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Constructing ClinicalUse: An Activity-Theoretical Perspectiveon Implementing NewTechnologyMervi HasuPublished online: 25 Aug 2010.

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Technology Analysis & Strategic Management, Vol. 12, No. 3, 2000

Constructing Clinical Use: An Activity-TheoreticalPerspective on Implementing New Technology

MERVI HASU

ABSTRACT How do individual users survive the introduction of an innovation into complextechnological and organizational contexts? An analysis is presented of the implementation of radicallynew technology, a neuromagnetic measuring system (MEG), to hospital environment. The analysis, in1997, covers the attempt during its �rst �ve months to take MEG into clinical use at a hospitallaboratory, and follows the central actor, a consulting physician who was hired to start the clinicalservice. An activity-theoretical framework is used to analyze the diÝculties of the multi-organizationa limplementation process. The framework (1) emphasizes the importance of analyzing the perspectives ofdiÚerent actors on implementation; (2) provides means to explore the developmentally signi�cantcontradictions in an organizational setting of an implementation and (3) discusses the user problemsand user initiatives signalling a need for collective learning within implementation.

Introduction

Introduction of new technology has been a continuous research interest in the studies ofthe economics and management of innovation.1 They have addressed the non-linear,iterative and interactive nature of innovation process. The assumption has been main-tained that the impediments to the introduction into the market are a matter of temporaryunbalance between demand and supply that can be passed over with the help of policymeasures, strategic planning and managerial operations. Accordingly, demand and userneed appear as something pre-existing that can be recognized in advance. This logiccontradicts the notion of innovation: How can users have a prior need of something thatdoes not even exist?

Kenneth Green2 challenges the assumption of pre-existing demand and marketsuggesting that commercialization of radically original products based on new technologies‘has to involve the shaping of a market as well as the shaping of a technology’ and,particularly, that ‘the shaping of the artefacts and the shaping of certain institutions thatset up the demand for those artefacts must go together’. Green shows that the simultaneouscoming together of artefacts and institutions is often constrained by lack of appropriateinstitutional structures and regulatory agencies, as well as by professional practitioners’hostility towards adopting a new innovation. While Green’s critique of pre-existingdemand does not include an analysis of organizational processes and interactions between� rms and their customers, Blackler identi� es mechanistic interpretations of technologyand institutions in recent approaches to management and organization analyses that

Mervi Hasu, Center for Activity Theory and Developmental Work Research, University of Helsinki, P.O. Box 47,00014 University of Helsinki, Finland; E-mail: mervi.hasu@helsinki.�

ISSN 0953-7325 print; 1465-3990 online/00/030369-14 © 2000 Taylor & Francis Ltd

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encourage conceptions of technologies as distinct from the people who use them.3 BothGreen and Blackler stress a need to look into not only what � rms, organizations andindividuals already have or may acquire, but also what they do as they seek to createnew conditions and make sense of the world they live in.

To broaden the analysis of technology in use, I shall examine the transition processof new medical technology from its developers to clinical users. The innovation is aneuromagnetic measuring system (MEG)4 for brain research and diagnostics, developedand manufactured by a Finnish company Brainview.5 Three organizations were involvedin the implementation of MEG: (1) the original developer of the technology, the LowTemperature Laboratory (LTL) at the Helsinki University of Technology, (2) a spin-o Ú

company Brainview, the manufacturer of the MEG devices, and (3) the user laboratoryBioMag at the Helsinki University Central Hospital (HUCH). My interests lies inexamining the preconditions of the users as they became involved in the developmentand subsequent implementation of the device and in following their e Ú orts to shape aviable tool for their activity.

The analysis covers a � ve-month period of the � rst attempt to implement MEG toclinical use at the hospital laboratory BioMag, in 1997. A medical doctor was then hiredby BioMag to start the clinical service and a support group of product developers wasestablished to assist her in the work. However, the physician, Dr Sara, resigned afterhaving run into serious problems in producing the clinical reports, and the attempt wasinterrupted. What can be learnt from these di Ý culties of implementation?

First, I shall provide a framework for the analysis of the implementation process andthen examine, in more detail, the three phases of the process. The central actor followedhere is the above-mentioned consulting physician who was hired to start the clinicalservice. I shall trace the signi� cant turning points, breakdowns and new initiatives in theprocess and bring them under a detailed scrutiny. Finally, I shall discuss my � ndingsfrom the case analysis. I shall argue that the attempt failed because the building of theclinical service was not constructed and articulated as a shared object of activityamong the key participants of the implementation. Resolution of historically constructedcontradictions within and between organizations are required as a precondition for theemergence of a shared object of implementation and, consequently, for the transition ofan innovation toward practical use.

Conceptual Framework

To analyze the complicated nature of the implementation of new technology and tounderstand individual and collective actions connected to it, I shall use an activity-theoretical framework.6 I consider the organizations involved in the implementation asactivity systems7 mediated by cultural tools (both material and conceptual), rules anddivision of labor. The distinction between individual goal-oriented action and collectiveobject-oriented activity is of crucial importance here. The temporal duration of actionsis relatively short. Activity systems are relatively durable, historically evolving collectiveformations that produce individual actions and consist of members who share the samegeneral object. The developmental aspects of an activity can only be grasped when theunit of analysis is expanded to the collective activity system.

