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When patient empowerment encounters professional autonomy: The conflict and negotiation process of inscribing an eHealth service

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Abstract

In Sweden, as in many other European countries, government and public agencies have promoted the expansion of eHealth in recent years, arguing that this development enhances patient participation, empowerment and cost efficiency. This article presents a study of the development of My medical record on the Internet, a civic service originally inspired by the home banking concept. The study illustrates how the technology is developed and inscribed with new technical norms, dictating access and use. These norms are in turn shaped by negotiations between social and legal norms as well as the values and beliefs of several different actors involved in the development process. Supported by the study, we conclude: 1) that the new technology challenges the medical professionals, thus causing resistance as the institutional boundaries are changed when patients are given digital access to their medical record; 2) that the technology changes or inscribes the law; 3) that a pilot project of this type is dependent on an enthusiast, seeing the project through until it becomes accepted on a larger scale; and 4) that increased patient participation requires improved access to information which differs from the NPM rhetoric advocating more service to customers.
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... The project started in 2010 and has since spread throughout the US [3]. Similar schemes have been initiated in Australia [4], Finland [5], Canada [6], Denmark [7], Estonia [8], UK [9], and in Sweden [10]. However different strategies and approaches affect uptake and impact. ...
... However different strategies and approaches affect uptake and impact. Implementation progress has in several countries been slow both because of legal constraints [11,12] and because of concerns about for example security and privacy among medical professionals [6,10,13]. ...
... The list includes healthcare professionals as well as anyone the patient have chosen to share their record with and patients can make use of the list to check whether there has been unexpected access. Although patients and their use of and attitudes towards PAEHRs have been studied to some degree, research on PAEHRs has up until today mostly focused on the healthcare professionals' perspective [6,10,16,17,18]. For example, healthcare professionals have had several concerns, such as negative impact on workload, privacy risks, and fear of increased anxiety in patients [18]. ...
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BACKGROUND Internationally, there is a movement toward providing patients a Web-based access to their electronic health records (EHRs). In Sweden, Region Uppsala was the first to introduce patient-accessible EHRs (PAEHRs) in 2012. By the summer of 2016, 17 of 21 county councils had given citizens Web-based access to their medical information. Studies on the effect of PAEHRs on the work environment of health care professionals have been conducted, but up until now, few extensive studies have been conducted regarding patients’ experiences of using PAEHRs in Sweden or Europe, more generally. OBJECTIVE The objective of our study was to investigate patients’ experiences of accessing their EHRs through the Swedish national patient portal. In this study, we have focused on describing user characteristics, usage, and attitudes toward the system. METHODS A national patient survey was designed, based on previous interview and survey studies with patients and health care professionals. Data were collected during a 5-month period in 2016. The survey was made available through the PAEHR system, called Journalen, in Sweden. The total number of patients that logged in and could access the survey during the study period was 423,141. In addition to descriptive statistics reporting response frequencies on Likert scale questions, Mann-Whitney tests, Kruskal-Wallis tests, and chi-square tests were used to compare answers between different county councils as well as between respondents working in health care and all other respondents. RESULTS Overall, 2587 users completed the survey with a response rate of 0.61% (2587/423,141). Two participants were excluded from the analysis because they had only received care in a county council that did not yet show any information in Journalen. The results showed that 62.97% (1629/2587) of respondents were women and 39.81% (1030/2587) were working or had been working in health care. In addition, 72.08% (1794/2489) of respondents used Journalen about once a month, and the main reason for use was to gain an overview of one’s health status. Furthermore, respondents reported that lab results were the most important information for them to access; 68.41% (1737/2539) of respondents wanted access to new information within a day, and 96.58% (2454/2541) of users reported that they are positive toward Journalen. CONCLUSIONS In this study, respondents provided several important reasons for why they use Journalen and why it is important for them to be able to access information in this way—several related to patient empowerment, involvement, and security. Considering the overall positive attitude, PAEHRs seem to fill important needs for patients.
... In the literature, transparency related to visualizing technologies [10,11] and, to a certain degree, the EHR [12,13] has been investigated empirically and discussed in theoretical terms. When it comes to Open Notes, however, most of the research is still at an early stage and either descriptive [14][15][16][17] or normative [18,19], with few exceptions [20,21]. ...
