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: : : : a; a; a; xj zj zj zj zj zj zj $ [l h n d j P a; a; P P j : : j W W W P x : : c W P xj W W FZ Z : p7 -K1 H5 R ^Z ` j 0 j fZ , 'o T 'o Z 'o Z a; uB W G K a; a; a; j j fW ^ a; a; a; j P P P P D d d Constructing the Patient through Problems of Safety, Uninsurance, and Unequal Treatment, a Discourse Analysis of IOM Executive Summaries
Lisa J. Trigg, MN, APRN, BC
School of Nursing; Biomedical & Health Informatics, School of Medicine
University of Washington
Seattle, WA
Abstract
This is a second preliminary report from a larger research project. The purpose of the larger research project is to study how the Institute of Medicine discourse promoting the National Health Information Infrastructure may reproduce existing social inequality in healthcare. Social constructionist and critical discourse analysis combined with corpus linguistics methods informed by Value Sensitive Design goals has been used to study the subject positions constructed for patients across the executive summaries of three different Institute of Medicine reports. Preliminary data analysis revealed differences in the way receivers of health care are constructed in the three texts selected for this study.
Keywords: Corpus Linguistics, Critical Theory, Discourse Analysis, Health Information Technology, National Health Information Infrastructure, Social Constructionism, Social Inequality, Social Justice, Value Sensitive Design
Introduction
This is a second preliminary report from a study of how the Institute of Medicine (IOM) discourse promoting the deployment of health information technology and the development of the proposed National Health Information Infrastructure (NHII) may reproduce social inequality in health care. This research is in progress using critical discourse analysis of two Institute of Medicine report series: the Quality Chasm, and the Insuring Health series, as well as several standalone reports on the subject of disparity in healthcare, including Unequal Treatment ADDIN REFMGR.CITE Institute of Medicine2005420Crossing the Quality Chasm: The IOM Health Care Quality InitiativeElectronic Citation420Crossing the Quality Chasm: The IOM Health Care Quality InitiativeInstitute of MedicineBoard on Health Care Services2005HealthQualityNot in FileInstitute of Medicine2006/2/22Web Pagehttp://www.iom.edu/CMS/8089.aspxInstitute of Medicine34Institute of Medicine2004423Consequences of Uninsurance ProjectElectronic Citation423Consequences of Uninsurance ProjectInstitute of MedicineCommittee on the Consequences of Uninsurance2004UninsuranceUninsuredNot in FileInstitute of Medicine2006/2/22Web Pagehttp://www.iom.edu/project.asp?id=4660Institute of Medicine34Smedley2003327Unequal treatment confronting racial and ethnic disparities in health careBook, Whole327Unequal treatment confronting racial and ethnic disparities in health careSmedley,Brian D.Stith,Adrienne Y.Nelson,Alan R.Institute of MedicineCommittee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care2003Cross-cultural studiesDiscrimination in medical careEthnic GroupsHealthHealth services accessibilityMedical careMedicineMinoritiesMinority GroupsOfQuality of Health CareRace discriminationRacismScienceSocial medicineUnited StatesNot in FileWashington, D.CNational Academy Press030908265X (hardcover)Book, Whole2[1-3].
