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Abstract and Figures

Infrastructure is widely regarded merely as a material (lifeless) system that brings together the activities of diverse practices. In contrast to this view, we propose that when infrastructure provides a site where practices are held at once both near and apart, life under the influence of these practices is ‘lived to the full’. We call the resultant whole ‘living infrastructure’ to denote that it is both infrastructure for living and infrastructure that ‘lives’. The key idea is that a living infrastructure becomes the site where an opening between certain regions of life, that share some concern, happens. We will argue that such infrastructure is an on-going achievement of becoming, which requires nurturing and vigilance to maintain its continued productivity: otherwise it will cease to ‘live’. We present an empirical case from the German healthcare environment - the Federal Unified Medication Plan for medication therapy safety. We argue in detail that this is a nascent living infrastructure providing a site where a productive opening ‘happens’ between multiple practices involved in medication therapy safety. We analyse this ‘happening’ to establish how this opening took hold, how it was kept open, and how it was kept productive.
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Living Infrastructure
Kai Reimers1 and Robert B. Johnston2
1RTWH Aachen University, Germany
reimers@wi.rwth-aachen.de
2University of Sydney and Monash University, Australia
robert.johnston@sydney.edu.au
1. Introduction
Infrastructure is widely regarded as a material system that coordinates the activities of diverse
practices. On one view, the ideal for infrastructure is to mechanise sanctioned forms of interaction
between practices pursuing different and often conflicting goals, such that the resulting whole forms
a well-oiled machine operating under a negotiated highest common denominator (Edwards, 2010).
On another view, infrastructure should become an un-noticed lowest common denominator, on the
basis of which diverse practices draw meaning and support, but get out of each other’s way and act
as independently as possible (Hanseth and Lyytinen, 2010).
In this essay, we argue against the notion that infrastructure is a material enabler of either a tight or
loose coupling of activities of diverse practices. Instead, we propose that when infrastructure provides
a site for an ‘opening’ in which practices are held at once both near and apart - both already familiar
and not yet familiar, both same and other, both resisting and accommodating - life under the influence
of these practices is lived to the full. We call the resultant whole ‘living infrastructure’ to denote that
it is both infrastructure for living and infrastructure that lives
1
. We will argue that such infrastructure
is an on-going achievement of becoming
2
, which requires nurturing to maintain its continued
productivity, and vigilance against the three-fold threats of tokenization, colonization and
mechanization: otherwise it will cease to ‘live’.
First we present the Medieval European City Square as a motivating example of a living infrastructure.
We will employ this exemplar to define the conceptual parts which together we take to constitute
‘living infrastructure’. Next we introduce a contemporary empirical case from the German healthcare
environment. This is the Federal Unified Medication Plan for medication therapy safety. We argue in
detail that this is a nascent living infrastructure providing a site where a productive opening ‘happens’
between multiple practices involved in medication therapy safety. We analyse this ‘happening’ to
further refine the notion of living infrastructure, by establishing how this opening took hold, how it
was kept open, and how it was kept productive. We conclude by briefly contrasting living
infrastructure with the traditional view.
1
Hubert Dreyfus (2017) would say, in the same vein, that it ‘shines’. See also Heidegger (1950/1971, p180).
2
In other words, a process in the strong sense (Tsoukas and Chia, 2002; Langley et al, 2013).
2
2. Conceptual Preliminaries
Our aim in this section is to provide an initial conceptual framework for discussing living infrastructure
and the terminology we will employ in the remainder of the paper.
2.1 The Medieval City Square
The city square arose as an important part of the Medieval European city layout and provided an open
area in which city inhabitants could conduct the various aspects of their daily public lives. Frequently,
city squares arose around a public water-well that became their centre piece, and on their sides stood
various institutional buildings - for instance a church, a market, the town hall, a school - that made
available to the inhabitants important influences on the conduct of a rich city life - such as religion,
commerce, government and culture.
The city square thus established the presence of different ‘regions’ of public city life to the inhabitants,
but importantly, it also held regions with a natural antipathy (such and the spiritual and the corporal,
or the personal and the social) apart. The geography of the square quite literally protects life in the
square from domination by any one region of city life, by placing its institutional representatives on
different bounding sides of the square.
We suggest that the medieval square provides a conceptual exemplar for living infrastructure in this
case infrastructure for public city life to be lived to the full. The city square arises as an opening in the
clutter of the city; it is maintained as an opening in city life because regions of that life are established
as both present and distinct by its layout; and it is productive of a good life because it encourages a
continual encounter and evaluation of the regions of city life in the course of daily interaction, and
thus a continual on-going evaluation of what a good city life could be. In the opening of the city square,
the contrasting regions of life are established as regions, and a good city life lived in the presence of
these regions is disclosed to those who dwell there.