... When it comes to Open Notes, however, most of the research is still at an early stage and either descriptive [14][15][16][17] or normative [18,19], with few exceptions [20,21]. Professionals and researchers in the field have interpreted Open Notes as a means of enhancing the transparency of health care professionals' (HCPs) work and their work tool [13,[22][23][24][25][26]. Research on transparency rising from Open Notes reform has been published [27][28][29][30][31][32][33][34], but few attempts have been made to theorize the transparency based on empirical material. ...
Article
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Background: The New Public Management movement strove for transparency so that policy makers and citizens could gain insight into the work and performance of health care. As the use of the electronic health record (EHR) started to diffuse, a foundation was laid for enhanced transparency within and between health care organizations. Now we appear to be experiencing a new kind of transparency in the health care sector. Many health care providers offer their patients online access to their EHRs (here referred to as Open Notes). The Open Notes system enables and strives for transparency between the health care organization and the patient. Hence, this study investigates health care professional (HCP) perceptions of Open Notes and deepens the understanding of the transparency that Open Notes implies. Objective: Based on two survey studies of HCP perceptions of Open Notes, this paper aims to deepen the academic writing on the type of transparency that is connected to Open Notes. Methods: HCPs in adult psychiatry in Region Skåne, Sweden, were surveyed before and after implementation of Open Notes. The empirical material presented consists of 1554 free-text answers from two Web surveys. A qualitative content analysis was performed. Results: The theoretically informed analysis pivots around the following factors connected to transparency: effectiveness; trust; accountability; autonomy and control; confidentiality, privacy, and anonymity; fairness; and legitimacy. The results show that free-text answers can be sorted under these factors as trade-offs with transparency. According to HCPs, trade-offs affect their work, their relationship with patients, and not least, their work tool, the EHR. However, since many HCPs also state that they have not met many patients, and in some cases none, who have read their EHRs, these effects seem to be more connected to the possibility (or threat) of transparency than to the actual effectuated transparency. Conclusions: The implementation (or reform) of Open Notes is policy driven while demanding real-time transparency on behalf of citizens/patients and not the authorities, which makes this particular form of transparency quite unique and interesting. We have chosen to call it governed individual real-time transparency. The effects of Open Notes may vary between different medical specialties relative to their sensitivity to both total and real-time transparency. When HCPs react by changing their ways of writing notes, Open Notes can affect the efficiency of the work of HCPs and the service itself in a negative manner. HCP reactions are aimed primarily at protecting patients and their relatives as well as their own relationship with the patients and secondly at protecting themselves. Thus, governed individual real-time transparency that provides full transparency of an actual practice in health care may have the intended positive effects but can also result in negative trade-offs between transparency and efficiency of the actual practice. This may imply that full transparency is not always most desirable but that other options can be considered on a scale between none and full transparency.
... In many cases, the launch of PAEHR has been a very controversial process. [18][19][20][21][22][23] Healthcare professionals have expressed worries related to, for example, confusion among patients, increased workload and negative changes in documentation practices. 17 24-26 A few studies look into the experienced effects of PAEHR on the nurses' work environment in the short 27 28 and the long run. ...
Article
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Objectives The introduction of information and communication technology influences the work environment of large groups of employees in healthcare. In Sweden, a national healthcare service providing patient accessible electronic health records (PAEHR) has been deployed, and this paper investigates nurses’ expected effects of this implementation. Setting Nurses associated with the Swedish Association of Health Professionals working in healthcare such as primary care, hospitals and midwives in Sweden. Before a full-scale national implementation of PAEHR, a web survey study was distributed nationally. The respondents represented all 21 Swedish regions. Questions included five-point Likert scale questions and open questions. Participants A survey link was distributed via email to 8460 registered nurses, midwives and union representatives in Sweden. The response rate was 35.4% (2867 respondents: registered nurses 84%; midwives 6%; chief position 5%; in projects 2% and other 3%). Three reminders were sent out, all of them increasing the response rate. A majority of the respondents were female (89.9%), 8.4% male, whereas 1.7% did not indicate their gender. 31.4% were under 40 years old, 53.8% 40–59 and 13.7% over 60. Results Data were analysed using exploratory factor analysis with principal component analysis as the extraction method. The analysis revealed three distinct factors related to nurses’ expectations of PAEHR: (1) PAEHR improves the quality of care, (2) PAEHR improves the quality of the work environment and (3) risk and fears concerning patients’ well-being. Some interesting results include that more experienced nurses are more favourable to PAEHR. Our analysis also shows that the view of the nurse–patient relationship is an essential underlying factor related to positive or negative expectations. Conclusions Results show that the expectations and perceptions of PAEHR vary depending on the nurse’s view of who the electronic record belongs to. Younger nurses are somewhat more negative towards PAEHR than older nurses.
