estimate
that the inappropriately organized, highly computerized
firms lag the appropriately organized, highly computer-
ized firms by 10%.

Resolving the productivity paradox lies in the future.
The productivity paradox gives us reason to believe that
current strategies of computerization do not readily pro-
duce expected economic and social benefits in a vast num-
ber of cases. In particular, technology alone, even good
technology alone, is not sufficient to create social or eco-
nomic value. This discussion offers an entry point into an
interesting set of studies and theories about the ways that
effective computerization depends upon close attention to
workplace organization and practices. I will discuss this
idea in greater depth later on.

4. EARLY RESEARCH IN SOCIAL INFORMATICS

Through the 1970s and 1980s, much of the social informat-
ics research focused on organizations because they were
the major sites of computerization. It is only in the last few
years that many people who are not themselves technical
specialists have gotten computer systems for home use.
The era of the Internet, or particularly public access to the
Internet, raises issues of work at home, communication at
home, entertainment, access to medical information, and
other personal uses. These are significant phenomena, but
are different from the topics I will emphasize. They are part
of social informatics, but they open up different lines of
analysis that warrant serious study and understanding (see,
for example, Anderson et al., 1995; Kahin & Keller, 1995).

In the 1970s and 1980s, often the questions about com-
puterization were phrased as deterministic impact ques-
tions, such as: “What would be the impact of computers
on organizational behavior if we did X?”; “What would be
the changes in social life if we did X?”; “Will computer
systems, for example, improve or degrade the quality of
work?” There are a number of studies in which people
try to answer this last question, whether work life would
improve for clerks, for engineers, for managers, and so
on. The questions were often phrased in very simple, di-
rect terms, namely: “What will happen, X or Y?” And the

208 R. KLING

answer was: “sometimes X, and sometimes Y.” There was
no simple, direct effect. Much of the character of changes
depended on the relative power of workers. For example,
clerks fared less well, on the average, than professionals.
But sometimes secretaries, who are the aristocrats of the
clerical class, were able to have greater improvements in
their work lives than were the people, primarily women,
who were doing transaction processing in the back rooms
of banks and insurance companies. Occupational power
played an important role in mediating and shaping the way
that computerization restructured workplaces (see Kling,
1980; Attewell, 1987; Iacono & Kling, 1987).

Other sets of questions were also examined. To what
extent were organizations centralized? There were ma-
jor arguments that computer systems would enable upper
managers to have much more detailed information about
the operations on workplaces, such as the shop floor, the
editorial room, and the classroom, and that organizations
would become more centralized. Others argued that they
would become more decentralized. Many people wanted to
know: “Well, which is it? Is it A or B?” Some studies found
that information technology use led to some organizations
centralizing, and other studies found that information tech-
nology use led to decentralization. Many of the arguments
which were engaged in a form of “Is it A or B?” were based
upon simple technological determinism that has not been
borne out in reviews of the careful studies (see King, 1983;
George & King, 1991). The analytical failure of techno-
logical determinism is one of the interesting and durable
findings from social informatics research.

Today some analysts (and many pundits) frame claims
about information technology in social life in deterministic
ways, with claims such as, “The Web means that the public
will get better information than ever before.” That fram-
ing is one that people who study social informatics would
be skeptical of. We ask: “When will the Web enable the
public to locate ‘better information’? Under what condi-
tions? Who? For what?” Are people seeking information
to help them make a better choice of doctors, and then
placing more trust in that doctor? Or are people seeking
alternatives to doctor-mediated medical care—whether in-
formation about health, herbal medicine, or postoperative
care? Those contingency questions don’t lend themselves
to lively sound bites. But they do yield a very nuanced pro-
fessional understanding. This kind of contextual inquiry il-
lustrates the ways that social informatics researchers frame
questions to develop an analytical understanding of infor-
mation technologies in social life.

5. SOME KEY IDEAS OF SOCIAL INFORMATICS

5.1 How Social Context Matters: Intranets in Action

One way to illustrate a contextual inquiry of information
technology in social life is to discuss some studies of the

ways consulting firms have adopted and used computer-
ized documentary systems.1 One major consulting firm,
PriceWaterhouse, bought 10,000 copies of Lotus Notes,
a documentary support system, for its staff in 1989. Lo-
tus Notes is superficially similar to an Internet-like system
with bulletin boards and posting mechanisms and discus-
sion groups and electronic mail for organizations. Depend-
ing upon how Notes is used, it can act as an e-mail system, a
discussion system, an electronic publishing system, and/or
a set of digital libraries.

PriceWaterhouse is an international consulting firm
with tens of thousands of employees worldwide, and about
10,000 of them are located in the United States. Their vice-
president of information systems believed that Lotus Notes
was such a powerful technology that it would sell itself,
that the main thing to do was to rapidly roll it out to the
consulting staff, and let them use it to find creative ways
to share information.

He was concerned that his firm employed thousands
of “line consultants” in different offices all over North
America, who work on similar problems and who rarely
share their expertise. Sometimes a consulting team in
Boston is dealing with the same kind of issue that a con-
sulting team in Toronto or San Francisco would be deal-
ing with, or very close. They had no easy way of sharing
their growing understanding of the problems they were
facing with their clients. Could the firm’s line consultants
use some kind of communication and computerized in-
formation system to store what they knew, and share it?
The first test was with the information technology staff.
They tended to use Notes; they found it interesting; and
they used it fairly aggressively for sharing information
about their own projects. PriceWaterhouse’s tax consul-
tants in Washington, DC, were another group that used
Lotus Notes (Mehler, 1992). These tax consultants studied
the behavior of the Internal Revenue Service and the U.S.
Congress, and disseminated tax advisories to PriceWater-
house offices around the country about shifting changes
in tax legislation that might affect their clients. These tax
consultants made substantial use of Lotus Notes to broad-
cast their tax advisories.

The line consultants were supposed to become Lotus
Notes’ primary users. The vice-president of information
technology felt that Notes was so revolutionary that people
didn’t even have to be shown how to use it; examples could
even stunt their imaginations. The consultants should sim-
ply be given an opportunity to use it, and they would learn
how to use it in creative ways. Orlikowski (1993) found
that the senior line consultants, who were partners in the
firm, tended to be modest users.2 The more numerous
junior line consultants, called associates, were low users.
They often seemed uninterested in learning how to use
Notes, readily gave up if they faced early frustrations with
Notes, and as a group did not spend much time with it.