2.2 The City Square as Living Infrastructure
In what follows we will draw on the city square exemplar to give an account of how infrastructure
more generally can ‘live’ when it provides the site where such a productive opening can take hold. It
‘lives’ when such an opening ‘happens, and this happening
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is living life to the full. However, first we
must take some care to point out in what respects the example instantiates ‘a productive opening’ as
we see it, and what aspects of the example might lead the reader astray.
Firstly, it is not the square as a material entity creating an open physical space in the city, nor the
geography of the square mediating the opposition of the institutional buildings, that we wish to
identify with such an opening. That is, here we are not interested in the usual conception of
infrastructure as a material structure that coordinates diverse activities. Secondly, we are not
interested in the square as a politically negotiated creation of the institutions to demarcate their
various territories in their subjects lives. That is, we are not treating infrastructure as an outcome of
social negotiation between ‘stake holders’ in city living.
Rather, we view the city square as making possible particular lived interactions of the city dwellers
that already happen under the aegis of these institutions. Thus, the square as a built place is merely
3
We use ‘happening’ in line with Heidegger’s notion of Ereignis (Polt, 2005) a productive, dialectical, gathering
event (in the extended sense of event).
3
the ‘site’ where certain oppositions of nearness and farness among the ‘regions’ of the overall
concern of the square (that is, a good city life) already lived there, are made possible. By connecting
and opposing the institutions that embody these regions of life in the built place, the opening that the
square grounds establishes them as distinct regions of the life lived there. What is productive about
the city square is not its spatial or institutional geography but the distinction-making function of its
openness. It is the openness of the square - not the square as such - that we view as the opening.
The common concern enacted in the square, the regions of life founded by the square, the openness
of the square, the square as the site of this opening, and the happening of this openness, are what
together constitute living infrastructure (see Table 1).
Thus, facilitating a good city life is not simply a matter of building a square that coordinates or controls
access to the separate, opposing institutions of life. Nor is it a matter of regulating the real estate of
the square to prevent institutional encroachment on the political balance of city life. Rather, it is a
matter of creating the conditions under which a square as a region-defining opening can arise, be kept
open, and can continue to be productive. Only then can the square become infrastructure that ‘lives’.
The nature of an opening that makes this happen is the issue that we take up in the remainder of the
paper.
We have not created these ideas ex nihilo: our conception of the city square as a productive opening
has been inspired by our reading of various works from the later philosophical period of Martin
Heidegger, in particular the essays “Building, Dwelling, Thinking”, “The Thing” and “The Origin of the
Work of Art” (Heidegger, 1971).
Table 1. Conceptual parts that constitute living infrastructure
Concept
Definition
Example (City Square)
Concern
A concern defines that aspect of human
existence with which the infrastructure
deals
The concern is living a good life in a city
Region
Regions are distinct aspects of the concern
they are distinct locations on a mapof
the concern.
The regions are the institutions of town life
religion, state, commerce, and
education/culture
Opening
An opening is the establishment of
productive distinctions between the
regions of the concern
The establishment of distinctions between
spiritual, corporal, individual and social
aspects of a good city life
Site of an opening
Where a productive opening takes hold
The lived-in city square that provides the
conditions of an opening between church,
town hall, market and school to happen
The happening of an
opening
How an opening takes hold, is kept open,
and continues to be productive
For any particular city square this could only
be uncovered by detailed historical
scholarship
3. Case Background
Thanks to advances in general living conditions as well as the medical sciences, people now live much
longer but also tend to live with chronic and multiple diseases when they are old, a condition known
as multi-morbidity. This condition, in turn, is associated with the continuous use of a cocktail of drugs,
so-called poly-pharmacy. Healthcare systems in most developed countries, however, have been
erected on the assumption that people fall ill only occasionally and then, for a limited time, use a drug
targeted specifically at that illness. Healthcare systems are generally not equipped to cope with
monitoring and continuously adapting medication regimes of multiple drugs taken over long periods.
This often results in combinations of drugs which are ineffective, due to cancellation of their effects,
or risky, if effects of drugs amplify one another in unanticipated ways.
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In Germany, the term ‘medication therapy safety’ was coined for this issue as part of a national action
plan published by the Ministry of Health in 2007. This National Action Plan for the Improvement of
Medication Therapy Safety’ has since been updated three more times with the current action plan
covering the period 2016-2019. These plans are supported by a ‘Coordination Group on Implementing
and Updating the Action Plan for Improving Medication Therapy Safety’, in the following just
‘Coordination Group’. This group has met regularly about three times per year since the publication
of the first action plan. The group comprises representatives of various national-level professional
associations, the Ministry of Health, and patient groups. Initially, it was mostly physicians, as well as
community and hospital pharmacists, who participated in the meetings as professional specialists.
Later, members of a national nursing association, the national hospital association, and the federal
association of panel doctors concerned with administering the reimbursement of doctors officially
joined the group.