These preliminary research reports focus on methods testing using very limited corpora: the executive summaries of To Err is Human, Coverage Matters, and Unequal Treatment. The first preliminary report described early results of the textually oriented phase of this research, and demonstrated the benefit of using critical discourse analysis combined with corpus linguistics to study the stated research problem. The most notable findings of the first preliminary data analysis were the lack of overlap in the research discursive space created by each executive summary, and marked stylistic differences in the framing of the three health quality problems in the opening paragraphs of each respective IOM report executive summary ADDIN REFMGR.CITE Trigg200678Reproducing social inequality in the National Health Information Infrastructure, a discourse analysisConference Proceeding78Reproducing social inequality in the National Health Information Infrastructure, a discourse analysisTrigg,Lisa J.2006Not in FileSeoul, Korea9th International Congress of Nursing Informatics2006/6/1912[4]. Methods testing has continued in this project and this paper presents the results of a textually oriented comparison of how people, specifically receivers of health care, are discursively constructed in the executive summaries from the IOM reports Coverage Matters, To Err is Human, and Unequal Treatment ADDIN REFMGR.CITE Institute of Medicine2001428Coverage matters insurance and health careBook, Whole428Coverage matters insurance and health careInstitute of MedicineCommittee on the Consequences of Uninsurance2001Delivery of Health CareHealthInsurance,HealthMedical careMedically UninsuredMedically uninsured personsMedicineOfUnited StatesNot in FileWashington, D.CNational Academy PressInsuring health0309076099Book, Whole2Institute of Medicine2000196To Err is Human: Building a Safer Healthcare SystemReport196To Err is Human: Building a Safer Healthcare SystemInstitute of Medicine2000HumanNot in FileKohn,Linda T.Corrigan,Janet M.Donaldson,Molla S.Washington, D.C.National Academy PressReporthttp://books.nap.edu/books/0309068371/html/;http://books.nap.edu/books/0309068371/html/24Smedley2003327Unequal treatment confronting racial and ethnic disparities in health careBook, Whole327Unequal treatment confronting racial and ethnic disparities in health careSmedley,Brian D.Stith,Adrienne Y.Nelson,Alan R.Institute of MedicineCommittee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care2003Cross-cultural studiesDiscrimination in medical careEthnic GroupsHealthHealth services accessibilityMedical careMedicineMinoritiesMinority GroupsOfQuality of Health CareRace discriminationRacismScienceSocial medicineUnited StatesNot in FileWashington, D.CNational Academy Press030908265X (hardcover)Book, Whole2[3;5;6].
Background & Significance
The 2003 American Medical Informatics Association Spring Congress outlined a social justice agenda for health informatics by calling for the development of health information technologies (HIT) that bridge the digital divide and support improved health care outcomes for both vulnerable and underserved populations. The white paper reporting on this Congress outlined barriers for HIT development for vulnerable and underserved populations and offered policy, funding, research, and education and training recommendations to overcome these barriers. One policy recommendation relevant to the current research project was to increase NHII to address specific risks for underserved populations, as well as preventive health education networks (p. 453) ADDIN REFMGR.CITE Chang2004504Bridging the Digital Divide: Reaching Vulnerable PopulationsJournal504Bridging the Digital Divide: Reaching Vulnerable PopulationsChang,Betty L.Bakken,SuzanneBrown,S.ScottHouston,Thomas K.Kreps,Gary L.Kukafka,RitaSafran,CharlesStavri,P.Zoe2004/11/1CommunicationCongresseseducationEvaluationHealthMethodologyOfResearchStandardsTechnologytrendsNot in File448457J.Am.Med.Inform.Assoc.116http://www.jamia.org/cgi/content/abstract/11/6/448Journal of the American Medical Informatics AssociationJ.Am.Med.Inform.Assoc.1[7].
For this research, this investigator assumes that the IOM literature promoting the deployment of HIT and the development of the NHII contributes to a policy level requirements specification for the NHII, even if this is not specifically stated. The overarching goal of this research is to examine these texts for their contribution to the social justice agenda outlined by the 2003 AMIA Spring Congress.