... For example, patients as indirect stakeholders are often not considered when developing electronic medical records, even though the records are about them [62]. Similarly, in the case of developing an eHealth service that gives patients access to their records in Sweden, the "medical profession was not really perceived as a legitimate actor in the development process" [63]. At the same time, the medical profession (clinicians and nurses) in this particular case contested the very idea of the project and was not interested in participating in the design process [64], which created another challenge. ...
Article
Human-centered design (HCD) is widely regarded as the best design approach for creating eHealth innovations that align with end users’ needs, wishes, and context and has the potential to impact health care. However, critical reflections on applying HCD within the context of eHealth are lacking. Applying a critical eye to the use of HCD approaches within eHealth, we present and discuss 9 limitations that the current practices of HCD in eHealth innovation often carry. The limitations identified range from limited reach and bias to narrow contextual and temporal focus. Design teams should carefully consider if, how, and when they should involve end users and other stakeholders in the design process and how they can combine their insights with existing knowledge and design skills. Finally, we discuss how a more critical perspective on using HCD in eHealth innovation can move the field forward and offer 3 directions of inspiration to improve our design practices: value-sensitive design, citizen science, and more-than-human design. Although value-sensitive design approaches offer a solution to some of the biased or limited views of traditional HCD approaches, combining a citizen science approach with design inspiration and imagining new futures could widen our view on eHealth innovation. Finally, a more-than-human design approach will allow eHealth solutions to care for both people and the environment. These directions can be seen as starting points that invite and support the field of eHealth innovation to do better and to try and develop more inclusive, fair, and valuable eHealth innovations that will have an impact on health and care.
... Research has shown that, in an international comparison, the Swedish healthcare sector has previously acted as a pioneer in providing digitalized healthcare services to increase patient access (cf. Erlingsdottir & Lindholm, 2015;Huvila, Cajander, Daniels, & Åhlfeldt, 2015). ...
Article
The aim of the study is to better understand start-ups' entrepreneurial business formation processes from a contextual perspective. We examine a digitalization process in the healthcare sector in Sweden, and investigate the start-up processes taking place in order to reach a better understanding of what it takes for new actors to obtain an insider position in this particular type of highly regulated networks. The study offers important insights into the dynamics of constituent elements in the process, including the sequences of events through which start-up processes evolve, and insights into new ventures' initial entry into a business network. It is concluded that the studied processes were interactive, forcing the start-ups to be both innovative and able to conform. It was also found that legitimacy constitute an important resource in this type of politically sensitive context.
... This complexity needs to be considered [8][9][10][11] for successful implementation of new technology, particularly with regard to how the implementation is communicated to employees [12,13]. When a reform directly affects professionals, this is obvious; however, when Open Notes was implemented in adult psychiatry in Region Skåne [14,15], the aim was to empower patients and the new policy was not expected to influence the work of health care professionals [16]. Because the professionals are required to input notes into the system and thus cannot opt out from the service, the implementation of Open Notes was regarded as a service related to their work tool, the EHR, which would enhance the transparency of their work [17], but was not supposed to influence the way they used the work tool. ...