The structure of the various action plans has remained relatively stable over the years. Sections outline
establishing awareness of the problem of medication therapy safety both among medical
professionals and patients, creating a ‘safety culture’, and various more specific measures such as
encouraging physicians to report side effects to a national registry, with each attracting funds from
the Ministry of Health by competitive tendering. The implementation of some of these measures is
the responsibility of the Coordination Group itself, including a project to design and distribute an
information flyer for patients to increase awareness for the problem and to establish a safety culture.
One idea was to include the template for a medication plan in this flyer so that patients could create
their own medication plans.
However, over time this idea took on larger proportions; the group began to discuss what is now called
the ‘Federal Unified Medication Plan’ (‘Medication Plan’ in the following) as an information and
communication tool for all those involved in the medication process. Eventually, the Medication Plan
became part of a new law, the so-called e-health law, published in December 2015, obliging physicians
from October 2016 to create and print out a medication plan for patients who regularly take three or
more drugs. From April 2017, such medication plans must comply with a detailed specification of the
Medication Plan. This includes a 2D barcode so that a patient’s medication plan can be machine-read
and updated. How this Medication Plan came to productively structure interactions among the
practices of the Coordination Group is the focus of our case.
4. Case Materials
We draw on two kinds of empirical material. Our main source for reconstructing and interpreting the
story of the Medication Plan is the published meeting minutes of the Coordination Group. Since the
publication of the first action plan in 2007, the group has met 30 times. All 29 publically available
meeting minutes were first read from last to first by one of the authors and then, in the reverse order,
excerpted and summarized into four categories: (1) composition of the group; (2) discussions
concerning the definition of medication therapy safety; (3) discussions concerning the medication
plan; (4) other relevant aspects of the discussion.
The second empirical source is the experiences of one of the authors as a founder of the ‘Aachen
Learning Community on Innovative Use of IT in Drug Distribution’ (Claßen et al., 2015), a group of
healthcare practitioners that has met about twice per year since February 2012 and which mirrors the
composition and concerns of the Coordination Group, albeit at the local level. Recently, this group has
started a project to document and reflect on experiences of physicians, pharmacists, and patients with
the Medication Plan through an ongoing series of reflective video conversations. Apart from using
domain specific knowledge from one of the author’s active participation in the discussions and
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activities of the Aachen Learning Community, we will also draw on findings from the first series of
reflective video conversations.
5. Case Findings
In this section, we describe and interpret the story of the Medication Plan. The development of this
case narrative has also contributed to developing the notion of living infrastructure as the happening
of an opening and therefore serves to illuminate rather than just illustrate our basic concepts. The
story of the Medication Plan thus serves a similar function to our city square example, namely, as an
archetype of a general principle. While the city square metaphor was useful for deriving the basic
concepts as defined in Table 1, the concrete contours of the happening of an opening could only be
fleshed out through detailed historical analysis of a particular case. This led us to distinguish three
issues that together reveal the happening of an opening:
1. How the opening took hold,
2. How the opening was kept open,
3. How the opening was kept productive.
While it would be tempting to associate these issues with distinct phases in a linear development
process, we will argue later that they are better understood as constitutive parts of the happening of
an opening. Thus, in each sub-section below, we present an episode particularly appropriate to each
issue and do not intend these to be read as chronological.
5.1 How the Opening Took Hold
In this section, we will document how the various practices making up the Coordination Group came
to encounter each other in a way that opened up the possibility of talking about and probing into new
ways, not entirely managed and controlled by physicians, for determining and adjusting the
medication therapy of patients. Out of this re-orienting of the dialogue between practices arose the
Medication Plan which, in turn, became a site for re-orienting the relationships between the practices,
initially those of physicians and pharmacists, but later also of regulators and patients.
Traditionally, the relationship between physician and pharmacist is perceived to be asymmetrical,
although that was not always the case (Schmitz, 1998). Accordingly, the pharmacist is supposed to
merely follow the prescription written by the physician, dispensing the specific drug intended by the
physician to the patient. Only in cases when a certain drug may threaten the life of a patient is the
pharmacist expected and obliged to intervene in the physician’s medication decision by refusing to
dispense that drug. In addition, the pharmacist is supposed to look out for possible prescribing errors,
for example where the names of two drugs are very similar. As these are exceptional situations, it is
not customary for the pharmacist to seek to communicate with the prescribing physician and
physicians tend to evade direct conversation with pharmacists about the medication of a particular
patient.
This separation between the two practices is reflected in the institutional structure of the German
healthcare system which has very few platforms where physicians and pharmacists are able to interact
as professionals. To the extent that such institutionalized forums for the interaction exist, these are
typically concerned with allocating resources and workloads but not with medication. The constitution
of the Coordination Group was therefore an unlikely gathering because the participating practices,
especially those of physicians and pharmacists, could come together under the aegis of a shared
professional concern, namely medication therapy safety.
