Polyxeni Vassilakopoulou

Infrastructures in healthcare: The interplay between generativity and standardization

OBJECTIVE To investigate how the design, development and implementation process of a new patient-centered portal unfolds by focusing on its evolutionary infrastructural development. DESIGN We conducted a case study on a patient-centred portal in Norway. We used qualitative data collection techniques including observations, interviews and attendance of design workshops with users. We performed an interpretive analysis of the data through the lens of technology enactment. RESULTS The case analysis reveals that the patient-centred portal has a strong generative character. However, for the enactment of the technology continuous sociotechnical negotiations take place. Grounded in the empirical data and their analysis we complement and expand the existing understanding of generativity. DISCUSSION We characterize generativity as sociotechnical and resulting from negotiations for technology enactment. We discuss in detail such negotiations and show how they shape the evolution of infrastructures that are generative while standardized.

Challenges in institutionalising electronic platforms for patient-healthcare provider communication.

Electronic platforms for patient?healthcare provider communication are instrumental for enabling a new, more active patient role supporting efficient and effective healthcare delivery. However, benefit realisation from implementing such communication platforms comes after they get established as parts of healthcare information infrastructures. In this paper, drawing from information infrastructure theory, we analyse the process of establishing a durable solution and identify the socio-technical challenges it entails. Based on a case study in the Norwegian healthcare context, the focus of the paper is on the ongoing institutionalising practices of the project management team. Three major challenges are identified. The first challenge is related to the constitution of identity for the new artefact. The second and third challenges are related to the difficulties in building a platform that is stable enough to allow the exploitation of technological potential, and at the same time flexible enough to provide exploration and adaptation possibilities.

The Work of Infrastructuring: A Study of a National eHealth Project

In this paper we examine a national initiative to further develop the Norwegian healthcare information infrastructure. Specifically, we analyse the work of a project team engaged in the design and development of new web-based capabilities for communication between citizens and primary healthcare practitioners. We foreground the work of infrastructuring which entails conceptualising new technological capabilities not as standalone objects, but as elements in larger arrangements that are sociotechnical in nature. Our findings show how the work within the project was shaped by concerns for embeddedness and durability that led to certain design decisions. Furthermore, we find that these decisions had significant repercussions on the development process and created a complex situation where the cooperation of an evolving constellation of multiple actors was required. Our research contributes an initial understanding of how an infrastructural project is different to projects aimed to the development of specific software artefacts.

Workaround identification as an instrument for work analysis and design: a case study on ePrescription.

This paper investigates workarounds occurring while pharmacists use an electronic prescription (ePrescription) application. ePrescription enables physicians to send prescriptions electronically to pharmacies and was recently introduced in Greece as a solution for controlling the ever-increasing medication costs and improving patient safety. The research was carried out in two phases: (i) review of the relevant documentation, (ii) fieldwork (field observations and semi-structured interviews with the pharmacists) in three pharmacies. The workarounds identified fall into five categories and namely: (a) bypass of ePrescription application (i.e. ePrescription application is not used at all), (b) temporal nonconformity in the use of ePrescription application (i.e. usage of the application, but not at the formally specified time), (c) catachresis of ePrescription application (i.e. usage of the application, but not according to the intended way), (d) ePrescription application substitution by another electronic application, and (e) delegation of ePrescription application usage to non-authorized users. The outcome of the research can be used for the improvement of multiple work system elements such as the tools, the procedures, the organisational arrangements and the policies.

Re-Infrastructuring for eHealth: Dealing with Turns in Infrastructure Development

In this paper, we examine infrastructuring in the context of developing national, public eHealth services in Norway. Specifically, we analyze the work of a project team engaged in the design and development of new web-based capabilities for communication between citizens and primary healthcare practitioners. We frame the case as a study of re-infrastructuring to signify a particular occasion of infrastructuring that entails facilitating a new logic within established social and technological networks. To make sense of the particularities of re-infrastructuring, we draw from research in infrastructure studies which considers embeddedness as a resource in infrastructure evolution. We analyze how actors worked to re-infrastructure through adapting primary care information systems, information flows and representations of patient data. Our findings show how the work of re-infrastructuring revolves around addressing two key design concerns: a) bringing novelty without being trapped in the existing arrangements or harming what is in place, b) bringing changes that are within a specific direction although they happen through distributed decision taking.