As stated above, this phase of the research has been a study of the discursive construction of subject positions of certain kinds of people in the selected texts. This paper reports on the discursive construction of receivers of health care. Subject position is a poststructural concept associated with critical theory, cultural studies, and discourse analysis which posit individual humans as multi-forming and fragmentarynot unitary and integrated (p. 95) ADDIN REFMGR.CITE Lewis2002512Cultural studies the basicsBook, Whole512Cultural studies the basicsLewis,Jeff2002CultureStudy and teachingNot in FileLondonSAGE Publications0761963243viii, 492 p2[8]. It is important to differentiate between the empiricist concept of a subject who is a member of a study group in an experiment, and a subject position in critical or poststructural theory. Critical theory holds that fragmentary individuals and groups are constructed by subject positions through representations in texts and discursive practices. Critical theory assumes that subjects are both produced by and involved in or contribute to constitutive social processes which are reflected in texts, discourses and discursive practices ADDIN REFMGR.CITE Macey2001456The Penguin dictionary of critical theoryBook, Whole456The Penguin dictionary of critical theoryMacey,David2001Critical theoryCriticismDictionariesLiteratureOfTheoriesNot in FileLondonPenguin Books0140513698 (pbk.)Book, Whole2[9]. Critical and social constructionist discourse theory assumes that any single specific individual or group may actually occupy, or perform, or have imposed upon her or them, a number of different and possibly competing subject positions, such as elderly, African American, female, patient, stakeholder, end-user, etc., ADDIN REFMGR.CITE Howarth2000186Discourse Theory And Political Analysis Identities, Hegemonies, And Social ChangeBook, Whole186Discourse Theory And Political Analysis Identities, Hegemonies, And Social ChangeHowarth,David R.Norval,Aletta J.Stavrakakis,Yannis2000Discourse analysisPolitical aspectsPolitical scienceTheoriesNot in FileManchesterManchester University Press0719056632 (hardback)Book, Whole2Jorgensen2002431Discourse analysis as theory and methodBook, Whole431Discourse analysis as theory and methodJorgensen,MariannePhillips,Louise2002Discourse analysisTheoriesNot in FileLondonSage Publications0761971114Book, Whole2[10;11]. The words within quotation marks in the preceding sentence represent some of the ways in which patients may be classified in subject positions for any given health care or health information technology purpose. The study of the representation and positioning of subjects (i.e. as in elderly African American female patient) within a discursive structure may reveal latent assumptions about people which are socially and historically contingent, taken-for-granted, inaccurate, and/or unjust ADDIN REFMGR.CITE Laclau2001223Hegemony and socialist strategy towards a radical democratic politicsBook, Whole223Hegemony and socialist strategy towards a radical democratic politicsLaclau,ErnestoMouffe,Chantal2001PhilosophySocialismNot in File2nd edLondonVerso1859846211Book, Whole2[12]. Such representations of subjects may lead to inadequate and/or unjust requirements specification for an information technology project.
Methodology
This research has been conducted from a social constructionist and critical theoretical point of view using discourse analysis (DA) and corpus linguistics (CL), informed by the goals of Value Sensitive Design (VSD).
Social Constructionism. Burr (2003) outlined the family resemblances (2003:2-5) of social constructionism as:
A critical stance toward taken-for-granted knowledge.
Assumption of historical and cultural specificity.
Assumption that knowledge is sustained by social processes.
Assumption that knowledge and social action go together.
Burr (2003) further described social constructionism as an anti-essentialist anti-foundationalist epistemic point of view which considers language use as a form of social action ADDIN REFMGR.CITE Burr2003505Social constructionismBook, Whole505Social constructionismBurr,Vivien2003Cultural relativismDiscourse analysisLanguageOfResearchRoleSocial interactionSocial problemsSocial psychologySubjectivityNot in File2nd edLondonRoutledge0415317614 (alk. paper)p. cm2[13].
Critical Theory. When using critical theory, the research product is critique. Critique is distinguished from criticism from a neutral position in that critical theorists question the ability to achieve a neutral position. Therefore, critique takes an articulated political position with respect to the object of study and in the research process, and is used to uncover contradictory tendencies ADDIN REFMGR.CITE Brooker2002385A glossary of cultural theoryBook, Whole385A glossary of cultural theoryBrooker,Peter2002CultureOfterminologyTheoriesNot in File2ndLondonArnold0340807008 (hb)Book, Whole2[14] and power relations, and to foreground the structuring of knowledge around an array of social relations ADDIN REFMGR.CITE Harvey1990413Critical Social ResearchBook, Whole413Critical Social ResearchHarvey,Lee1990critical socialResearchNot in FileCambridge, MA.Unwin Hyman IncContemporary Social ResearchBulmer,MartinBook, Whole2[15]. Critical inquiry is a search for emancipatory knowledge in the interest of supporting action that promotes freedom ADDIN REFMGR.CITE Crotty1998513The foundations of social research meaning and perspective in the research processBook, Whole513The foundations of social research meaning and perspective in the research processCrotty,Michael1998MethodologyOfPhilosophyResearchSocial sciencesSociologyNot in FileLondonSage Publications0761961054 (hbk.)vii, 248 p2[16] and is frequently used in emancipatory projects with social justice goals.