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The idea of the Medication Plan evolved from an addendum to an information flyer for patients, into
an information and communication tool for all actors involved in medication. As such, the Medication
Plan announces the possibility of more intense and frequent communication and cooperation
between the various practices, in contrast to the then current one-directional information flow from
physicians to patients, pharmacists, and nurses and relatives. However, the potential shift in how
these various practices might be re-oriented through the Medication Plan was not explicitly discussed
by the Coordination Group. Rather, discussions were about whether the information flyer should
include a ‘unified’ medication plan as a template for patients or not. Physicians were initially opposed
to that idea, arguing that patients should design a medication plan according to their needs.
The possibility that the medication plan might become a new information tool for all those involved
in medication decisions marked a significant broadening of its purpose, here signified by our
capitalization of the medication plan as Medication Plan. Such a possibility was explicitly announced
in the second ministerial action plan, published immediately after the group’s eighth meeting. The
second action plan also specified a measure to hold a workshop with software providers to
implement the Medication Plan in software systems for general physicians, community pharmacists,
and hospitals. Thus, there was a clear intention to broaden the reach of the medication plan from an
information tool for patients to these other practices, which would allow them to become involved in
novel ways in medication processes. The action plan justified this new position by referring to the
discussions in the Coordination Group; however, prior to the publication of the second action plan
these discussions only referred to the medication plan as an addendum to the information flyer.
Even though there are no indications in the meeting minutes that the Coordination Group explicitly
discussed using the Medication Plan for re-orienting the various practices, there must have been an
openness for this possibility. Otherwise, the action plan could not have referred to these discussions
to justify the idea that the medication plan was to become a new information tool for all practices
involved in medication processes, since that implies a significant shift from current practice using the
prescription as a one-directional information tool. It appears that another discussion, which occurred
concurrently with the discussions of the Medication Plan, greatly contributed to creating this
openness, namely, a discussion concerning the definition of key terms related to medication therapy
safety. One important aspect of that discussion was a proposal to distinguish between ‘undesired drug
effects’ and ‘undesired drug events’. While undesired biochemical drug effects cannot be avoided,
some undesired drug events can be avoided, for example, by changing the way or the time that a
certain drug is taken. Making this distinction turned out to be important. For example, in one session
the group had queried the federal association of physicians about whether the current education of
physicians sufficiently addressed medication therapy safety. The association had replied in the
affirmative, arguing that the topic of pharmacovigilance is firmly established in medical curricula.
Pharmacovigilance, however, only addresses undesired drug effects but not undesired drug events,
such as interactions between various drugs. The group therefore decided that there was a need to
educate physicians about the difference between pharmacovigilance and medication therapy safety.
The distinction between undesired drug effects and events opened the possibility for a legitimate and
substantial involvement of pharmacists in medication decisions. Pharmacists are recognized to be
‘experts in drugs’ and could therefore better fine-tune a certain drug regime to make sure that
avoidable undesired drug events are indeed avoided: as long as only undesired drug effects
(colloquially known as ‘side effects’) mattered, it was clear that only physicians should make
medication decisions because only they could trade off side effects against intended effects.
4
4
It is interesting to note that the group maintained that distinction for a considerable time even after a European
directive had re-defined undesired drug effects to include medication errors, a re-definition which effectively
7
We interpret these events as indicative of an opening taking hold. Initially, only a certain openness to
an as-yet unspecified possibility of a new way of orienting the various practices is noticeable. This
openness is manifest in both the readiness to see the Medication Plan as something more substantial
than was initially envisaged, and in the making of the distinction between undesired drug events and
effects. Both these manifestations announce the possibility of a more significant involvement of
pharmacists and other practices in medication processes which, however, was not yet specified or
even thematised. Yet, following the publication of the second action plan, the Medication Plan would
become the main site for working out these new roles, which came to concern the relationship
between patient and regulatory practices in addition to pharmacists and physicians. Thus, the taking
hold of the opening involved the anticipation of a possibility that had yet to be worked out and
defined.
5.2 How the Opening was Kept Open
In this section, we will describe (1) how, in the discussions within the Coordination Group, various
efforts to ‘appropriate’ the Medication Plan by particular practices involved were fended off, and (2)
how this keeping at bay contributed to working out the emerging re-orienting of these practices that
the opening had already brought forth.
The composition of the Coordination Group had stabilized after the first few meetings to
representatives of
the Ministry of Health, which we here interpret as articulating the regulatory practices
concerned with allocating costs and benefits within the healthcare system,
the drug committee of the federal association of physicians
the federal associations of hospital and community pharmacists,
an ‘action platform for patient safety’ which includes patient organizations but is dominated
by healthcare professionals,
and of federal patient and nursing organizations.
Thus, the group comprised five practices, namely those of regulators, physicians, pharmacists,
patients, and nurses.
There were two kinds of moves to claim ownership of the Medication Plan which we characterize as
attempts at ‘appropriation’ in the following, namely, (1) proposals to restrict its purpose, and (2)
proposals to limit the leeway users have in filling in medication data.