The activity-theoretical notion of object should not be confused with the concept ofgoal or objective. The object is to be understood as a project under construction, movingfrom potential ‘raw material’ to a meaningful shape and outcome. The motive is thusembedded in the object of activity. The motive is formed when a collective need meetsan object that has the potential to ful� ll that need. Separate historical layers and

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Constructing Clinical Use 371

perspectives meet and interact in object construction. As an object and motive ofcollective activity is sought after, the members of the activity will take di Ú erent perspectivestoward it. Perspectives can be characterized as contingent and historical, situationallyemergent, collective productions that involve the capacity of humans to apprehend theconditions of their activity and to change those very conditions.8

The construction of the object is no harmonious process in itself. Activity theoryregards developmentally signi� cant contradictions as sources of dynamics and change inthe implementation process. Contradictions manifest themselves in everyday breakdownsand disturbances9 and in participants’ improvised solutions appearing in the concrete usesituations of the technology.

Implementation of new technology in an organizational setting can be regarded asthe construction and reconstruction of the object of activity. As activity systems undergotransitions, for instance, by implementing new artifacts, they typically rede� ne andexpand their objects. The expansive object can take various forms and is manifested invisions, actions and material conditions that people create during the change process.The anticipated object determines the horizon of possible individual and group actionswithin the collective activity.

The Implementation Process

The implementation process took place at the hospital laboratory BioMag and lasted for� ve months from January to May 1997.10 I distinguished three phases in the process: (1)an initial phase, starting from a user seminar and proceeding to the recruitment of theconsultant doctor to start the clinical work at BioMag, (2) a pilot phase, starting from the� rst referral measurement and ending with the decision of the consultant doctor to resign,and � nally, (3) a phase of fading, during which the endeavor gradually scaled down.

Initial Phase: Diverse Perspectives and the Emerging New Object

In interviews conducted in 1996, the potential users at the hospital expressed their vitalinterest in the clinical utility of MEG, and, at the same time, feelings of confusion aboutthe availability of patient measurements in the BioMag laboratory. In a user seminar11

organized together with the Brainview Co., in January 1997, the clinicians addressedthree preconditions central to the clinical applicability of MEG: (1) standardized measure-ment and analysis service, (2) validation of data, and, (3) further R&D. These issues wereinterdependent. From the clinicians’ points of view, the clinical utility of MEG stillrequired better understanding of the signi� cance of the MEG results. The collection ofstandardized data was then a precondition for the users to start a more systematicutilization of the device and the method.

The BioMag laboratory was organized as a centralized facility for basic and pre-clinical research. It was not a Ý liated with any hospital clinic. The way the measurementswere organized at the laboratory, each isolated researcher being responsible for his orher own measurements, did not provide good conditions for creating routine, standardizedmeasurements. The primary developmental challenge of the BioMag activity system wasthe expansion of the object from a single, experimental measurement and analysis taskto standardized measurements of real patients.

Shortly after the user seminar, the BioMag laboratory recruited the clinical neurophy-siologist mentioned above, Dr Sara (henceforth Dr S). The spin-o Ú company Brainview,in its turn, founded a support group for Dr S to help her with the measurement andanalysis systems. For the company, the recruitment of a physician was a long-expected

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and positive development in the user laboratory. The managing director of the companywas enthusiastic about the good news and satis� ed with the particular person chosen.

Director of Brainview: Well, we have waited for this to happen, it surely is a positivesign. We feel that the doctor is also Brainview’s friend, a kind of pseudophysicistactually! She understands the technology and the method. We have already talkedwith her and now we will support her work in the lab. We will only do the technicalsupport; medical supervision is not our job. (12 February 1997)

In this way, by referring to Dr S’s individual capabilities and her familiarity with theinstrument, the director constructed a perspective of individual mastery of the speci� ctechnology related to the emerging new object. The role of the company was to providespeci� c technical support for Dr S’s work, and not to get involved in the organization ofmedical practice.

According to the manager of the BioMag laboratory, there had not been su Ý cientfunds for the development of clinical work at the laboratory. The situation had changedonly recently, as the laboratory received a new grant and was able to hire the consultantphysician. The manager admitted that meeting with the clinical users did speed up thedecision to hire Dr S. To quote the manager, ‘the meeting provoked us to think aboutthe situation di Ú erently’. The manager of the laboratory emphasized the good start andthe forthcoming tasks of the newly hired doctor.

Laboratory manager of BioMag: Her main job is to develop the clinical routines. She isdoing well, she has already been contacting the clinics and two patients will becoming. But, before that, there is a need to develop standard measurement protocolsand report forms. It may turn out to be somewhat di Ý cult because the patients arerather heterogeneous. So, there is a lot to do. Also Brainview has a role here inworking these things out. (12 March 1997)

By referring to clinical routines (e.g. standard protocols and report forms), the managerrecognized the di Ú erence between performing experimental measurements and runninga clinical service. On the other hand, he referred to Dr S as a single actor, planning andstarting the measurement and analysis service (e.g. ‘she has been contacting the clinics’).He constructed a perspective of solo responsibility (and solo performance) with regard tothe emerging object.