WHAT IS SOCIAL INFORMATICS AND WHY DOES IT MATTER? 209

Here we have a pattern of different groups in an organi-
zation having different practices in working with Notes.
How can we explain such differences?

One explanation focuses upon the incentive systems
in the firm. A good place to start our analysis is with the
associate consultants and the partners. PriceWaterhouse—
and many other large consulting firms in North America—
reviews its consultants through a demanding promotion
system. The associates are reviewed every 2 years, for “up
or out” promotions. In the first few rounds at major firms,
about half of the associates are fired at each review. In their
“up or out” system, the many associate consultants’ goals
are to be promoted to the status of partner. Consultants who
are promoted to the status of partners can expect annual
incomes over $300,000 at these major firms. Partnerships
are the golden ring that these firms use to motivate their
associate consultants.

The associates are valued for their billable hours, and
were effectively required to bill almost all of their time. As
they become more senior, their ability to attract new busi-
ness becomes more critical. “Billable hours” means they
have an account that they can charge their time to. Lotus
Notes, the revolutionary technology, was not provided to
them with a “training account” to bill their time to. Con-
sultants who wanted to use Notes had to have an account
to charge their time against, and the initial learning time
was in the order of 20 to 30 hours. In 1991, the consultants
were billed at about $150 an hour, so they had to find a
client who would be willing to pay $3,000 to $4,500 for
them to learn a system whose value wasn’t yet clear to
them (but that could be revolutionary). Many had trou-
ble justifying that amount of expenditure to any of their
clients at the time that they were participating in the Notes
rollout. There was a major question about what the con-
sultants would actually do with Notes after they learned
how to use it. Consequently, relatively few associates saw
value in Notes; there were no exemplary demonstrations
showing them how other successful line consultants used
Notes.

On the other hand, the partners had substantial job se-
curity (which was similar to university tenure). They could
afford to experiment with Notes. They were more willing
to invest some time to explore, often using e-mail, occa-
sionally developing and sending memos, and so on. This
case study contradicts the popular “Nintendo generation”
explanation: “In the future, we don’t have to train people
about computing, because the Nintendo kids (or the Net
kids) will learn quickly.” In this case, generally, younger
consultants had less incentive to learn Notes than did the
middle-aged and elderly partners.

But what about the information technology staff and
the tax consultants? These groups had a certain advantage
in their forms of job security. Many of the information
technology staff were technophiles who were willing to

work with an interesting new application. Lotus Notes has
been helpful for people who can invest time in learning
how to use it, especially when they have joint projects and
major motivations for communicating, for documenting
work, for sharing memos, and so on.

The tax consultants, who were located in Washington,
DC, had a significant incentive to show that they were visi-
ble and valuable in the firm. In their case, salary didn’t give
them an incentive, it gave them protection. Lotus Notes
allowed them to broadcast for visibility: It gave them the
ability, in effect, to electronically publish their advice and
make it quickly available to many of the consultants around
the firm who wanted to read the Notes database. They
hoped it would enhance their visibility, and thus show that
the Washington office was not just overhead, but an impor-
tant contributing part of the firm. In short, organizational
incentive systems were not part of the original marketing
story of Lotus Notes. The interesting information process-
ing features enabled by Lotus Notes were emphasized in
numerous stories in the technical press (see, for example,
Kirkpatrick, 1993.)

An organization, or organizational subunits with dif-
ferent incentive systems, might use Notes very differently.
The way that some consultants in Ernst and Young (E&Y),
another major consulting firm, use Notes is instructive
(Davenport, 1997; Gierkink & Ruggles, n.d.). In brief,
E&Y created an organization (Center for Business Knowl-
edge) whose charter was to organize E&Y’s consultants’
know-how in specific high profile areas. By 1997, E&Y
had developed 22 distinct social cross-office networks of
consultants with expertise in certain industries, organiza-
tional reforms, or technologies that were a focus of E&Y’s
business.

Each network was assigned a half-time person to cod-
ify in Notes databases the insights from specific consulting
projects, to prompt line consultants to add their own in-
sights, and to edit and prune a project’s discussion and
document databases. In some cases, they were charged
to develop topical “Power Packs” in Notes—a structured
and filtered set of online materials including sales presen-
tations and proposal templates. Davenport observed that
these “knowledge networkers” understood their network’s
domains and that these were short-term assignments for
line consultants.

In this case, E&Y designed a human organizational “in-
telligence system” for sharing insights, ideas, and mate-
rials in specific topical areas. Lotus Notes served as an
information support system—a medium for storing, orga-
nizing, and communicating these materials.

Taken together, these cases illustrate varied conse-
quences of Notes’ use in large consulting firms, not one
fixed effect. Varied, conflicting consequences in differ-
ent settings are common in this body of research. Our
job as researchers is not simply to document the various

210 R. KLING

consequences of computerization, but also to theorize
them (see Lamb, 1996; Robey, 1997). Different organi-
zational incentive systems for different professionals is
one way to conceptualize a key concept that helps to inte-
grate some of these seemingly disparate cases. (Also see
Markus and Keil, 1994, for a case study of a little-used
large-scale expert system whose use was not supported
by organizational incentive systems.) It is possible that
the way that Notes is used at both PriceWaterhouse (now
merged with Coopers-Lybrand) and E&Y have changed
since the studies that inform this article were written. Our
point here is not to praise E&Y and to criticize PriceWa-
terhouse. Rather, it is to understand how their behavior can
help us develop empirically grounded concepts that help
us to predict (or at least understand) variations in the ways
that people and groups use information technologies.

One key idea of social informatics research is that the
“social context” of information technology development
and use plays a significant role in influencing the ways
that people use information and technologies, and thus
influences their consequences for work, organizations, and
other social relationships. Social context does not refer
to some abstracted “cloud” that hovers above people and
information technology; it refers to a specific matrix of
social relationships. Here, social context is characterized
by particular incentive systems for using, organizing, and
sharing information at work. In the cases just described,
different groups within PriceWaterhouse and E&Y have
different incentives to share information about the project
know-how, and, thus, how they use or avoid Lotus Notes.

The case of E&Y also illustrates an important idea—
that of conceptualizing the design of computer and net-
worked systems as a set of interrelated decisions about
technology and the organization of work. Unfortunately,
thinking and talking about computerization as the devel-
opment of socio-technical configurations, rather than as
simply installing and using a new technology, is not com-
monplace. It is common for managers and technologists
to discuss some social repercussions of new technologies,
such as the sponsorship of projects, training people to
use new systems, and controls over access to information.
However, these discussions usually treat all or most social
behavior as separable from the technologies, whereas the
E&Y case suggests how a more integrated socio-technical
view is critical. We will amplify this key idea with addi-
tional examples.