The first type of appropriation gesture, proposals to restrict the purpose of the Medication Plan, aimed
at positioning it primarily as a document for patients to help them comply with the instructions of
physicians. Such proposals were successfully countered with the argument that the communication
function of the Medication Plan is essential for improving medication therapy safety. The topic of
these discussions was whether the Medication Plan should also include a 2D barcode. This barcode
would facilitate communication between the various practices. For example, patients may also buy
some Over-The-Counter (OTC) drugs when presenting a prescription to a pharmacist. The pharmacist
collapses the distinction between undesired drug effects and undesired drug events and which the group
eventually incorporated into its glossary. However, even one year after the need for adapting to the European
directive had been first discussed by the group, the group decided that a proposed project would only be funded
if the distinction between undesired drug effects and medication errors is accepted and worked into the project
proposal. Thus, the group maintained this distinction in the face of considerable external pressure to give it up.
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could then read the 2D barcode into her system, add the OTC drugs to the Medication Plan, check for
possible undesired drug events, and print out the updated and validated Medication Plan. On his next
visit to the physician, the patient would present the updated Medication Plan again so that the data
entered by the pharmacist are now available to the physician too. This might include information
about why the patient has been dispensed the OTC drugs, thus facilitating a direct professional
exchange between pharmacist and physician.
On two occasions, participants expressly opposed this inclusion of the barcode as part of the
Medication Plan, arguing that the purpose of the Medication Plan was primarily to instruct patients.
Opposition to the 2D barcode was articulated by the representative of the Ministry of Health, who
argued that dropping the barcode would avoid the necessity of equipping physician practices with
scanners. Also, the representative of the hospital association was against inclusion of the 2D barcode
in the Medication Plan, arguing that pursuing purposes other than instructing patients about the right
way to take drugs would increase the barriers to its adoption. These two arguments reflect concerns
about the costs of implementing the Medication Plan in physician practices and hospitals. However,
restricting the purpose of the Medication Plan to ensuring compliance by patients would have also
strengthened a traditional understanding of the role of physicians as having complete authority over
the medication of a patient.
By fending off this closure gesture, the opening that had emerged in the initial meetings of the
Coordination Group, as a potential re-orienting of the practices of pharmacist and physician, was kept
open. This keeping open did not just consist of rejecting a narrow understanding of the purpose of
the Medication Plan, but also specified a way in which the professions involved in medication decisions
might communicate with each other. This is significant since the traditional means of communication
between physician and pharmacist, the prescription, does not allow for a ‘talking back’ of the
pharmacist to the physician. Hence, fending off efforts to restrict the Medication Plan to a single
purpose also helped to further clarify the relationship between physician and pharmacist and to
elaborate the opening that had emerged as a potential re-orienting of these practice.
The second appropriating move concerned various proposals to use coding systems for automatically
filling in medication data. Instead of entering plaintext into a particular field, users would have to enter
a code into software that would retrieve and fill the field contents from an appropriate database. The
range of possible entries into a data field would thus be significantly constrained as compared to a
plaintext field. Specifically, pharmacists proposed to use codes for, among others, the fields ‘active
ingredient’, ‘suggestions for taking a particular drug’ (e.g. ‘before the meal’), and ‘reason for taking a
particular drug’ (e.g. ‘against high blood pressure’). The first field, ‘active ingredient’, concerns the
relationship between pharmacist and physician, the second and third fields the relations between
pharmacist, physician, and patient.
The proposal to use codes for the field ‘active ingredient’ were related to a prominent project located
in East Germany. There, a different form of re-orientation between the professions of pharmacists
and physicians was proposed and tried out. This project was initiated by the federal association of
pharmacists, which is also an institutional member of the Coordination Group, and the federal
association of panel physicians, which was often present as a guest in the Coordination Group
meetings before becoming a regular member. The most important element of this project was an
agreement that physicians only prescribe so-called active ingredients, the chemical substance that
causes the intended as well as the unintended effects of a drug in the human body, and pharmacists
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then select the appropriate drug.
5
Within the East German project, a complex choreography of
interactions between the physician and the pharmacist was designed that would produce a
medication plan which reflected their joint decision making, which is then handed over to the patient.
The two projects are thus similar but also distinct. The Medication Plan, as envisaged by the
Coordination Group, is (also) a communication tool for pharmacist and physician; by contrast, the
medication plan as envisioned in the East German project is seen as the result of such communication.
Moreover, as part of that project the roles of physician and pharmacist are precisely defined and their
communication is precisely choreographed. This vision would have transformed the Medication Plan
into a mechanistic form of communication a coordination mechanism. As such this vision would have
threatened the Medication Plan as the site of an opening where new forms of orienting the practices
involved could continually be discovered and tried out. While the Coordination Group did not
thematise advantages and disadvantages of the East German model, it rejected the proposal to use a
coding system for filling the data field ‘active ingredient’ on the grounds that no mature coding
systems are available for that purpose, thus fending off the possible closure that would have resulted
from bringing the medication plan idea under the influence of the East German project.