The Brainview Co. and the BioMag laboratory had di Ú erent perceptions about thenecessity of collaboration with the Low Temperature Laboratory (LTL), the originalfounder of the MEG technology and the method. The relations between the threeorganizations were historically complex.12 The LTL Brain Research Unit was led by amedical practitioner and leading � gure in the MEG method and analysis. The expertuse of MEG resided with the Unit. Brainview’s managing director was planning to getthe Unit involved in the support group, while the manager of BioMag did not regardcollaboration with the Brain Research Unit as essential. He emphasized that, to a certainextent, the expert know-how of MEG had already been transferred from the Unit topersons and groups currently working with the BioMag laboratory. He saw the work atBioMag largely independent of the work carried out in LTL. He constructed a perspectiveof independent development of expertise in the building of the clinical measurement andanalysis service.

Laboratory manager: BioMag is not in the least dependent on the Low TemperatureLaboratory, and the other way round. And I would rather say that they don’t wantto collaborate with us. Well, of course there would be certain advantages, for

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Constructing Clinical Use 373

instance, we could get particular software programs for common use more quickly. . . .Both BioMag and the Low Temperature Laboratory have their own functions.(12 March 1997)

When hired, Dr S was on research leave from the department of clinical neurophysiologyof the local district hospital. In addition to routine EEG work skills at the hospital, shehad also acquired experience with MEG. She had taken the job for her interest inapplying MEG to clinical work. After having worked at the lab for a few weeks, sheencountered serious constraints to her tasks and position.

Doctor Sara: . . . the most important thing here is to get proof of the clinical value ofMEG. . . . [to] prove that we have at least one or two routine measurement protocolsfor the clinicians to utilize in their work of diagnosing or treating patients. . . . It isactually a very clear and concrete task. It is quite similar to the work I have beendoing for the last few years in the N. N. Hospital. When I started to work there, thelaboratory was like a museum, almost dying, and my job was to enlarge and buildit up, and it succeeded. The situation here is much more complicated, more exactingand, also, let’s say, a more risky thing. Because over there, I had sta Ú ready andavailable, my task was to expand the lab on a solid basis. Here, I have got nothing.All the pieces lie scattered. (17 March 1997)

First, by relating her goal with MEG to clinical value and usability in practical medicalwork, Dr S constructed a perspective of clinical practice. This topic led her to deal withthe ‘clear and concrete task’ of organizing the practical work to accomplish the goal. Inthis way, she also constructed a perspective of organizing the practical clinical work. Theperspective shows an expansion of object: an intention of running a clinical serviceinstead of accomplishing isolated measurements with the help of individual researchers.As she turned to compare her current task with her former experience in organizingclinical work, the mode of the interview changed. It indicates her becoming aware oflimits of solo responsibility and lack of resources in a challenging new task.

From this point on, Dr S touched upon various constraints in the conditions of herjob. In terms of activity system, she re� ected on the rules, community and division oflabor of her work in the laboratory and in the broader network. She was confused aboutthe various support groups that had been established to support her work. It seemed thatshe was not supposed to be the central actor, gathering together the group and de� ningthe participants’ tasks. In addition to the technical support group of the company, alsoan ‘uno Ý cial’ background group from the LTL was showing interest in her task.

They [LTL] seem to have ideas of how this should be handled routinely. Somehow,I feel like an outsider—Maybe it is because of this new situation, I am some kind ofoddity here. My tasks are not actually de� ned, at least I am not aware of it. . . . Idon’t know for how far my power extends. . . . This social environment really is quitecomplicated. (Dr Sara, 17 March 1997)

The constraints of her situation were closely related to the community of BioMag. Dr Swas meant to perform a large variety of fairly demanding tasks, yet she was not o Ú eredany clear status of authority within the community. She was in danger of becoming tool-less in the organizing work necessitating negotiations and a leadership position withinthe hospital.

Dr S associated her constraints with the multiplicity of goals and groups workingwithin the BioMag laboratory. Formulated in activity-theoretical terms, the currentobject(s) and rules of BioMag were not supporting her new position and work. A

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contradiction between the new object and the rules of a centralized research facilityemerged. She was becoming aware of a situation where the new object held only a smallshare of interest among the goals of the laboratory. To quote Dr S: ‘My job is to developthe entire routine, but in the lab’s objectives it plays only a small role’.

Amidst these emerging tensions and constraints in the community, she was requiredalso to learn and use a large variety of software tools and other equipment. She wasexpected to organize the entire activity: plan the procedures, make contacts, negotiateproblems and master the new tools simultaneously. She was stressed out and worried,wondering how to cope with all the pressure.

To sum up, at the initial phase of the implementation, the central actors constructedmultiple perspectives to the new object. These diverse perspectives were manifestationsof the heterogeneous objects of activity among the key actors. The managing director ofBrainview regarded involvement with the third party, the Low Temperature Laboratory,as essential for the endeavour; BioMag’s manager, for his part, deemed importantcollaboration with Brainview only. Inclusion of such ‘other parties’ advocated by themanagers indicated partial expansion of object, an intention to broaden the expertiseneeded in the endeavour. On the other hand, both managers focused on individual, soloperformance, and, thus, on operational straightforwardness of the task. There were nonegotiations held between BioMag, Brainview and the Low Temperature Laboratory tocreate a shared vision about the endeavour.