Discourse Analysis. Jaworski and Coupland (1999) hold that discourse analysis evolved in response to the rise in the information age. They describe discourse analysis as an interdisciplinary movement, with discourse analysis approaches arising almost simultaneously in a number of different and unrelated disciplines including linguistics, communications, geography, philosophy, sociology, social psychology, anthropology, etc. In the introduction to their reader of the traditions of discourse analysis, Jaworski and Coupland (1999) attribute this rise in DA to a weakening in confidence in traditional ways of explaining phenomena (p3) and to the commodification of language through communications media. They observe that academic study and knowledge production are based on acts of classificationdefining boundaries between conceptual classeslabeling those classes and the relationships between them (p4). Discourse analysis is used to study language use as social action and the ways in which language use influences or constitutes knowledge development and representation ADDIN REFMGR.CITE Jaworski1999204The discourse readerBook, Whole204The discourse readerJaworski,AdamCoupland,Nikolas1999Discourse analysisNot in FileLondonRoutledge0415197333Book, Whole2[17]. It is often used to identify systematic language based bias, ideology, and taken for granted and historically contingent assumptions which result in systematic institutional social injustice ADDIN REFMGR.CITE Fairclough1989100Language and powerBook, Whole100Language and powerFairclough,Norman1989Discourse analysisLanguageSocial aspectsSociolinguisticsNot in FileLondonLongmanLanguage in social life series0582009766 (pbk.)Book, Whole2Fairclough199299Discourse and Social ChangeBook, Whole99Discourse and Social ChangeFairclough,Norman1992Not in FileMalden, MABlackwell Publishing0745612180Book, Whole2Gee1996404Social linguistics and literacies ideology in discoursesBook, Whole404Social linguistics and literacies ideology in discoursesGee,James Paul1996Discourse analysiseducationLanguage acquisitionLinguisticsLiteracySociolinguisticsNot in File2nd edLondonTaylor & FrancisCritical perspectives on literacy and education0748404996Book, Whole2Gee1999403An introduction to discourse analysis theory and methodBook, Whole403An introduction to discourse analysis theory and methodGee,James Paul1999Discourse analysisTheoriesNot in FileLondonRoutledge0415211867Book, Whole2[18-21]. Given that a large part of health care informatics work is concerned with the development of classification systems to enable computerized data management, discourse analysis may prove particularly useful for social justice projects in health informatics.
Corpus Linguistics. Corpus linguistics is a methodology employed to study language use for achieving communicative goals in large collections of naturally occurring texts called corpora ADDIN REFMGR.CITE Meyer2002254English corpus linguistics an introductionBook, Whole254English corpus linguistics an introductionMeyer,Charles F.2002Computational linguisticsData processingDiscourse analysisEnglish languageLanguageLinguisticsResearchNot in FileCambridge, UKCambridge University PressStudies in English language0521808790 (hardback)Book, Wholehttp://www.loc.gov/catdir/samples/cam033/2001052491.html; http://www.loc.gov/catdir/description/cam022/2001052491.html; http://www.loc.gov/catdir/toc/cam024/2001052491.html2[22]. Computerized linguistic analysis of corpora includes the construction of keyword in context (KWIC) concordances. A concordance is an index or list of lines containing all instances and contexts of use of a node word ADDIN REFMGR.CITE Halliday2004511Lexicology and corpus linguistics an introductionBook, Whole511Lexicology and corpus linguistics an introductionHalliday,M.A.K.2004LexicologyLinguisticsNot in FileLondonContinuumOpen linguistics series0826448615184 phttp://www.loc.gov/catdir/toc/fy046/2004556100.html2[23]. A concordance can be used to study language as social action through the analysis of word frequencies and clusters, keyword lists, word collocations, etc. ADDIN REFMGR.CITE Hunston2002188Corpora in Applied LinguisticsBook, Whole188Corpora in Applied LinguisticsHunston,Susan2002corporaLinguisticsNot in FileThe Cambridge Applied Linguistics SeriesLong,MichaelRichards,Jack C.0521801710Book, Whole2Stubbs1996340Text and corpus analysis: computer-assisted studies of language and cultureBook, Whole340Text and corpus analysis: computer-assisted studies of language and cultureStubbs,Michael1996CultureData processingDiscourse analysisEnglish languageLanguageLanguage and cultureModalityOfNot in File23Oxford, OX, UKBlackwell PublishersLanguage in society (Oxford, England)0631195114 (acid-free paper)Book, Whole2[24;25]. Stubbs (1996) and Hunston (2002) have both outlined ways in which computer assisted corpus linguistic methods can enrich discourse analysis by automating some aspects of close textual analysis of patterns of language use in large corpora. Fairclough (2000) combined corpus linguistics with critical discourse analysis in his study of the social action of language in use in the New Labor political movement in the United Kingdom ADDIN REFMGR.CITE Fairclough200098New Labour, new language?Book, Whole98New Labour, new language?Fairclough,Norman20001953-1997-20th centuryBlair,TonyEnglish languageGreat BritainHistoryLanguagePolitical aspectsPolitical oratoryPoliticiansPolitics and governmentSocialismNot in FileNew YorkRoutledge0415218268 (hbk)Book, Wholehttp://lcweb.loc.gov/catdir/toc/99046501.html2[26].