Proposals, also by pharmacist members of the Coordination Group, to use codes for the fields
‘suggestions for taking a particular drug’ and ‘reason for taking a particular drug’ were also rejected
because of concerns about possible misinterpretations of these codes, especially by patients. The
requirement that the contents of the medication plan must be intelligible to patients was emphasized
several times in the context of discussing the use of codes. The group decided to use plaintext for
these two fields in order to prevent any kind of ‘wrong interpretation’ until sufficient feedback from
real-life tests had evaluated whether codes are helpful for users. Through this rejection, the group
thus made it clear that patients are to be involved as active users of the medication plan, without
specifying what ‘active use’ really means. By fending off the interests of professionals, pharmacists in
this case, the group came to assign a positive role to patients as users of the medication plan.
We interpret these moves and counter-moves as an ongoing, dialectical working out of the opening.
Efforts to appropriate the Medication Plan exclusively as an instructional device to ensure compliance
by patients and as a tool to enforce a legalistic and technical version of medication management were
fended off. These counter-moves, however, also produced a more nuanced picture of how the
Medication Plan could function in a new form of interaction between the practices of physicians,
pharmacists, and patients, while continuing to resist specifying how this interaction should or must
look like on each occasion. Hence, the opening was kept open in these discussions and this also
elaborated the re-orienting of the various practices involved.
5.3 How the Opening was Kept Productive
In this section, we document how, as the Medication Plan was tested, distinctions characterizing the
involved practices came to the fore that had been glossed over in prior discussions. Articulation of
these distinctions led to a further elaboration of the re-orienting of practices involved in medication.
Moreover, as the Medication Plan was thematised in practice, the concern out of which it emerged
was also elaborated.
Projects to test the Medication Plan were announced along with the publication of the concept itself
after the eighth meeting; however, the first test results were thematised only about five years later.
As of October 2016, general practitioners are legally obliged to prepare and print a medication plan
5
Drugs whose patent protection has expired are normally offered by several manufacturers. These drugs differ
in price but also in composition concerning additives and other substances, and probably in quality as well.
10
for patients who regularly take three or more prescription drugs, and as of April 2017 such medication
plans have to be compliant with the specification of the Medication Plan published by the group,
including the specifications for the 2D barcode.
A continuing theme throughout the discussions of the group relating to these tests and initial
experiences with the Medication Plan concerned problems with the various coding systems for
automatic data filling. While the group rejected proposals to use such coding systems for several
fields, as described above, four fields can be filled automatically by drawing on a code system for drug
names known as the ‘PZN’ which emerged in the 1970s and is maintained jointly by trade associations
of pharmaceutical manufacturers, wholesalers, and community pharmacies (Wagner, 2005). The PZN
code acts as a data key for retrieving further drug-related information from commercially operated
databases, including the trade name of the drug as registered with the authorities, the name of the
active ingredient, the pharmaceutical form (e.g. tablet or a liquid), and the quantity of the active
ingredient in one unit. A further field concerns the medication schedule, when to take each unit of the
medicine.
When creating a Medication Plan, a physician or a pharmacist could use their computer system to
retrieve drug-related data from the databases of several data providers using the PZN as a key.
6
However, field tests consistently showed that there are differences between data providers in how
such data are maintained, especially the active ingredient and pharmaceutical form but also the
trade name fields. As a result of these inconsistency, the contents of the Medication Plan may change
when it is scanned compared to when it is printed out again, even though the medication itself did
not change.
While in their discussions of these problems the members of the Coordination Group were mostly
concerned with the costs of making the various data sources consistent, the discovery of these
inconsistencies was also productive. For example, the group decided to design their own classification
system for pharmaceutical forms. This move was heavily criticized by the three main database
providers who feared damage to their businesses. They meanwhile cooperated to make their own
classification systems for the pharmaceutical form of drugs consistent. However, the Coordination
Group decided that it would continue to maintain and make available its own classification system,
arguing that contents used in the Medication Plan should be in the public domain. More importantly,
the group also argued that all contents of the Medication Plan must be intelligible to patients, an
argument that had been made in other contexts as well, as reported above. Thus, the discovery of
these data inconsistencies also contributed to a further elaboration of the re-orienting of the practices
involved in medication processes by reasserting the active role of patients in its use.
While most tests of the Medication Plan involving patients concerned questions of usability and
legibility, a project of the Aachen Learning Community, in which one of the authors is actively involved,
studied how the Medication Plan changes the relations of the various practices by conducting
reflective video conversations with patients, pharmacists, and physicians. One finding from these
conversations is noteworthy. It became clear that the Medication Plan can become an occasion to
bring into view the medication of a patient as a whole. This was most clearly articulated by a diabetes
patient, but also by the physician member of the Learning Community. The patient reported how the
Medication Plan had enabled thematising her medication holistically in both her interactions with her
6
While the ‘e-health law’ later specified that only physicians are obliged to create and print out a Medication
Plan, earlier discussions in the group show that the group also envisaged that pharmacists can create and print
a Medication Plan for patients. Presently, the role of pharmacists in creating and updating the Medication Plan
has not yet become clear.