5.2 Work Processes Matters With Documentary
Systems

The social informatics approaches have been applied to
some issues that are of particular concern to designers
of digital libraries—working with documentary systems.
How do people work with documentary systems in prac-

tice? We know that certain visions did not come about,
such as the early 1980s vision of the paperless office. It is
intriguing to speculate why one of the hot items in a “paper-
less office” is a laser printer. Why are laser printer sales
rising steadily—and faster ones, more colorful ones—if
the direction of development is to abandon paper? There
is a conceptual disconnect here. It is not because people
like paper in the same way that people have an affection
for dogs or cats. It is not a sentimental attachment. Laser
printers are not popular because people enjoy the look and
feel of typical 8-1/2′′ × 11′′, 20-pound bond.

Some people do like the hand-feel of richly textured
paper. Wired Magazine, at least, is printed in vivid colors.
It is visually engaging, although some people are put off
by its intensely colored pages. People at times like books
and other documents which are printed on nicely textured
paper. We should not ignore the sensual qualities of some
high-quality papers. But standard 20-pound printer and
copier papers are not designed for sensuality.

Careful studies of professional and clerical docu-
mentary work find that many people engage in com-
plex activities—such as annotating documents; comparing
them, for instance, as an editor compares two versions of
a paper or a book chapter to see what the changes were; or
integrating them, for instance, in assembling a long report
(see Suchman, 1996). The screen spaces of the more com-
mon 14-, 15-, or even 17-inch displays are too limited. To
compare two full-page manuscripts, it helps to put them
side by side. That would require about 24 inches of display.
Today, 24-inch displays, priced at about $1500, are too
costly for most offices. While the costs and overall mass
of large-screen monitors will decline in the next decade,
paper has other virtues. Many people who work with mul-
tiple documents mark them up with quick annotations and
diagrams that are more clumsy with word processors and
take them to different places; paper is simple and versatile.

For certain transaction systems, such as airline reserva-
tion systems, the move to paperless transactions has been
workable—because it reduces operational costs in reissu-
ing new tickets and people make few additional notations
on their tickets. In contrast, people who are doing ana-
lytical work with manuscripts have found paper to be an
extremely durable and useful medium, for a variety of rea-
sons. Some of the value of paper is based on the work of
comparing and working with documents side by side. It is
partly a real estate issue, and partly a portability issue—
documents can be moved around an office or taken off-site
quickly and easily without having to have a running device.

Paper plays important roles in some places where we
don’t think it is in use. An interesting example is in civilian
air traffic control systems. The movie version of air traffic
controllers shows them staring at bright green displays.
In real life they do depend upon computer displays. But
they also keep track of the planes that they are monitoring

WHAT IS SOCIAL INFORMATICS AND WHY DOES IT MATTER? 211

on little pieces of paper a little bigger than that of fortune
cookies, which record flights, flight vectors, and speed,
among other things. Because they divide their work by air
space, when the plane moves from one scope to the next,
they pass the paper over. Gary Stix (1994) examines (a) the
nature of the work and communication via paper strips, and
(b) IBM’s efforts in 1993 to automate it. Stix reports that
IBM had a database with 65 fields—a little complicated for
real-time control! That project has since been abandoned
by the Federal Aviation Agency (FAA) in the United States
at a cost of several hundreds of millions dollars. But the
FAA will continue to develop upgrades, because the com-
puters on which the air traffic control system runs are ag-
ing, and it is hard to get spare parts, technicians, and so on.

This “work-oriented view” of how people work and
use computer systems in practice is not always inspiring.
Many people work hard, and they do many interesting
things, but their work with information technologies is not
streamlined. Professionals, for example, often work across
media, across technologies, and across social boundaries
in ways that new, computer-based systems don’t readily
integrate. Their workspaces can appear messy and their
workflow cumbersome, even when they have good com-
puter systems to help with part of their work. Social infor-
matics is one sustained way of understanding these issues
in ways that do help improve the workability and design
of systems and information services for various workers
and the public.

5.3 Socio-Technical Systems and Electronic Journals

The use of the Internet to support scientific communica-
tion is one of the major shifts in the practice of science
in this era, and it has generated numerous experiments
and significant discussion. In the scientific communities,
these communications include informal e-mail, the com-
munication of conference programs as they gel, the shar-
ing of preprints, access to electronic versions of journal
articles, and the development of shared disciplinary cor-
puses. These communicative practices are becoming more
important in many fields, although they are rarely the cen-
tral communications media. However, only a few analyses
take sufficient account of the ways in which the social di-
mensions of publications, such as the design of electronic
journals, influence their use (see, for example, Kling &
Covi, 1995).

One common approach to conceptualizing new forms
such as electronic journals, online newspapers, electronic
forums, Web sites, and digital libraries emphasizes their
technologically based information-processing features,
such as enabling authors and readers to communicate more
directly without the mediation of libraries or expensive
publishers. The socio-technical approach, explained next,
views these new forms as mixing together both technolog-

ical elements and social relationships into an effectively
inseparable ensemble.

From a technological information-processing perspec-
tive, new media—such as electronic journals,3 databases,
preprint servers—are said to reduce the costs of commu-
nication, expand the range of people and locations from
which materials are accessible, and generally speed com-
munications. According to this view, as scholars in all
scientific fields work with data, and communicate both
formally and informally with other scholars, all of these
electronic media forums should be adopted and used fairly
uniformly. Differences in value would rest upon the dif-
ferences in technical architectures. For example, readers
would be more likely to read electronic journal A rather
than journal B if journal A added more informational
value, such as having an elaborate set of crosslinks be-
tween articles, or including more extensive sets of data
and graphics.

Even the strongest proponents of electronic journals
agree that technological design alone is not sufficient to
insure a good quality journal. There is a strong consensus
that the quality of a journal’s scholarly content is impor-
tant in making it viable, but there is substantial disagree-
ment about the means of attracting high-quality materials.
All the proposals and counterproposals for attracting high-
quality authors rest on social analyses of a journal, rather
than purely technological analyses. For example, one as-
pect of electronic journals that is commonly discussed is
the role of peer review.4 There are many ways of organiz-
ing peer reviews, but each strategy for selecting reviewers
and translating their assessments into feedback for authors
and publication criteria for the journal is a social process.
These social processes are supported by communication
media, and electronic media may facilitate or inhibit spe-
cific ways of organizing reviewers, reviewing, and editing.