Article
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Background The literature on how to communicate reform in organizations has mainly focused on levels of hierarchy and has largely ignored the variety of professions that may be found within an organization. In this study, we focus on the relationship between media type and professional responses. Objective The objective of this study was to investigate whether and how belonging to a profession influences the choice of communication media and the perception of information when a technical innovation is implemented in a health care setting. Methods This study followed a mixed methods design based on observations and participant studies, as well as a survey of professionals in psychiatric health care in Sweden. The χ2 test was used to detect differences in perceptions between professional groups. Results The use of available communication media differed among professions. These differences seem to be related to the status attached to each profession. The sense-making of the information appears to be similar among the professions, but is based on their traditional professional norms rather than on reflection on the reform at hand. Conclusions When communicating about the implementation of a new technology, the choice of media and the message need to be attuned to the employees in both hierarchical and professional terms. This also applies to situations where professional employees are only indirectly affected by the implementation. A differentiated communication strategy is preferred over a downward cascade of information.
... In some countries, these are local implementations at a specific hospital or region, whereas others have national solutions. Differences in strategies and approaches have affected the uptake and impact, and the implementation progress has, in several countries, been slow due to legal constraints [3,4] and concerns about security and privacy among health care professionals [5][6][7]. A PAEHR often includes the clinical notes written by different health care professionals, as well as other parts of the EHR (eg, lab results, referrals, and medications). ...
Article
Background Transparency is increasingly called for in health care, especially, when it comes to patients’ access to their electronic health records. In Sweden, the e-service Journalen is a national patient accessible electronic health record (PAEHR), accessible online via the national patient portal. User characteristics and perceived benefits of using a PAEHR influence behavioral intention for use and adoption, but poor usability that increases the effort expectancy can have a negative impact. It is, therefore, of interest to explore how users of the PAEHR Journalen perceive its usability and usefulness. Objective The aim of this study was to explore how the users of the Swedish PAEHR experience the usability of the system and to identify differences in these experiences based on the level of transparency of the region. Methods A survey study was conducted to elicit opinions and experiences of patients using Journalen. The data were collected from June to October 2016. The questionnaire included questions regarding the usability of the system from the System Usability Scale (SUS). The SUS analysis was the focus of this paper. Analysis was performed on different levels: nationally looking at the whole data set and breaking it down by focusing on 2 different regions to explore differences in experienced usability based on the level of transparency. Results During the survey period, 423,141 users logged into Journalen, of which 2587 unique users completed the survey (response rate 0.61%). The total mean score for all respondents to the SUS items was 79.81 (SD 14.25), which corresponds to a system with good usability. To further explore whether the level of transparency in a region would affect the user’s experience of the usability of the system, we analyzed the 2 regions with the most respondents: Region Uppsala (the first to launch, with a high level of transparency), and Region Skåne (an early implementer, with a low level of transparency at the time of the survey). Of the participants who responded to at least 1 SUS statement, 520 stated that they had received care in Region Skåne, whereas 331 participants had received care in Region Uppsala. Uppsala’s mean SUS score was 80.71 (SD 13.41), compared with Skåne’s mean of 79.37 (SD 13.78). Conclusions The Swedish national PAEHR Journalen has a reasonably good usability (mean SUS score 79.81, SD 14.25); however, further research into more specific usability areas are needed to ensure usefulness and ease of use in the future. A somewhat higher SUS score for the region with high transparency compared with the region with low transparency could indicate a relationship between the perceived usability of a PAEHR and the level of transparency offered, but further research on the relationship between transparency and usability is required.
... This was considered particularly problematic if patients access their records during weekends and evenings, when no staff is available at healthcare units to answer patients' questions or deal with their concerns. 11,12 Some healthcare professionals have also raised a concern that patients might misuse the information -attempt to diagnose themselves or decline beneficial treatment because they have misunderstood the content of the record. These concerns are not unique to Swedish clinicians. ...
Article
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This study investigates differences in attitudes towards, and experiences with, online electronic health records between cancer patients and patients with other conditions, highlighting what is characteristic to cancer patients. A national patient survey on online access to electronic health records was conducted, where cancer patients were compared with all other respondents. Overall, 2587 patients completed the survey (response rate 0.61%). A total of 347 respondents (13.4%) indicated that they suffered from cancer. Results showed that cancer patients are less likely than other patients to use online electronic health records due to general interest (p < 0.001), but more likely for getting an overview of their health history (p = 0.001) and to prepare for visits (p < 0.001). Moreover, cancer patients rate benefits of accessing their electronic health records online higher than other patients and see larger positive effects regarding improved communication with and involvement in healthcare.