Value Sensitive Design. The methodology developed for this research was inspired by the goals of Value Sensitive Design (VSD). The evolution of VSD follows in the tradition of Computer Ethics, Social Informatics, Computer Supported Collaborative Work, and Participatory Design ADDIN REFMGR.CITE Friedman2003509Human Values, Ethics, and DesignBook Chapter509Human Values, Ethics, and DesignFriedman,BatyaKahn,Peter H.2003HumanEthicsergonomicsNot in File11771201The Human-Computer Interaction HandbookJacko,Julie A.Sears,Andrew61Mahwah, NJLawrence Erlbaum AssociatesHuman Facorr and ErgonomicsSalvendy,Gavriel0-8058-4468-63[27]. It is distinguished from these by its application during the design phase, when technology problems can be inexpensively corrected. VSD goals place a premium on supporting values that are critical to the optimal social functioning and work processes of all stakeholders in the information system ADDIN REFMGR.CITE Friedman1997128Bias in Computer SystemsBook Chapter128Bias in Computer SystemsFriedman,BatyaNissenbaum,Helen1997HumanOfTechnologyNot in File2340Human Values in the Design of Computer TechnologyFriedman,Batya1Stanford, CACSLI Publications, Cambridge University PressBook, Section3Friedman2002126Informed Consent in the Mozilla Browser: Implementing Value Sensitive DesignConference Proceeding126Informed Consent in the Mozilla Browser: Implementing Value Sensitive DesignFriedman,BatyaHowe,Daniel C.Felton,Edward2002Not in File35th Hawaii International Conference on System SciencesConference Proceedingshttp://www.hicss.hawaii.edu/HICSS_35/HICSSpapers/PDFdocuments/OSPEI01.pdf;http://www.hicss.hawaii.edu/HICSS_35/HICSSpapers/PDFdocuments/OSPEI01.pdf12Friedman2003509Human Values, Ethics, and DesignBook Chapter509Human Values, Ethics, and DesignFriedman,BatyaKahn,Peter H.2003HumanEthicsergonomicsNot in File11771201The Human-Computer Interaction HandbookJacko,Julie A.Sears,Andrew61Mahwah, NJLawrence Erlbaum AssociatesHuman Facorr and ErgonomicsSalvendy,Gavriel0-8058-4468-63[27-29]. VSD assumes that technology can either support or interfere with human values, and that technology is never value neutral ADDIN REFMGR.CITE Friedman1997128Bias in Computer SystemsBook Chapter128Bias in Computer SystemsFriedman,BatyaNissenbaum,Helen1997HumanOfTechnologyNot in File2340Human Values in the Design of Computer TechnologyFriedman,Batya1Stanford, CACSLI Publications, Cambridge University PressBook, Section3[28]. At least three kinds of bias may be introduced via computer systems: 1) pre-existing bias (rooted in social practices, institutions), 2) technical bias (arising out of technical and algorithmic constraints), and 3) emergent bias (arising in context of use) ADDIN REFMGR.CITE Friedman1997128Bias in Computer SystemsBook Chapter128Bias in Computer SystemsFriedman,BatyaNissenbaum,Helen1997HumanOfTechnologyNot in File2340Human Values in the Design of Computer TechnologyFriedman,Batya1Stanford, CACSLI Publications, Cambridge University PressBook, Section3[28]. Trade-offs between competing human values are required in designing information systems, as in every other area of human activity. By using a VSD perspective, these trade-offs can be made on a conscious and articulated basis during the design process. The goal of VSD is to find ways to mitigate potentially crippling values conflicts embedded in systems before the design, construction, and implementation of the application is complete. To accomplish early detection of values conflicts, VSD prescribes iterative application of three kinds of studies throughout the technology development process: conceptual, technical, and empirical ADDIN REFMGR.CITE Friedman1997128Bias in Computer SystemsBook Chapter128Bias in Computer SystemsFriedman,BatyaNissenbaum,Helen1997HumanOfTechnologyNot in File2340Human Values in the Design of Computer TechnologyFriedman,Batya1Stanford, CACSLI Publications, Cambridge University PressBook, Section3Friedman2002126Informed Consent in the Mozilla Browser: Implementing Value Sensitive DesignConference Proceeding126Informed Consent in the Mozilla Browser: Implementing Value Sensitive DesignFriedman,BatyaHowe,Daniel C.Felton,Edward2002Not in File35th Hawaii International Conference on System SciencesConference Proceedingshttp://www.hicss.hawaii.edu/HICSS_35/HICSSpapers/PDFdocuments/OSPEI01.pdf;http://www.hicss.hawaii.edu/HICSS_35/HICSSpapers/PDFdocuments/OSPEI01.pdf12[28;29].