The value of a socio-technical analysis can be illustrated
by contrasting the design and functioning of two different
electronic journals: Electronic Transactions of Artificial
Intelligence and The Electronic Journal of Cognitive and
Brain Sciences. Superficially, these scientific electronic
journals have much in common: Each is hosted on a Web
site, relies upon peer review to select high-quality articles,
and posts articles for public prereview before they are ac-
cepted or rejected for formal publication. Both journals
were established in 1997 and have had about 18 months of
activity to establish a publishing pattern. These two jour-
nals are especially interesting in the ways that their de-
signers envision attracting authors to submit high-quality
articles, and to insure that only high-quality articles are
actually published.

However, one of these journals seems to be viable
and one seems moribund. The technological publica-
tion system for each journal functions effectively, and I
will indicate how the differences rest on their design as

212 R. KLING

socio-technical systems. Rather than analyze the journals
as I describe them, I believe that it would be useful for read-
ers to note the contrasts in the two journals’ designs, and to
try to evaluate which journal is the more viable and why.

Electronic Transactions on Artificial Intelligence
(ETAI). The ECCAI (European Coordinating Committee
for Artificial Intelligence) announced the ETAI as a journal
in May 1997, with Professor Erik Sandewall, a pioneer of
artificial intelligence research in Scandinavia, as its editor-
in-chief. The journal’s editors and organizers sought to
make the review process of articles more open for authors
and readers, by making some aspects of an article’s review
very public. ETAI’s editors claim:

“The ETAI represents a novel approach to electronic
publishing. We do not simply inherit the patterns from
the older technology, but instead we have rethought the
structure of scientific communication in order to make the
best possible use of international computer networks as
well as electronic document and database technologies.”

They describe their editorial process as follows: “Arti-
cles submitted to the ETAI are reviewed in a 2-phase pro-
cess. After submission, an article is open to public online
discussion in the area’s News Journal [part of the journal’s
Web site]. After the discussion period of three months,
and after the authors have had a chance to revise it, the
article is reviewed for acceptance by the ETAI, using con-
fidential peer review and journal level quality criteria. This
second phase is expected to be rather short because of the
preceding discussion and possible revision. During the en-
tire reviewing process, the article is already published in a
“First Publication Archive”, which compares to publica-
tion as a departmental tech report.” (From ETAI, 1997; see
Sandewall, 1998 for a more elaborate description of their
editorial process.)

The ETAI is divided into several topical sections, each
section with its own section editor. The ETAI Web site
has a public discussion section linked to each submitted
article. An annual paper edition of the articles, without the
discussion, is published by the Royal Swedish Academy
of Sciences (KVA).

The Electronic Journal of Cognitive and Brain Sci-
ences (EJCBS). The EJCBS was devised by Dr. Zoltan
Nadasdy of Rutgers University as an e-journal “that works
without editors” and that offers the following features
(Nadasdy, 1998a)5 :

“Instead of a hidebound peer-review system, we use
an interactive “vote,” in which those with comments and
suggestions post them along with the article.”

“Instead of a lengthy discussion carried out over a pe-
riod of months and years as letters are submitted to journals
and await publication, we allow anyone to post letters, and
allow authors to answer them immediately.”

“Instead of layout designers, we make use of
. . . automated-formatting software that converts simple

ASCII documents into HTML. The system supports graph-
ical illustrations and automatically inserts them into the
text. Hypertext is also inserted into the articles.”

Nadasdy sought to devise “an autonomous system” that
could run on its own after it was programmed. It would
rely upon readers to be referees, and not rely upon an
editorial board. He designed it with the aim “that [it] would
be able to control itself based on reasonable rules.” He
developed software to automatically create a Web page
with graphics for each submitted article, so that no human
editorial activity would be required to post articles.

“EJCBS uses a two-tier acceptance procedure that
makes reviewing automatic and allows readers to control
final acceptance: review status and archive status. Papers
in review status are evaluated by the readers . . . a weight
system controls the score given by different reader cate-
gories. The scores are transferred to a database that will
be averaged at the end of a month, and the final status
of the paper will be decided accordingly. Articles that re-
ceive a certain average score, or higher, are transferred to
an archive of accepted papers. Those papers that do not
receive the minimal average scores are rejected.”

Nadasdy designed EJCBS to improve the speed of publi-
cation, be low cost, enhance interactivity, and enable broad
distribution. He claims that “those features are all inte-
grated into the system I call “interactive publishing.” The
impact of interactive publishing could be enormous. It re-
defines concepts of traditional publishing, such as editing,
acceptance, reviews and comments, and archives.”

The reviewing practices of EJCBS and ETAI differ con-
siderably. EJCBS relies on anonymous reviewing by (self-
selected) readers. They visit its Web site and rate an article
on several 7-point scales to indicate their views of its qual-
ity and importance. Nadasdy hoped that EJCBS could “run
itself” and has tried to automate key editorial processes. It
is an extreme example of removing editorial attention and
guidance from the publishing process and relying upon a
readers’ plebiscite.

In contrast, an article that is submitted to ETAI is a topic
for public discussion by participants in the research com-
munity. During the 3-month open review period, questions
and comments are signed. In an informal reading of the
discussion about several articles, I found that only a few
questions were typically posted. However, they reflected
a deep understanding of the topics, and some were elab-
orate counterexamples or reformulations of the authors’
positions. Authors’ replies were also public, and seemed
to engage the technical issues raised in the queries.

Both ETAI and EJCBS were initiated in 1997. ETAI
accepted five articles for publication in 1997, while EJCBS
posted two short articles in September 1997 but has not
accepted any. ETAI continues to receive a steady stream
of submissions (eight articles in 1998) while EJCBS does
not.6 The contrast between the ETAI and the EJCBS offers

WHAT IS SOCIAL INFORMATICS AND WHY DOES IT MATTER? 213

an interesting illustration of a (simplified) socio-technical
systems analysis.

5.3.1 Socio-Technical Systems. Social informatics
research has produced some useful ideas and findings that
are applicable to many kinds of information technologies
and shed interesting light on these dilemmas of Internet
use. The concept of “computerized information systems
as social technical systems” is one such idea that helps
us understand the character of e-journals, as well as other
e-media.