Dr S’s perspective showed expansive distinction between performing a single measure-ment and running a clinical service. Simultaneously, it opened a horizon of constraintsrelated to the contradiction within the BioMag activity system between the emergingnew object and the old rules of a centralized research facility with multiple objects. Dr Swas indeed becoming aware of the complexity of the task and the social environment, ofher being left alone with the challenge.

Pilot Phase: Disturbances and Innovative Initiatives

Expansive dimensions of the new object. At the initial phase of the implementation process,I asked Dr S to envision certain basic steps—a rudimentary script13—of the clinicalmeasurement and analysis service. In her words, the script included: (1) a referral for aMEG measurement from a physician, (2) the measurement event, (3) data analysis, (4) aclinical report, and (5) forwarding the report(s) and documenting the information. Inaddition to the MEG measurement, a parallel clinical study, a magnetic resonance image(MRI) physically located at the radiology department, was also needed to provideinformation for the neurologists and neurosurgeons working on pre-operative planning.The planned clinical service was a combination of these two imaging modalities: thelocations of the functional areas of the brain provided by MEG were shown in relationto the structural information provided by MRI.

This is a combination of two clinical measurements actually. We have to communi-cate with the radiology department, since the patients will go there for MRI, andwe need to get the images here routinely and quickly. Helena [the nurse of BioMag]has made some inquiries about whether we could get access to the hospital patientrecords and other systems. . . . (Dr Sara, 17 March 1997)

The simple script envisioned by Dr S was a step forward in concretizing the emergingand still ‘ideal’ new object: the measurement and analysis service. These procedural stepsimplied the expansion of the object from a single experimental measurement and analysistask to standardized measurements and analysis on real patients.

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Constructing Clinical Use 375

The envisioned script represents expansion along three dimensions.14 First, it altersthe temporal organization of the object. In basic research, an individual researcherwriting a scienti� c article has a � nite measurement and analysis cycle consisting of weeksor months, whereas running a clinical service is a continuous process. The time dimensionbecomes also more intense. In clinical work where the information is used by cliniciansworking on actual pre-operative planning, each measurement and analysis cycle must bereduced into a few days. Mastering these new challenges of continuity and intensityrequires trained personnel and viable software tools for data analysis and reportingpractices, in other words, expansion of the subject and tools of the activity.

Second, the script expands the object spatially. The clinical service, being a combina-tion of two clinical measurements, MEG and MRI, was presently located in two di Ú erentlaboratories. This called for negotiated organization between the BioMag laboratory andthe radiology department and, due to the developmental character of this enterprise, alsowith the other parties, Brainview Co. in particular. The user of the measurement andanalysis service will no longer be an individual scientist or physician-researcher. Clinicalcommunities will emerge as users, which will require communication with cliniciangroups. As new practitioners join the emerging activity, also the community and thedivision of labor between those practitioners will require expansion.

Third, the anticipated clinical service implies an expansion along the developmentaldimension. Both the technology and the new way of applying it—clinical use andprocedural scripts—are under development, and they will become tested and furtherimproved in the emerging clinical trials. Besides the object, also the tools, rules, communityand division of labor—the entire activity system—will be constructed through clusters ofactions aimed at solving emerging problems of the activity.

Data analysis as bottleneck. Dr S, the laboratory manager and the other researchers hadtheir o Ý ces in a separate building, but during data-analysis sessions Dr S worked at thelab where she did not have a desk of her own or any data analysis workstation for herpersonal use.

After the � rst pilot case of an adult epilepsy patient, Dr S started to analyze themeasurement data. The referring doctor, a neurologist from the Neurological Rehabilita-tion Center, was interested in a MEG evaluation to con� rm the estimated location ofthe epileptic foci obtained by other clinical measurements. Simultaneously with the MEGregistration, EEG data was also gathered. Dr S began to look at the MEG and EEGsignals simultaneously with the help of a special program developed by the BrainviewCo.’s programmer. The clinical report for the � rst patient was supposed to be forwardedto the referring doctor within a week. However, Dr S immediately started to experienceproblems with the analysis programs, which seriously delayed the clinical report.

Dr S’s time was not consumed in the analysis work. Instead, waiting seemed tobecome the main object of her activity. Observation during the pilot phase revealedseveral occasions of prolonged waiting which can be traced back to contradictions withinthe BioMag activity system as well as to the complex relations between the BioMaglaboratory, Brainview Co., and Low Temperature Laboratory (LTL). During the pilotphase, Dr S had to wait for help from the product developers to various user problems,such as installation of a new analysis program developed at the LTL, user training forthe new program from its originator, a support group meeting, new program features fordata analysis work, etc.

In two data-analysis sessions conducted by Dr S, seven types of actions were foundin the observation data (Table 1).