VSD as practiced by its originator Batya Friedman and her colleagues is based on an essentialist and foundationalist epistemic point of view and investigates for violations of specific universal human values ADDIN REFMGR.CITE Friedman2003509Human Values, Ethics, and DesignBook Chapter509Human Values, Ethics, and DesignFriedman,BatyaKahn,Peter H.2003HumanEthicsergonomicsNot in File11771201The Human-Computer Interaction HandbookJacko,Julie A.Sears,Andrew61Mahwah, NJLawrence Erlbaum AssociatesHuman Facorr and ErgonomicsSalvendy,Gavriel0-8058-4468-63[27]. The research approach in this study does not assume universal values other than an interest in social justice, and emancipatory research and action. Nonetheless, this investigator believes that the goals of VSD, and the iterative application of conceptual, technical, and empirical studies can contribute to this and other critical, social constructionist and social justice research projects regarding technology development. This current research is an empirical study conducted in the interest of revealing or uncovering potential hidden and taken for granted assumptions in the IOM health policy reports which may lead to the translation of pre-existing institutional bias into the NHII.
Methods
Data. A detailed description of the data selection for this research was outlined in the first preliminary report ADDIN REFMGR.CITE Trigg200678Reproducing social inequality in the National Health Information Infrastructure, a discourse analysisConference Proceeding78Reproducing social inequality in the National Health Information Infrastructure, a discourse analysisTrigg,Lisa J.2006Not in FileSeoul, Korea9th International Congress of Nursing Informatics2006/6/1912[4]. The IOM report series Quality Chasm was selected because these texts include strong recommendations for HIT in the interest of improving health care safety and quality ADDIN REFMGR.CITE Institute of Medicine2005420Crossing the Quality Chasm: The IOM Health Care Quality InitiativeElectronic Citation420Crossing the Quality Chasm: The IOM Health Care Quality InitiativeInstitute of MedicineBoard on Health Care Services2005HealthQualityNot in FileInstitute of Medicine2006/2/22Web Pagehttp://www.iom.edu/CMS/8089.aspxInstitute of Medicine34[1] and are widely quoted in literature supporting the deployment of HIT and the construction of the NHII ADDIN REFMGR.CITE National Committee on Vital & Health Statistics2005269The National Health Information Infrastructure (NHII) 2002-2004Electronic Citation269The National Health Information Infrastructure (NHII) 2002-2004National Committee on Vital & Health Statistics2005HealthNational Health Information InfrastructureNot in FileUS Department of Health & Human Services2006/2/22Web Pagehttp://aspe.hhs.gov/sp/nhii/US Department of Health & Human Services34[30]. The Insuring Health series ADDIN REFMGR.CITE Institute of Medicine2004423Consequences of Uninsurance ProjectElectronic Citation423Consequences of Uninsurance ProjectInstitute of MedicineCommittee on the Consequences of Uninsurance2004UninsuranceUninsuredNot in FileInstitute of Medicine2006/2/22Web Pagehttp://www.iom.edu/project.asp?id=4660Institute of Medicine34[2] and the standalone report Unequal Treatment ADDIN REFMGR.CITE Smedley2003327Unequal treatment confronting racial and ethnic disparities in health careBook, Whole327Unequal treatment confronting racial and ethnic disparities in health careSmedley,Brian D.Stith,Adrienne Y.Nelson,Alan R.Institute of MedicineCommittee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care2003Cross-cultural studiesDiscrimination in medical careEthnic GroupsHealthHealth services accessibilityMedical careMedicineMinoritiesMinority GroupsOfQuality of Health CareRace discriminationRacismScienceSocial medicineUnited StatesNot in FileWashington, D.CNational Academy Press030908265X (hardcover)Book, Whole2[3] were selected because they outline specific social justice problems in health carethose associated with uninsurance and the unequal treatment of racialized populations in United States health care. These reports were published by the IOM contemporaneously with the Quality Chasm series, between 2000 and 2005, and form a large corpus of naturally occurring texts from one of the leading health policy advisory organizations in the United States ADDIN REFMGR.CITE Institute of Medicine2006506About the Institute of MedicineElectronic Citation506About the Institute of MedicineInstitute of Medicine2006OfMedicineNot in FileInstitute of Medicine2006/2/22http://www.iom.edu/CMS/3239.aspxInstitute of Medicine34[31]. The executive summaries of the first text in both series and the standalone report were selected for the preliminary data analysis in order to limit the scope of the project for methods testing.