Information and communication technologies are of-
ten discussed as tools or simple appliances, even when
they refer to complex arrangements of varied equipment,
rules/roles/resources, and actual organizational practices,
as with WWW sites or airline reservation systems. It is
more interesting to view specific information technolo-
gies as “socio-technical systems”7 —a complex, interde-
pendent system comprised of:

� People in various roles and relationships with each
other and with other system elements;

� Hardware (computer mainframes, workstations,
peripherals, telecommunications equipment);

� Software (operating systems, utilities and appli-
cation programs);

� Techniques (management science models, voting
schemes);

� Support resources (training/support/help); and
� Information structures (content and content

providers, rules/norms/regulations, such as those
that authorize people to use systems and informa-
tion in specific ways, access controls).

These elements are not simply a static list, but are
interrelated within a matrix of social and technical
dependencies.8

A systems designer with a socio-technical orientation
does not simply consider these elements while work-
ing in a “design studio” far away from the people who
will use a specific system. Effectively designing socio-
technical systems also requires upon a set of “discovery
processes” to help the designers understand which fea-
tures and trade-offs will most appeal to the people who
are most likely to use the system.9 There are a number of
discovery processes for learning about the preferences of
the men and women who are likely to use these systems.
These discovery processes include workplace ethnogra-
phy (Simonsen & Kensing, 1997), focus groups, user par-
ticipation in design teams (Bolstrom & Heinen, 1977b;
Carmel, Whittaker, & George, 1993), and participatory
design strategies (Schuler & Namioka, 1993; Eckehard
et al., 1997). These approaches differ in many significant
ways, such as the contextual richness of the understand-
ings that they reveal and the extent to which they give the

people who will use systems influence and power in their
design. These issues are the subject of a lively body of
research that overlaps social informatics. However, to dis-
cuss it in detail here would lead us away from our focus
on the structural elements of a socio-technical analysis.

For our post hoc analytical purposes, we can focus on
the structural features of the socio-technical system that we
have just listed. We view the design of ETAI and EJCBS
not simply as one of artifacts, such as the compilers that
Nadasdy developed to automatically translate submitted
article files into postable WWW pages for EJCBS. Rather,
the interplay of social assumptions and practices that are
reflected in technological design features helps us to un-
derstand the relative success of these two e-journals.

In the case of ETAI, authors link up with potential read-
ers through the journal’s published articles. However, in
order to have an article published, an author must be will-
ing to discuss it in a public forum with other self-identified
artificial intelligence (AI) researchers. This arrangement
adds an important social and discursive element to publish-
ing in the journal: Authors must be willing to participate
in this part of the AI community by discussing their re-
search. Publication in ETAI entails a set of relatively pub-
lic social actions. Further, the editorial board of the ETAI
was developed to include senior members European Co-
ordinating Committee for Artificial Intelligence and paper
publication through the Royal Swedish Academy of Sci-
ences. Potential authors have good reason to believe that
their articles will be known to participants in the European
AI research community. According to Erik Sandewall, this
visibility is a mixed blessing: It can enhance one’s status
for work that is well received, but also can be embarrass-
ing for authors whose work is ill-conceived, is not well
developed, or is not well received.

The EJCBS looks more problematic as a socio-technical
system. An author who submits an article will receive
votes and possible comments from anonymous readers,
but does not have a forum in which to respond or to de-
velop a discussion with the readers. While the ETAI has an
editorial board whose members participate in a variety of
high status scientific social networks and promote the jour-
nal, the EJCBS was designed by one relatively low-status
and not well connected bio-scientist who would like to
have it work without promotional or editorial attention—
autonomously. Authors who publish in EJCBS are not
guaranteed any attention among highly active scientists
in their field.

Nadasdy (1998b) believes that he has “shown that the
(journal) concept works, and that people just have to come
around to use it.” His comment reflects a technologically
focused view of e-publishing, one that pays much more
attention to automating scripts and voting procedures than
to seeking ways to effectively mobilize a lively group of
authors and readers around the journal.

214 R. KLING

I have developed these two examples at some length
because they help us to see how a socio-technical per-
spective on e-journals helps us to better understand how
they may or may not serve as vibrant media for com-
munity communication. Nadasdy did “market the jour-
nal” by encouraging about 100 senior scientists to publish
their articles in it. A few of them sent encouraging com-
ments, but none submitted their research articles for review
and possible publication. Nadasdy’s software works; if an
e-journal is only a technological artifact, he “has a work-
ing journal.” However, a genuine “working journal” re-
quires a continuing stream of authors and readers, then
the design requires a more sophisticated social-technical
approach than Nadasdy has taken on. These ideas extend
beyond e-journals, to digital libraries, electronic forums,
and so on.

It is also possible to revisit the cases of Lotus Notes
use in consulting firms to examine their design as socio-
technical communication systems within the social net-
works of the firms. One major difference between Price-
Waterhouse and E&Y lies in E&Y’s creating new social
groups with a responsibility for collecting, organizing, and
disseminating information for which Lotus Notes could be
a helpful medium.

Further, the concept of socio-technical systems can help
us understand some of the differences between WWW
sites and digital libraries that are highly used or little used.
As technological systems, they are collections of software,
data (text, picture files, etc.), links, and metadata (indices,
etc.) that run on networked computers. For socio-technical
systems, we can pay special attention to:
� People in various roles and relationships with each

other and with other system elements;
� Support resources (training/support/help); and
� Information structures (content and content

providers, rules/norms/regulations, such as those
that authorize people to use systems and informa-
tion in specific ways, access controls).

We ask about the importance of their content for various
constituencies, who is authorized to change content and
how that matters, etc.

There are many such questions that help us connect
technological artifacts in a lively way to a social world.
As a design practice, a “socio-technical approach” also
requires a discovery process that helps designers to effec-
tively understand the relevant life worlds and work worlds
of the people who will use their systems.

5.4 Computing Infrastructure and Public Access
to Information Via the Internet

There are innumerable examples of the use and value of
the Internet in providing new kinds of communications to

support a cornucopia of human activities in virtually every
profession and kind of institution. In the United States, the
professional and middle classes have found the Internet to
be useful for communication with some government agen-
cies, for some forms of shopping, for tackling investments,
for maintaining ties with friends and family via email, and
as a source of entertainment.

There are also many examples where the Internet en-
ables the middle-class public to have better access to im-
portant information (see Kahin and Keller, 1995). In the
United States, the public is beginning to turn to medi-
cal sources on the Web, to get alternative answers on the
Internet, in discussion groups and so on, and sometimes
bypassing the medical establishment.