... The disease groups 'Cancer' and 'Psychiatry' were analysed individually since they have been specifically highlighted in research on PAEHR in both Sweden and abroad. 17,22 The Friedman test showed significant effects on modes of sharing for both cancer (χ 2 = 296.4, p < 0.001) and psychiatry patients (χ 2 = 332.2, ...
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This study explores patients’ perspectives on sharing their personal health data, which is traditionally shared through discussions with peers and relatives. However, other possibilities for sharing have emerged through the introduction of online services such as Patient Accessible Electronic Health Records (PAEHR). In this article, we investigate strategies that patients adopt in sharing their PAEHR. Data were collected through a survey with 2587 patients and through 15 semi-structured interviews with cancer patients. Results show that surprisingly few patients share their information, and that older patients and patients with lower educational levels share more frequently. A large majority of patients trust the security of the system when sharing despite the high sensitivity of health information. Finally, we discuss the design implications addressing identified problems when sharing PAEHR, as well as security and privacy issues connected to sharing.
... 8 Some patient groups also make use of it to follow their care process and some patients prefer receiving information through PAEHR about test results before meeting their physician. 9 However, health-care professionals globally have had initial concerns about PAEHR and some studies show that it has been a very controversial change process, 10 and that health-care professionals express concerns related to increased workload, confused patients and changed documentation practices and so on. [11][12][13][14] In Sweden, all patients can access PAEHR through a national eHealth portal which is the result of an initiative that started in Region Uppsala in the 1990s. ...
Article
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Patient accessible electronic health records have been launched in many countries, and generally, health-care professionals have had strong initial concerns related to the areas patient contact, documentation practices and quality of care. Especially, oncology care was discussed in media when launching patient accessible electronic health records in Sweden. However, few studies have investigated clinician-perceived effects several years after the launch. A survey covering these areas, as well as supposed effects for patients, was distributed to oncology health-care professionals 6 years after the launch of patient accessible electronic health records and answered by N = 176. Results show that patient accessible electronic health records have had small effects within the covered areas, and that the area most affected was documentation practices. Very few significant differences could be found between physicians and nurses. A comparison with results from interviews and surveys conducted shortly after the launch of patient accessible electronic health records clearly indicates that the experienced negative effects are not as big as originally feared.
Chapter
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In this chapter I review the idea that institutions are inscribed in machines and technical norms, in order to see what consequences it may have for such projects as e-justice and e-government. I therefore turn to recent writings commenting on the developments of and the on Internet, noting that they focus mostly on the issues of control of the Internet, rather than control by the Internet. This issue remains open to speculation, and I end the chapter by considering gains to be accrued from an increased consideration of the ways the Internet and its norms can join the mechanisms of societal control.
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This article relates technology studies to organization research and examines the technology-as-text metaphor. The study of organization is incomplete as long as tangible technology remains in its blind spot. Linguistic metaphors and analogies, while capturing and indeed amplifying much of received understandings of technology, succeed only partially in repairing the situation. The image of the palimpsest is used to highlight this critique and to visualize ways out. Thus, while the main concern of the paper is to re-situate technology to the study of organization, an argument is also put forward for a specific approach to the study of technology.
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This article investigates variations in two professions’ adaption of quality reforms. The adaption of reforms is viewed as a part of the professions’ legitimacy and identity processes. Literature in the area suggests that the adaption of reforms is influenced by the profession’s knowledge base, professional norms, organizational belonging and organizational field. The two cases here on how doctors and auditors adapt to quality reforms show that the influences of these factors are, however, moulded by the professions’ strategies and the salience of the different aforementioned factors. A general conclusion is that compatibility between the bases of knowledge and the professional norms are vital for the adaption of reforms and that organizational fields are important for setting the agenda. Organizational belongings, on the other hand, seem of less importance for adaption of quality reforms.