Data Management & Processing. All texts were purchased from the National Academies Press ADDIN REFMGR.CITE National Academy of Sciences2006266About the National Academies PressElectronic Citation266About the National Academies PressNational Academy of Sciences2006Not in FileNational Academies Press2006/2/22Web Pagewww.nap.edu National Academies Press34[32] in both paper book and digital .PDF formats to facilitate comparison of surface features of all texts and random checking of agreement between the text versions. The .PDF documents were converted to the rich text format in batches using ConvertDocTM ADDIN REFMGR.CITE Softinterface2006508ConvertDocElectronic Citation508ConvertDocSoftinterface,Inc.2006Not in FileSoftinterface, Inc.2006/2/22http://www.softinterface.com/Convert-Doc/Convert-Doc.htmSoftinterface, Inc.34[33] in preparation for analysis using corpus linguistics computer analysis tools. Headers repeated on each page of all three executive summaries were removed because of their likelihood of skewing word frequency counts. For the larger project, Oxford WordSmithTM Tools 4.0 ADDIN REFMGR.CITE Scott2006507Oxford WordSmith Tools 4.0Electronic Citation507Oxford WordSmith Tools 4.0Scott,MikeOxford University Press2006Not in FileOxford University PressOxford University Press2006/2/22http://www.lexically.net/wordsmith/index.htmlOxford University Press34[34] will be used to create wordlists, word frequency and cluster counts, keyword lists, and concordances, and to search for collocation patterns of selected words and phrases. For the currently described methods testing research, Oxford WordSmithTM Tools 4.0 was used initially to create KWIC concordances for the three separate executive summaries for the keyword patient*. Subsequent keyword concordances for the words person* and consumer* were created based on analysis of the results of the initial patient* concordances.
Results
In this section only, Coverage Matters = CM, To Err is Human = TEH, and Unequal Treatment = UT. The methods testing in this phase of the research has included the construction of KWIC concordances of the executive summaries of CM, TEH, and UT using keywords representing receivers of health care in the texts. The sentence Uninsured persons may be charged more than patients with coverage (p.5) in the CM concordance prompted a second set of concordances for all three texts using the keyword person*, and a third for the word consumer*. The results of all three sets of concordances appear in Table 1. This data is provided to give a sense of the size of the individual texts and the number of times that each word is used in each text, since the page limitation of this venue makes it impossible to show the KWIC concordances in this paper. There is no direct statistical correlation between word usage and meaning production ADDIN REFMGR.CITE Stubbs1996340Text and corpus analysis: computer-assisted studies of language and cultureBook, Whole340Text and corpus analysis: computer-assisted studies of language and cultureStubbs,Michael1996CultureData processingDiscourse analysisEnglish languageLanguageLanguage and cultureModalityOfNot in File23Oxford, OX, UKBlackwell PublishersLanguage in society (Oxford, England)0631195114 (acid-free paper)Book, Whole2[25], however such frequencies can point to node words which bear further scrutiny in the next phases of this research.
Table 1. Word FrequenciesKWICCMTEHUTPatient*281129Person*2723Consumer*371Total word tokens476451397729Table SEQ Table \* ARABIC 1. This table shows the number of times each keyword appears in each text according to the KWIC concordance.