Premises for Clinical Genetics Data Governance: Grappling with Diverse Value Logics

This chapter discusses emerging tensions related to data ownership and sharing in global genetic data repositories, accessed by researchers and clinicians, from both public and private institutions. We describe the on-going controversies around collecting and sharing genetic mutation data on the BRCA1 and BRCA2 genes: the creation of the Breast Information Core (BIC) database in 1995, the decision by Myriad Genetics to stop sharing information in 2004, the subsequent reaction from the community through the “Sharing Clinical Reports Project” and “Free the Data” initiatives and the recent creation of the open ClinVar repository and the public-private BRCA Share resource. We analyse these experiences, elaborate on the unique characteristics of BRCA data and identify different logics shaping the field. Based on this analysis we suggest drawing from the literature on collective action and the governance of commons for addressing the multiplicity of logics identified. We conclude by discussing the usefulness of foregrounding fundamental questions related to equity, efficiency and sustainability for shaping and evaluating governance arrangements in the field.

Co-Creation of Patient-Oriented Services: Design of Electronic Booking for Norwegian Healthcare

Recent perspectives in service design discuss how it entails a process of co-creation with the active engagement of users. In this paper we take this lens of service design to analyze two empirical cases on the design of two patient-oriented electronic services for appointments with healthcare providers in Norway. Specifically, we focus on how the service concepts were initially conceived, how they were gradually concretized and how different user groups (patients and healthcare providers) were involved in this process. Our findings show how the involved actors gradually realized that the design of appointment services requires more co-production than initially assumed. This realization made the design scope go beyond the interactive artifacts and extend towards the overall shaping of complex interactive relationships.

Friction forces and patient-centredness: Understanding how established logics endure during infrastructure transformation

In this article, we examine three cases of e-health solutions for patients in Norway. For the analysis of the three cases, we focused on friction forces that come into play when different established arrangements need to change to accommodate novelty. We argue that the design of new technologies was shaped by friction related to institutionalised practices, regulatory regimes and entrenched patient roles. These friction forces connect the past with the present, come into action when aiming for novelty and result to the perpetuation of constituents of the past during change processes. Specifically, the e-health solutions under study were strongly influenced by established healthcare provision logics. All three initiatives expanded the healthcare information infrastructure towards the patients with as little disruption to established arrangements as possible.

Information Infrastructures and the Challenge of the Installed Base

In this chapter we present the theoretical perspective of information infrastructures, which is used to analyze the empirical cases in the book. In this perspective, information technology is seen as intimately intertwined with organizational structures, procedures and work practices, and as an underlying, supporting and often invisible infrastructure. Information infrastructures are not only local, but shared among distributed actors which can have multiple and different needs and interests. Understanding the complexities and mechanisms involved in the evolution of information infrastructures is at the core of this perspective which challenges traditional management approaches. Instead of the control paradigm, iterative and incremental strategies, often called “cultivation” strategies, are advocated. Central for this perspective is the notion of the “installed base”, i.e. the organizational, institutional, regulatory and technical arrangements that are already in place. The installed base serves as the foundation for any change and development, however, the installed base can be both enabling and constraining. New developments need to fit and make use of existing arrangements and at the same time transform them. This paradoxical relationship is illuminated through the book’s empirical investigations of how new eHealth initiatives make use of existing arrangements and at the same time transform them.

Integrating Process Modeling and Simulation with Benchmarking using a Business Process Management System for Local Government

—Recently, the strategic approaches of public sector organizations are reevaluated in order to achieve modern effective operations and provide better services to their customers (citizens and businesses). Business Process Management (BPM) solutions are recognized as essential tools for public services transformation, as they enable public organizations to be more efficient, to meet business challenges rapidly and flexibly, and to improve the customers experience by resolving incidents and responding to requests in a timely fashion. Within this context, this paper describes the development of a BPM System (BPMS) as a part of a web-based integrated system for benchmarking, monitoring, simulation and redesigning processes. This system will be deployed initially in Municipalities and later on in several Greek government agencies, in order to offer more efficient, personalized and consistent services to citizens and businesses, in a reduced operational cost. The paper presents the methodological approach followed for BPMS development. It also highlights systems functionality and its usefulness in process design, benchmarking, redesign and continuous improvement.