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Abstract The paper relates technology studies to organization,research and examines the technology- as-text metaphor. The study of organization,is incomplete,as long,as tangible technology re- mains in its blind spot. Linguistic metaphors and analogues, while capturing and indeed am- plifying much of received understandings of technology, succeed only partially in repairing the situation. The image of the palimpsest is used to highlight this critique and to visualize ways out. Thus, while the paper‚s main concern is to bring back technology to the study of organization, a specific approach to the study of technology is also argued for. 2 Silent Inscription
Thesis
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Summary Purpose and theoretical framework The purpose of this thesis is to identify and illustrate the displacement, in Sweden, of the patient position in health care between the years 1970 and 2000. The questions examined are: What were the conditions of possibility to talk of the sick in terms of customers (1), how did this displacement of the notion of the sick appear and (2) what does such a displacement entail (3)? Based on these questions the thesis is divided into three parts. The first part introduces the arrival of market ideas and notions on individual rights for patients. The second part discusses the discursive formation of a customer position in health care. The third part deals with the merits that such a position either supply or eliminate. The theoretical analytic framework is inspired by Michel Foucault’s understanding of discourse. The discursive formation and the order of discourse are the analytic tools used (Foucault 1972, 1993). The summary below is concerned with the three research questions. 1 The arrival of market ideas and ideas on patient rights A new kind of market ideas, which has attempted to replace previous public administration ideals in health care, has gradually transformed health care in the end of the 20th century (Rose 1999). The conditions of possibility for this transformation of health care, which are discussed in the fist part of the thesis, have been the social impact of the market discourse and the discourse on patient rights. The market discourse can be described as a homogeneous system of ideas, a positivity (Foucault 1972), organizing words like freedom, market, choice, customer and competition in strategic statements and themes. Health care, previously described as a combined utility, was, in the mid 1990ies, reconceptualized, through the influence of the market discourse, in order to comprise services that are priced, bought and sold on an internal, pseudo-characteristic market (Dean 1999, p. 6). At the same time we are witnessing an extensive privatisation of hospitals, the signing of private health care insurance and increased rates on health care services. The development toward a marketization of health care have followed two main lines of thoughts, one was the efficiency line, in the late 70ies, which were composed of organizational transformations, the use of various techniques for economical management and the introduction of market mechanisms. The other main line of thought emphasized the patients changing role and reinforced position in health care, from the mid 1990ies and onwards. One of the motives behind the second line was to give the patient the opportunity to choose a care giver, yet another, that it was considered a democratic and personal right for a patient to be a self-determinate part of the health care process; a third motive was that the patients status had to be strengthened by legal means through legislation. 2 The discursive formation of a customer position in health care There is a prevailing discursive order in health care which control the practice through which speech and writing is produced and interpreted, for example in dialogue between doctor and patient. The order of discourse gives rise to a situation where some discourses are practiced and others excluded (Jörgensen & Phillips 2000, p. 76). Previously, the welfare discourse and the medical discourse were predominant in the order of discourse. These are now being challenged first of all by the economic discourse, subsequently by the market- and management discourse, like the discourses of New Public Management and Total Quality Management, and added to this the legal discourse on patient rights, which have all made their way into the order of discourse of health care. At the end of the 1990ies the market discourse and the discourse on patient rights, brought about a discursive break in the discourse order of health care. This was a consequence of the fact that words from both discourses were displaced towards health care and were used in phrases such as “the right to choose hospital and physician” and “the right to participate in choosing of treatment”. I argue that the view of the sick person is displaced from patient to a customer with certain personal rights. The choice of the word displacement suggests that the change in linguistic usage, which I have noted and analysed, and which I interpret as a displacement, appear as a dynamic process. It is possible to illustrate the dynamics by analysing the way a theme like the voucher concept circulates between various discursive fields. By applying Foucault’s theory of how a discursive formation appear, it is possible to analyse how the voucher concept circulates in various texts, reappear with new words like voucher for care and capitation, is reorganized in new phrases and used in new contexts. With the support of an analytic scope inspired by Foucault, we can understand how a certain idea is gradually reinforced. It is the displacement of concepts and themes from one discursive field to another, which ultimately leads to a displacement from the position of patient to the position of customer. The first conclusion which may be drawn is that 75 years have passed since cardinal Bourne talked about the appropriateness of providing British families with a school credit, which would allow for the free choice of schools. This idea is the basis of current discussions on the voucher concept in elderly care and in health care. The second conclusion which may be