Some people seek either alternative medical advice or
information about issues that their doctors don’t deal with
very well. Surgeons, for example, may be good at doing
very skilled surgery, but they may not be very good for giv-
ing people an understanding of what it takes to go through
the recovery process. People sometimes find that certain
Internet sources can be extremely helpful as either alter-
natives or supplements. This is simply a hypothesis, but
there is anecdotal evidence that the Internet provides an
alternative communication means for many middle-class
people to bypass the medical establishment. Anecdotal
evidence suggests that doctors vary in their responses to
their patients feeling better informed, and sometimes chal-
lenging their advice—from encouragement to annoyance.
What kinds of changes in systematic patient–doctor rela-
tionships may result is as yet unclear.

In the United States, Vice-President Al Gore promotes
networking for libraries, clinics, and schools, by arguing
that if they are wired together, their use will improve pub-
lic education and enable substantially improved public
services. How to actually transform such networks into
meaningful social support systems is a question that re-
mains unanswered.

While many people install additional phone lines for
online computer use, affordable telephone service and In-
ternet service providers (ISPs) are available in urban areas
(Kahin & Keller, 1995). Access to ISPs, and even basic
telephone service, is more problematic in many rural ar-
eas. In 1995, about 28.8 million people in the United States
16 years and over had access to the Internet at work, school
or home; 16.4 million people used the Internet and 11.5
million people of these people used the Web. About 80%
of these people used the Internet at least once a week.
However, about 182 million people 16 years and over did
not have access to the Internet (Hoffman, Kalsbeek, &
Novak, 1996). A 1997 nation-wide household study found
that computer ownership and e-mail access were rising
rapidly—about 94% of households have telephones, 37%
have personal computers, 26% have modems, and 19%
have online access (McConnaughey & Lader. 1998). The

WHAT IS SOCIAL INFORMATICS AND WHY DOES IT MATTER? 215

numbers of people with Internet access continues to rise
rapidly.

It might appear that technological access is the pri-
mary roadblock to expanded Internet use. “Technolog-
ical access” refers to the physical availability of suit-
able equipment, including computers of adequate speed
and equipped with appropriate software for a given ac-
tivity. Scenarios of “ordinary people” using the Inter-
net often assume that computer support is easy to orga-
nize, and that access to information and services is not
problematic.

In contrast, “social access” refers to know-how, a mix of
professional knowledge economic resources, and techni-
cal skills, to use technologies in ways that enhance profes-
sional practices and social life. In practice, social access—
the abilities of diverse organizations and people from many
walks of life to actually use these services—will be critical
if they are to move from the laboratories and pilot projects
into widespread use where they can vitalize the nation and
the economy. Social access should not be viewed as an
“add on” to a technological structure. Many systems de-
signers have learned, for example, that a well-designed
system does not simply tack on a “computer interface”
after its internal structure has been set in place. The de-
sign of human interfaces and internal structures is highly
coupled for systems that effectively support people’s work
and communication (see National Research Council, 1997,
for an integrated review). In a similar way, social access
is integral to the design and development of systems and
services that are to be widely used.

Some analysts do not view social access to the Internet
for “ordinary people” as problematic, since they believe
that access costs will rapidly decline and the public’s com-
puting skills will continue to rise. In this view, time and
markets will resolve most access issues. In contrast, we
believe that social access to the Internet is likely to prove
vexing for many people, based on what careful studies of
computer use and Internet use have shown us.

Although 50% of U.S. households may have computers
by the year 2000, organizations have been the major sites
for adopting networked information systems, especially
as implementers of advanced technologies. There are few
studies of computer use in households. In one careful study
of “ordinary households” (HomeNet), researchers found
that using the Internet is too hard for many “ordinary peo-
ple” (Kiesler, Kraut, Mukhopadhyay, & Scherlis. 1997):

“Over 70% of the households called the help desk. Calls
to the help desk represented the behavior of some of the
more sophisticated users. Less sophisticated users dropped
out once they hit usability barriers. The kinds of prob-
lems logged by help desk staff included problems in in-
stalling phone service, configuring the telecommunication
software, busy signals (users often blamed themselves!),
buggy software, inexperience with mice, keyboards, scroll

bars, terminology, radio buttons, and menus. Yet, in our
home interviews, we noted there were many more prob-
lems participants had not called about.”

“. . . We thought that as everyone learned how to use
the computer and what the Internet could do for them,
the influence of their initial computer skill would decline
with time. We were wrong. Even after a year of experience
with the Internet, participants’ initial computer skill still
constrained their Internet usage. This result held across
different gender and age groups.”

These findings serve as a cautionary note about our
expecting the North American public to rapidly form a
“network nation.” One intriguing finding of the HomeNet
project is that families with adolescents made much more
use of the Internet than those without. We suspect that
many of these teenagers became critical “on-site” technical
consultants for their parents.

5.4.1 Infrastructure for Computing Support Is Social
as Well as Technological. Personal computers (PCs) are
much more complicated to install and use for a diverse
array of tasks than are “turnkey appliances” such as tele-
visions and VCRs. While it is a standing joke that most
people don’t know how to program their VCRs (and thus
watch an LCD blinking 00:00), most people can reliably
play a videotape and enjoy the resulting entertainment. In
contrast, PCs that use networked services require much
more complex configurations (including data rates and IP
numbers) that can change with changes in network con-
figurations and service providers.

Effective computer systems that use Internet ser-
vices will require reliable complementary technological
resources—such as printers and electricity (reliable in ur-
ban settings, sometimes problematic after disasters and in
remote regions). What is less well appreciated is how the
infrastructure for making computer systems workable also
includes a variety of resources that are social in charac-
ter. Skilled technical installers, trainers, and consultants
are the most obvious social resources. In addition, people
who use advanced networking applications need know-
how—to be able to learn to effectively integrate them into
their working practices—based on learning from others.

There is some debate about how much computer use has
simplified in the last decade. It is probably easier to use a
stand-alone PC “out of the box.” However, the dominant
operating systems, such as Windows 95/98/NT, and Unix
(and Linux), can still stump experts when applications or
components interact badly.

System infrastructure is a socio-technical system since
technical capabilities depend upon skilled people, ad-
ministrative procedures, etc.; and social capabilities are
enabled by simpler supporting technologies (e.g., word
processors for creating technical documents, cellular
telephones and pagers for contacting rapid-response

216 R. KLING

consultants) (Kling, 1992). Malfunctioning computer sys-
tems are not simply an opportunity loss, such as a book that
is bought but not read. When people organize their days
about the expectations that key technologies will work
well—and they don’t—they often spend considerable time
tinkering to get systems to work, waiting for help to come,
and so on.