In the � rst data-analysis session, the program functioned exceptionally slowly. Dr S

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Table 1. Distribution of time spent in various actions by Dr S, as revealed in two data-analysis sessions. (Total duration of a data-analysis session 5 100%)

User’s actions during data-analysis session Session I (%) Session II (%)

1. User’s independent repair actions or troubleshooting 25 282. Attempts to contact the programmer by telephone 17 03. Getting instructions by telephone 8 84. Waiting for the programmer to enter the lab 0 165. Negotiating with the programmer about the problems in the lab 0 86. Waiting for the programmer to � nish his troubleshooting 0 327. Conducting data-analysis work 50 8

Total (%) 100 100

together with the nurse, and, � nally, with the programmer, made several attempts todetermine the cause of it. Apparently, no one working at the lab at the time was familiarwith a speci� c program feature allowing for change of the default value of a particularfunction. Changing that value sped up the program and the analysis proceeded normally.In the second session, continuous breakdowns of the program were caused by a programerror, which came out only after an intensive troubleshooting session by the programmer.As a consequence, within the two data analysis sessions, Dr S spent about 80% of herwork time on things other than the actual data analysis.

In the � rst session, an obvious explanation would be lack of user experience with theprogram and, probably, inadequate user training. In the second session, the direct causefor the trouble seemed to be inadequate testing of the software by the programmer. Boththese situations, as such, are considered ‘everyday life’ noise in the development andpiloting of new technologies. Individual researchers who had been using these programsin writing scienti� c articles had also had to deal with these problems. This time, however,Dr S was not applying the programs for individual scienti� c work. The temporaldimension of her work had changed. From the point of view of the new object, theproblems with the analysis program—as well as the possible lack of user experience—became critical. Instead of being able to direct her actions forward and to provide aclinical report for the referring physician in time, Dr S was stuck with delay and dealingwith problems in the technology. The anticipated object of data analysis and clinicalreporting was replaced with problems in using the program.

Regardless of the various support groups that were envisioned to help her in herwork, Dr S was left alone and without basic tools to do the job. She worked in thelaboratory without a desk or a personal workstation. The only sign of the emerging newobject at the lab was her presence there—or her purse and a little notebook next to oneof the workstations. In other words, the appearance of the new object did not materializein concrete artifacts and spaces in the laboratory. Dr S, as a representative of the newobject, was unable to gain a status in the lab. She acted as any of the individualresearchers working at the lab. This showed a contradiction within the BioMag activitysystem between the emerging new object and the old rules of a centralized researchfacility with multiple objects.

The support group established by the managing director of the Brainview Co. wasnot regularly or immediately available at the laboratory when Dr S needed it. The‘group’ was not a stable entity working as a team. Instead, the director allocated thesupport tasks to individual designers responsible for particular, isolated problems. Dr S’sposition in relation to the group was ambiguous. No one in the key organizations seemedto be aware of the many di Ý culties besetting Dr S. The rule of solo responsibility and

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Constructing Clinical Use 377

solo performance was clearly not in line with the new object and the associateddevelopmental challenge of the BioMag activity system. The division of labor within theBioMag activity system did not promote the anticipated expansion of the object.

At the beginning of the process, the di Ú erent parties acted as separate entities, as ifnot having a common motive at all. They stayed physically in di Ú erent places andcommunicated mainly by telephone. When Dr S eventually called to the company,annoyed and frustrated, having experienced major problems, she politely and patientlyformulated her reason for the call trying to de� ne the problem clearly. She did not usestrong metacommunicative statements, such as demanding better customer service, wheninteracting with the designers. Similarly, when a programmer entered the lab, he talkedvery little and asked no questions outside the speci� c problem area that he was about todeal with. All these incidences point to segregated relations between the key activitysystems.

User initiative. Interestingly enough, one day, the nurse Helena from the BioMaglaboratory initiated a demonstration of an EEG data-analysis system to the developers ofthe Brainview Co. in a support-group meeting originally set up to consider the manytroubles with the data analysis. The initiative implicitly focused on the need to redevelopthe technology to meet the changing user needs. This initiative and the ensuing interactionbetween the users and the designers indicate an expansion of the users’ object and, thus,a partial construction of a shared object or a boundary object.15

The nurse, thus, reserved an EEG system workstation at the Clinical NeurophysiologyDepartment for the meeting, stressing the need for the designers to become acquaintedwith a system (Spectrum) partially similar to MEG and which was already used in routineclinical work.

Nurse Helena (on the phone with a nurse from the Department): . . . You see, thedevelopers of this [MEG] device, they have very little experience in many things . . .needed in the practical work, di Ú erent kinds of printouts from the data and so on.To me, it would be important for them to see how Spectrum works. Because in itall the functions can be seen on the screen, and in printing there is the possibilityto add comments and so on. . . . (Excerpt from a phone call on 11 April 1997)

The meeting was attended by the managing director and the main software developer ofthe company as well as by Dr S and the nurse. After identifying the main di Ý culties andmost urgent user needs with the equipment and data analysis programs, they joined thenurse to observe the functioning of the EEG system. The user-friendly features were nowdemonstrated to the developers of MEG. After joking for a while about the old-fashionedappearance of the almost ten-year old EEG device, the developers focused on looking atthe workstation screen and listening to the user’s point of view. The EEG system mediatedin the discussion exemplifying the desired properties of the MEG system and data-analysis software.

1. Developer (looking at the computer screen): What is nice here is this standardizedwindow which looks familiar all the time.