drawn is that the voucher concept is dispersed when it is combined with the idea of a freedom of choice. A new theme is then created, namely the concept of customer choice. The voucher thus becomes a device for realizing a political idea, the idea of creating a market within the health service and health care sectors, based on customer choice. The practical experiences of the introduction of the voucher in schools and elderly care (“skolpeng och äldrevårdspeng”) signals the importance that the voucher concept might have on the formation of a health care market. The third conclusion is that the voucher concept is dispersed in a form, which is reminiscent of an inter-textual chain that connects a series of texts under a long period of time by incorporating elements from other texts in each text. Fourthly it is clear that it is specific types of statements and groups of concepts that appear and create themes, such as the concept of customer choice. The example of voucher should be understood as an inter-discursive transformation, which means that borders between various discourses and within a specific discursive order are displaced. The discursive formation generate legitimacy for the customer position The notion of perceiving the sick person as a customer was preceded by the discursive formation of a customer position in health care. This formation consists of several influential voices, which are spreading accounts carrying specific concepts that subsequently are shaped into themes in various customer discourses. Economists and consultants within the area of management use the costumer concept on a regular basis. The think tanks Timbro and The Stockholm Network use economical terms such as corporation and market to describe the future of health care. The Federation of Swedish County Councils uses the term customer in its qualitative instrument QUL. Certain journalists at the morning paper Dagens Nyheter endorse market solutions in health care. Several directors of medical services started incorporating the term customer in their vocabulary at the end of the 1990ies. Physicians in managerial positions say that they have accepted the term but stress that it should not be used in direct health care since the concept lack legitimacy in the interaction between doctor and patient. Lawyers argue that patients are entitled to patient rights while politicians mix words from the market- and welfare discourses and the discourse on patient rights when they talk about the patient position. When these influential voices refer to freedom of choice, health care guarantee and voucher in care, when talking about health care, the implications of this is that the market discourse in health care is being legitimised. This does not imply that there is no lingering resistance against the market discourse. However, the aim of this thesis was not to analyse this resistance. 3 The characteristics of the customer position and its implications The market discourse presupposes that the price, supply and demand of services are fixed by customers and producers on a market while the population related budget governance proceed from an economic framework, for a need estimated by politicians. Hence we are dealing with two separate discourses, the discourse based on needs and the market discourse, which speaks via politicians. In practice it might come to the point where politicians establish market mechanisms but at the same time do not take into account how these mechanisms effect the consumption of health care, which is increasing, or the total cost development, which is rising or the demands for financing which will be the result of this. Hence the economic framework will adjust to the development of the operation later on, and not the other way around. The function of the overall budget as a halter is thus put out of play by the market discourse and the deficits have become part of the everyday discourse in health care. The effect of different voices formulating customer themes is a generalization of a vocabulary embracing concepts like customer (Fairclough 1995, p. 231), which is regarded as yet another effect of a marketization. A similar generalization is evident in primary municipalities (Forsell & Jansson 2000, p. 44) Through a generalization of concepts like customer and service in health care, the attitude towards how operational issues will be managed are changing, and an adjustment towards this approach of dealing with customers is evident, which interviews with various physicians have confirmed. Conclusion: Patient and customer With support in Foucault’s discourse theory, I have come to the conclusion that the market discourse, based on the discourse on personal rights for patients, despite opposition, constitutes a customer subject position which is evident in an increasing degree of personal choice, care guarantee, personal rights and right of self-determination in health care. A displacement of the market vocabulary toward health care has brought about a displacement of the notion of the sick person from a passive patient to an active customer who makes active decisions and participates in the care process. The constitution of the customer position does not entail however that the patient concept is being replaced but rather completed by the customer concept.
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As both technologies and organizations undergo dramatic changes in form and function, organizational researchers are increasingly turning to concepts of innovation, emergence, and improvisation to help explain the new ways of organizing and using technology evident in practice. With a similar intent, I propose an extension to the structurational perspective on technology that develops a practice lens to examine how people, as they interact with a technology in their ongoing practices, enact structures which shape their emergent and situated use of that technology. Viewing the use of technology as a process of enactment enables a deeper understanding of the constitutive role of social practices in the ongoing use and change of technologies in the workplace. After developing this lens, I offer an example of its use in research, and then suggest some implications for the study of technology in organizations.