Workable computer applications are usually supported
by a strong socio-technical infrastructure. The “surface
features” of computer systems are the most visible and the
primary subject of debates and systems analysis. But they
are only one part of computerization projects. Many key
parts of information systems are neither immediately visi-
ble nor interesting in their novelty. They include technical
infrastructure, such as reliable electricity (which may be
a given in urban America, but problematic in wilderness
areas, or in urban areas after a major devastation.) They
also involve a range of skilled support—from people to
document systems features and train people to use them,
to rapid-response consultants who can diagnose and repair
system failures.

Much of the research about appropriate infrastructure
comes from studies of systems that underperformed or
failed (Star & Ruhleder, 1996; Kling & Scacchi, 1982).
The social infrastructure for a given computer system is
not homogeneous across social sites. For example, the
Worm Community System was a collaboratory for molec-
ular biologists who worked in hundreds of university lab-
oratories; key social infrastructure for network connec-
tivity and (UNIX) skills depended upon the laboratory’s
work organization (and local university resources) (see
Star & Ruhleder, 1996). Researchers found that the Worm
Community System was technically well designed, but
it was rather weak as an effective collaboratory because
of the uneven and often limited support for its technical
requirements in various university labs. In short, a weak
local socio-technical infrastructure can undermine the ef-
fective workability of computer systems, including those
in people’s homes, as we have already discussed (also see
Haddon & Silverstone, 1995).

6. WHY SOCIAL INFORMATICS MATTERS

Social informatics research pertains to information tech-
nology use and social change in any sort of social set-
ting, not just organizations. Social informatics researchers
are specially interested in developing reliable knowledge
about information technology and social change, based on
systematic empirical research, to inform both public policy
debates and professional practice. Many of us have devel-
oped concepts to help understand the design, use, config-
uration, and/or consequences of information and commu-
nication technologies so that they are actually workable
for people. This contrasts with high-spirited but largely a

priori promotions of technologies that occasionally work
well for people, occasionally are valuable, are sometimes
abandoned, are sometimes unusable, and thus incur pre-
dictable waste and inspire misplaced hopes. That is one
important way that “social informatics matters” and one
that I have emphasized in this article. This view of social
informatics has important repercussions for public policy,
professional practice, and the education of information
technology professionals (see Kling, 1993; Kling & Allen,
1996; Kling, Crawford, Rosenbaum, Sawyer, & Weisband,
1999).

Social informatics research also investigates intriguing
new social phenomena that emerge when people use in-
formation technology, such as the ways that people de-
velop trust in virtual teams (Iacono & Weisband, 1997)
or the ways that disciplinary norms influence scholars use
of electronic communication media (Kling & McKim, in
press). But these phenomena would be the focus of another
article.

In this article I have identified a few key ideas that come
from 25 years of systematic analytical and critical research
about information technology and social life. There are
other sources for a more expanded treatment (see, for ex-
ample Kling, 1993; Kling & Allen, 1996; Bishop & Star,
1996; Kling & Star, 1998; Kling, Crawford, Rosenbaum,
Sawyer, & Weisband, 1999).

Other social informatics researchers might empha-
size other ideas. I have emphasized organizational exam-
ples because information technology and organizational
change (organizational informatics) have been more care-
fully researched and theorized in complex organizations
than computer use in settings such as households.

7. SOCIAL INFORMATICS AS A FIELD NAME

Social informatics is a neologism. I have written enthusi-
astically about social informatics, but many people are
appropriately cautious about catchy new terms whose
connotations can mislead. The label “social informatics”
emerged from discussions in 1996 within the community
of researchers who conduct the kind of research discussed
in this article. Several social informatics researchers par-
ticipated in a workshop at UCLA on social aspects of dig-
ital libraries in 1996 (see http://dlis.gseis.ucla.edu/DL/).
In the course of discussing research about digital libraries
and computer-supported cooperative work (CSCW), we
realized that we did not have a good label for the body
of research that we now call social informatics. We used
various labels, including “social analysis of computing,”
“social impacts of computing,” “information systems re-
search,” and “behavioral information systems research.”

Several of us felt that it was time to help make this
body of ongoing research much more accessible by find-
ing one name that could serve as an efficient pointer, and

WHAT IS SOCIAL INFORMATICS AND WHY DOES IT MATTER? 217

a banner. Instead of being skeptical of new nomencla-
ture, we should be willing to find a field name that we
could use. A number of us discussed alternatives such as
“social analysis of computing,” “interpretive informatics,”
“socio-technical systems”—and the term “social informat-
ics” came up as the least offensive alternative of the group.
For some people it inspired curiosity; for others, it simply
was not a turn-off, whereas for some, “interpretive infor-
matics” tended not to cross cultural lines.

The social informatics label energizes some faculty.
One colleague at another university told me that he didn’t
know how to succinctly characterize his interests when
he was searching for a professorship. When he learned
about social informatics, he felt that it was a terrific label
for his interests. But I also know some faculty, especially
those who are in single-discipline academic units, whose
research comfortably fits within social informatics who
will resist the term because adopting it doesn’t help them
in their struggles for research resources, good students, and
impact for their research within their traditionally defined
disciplines.

There are a number of journals that publish social infor-
matics research. A comprehensive list would be lengthy;
but most of the journals listed would be ones that have
published only a few social informatics articles. There
are a few journals that are good sources of social infor-
matics research, including The Information Society and
some journals in the information systems field, such as
Information Systems Research. Social informatics stud-
ies appear in communication journals such as the Journal
of Communication as well as in the electronic Journal of
Computer-Mediated Communication. The Journal of the
American Society of Information Science published a spe-
cial issue in October 1998 devoted to social informatics
(Kling, Rosenbaum, & Hert, 1998). The Communications
of the ACM, a magazine, also publishes articles that are
based on social informatics research. There are numerous
books (see Dutton, 1997; Huff & Finholt, 1994; Kling,
1996; Kiesler, 1997; Smith & Kollock, 1998; and De-
Sanctis & Fulk, in press, as entry points). The research
is conducted in several different disciplines, especially in
some social sciences, information science, computer sci-
ence, and information systems.

The National Science Foundation sponsored a work-
shop on Advances in Organizational and Social Infor-
matics in the Fall of 1997 to help to further develop
the field (see http://memex.lib.indiana.edu/siwkshop/
SocInfo1.html). The workshop’s participants character-
ized social informatics as “the interdisciplinary study of
the design, uses and consequences of information and
communication technologies that takes into account their
interaction with institutional and cultural contexts.”