2. Doctor Sara (operating the EEG system): It is nice, yes.3. Director: Because this is a tool for a person who examines a familiar phenomenon

daily—not like ‘how is it this time, this sure is an interesting view!’4. Doctor Sara: It should be that when a person looks at that window, the person

immediately perceives and gets the other ones in mind, and sees immediately‘okay’—

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5. Director: Yes, sure.6. Developer: But, on the other hand, the set-ups of the X [referring to the data

analysis program] actually do the same thing—7. Doctor Sara: Yes, but those [set-ups] should be delivered then . . .8. Director: Sure, the set-ups must be made!9. Developer: The most convenient way to get those set-ups is to get [Mr] Savola

[programmer of the particular software] available for a few hours, and then, hewill do them on-line quite quickly.

10. Doctor Sara: Well, yes, sure.11. Director: It would be good if those quite few essential set-ups could be optimal

just the way the user wants them, and after that they would not be touched.12. Doctor Sara: Yes, only by another user.13. Director: Yes.(Excerpt from the support group meeting on 14 April 1997)

In the course of the interaction, the managing director of Brainview made an interestingmetacommunicative statement. In turn three, he made a distinction between the practicaluse of the technology in accomplishing the daily work of medicine and the developmentor specialist use of the technology (i.e. experimental use of technology in scienti� c work).An ability to make this kind of distinctions is a crucial precondition for customer-orientedredesign of artefacts. In e Ú ect, the director constructed the critical shift between theobject and tool. This is the very point that the users implicitly attempted to make withtheir initiative.

The mention of the additional software components (set-ups) that the users consideredimportant (turns 6–9), shows the tendency of Dr S to avoid constructing discursively theobvious crisis of the ongoing data analysis (turn 7). Instead, the director used a strongdiscursive tool, the imperative, to underline the importance of the improvements (turn8). However, both the designer and the director left open the question of who would bein charge of involving the particular programmer in the improvements and when (turn9). Thus, the job to get the programmer to the lab was tacitly considered to fall onto DrS. She seemed to accept this (turn 10). In this way, the designers discursively � rst took intotheir hands the user’s object and then gave it back to her. The lack of metacommunicativestatements in constructing the crisis of the new object in the interaction between theparticipants still implies serious di Ý culties in maintaining the critical shift from objectto tool.

Phase of Fading: Re�ecting on the Process and Object of Activity

The contradiction within the BioMag activity system, between the new object and therules of a centralized research facility, manifested itself when Dr S was unable to constructfor herself a position of authority over the hospital organization and resources. Thebuilding of the measurement and analysis service at the lab was not led by the clinicalspecialty of the hospital. Dr S attempted to solve this contradiction by trying to establishfor herself a new authorized position within the hospital community. The negotiationsabout the position failed and as she was already frustrated about the troubles with thetechnology, she decided to resign. Her resignation may be seen as a signal of distressaddressed to the key activity systems involved in the process. In this respect, it is interestingto examine how the key actors re� ected on the situation and on the new object later inthe implementation process.

According to BioMag’s manager, Dr S resigned because she became worried about

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her position at BioMag. To the manager this was an unfortunate situation, but not acrisis: he was optimistic about � nding another specialist who would not have such astable position in another hospital as Dr S did. In addition, the manager saw the positionand specialty related to the new task as unproblematic.

Interviewer : At the moment, how do you see the position and expertise of the physicianwho will be in charge of starting the MEG service? Do you think there alreadyexists such expertise or is it a matter of creating it?Lab manager: Clinical neurophysiology is the expertise needed in the position. Ofcourse, MEG is a special technique which should be learnt, but it is easy to learnrelatively quickly, as compared to clinical neurophysiology that is a process of severalyears. So, what we need is a specialized clinical neurophysiologist. (24 April 1997)

As the above excerpt shows, the manager still perceived the physician’s work to consistmainly of mastering the MEG technique, without a need for special authority or seniority.The clinical work with MEG as a qualitatively new kind of learning task was not touchedupon. During the interview, the manager also made a strategic turn and introduced anew topic, the ongoing R&D project headed by him. This referred to the multiple,heterogeneous objects that had already become visible in the laboratory where theinstruments and materials of the technology-development team were expanding beyondthe small corner allotted to them. The creation of the measurement and analysis servicedid not become an urgent motive and object of the BioMag activity system during the� ve-month observation period.

The managing director of Brainview found the situation annoying. However, hebelieved that the work of Dr S had functioned as a ‘catalyst’ within the network. Headmitted that after having heard about Dr S’s forthcoming resignation, the support workof the company had waned. The situation did not lead the company director to seriouslyreconsider the quality of the technical support and user training in the process. He sawDr S’s resignation as an individual issue.

Sara has acted as some kind of catalyst here. . . . When she said she would not staythere, our enthusiasm to work things out somehow collapsed spontaneously. Afterthat, nothing has happened on our initiative. That’s the way things are. . . . So, theonly thing that comes out of this process is that the Neurology Clinic is � nallygenerating interest in the matter. That is a new situation. They have knownsomething, but they have not become involved. Now they have been asked to thinkabout this. (Director of Brainview, 12 May 1997)

In her last interview, Dr S outlined two alternative ways of organizing the measurementand analysis service. The � rst one, according to Dr S, was the current way of functioning,advocated by BioMag’s management. It was a model of a private laboratory functioningindependently: having patient records of its own, handling the orders separately andworking on the basis of the information that the patient brings with her or him. Thesecond way of organizing the work was an integrated model: the work was integrated toa clinic and led by clinical specialists. Dr S considered both these models as possible, butpreferred personally the integrated model.