11
physicians and her pharmacist. The most striking incidence of this concerned her interaction with a
neurologist. He had refused to create a Medication Plan for her on the grounds that he was not her
family doctor. However, talking about the Medication Plan led him to review her medication,
subsequently finding a medication error. Thus, the talk about the Medication Plan seems to have
changed the way that he views or comports to the medication, namely now in a more holistic manner.
A Medication Plan was eventually created and printed by her endocrinologist. This also included the
medication prescribed by the other physicians (about 6) she regularly sees as well as OTC drugs. Her
pharmacist then spent about half an hour going through the Medication Plan again. Both, her family
doctor and her pharmacist had initially responded rather negatively to her request to prepare and
check her medication plan but then became rather enthusiastic about this. Overall, she feels that her
medication has acquired a new quality that of being reviewed and approved holistically even in
cases where the medication was not changed. Moreover, her family doctor began to be concerned
with the way she takes certain drugs and has asked her to visit more often to follow up on her
medication-taking practice. The patient described this as ‘reining in’ her drug taking practice,
something that was not entirely unwelcome to her.
The physician member of the Aachen Learning Community confirmed these observations that the
Medication Plan provides an occasion to concern oneself more intensively and holistically with the
medication of a patient. In particular, he noted (our translation):
My experience is that the correct filling-in of the Medication Plan requires a lot of work, a lot
of thinking through; it also occasionally forces the physician to check whether everything
written down there [on the Medication Plan] is still up-to-date, is it still necessary? On the
other hand, it is an instrument which calls for a lot of dynamic, because the Medication Plan
is normally valid only for a few weeks or months and is then changed and modified again, and
this, on each occasion, requires a new thinking through of the plan and the medication. Of
course, not everything will be changed, but everything must be critically evaluated, and this is
an important process.
He also believes that the Medication Plan is important for both physician and patient. In addition, he
sees a need to comply with regulatory intentions.
We interpret these experiences as showing that the Medication Plan is ‘generative’ in the sense that,
in practical use and testing, it continues to generate discussions and discoveries, resulting in further
re-orienting of the practices involved in medication as the opening is further elaborated. This
elaboration results from an ongoing practical interpretation of the Medication Plan such that, as its
possible uses and purposes come to be better understood, each participant also comes to understand
their own practice better and in a more nuanced way.
6. Discussion
In this section, we will interpret the happening of an opening, revealed by the Medication Plan case
above, as a dialectic process of opposing proximity and distance between the practices as regions of
a concern. This overarching dialectic of nearness and farness can be analysed into three constituent
dialectics, namely, between the already familiar and the not yet familiar, between the self and the
other, and between resistance and accommodation. Each dialectic powers an aspect of the overall
happening of an opening and we will describe these sub-processes in the following sub-sections. To
bring out how and why these dialectical processes can be productive, we will also describe how the
delicate balance of nearness and farness in each is in constant danger of being closed down.
12
6.1 Recursive Processes in an Opening
The dialectic of the already familiar and the not yet familiar is the most fragile and hidden of the three
dialectics. It involves a recursive process because it is powered by the anticipation of a possibility which
has not yet become manifest, but which must still be assumed to be sufficiently solid to become the
basis for concrete action and to manifest itself as something familiar. For example, for the Medication
Plan to be able to become a site of an opening, the members of the Coordination Group had to allow
a possible reality for the Medication Plan to structure their discussions and thus, in a sense, to create
the foundations for its own coming into existence. Consequently, there was a high risk that such
intuitive action would not live-up to the expectations of participants or that it was ill-founded. As well
as being productive this process creates a particular vulnerability and fragility of the opening as well.
The danger which constantly threatens to break the productive tension inherent in this recursive
process is not that people refuse to allow a possible reality into their discourse this may be the case,
but would simply signify a lack of imagination but rather, that the possible reality that announces
itself in such discourse is seen merely as a token for some intentions that cannot or should not in fact
be expected to become actual. In other words, a rift is created between present reality and a purely
symbolic world that cannot be bridged. In our example, that danger could have manifested in a
discourse about the Medication Plan characterized by an expectation that the Medication Plan will
never acquire any real meaning, even if used in practice. This would amount to the discussion
acquiring such a token character. This danger of tokenization was ever present, not only in the initial
discussions, but also throughout the testing of the Medication Plan and in its everyday use.
Conversely, the opening for which the Medication Plan has become a site continues to be productive
only if, throughout its conception and everyday use an as yet unknown and unfamiliar reality is
allowed to structure the conversations about the Medication Plan and inform ways of using it. Since
this recursive process accounts for the taking hold of an opening, it follows that the taking hold is not
a singular event after which an opening ‘exists’, but part of the ongoing becoming of the opening, and
that there is an ever present danger that relations between practices may become unproductive and
the opening disappears.