This characterization sets some boundaries, as well as
articulating a focus for social informatics. For example,

simple surveys of the number of people who use the Inter-
net for specific purposes that did not examine these uses
in institutional and cultural contexts would not be a so-
cial informatics study. However, such survey data could
be useful as part of a social informatics analysis.

In addition, the workshop participants characterized
social informatics research as analytical, critical, or nor-
mative. The analytical orientation refers to studies that
develop theories about information technologies in insti-
tutional and cultural contexts or to empirical studies that
are organized to contribute to such theorizing. I have em-
phasized analytical research in this short article. The criti-
cal orientation refers to examining information technolo-
gies from perspectives that do not automatically and “un-
critically” adopt the goals and beliefs of the groups that
commission, design, or implement specific information
technologies.

Our discussion of the use of Lotus Notes in light of or-
ganizational incentive structures illustrates the analytical
orientation in social informatics. The critical orientation is
possibly the most novel (Agre & Schuler, 1997). It encour-
ages professionals and researchers to examine information
technologies from multiple perspectives (such as the var-
ious people who use them in different contexts, as well
as people who design, implement, or maintain them), and
to examine possible “failure modes” and service losses,
as well as ideal or routine ICT operations. This article il-
lustrates a critical perspective in the examination of Lotus
Notes’ use, the design of electronic journals, and public
access to the Internet.

A book based on this workshop examines the char-
acter of the field, some of the key ideas, and teach-
ing issues (Kling, Crawford, Rosenbaum, Sawyer, &
Weisband, 1999). It also includes discussions of ways
to develop the field, to communicate key ideas of so-
cial informatics to relevant scholarly and professional
communities, and to enrich the curricula for computing-
oriented students. Social informatics has a Web page at
http://www.slis.indiana.edu/SI and a small collection of
online discussion forums. The WWW page includes sec-
tions that list and link courses, research conferences, de-
gree programs, and so on. There are many opportunities
to conduct research in social informatics, to translate re-
search ideas into professional practice or to teach. I invite
you to join us in a lively adventure.

ACKNOWLEDGMENTS

This work has benefited from continuing conversations
about social informatics with many colleagues and stu-
dents. Phil Agre, Bill Arms, Holly Crawford, Blaise
Cronin, Elisabeth Davenport, Joanna Fortuna, Amy Fried-
lander, Roberta Lamb, Suzanne Iacono, Geoff McKim,
Javed Mostafa, Howard Rosenbaum, Steve Sawyer,

218 R. KLING

Deborah Shaw, Bob Travica, and Suzanne Weisband com-
mented on interim drafts of this article. The discussion of
scholarly communication on the Internet is based upon
joint research with Geoff McKim. This work was sup-
ported, in part, by NSF grants IRI-9714211 and SBR-
9872961.

NOTES

1. This account of Lotus Notes’ use is based on my integration of
data reported in Mehler (1992) and Orlikowski (1993). Mehler is a jour-
nalist who explicitly identifies PriceWaterhouse. Wanda Orlikowski, an
MIT professor who has made important contributions to organizational
informatics, protects the identity of this organization with a pseudonym.
This protection is often important for researchers to be able to publish
their studies, and normally is effective in masking an organization’s
identity. However, PriceWaterhouse’s unusual mass purchase of Notes
for all of its consulting staff was the subject of several reverential stories
in the technical and business press (see, for example, Dyson, 1990a,
1990b). PriceWaterhouse was widely known to be the first major con-
sulting firm to make a major commitment to Notes in the 1989–1991
period.

2. See previous note about Orliklowski’s study.
3. We will focus on those electronic journals whose primary distri-

bution medium is electronic, unless we note otherwise.
4. There are substantial criticisms of peer reviewing as well as de-

fenses (see, for example, Hibbitts 1996, 1997; Zariski, 1997a, 1997b).
5. I have restructured Nadasdy’s list to better fit this analysis.
6. It is worth noting that other refereed e-journals also publish only

a few articles per year. While these rates are a small fraction of the
number of articles published annually by quarterly paper journals, they
seem to be typical of refereed e-journals in the mid-1990s. For exam-
ple, the Chicago Journal of Theoretical Computer Science (CJTCS)
published the following number of articles: 1995 (4 articles), 1996 (6
articles), 1997 (5 articles). (See http://www.cs.uchicago.edu /publica-
tions/cjtcs/articles/contents.html.) This journal has an editorial board
of 41 members, but few of them publish in the journal. Even so, the
MIT Press assumed publishing responsibility for the CJCTS in 1998.
The MIT Press has also changed the circulation policy from one that
is “free” and publicly accessible to one that is restricted to subscribers.
It lists over 60 institutional subscribers whose subscription price is
$125/year.

7. The term “socio-technical systems” was most strongly advocated
in the 1950’s–1970s by a group of psychologists who were originally
associated with the Tavistock Institute in London, England. They were
particularly concerned with improving the effectiveness and psycholog-
ical well-being of production workers. They advocated ways to “jointly
optimize” the technological and social systems of workplaces, and ad-
vocated such practices as autonomous work teams, rotating jobs, and
pay for learning new skills. This usage has also influenced some think-
ing about information systems design, and is reflected in two classic
papers by Bostrom and Heinnen (1977a, 1997b). In this view, a tech-
nology is an artifact whose typical use has consequences for the social
interactions and social relationships of the people who use it. The socio-
technical analyst considers these social effects when designing a new
artifact (including information systems).

Our use of the concept of “socio-technical systems” goes beyond
this view. It differs in the typical social settings to which it is applied,

since we do not emphasize production workers or solutions such as
autonomous work teams or “joint optimization.” However, more fun-
damentally the systems that we characterize as socio-technical so inter-
twine social and technological elements that they are a complex admix-
ture (see Bowker, Star, Gasser, & Turner, 1997; Mansell & Silverstone,
1995; Wellman, et al., 1996).

8. We have referred to these relationships and dependencies as a
“web of computing” (Kling & Scacchi, 1982; Kling, 1992).

9. The term “user” is a bland descriptor of varied social roles that
people play in new media such as digital libraries and electronic jour-
nals. For example, the people who are likely to use digital libraries are
likely to include readers, as well as a variety of digital librarians to
support the documentary collection as a viable service. In the case of
electronic journals, “the users” refer to a variety of participants includ-
ing authors, readers, editors, and journal production staff.

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