. . . But if it functions as a private lab, they don’t need or ask for anything, theysimply do the work for the money with the scarce information they have, and putforward the output. They do not worry or assume responsibility over other thingsrelated to it. It is one way to do it, but—. . . . In my mind, the position of the doctoris connected to this issue. In my opinion, the work of that particular doctor should

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380 M. Hasu

be led by a medical authority, de� nitely. Otherwise, the working conditions arepoor. (Doctor Sara, 14 May 1997)

To a certain extent, Dr S re� ected on her own situation by envisioning alternative waysof organizing the new activity. Her decision to resign was not only an individual issuebut also a major institutional question related to the rules, community and division oflabor of the emerging activity. These two models can be seen as Dr S’s attempts atreconstructing a horizon, the zone of proximal development of the activity.16 As shownin the previous section, the constraints of the current activity, seen on the laboratoryshop � oor, highlight the obvious risks of the private model. Even the motive of theBioMag activity system in building the private model was largely invisible. Through afrustrating, but partly also expansive learning process, Dr S came to touch upon an issuewhich should have been the starting point for the negotiations and for the envisioning ofthe new object in the � rst place: which motive should run the clinical work?

Conclusions

To capture the dynamics of the implementation process, I focused on one key actor, DrS, as a user in the process. The problems calling for resolution were not only questionsof individual competence of the user or the managers involved, but also questions ofinteraction and collaboration between the key activity systems.

The clinical service of MEG would have required the creation of a new, shared objectof activity within and between the two activity systems of the developer companyBrainview and the hospital laboratory BioMag. Brainview’s object was the developmentof a speci� c technology. For the creation of a new clinical service at the hospital, theperspective of the speci� c technology was not enough. The perspectives of the centralactors needed to expand in the implementation process through collaborative learning.This learning was only in its beginning: indications of expansive learning emergedindividually, not yet within the entire organizations.

As a single actor, the physician hired to start the clinical work was unable to solvethe historically accumulated contradictions within and between the central activitysystems. Literally, the new object of activity did not � nd space among the various objectsof the laboratory. A challenging endeavour was given to an individual actor and newcomerwithout proper consideration of the systemic circumstances. The case showed how hardit is to become an e Ú ective boundary spanner17 if the role of the one who tries it is notrecognized within the activity systems.

I aimed to show how individual and collective actions are connected to the broadeningof a user network, potentially either constraining or enhancing the simultaneous shapingof the market and the technology. The activity-theoretical analysis applied in this paperreveals constraints of multi-organizational implementation of new technology. The caseanalysis implies a need to adopt a more sensitive theoretical and methodologicalperspective to the implementation of new technologies and to the interaction betweenthe organizations. In particular, user initiatives to overcome work-related problems shouldbe considered more carefully as possible solutions, signalling contradictions in the entireactivity and pointing to new directions.

In this case, users initiated innovative, improvised attempts to involve the di Ú erentparties of the implementation in joint problem solving. Those capable of expanding theirperspectives in relation to the new object were the ones concretely working and interactingwith it: in this case, Dr S and the nurse. They by-passed the management as a center ofcontrol and their action highlighted collective responsibility. The managers did not face

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the problems themselves: their perspectives remained largely unchanged. This is in linewith Blackler’s18 argument that all practitioner groups, not just � gures of authority,experts, or ‘knowledge workers’ are knowledgeable, capable of identifying and changingsystemic conditions of the activity.

However, the improvised, weakly articulated users’ attempts were not enough tobridge the gap between the participants’ perspectives and thus to maintain re� ectivedialogue between them. Everyday work with complex technology and with real patientsshould have been made visible to the managers and product developers to secure themovement toward user-oriented redesign of the innovation. The critical shift toward amature customer-intelligent product will require a deliberate attempt to resolve thedevelopmental contradictions within and between the central activity systems. Employ-ment of analytical tools, such as the activity-theoretical concepts used in this paper, isone possible way to enhance such an e Ú ort.

Notes and References

1. E. g. E.M. Rogers, DiÚusion of Innovations, 3rd ed (London, The Free Press, 1983); S.J. Kline & N.Rosenberg, ‘An Overview of Innovation’, in: R. Landau & N. Rosenberg (Eds), The Positive SumStrategy: Harnessing Technology for Economic Growth (Washington, DC, National Academy Press, 1986),pp. 275–305; E. von Hippel, The Sources of Innovation (New York, Oxford University Press, 1988);R.A. Burgelman & M. A. Maidique, Strategic Management of Technology and Innovation (Illinois, Irwin,1988); D.A. Preece, Managing the Adoption of New Technology (London, Routledge, 1989); R. Rothwell,‘Industrial Innovation: Success, Strategy, Trends’, in: M. Dodgson & R. Rothwell (Eds), TheHandbook of Industrial Innovation (London, Edgar Elvar, 1994), pp. 33–53.