The most notable result of the keyword in context concordancing was the small number of times that the word patient* was used in CM, compared with the number of times it was used in the other two texts. The sentence detected through the KWIC from CM and quoted in the last paragraph actually distinguishes between uninsured persons and patients with coverage, reporting that uninsured persons often pay more for medical care than patients with coverage. This distinction is curious and contradictory, given that if uninsured persons are paying more than others for medical care, they must at some time have also been patients. A person is one of the most general words we can use to describe an individual, while a patient is a very specific kind of person, engaged in very specific social relations with health care providers and the health care industry.
Oxford WordSmithTM Tools generates word cluster lists for each concordance if there are significant word clusters repeated throughout the texts. These are shown in Table 2.
Given that TEH is often referred to as one of the patient safety reports, it is no surprise that word clusters including variants of patient and safety, are repeated throughout the text. The same can be said for the cluster result for UT which examines unequal treatment of racialized populations.
Table 2. Word Cluster ListsTEHUTClusterFClusterFfor patient safety8racial and ethnic6patient safety and6minority patients and5to patient safety6are more likely5patient safety to5to improve patient5on patient safety5improve patient safety5center for patient5in patient safety5improving patient safety5Table SEQ Table \* ARABIC 2. Word clusters from concordances of executive summaries from To Err is Human and Unequal Treatment using keyword patient*. No word clusters resulted from the patient* KWIC concordance for Coverage Matters, or from the other two sets of KWIC concordances. F refers to number of times of the word cluster is repeated in the text.
Discussion
This has been a preliminary report of a textually oriented discourse analysis of three executive summaries from IOM reports. Due to the limited corpora used and the limited narrative data analysis which can be presented in this venue, only the most modest claims can be made on the basis of this research. These claims relate predominantly to the testing of the methods. However, the investigator believes that enough has been presented to demonstrate the usefulness of this approach to studying the stated research problem.
The KWIC concordancing enabled detection of differences in the words used to refer to receivers of health care in the three policy report executive summaries. To Err is Human, and Unequal Treatment predominantly use the word patient* and far less frequently person* and consumer*. Coverage Matters draws a sharp distinction between an uninsured person and a patient. Analysis of the sentence quoted above in the Results section shows the contradiction and erroneous assumption inherent in this distinction. Given the limited corpora used in this study, little can be made of this distinction. However if this distinction between uninsured persons and patients pervades the Insuring Health texts, and enters the policy level requirements specification for the NHII, the needs of receivers of health care who are uninsured may not be adequately represented in a NHII which is designed for patient safety.
The word clusters revealed in both To Err is Human and Unequal Treatment were predictable. However their identification through the use of KWIC concordancing demonstrates that this approach combined with critical and social constructionist discourse analysis has the potential to expose subtle differences in social action through language use between even very small corpora.
Conclusion
The combination of critical and social constructionist discourse analysis with corpus linguistics methods has proven to be adequate for investigating textual data for discursive signs of the reproduction of existing inequity in health care in IOM policy documents. It should prove useful in the larger study, which will use a much larger corpus, and make a closer interrogation of the textual data. The automation of corpus linguistics methods doesnt replace human interpretation but provides systematic ways to find language use patterns of interest to this research.
Acknowledgements
Many thanks to the NLM training grant # 5 T15 LM07442, Gail Stygall, Carole Schroeder, David Allen, Sherrilynne Fuller.
Contact
Lisa Trigg HYPERLINK "mailto:trigger@u.washington.edu" trigger@u.washington.edu
References
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[2] Institute of Medicine and Committee on the Consequences of Uninsurance (2004). Consequences of Uninsurance Project. Institute of Medicine [On-line]. Available: HYPERLINK "http://www.iom.edu/project.asp?id=4660" http://www.iom.edu/project.asp?id=4660 Retrieved: 2-22-2006
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[27] Friedman B, Kahn PH. Human Values, Ethics, and Design. In: Jacko JA, Sears A, editors. The Human-Computer Interaction Handbook. Mahwah, NJ: Lawrence Erlbaum Associates, 2003: 1177-1201.
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[34] Scott, M. and Oxford University Press (2006). Oxford WordSmith Tools 4.0. Oxford University Press [On-line]. Available: HYPERLINK "http://www.lexically.net/wordsmith/index.html" http://www.lexically.net/wordsmith/index.html Retrieved: 2-22-2006
Methods testing study #2
Submitted for American Medical Informatics Symposium 2006
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