2. K. Green, ‘Creating Demand for Biotechnology: Shaping Technologies and Markets’, in: R.Coombs, P. Saviotti & V. Walsh (Eds), Technological Change and Company Strategies (London, AcademicPress, 1992), pp. 164–184.

3. F. Blackler, ‘Knowledge, Knowledge Work and Organizations: An Overview and Interpretation’,Organization Studies, 16, 1995, pp. 1022–1046; for an exception to the line of analysis that Blacklercriticizes, see, e.g. S.R. Barley, ‘Technology as an Occasion for Structuring: Evidence fromObservations of CT Scanners and the Social Order of Radiology Departments’, Administrative ScienceQuarterly, 31, 1986, pp. 78–108, and F. Blackler, N. Crump & S. McDonald, ‘Managing Expertsand Competing Through Innovation: An Activity Theoretical Analysis’, Organization , 6, 1999,pp. 5–31.

4. The neuromagnetometer device (magnetoencephalography, MEG) is a complex system integratingleading-edge technology, data acquisition and analysis software. It is a science-based innovationinvolving biomagnetism, low temperature physics and superconductivity.

5. I will use here a pseudonym ‘Brainview’ referring to the spin-o Ú company set up for thecommercialization of MEG.

6. A.N. Leont’ev, Activity, Consciousness, and Personality (Englewood Cli Ú s, Prentice-Hall, 1978); Y.Engestrom, Learning by Expanding: An Activity-Theoretical Approach to Developmental Research (Helsinki,Orienta-Konsultit, 1987); M. Cole & Y. Engestrom, ‘A Cultural-Historical Approach to DistributedCognition’, in: G. Salomon (Ed.), Distributed Cognitions: Psychological and Educational Considerations(Cambridge: Cambridge University Press, 1993), pp. 1–46; Y. Engestrom, R. Miettinen & R-L.Punamaki (Eds), Perspectives on Activity Theory (Cambridge, Cambridge University Press, 1998); R.Miettinen, ‘Object Construction and Networks in Research Work: the Case of Research onCellulose-Degrading Enzymes’, Social Studies of Science, 28, 1998, pp. 423–463.

7. Y. Engestrom, Learning, Working and Imagining: Twelve Studies in Activity Theory (Helsinki, Orienta-Konsultit, 1990); Y. Engestrom, ‘Expansive Visibilization of Work: An Activity-Theoretical Perspec-tive’, Computer-Supported Cooperative Work, 8, 1999, pp. 63–93.

8. D. Holland & J.R. Reeves, ‘Activity Theory and the View from Somewhere: Team Perspectives onthe Intellectual Work of Programming’, Mind, Culture and Activity, 1, 1994, pp. 8–24.

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9. T. Koschmann, K. Kuutti & L. Hickman, ‘The Concept of Breakdown in Heidegger, Leont’ev,and Dewey and its Implications for Education’, Mind, Culture and Activity, 5, 1998, pp. 25–41.

10. The data consist of ethnographic observation of laboratory activities, audio-recorded interviews ofthe participants as well as video-recorded work situations covering a span of � ve months (from7 January to 14 May 1997). Participants were interviewed several times during the observationperiod. The data are part of the � eld work conducted by the author in 1996–1997.

11. The data from the user seminar are reported in: R. Miettinen & M. Hasu, ‘Articulating User Needsin Collaborative Design. Towards an Activity-Theoretical Approach’, Computer-Supported CooperativeWork, special issue, ‘Activity Theory and Design’ (in press).

12. The analysis of relations within the local network is presented in: M. Hasu & Y. Engestrom,‘Measurement in Action. An Activity-Theoretical Perspective on Producer–User Interaction’,International Journal of Human-Computer Studies, special issue, ‘Understanding Work and DesigningArtifacts’ (in press).

13. E. g. I.L. Mangham, ‘Scripts, Talk and Double Talk’, Management Learning, 26, 1995, pp. 493–511.Here, the script refers to envisioned sequences of actions, the procedural steps of activity inparticular organizational setting.

14. Y. Engestrom, ‘Making Expansive Decisions. An Activity-Theoretical Study of Practitioners BuildingCollaborative Medical Care for Children’, in: C.M. Allwood & M. Selart (Eds), Decision Making:Social and Creative Dimensions (Dordrecht, Kluwer, in press).

15. S. L. Star, ‘The Structure of Ill-Structured Solutions: Boundary Object and HererogeneousDistributed Problem Solving’, in: L. Gasser & M.N. Huhns (Eds), Readings in Distributed Arti�cialIntelligence , Vol. 3 (Menlo Park, Morgan Koufmann, 1989), pp. 37–54.

16. Y. Engestrom, ‘Expansive Visibilization of Work: an Activity-Theoretical Perspective’, Computer-Supported Cooperative Work, 8, 1999, p. 67.

17. E. g. D. Leonard, Wellsprings of Knowledge. Building and Sustaining the Sources of Innovation (Boston,Harvard Business School Press, 1998), pp. 158–159.

18. F. Blackler, ‘Knowledge, Knowledge Work and Organizations: An Overview and Interpretation’,Organization Studies, 16, 1995, p. 1026.

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