6.2 Assertive Processes in an Opening
An opening is also at risk from efforts to take over control over it to appropriate it. For example,
pharmacist members in the Coordination Group have repeatedly attempted to transform the
character of the Medication Plan into a primarily pharmaceutical document through proposals to add
various fields that are especially important from a pharmaceutical perspective. Likewise, members of
the pharmacist and the regulatory practices have attempted to transform the Medication Plan into a
coordination mechanism by proposing a detailed choreography of interactions between pharmacist
and physician which would impose a narrow technical understanding of medication processes on
physicians. Such efforts, however, were opposed by other members and eventually fended off.
The interplay between appropriation moves and assertive countermoves are the manifestation of
another kind of process at work in the happening of an opening. Again there is a dialectic at work here
because, while counter-actions mainly served to keep practices from dominating or ‘colonizing’ the
Medication Plan as the site of the opening, they also contributed to the further working out of the
relationships between the various practices. Such assertive processes are thus powered by a
productive opposition between oneself and the other. They are productive to the extent that
engagement with the other not only contributes to a better understanding of the other but also to a
better understanding of one’s own role and possibilities. The danger is that the opening becomes
colonized by one practice that imposes its way of understanding and acting on the other practices to
such an extent that there is no openness to alternate perspectives.
13
6.3 Performative Processes in an Opening
There is a third process in the happening of an opening which is highly significant for its productivity.
It is powered by a dialectical encounter between the materiality of the site of the opening and the
human agency of the practitioners. For example, in field tests it was discovered that certain
medication schedules could not be captured by the Medication Plan. Such discoveries, however, were
not interpreted as uncovering deficiencies in the design of the Medication Plan that should and could
be eliminated by re-designing the Medication Plan as an artefact. Rather, they were performed in
subsequent actions as disclosing further meaningful distinctions that needed somehow to be
addressed. Tellingly, the Coordination Group appreciated the existence of more complex medication
regimes while also resisting calls for re-designing the Medication Plan to capture such medication
regimes more mechanically. Other examples concern the practical interactions of physicians and
pharmacists with the Medication Plan, which led them to change their comportment toward it and to
understand the medication of their patients in a more holistic manner.
We interpret such discoveries as resulting from a performative dialectic of resistance and
accommodation in interactions between human agency and a certain material agency of the site of
the opening, as described by Pickering’s mangle of practice concept (1995). For instance, when
interacting with the Medication Plan, one does not just encounter a certain material artefact, but all
the other practices involved in medication processes in a performative manner. Such encounters with
the resistance offered by the site of the opening may thus be experienced as a form of ‘practice
resistance (Johnston, Reimers and Klein, 2016) that calls into question or renders problematic certain
aspects of one’s own interpretations and understandings. By accommodating to such resistance by
adjusting one’s understanding and way of acting, the relationships between the various practices are
further refined and elaborated. This dialectic is, therefore, also productive. The danger consists in
reconciling such discrepancies in a mechanical manner, for example, by re-designing the Medication
Plan to accommodate every variation that occurs in practice. Another form of ‘mechanizing’ the
Medication Plan would be to prescribe ways of interacting through it so tightly that human agency is
entirely deleted, as envisioned by the East German project. In both kinds of mechanization, a
seemingly straightforward mechanical ‘solution’ to an existing problem would be ‘implemented’: the
result would be to close down an ‘opportunity’ to disclose new meaningful distinctions that support
more nuanced productive relations between the practices.
In sum, the nature of an opening consists in a certain way of re-orienting the various practices to one
another which is productive. Three dialectics are at work in this re-orienting: a recursive dialectic that
allows an opening to take hold, an assertive dialectic that keeps multiple perspectives in play, and a
performative dialectic the keeps the opening productive. Each dialectic process is powered by a
distinct opposition at work among practices, namely, between the already familiar and the not yet
familiar, between self and other, and between resistance and accommodation. As such, they are each
aspects of a more general dialectic of nearness and farness. Together these dialectics hold the
practices apart as distinct and autonomous regions of a concern, and at the same time, provide a site
where creative tensions and new meaningful distinctions are kept in play through close productive
interaction.
14
7 Conclusion
We set out to elaborate the notion of ‘living infrastructure’. We drew on the example of the Medieval
European City Square to suggest what a living infrastructure might consist of, and what might justify
the adjective ‘living’ to distinguish it from traditional conceptions of infrastructure. The key idea is the
notion that a living infrastructure becomes the site where an opening between certain regions of life,
that share some concern, happens. This happening of the opening is an on-going process of nurturing
and safeguarding certain productive oppositions between the regions of living that are at once
recursive, assertive and performative in the sense developed in the previous section.
We then presented an empirical case of the Federal Unified Medication Plan for medication therapy
safety in the German healthcare environment. By a careful interpretation of the case materials we
sharpened our conceptual tools and showed that this Medication Plan provides a site where a
productive opening happens between multiple practices involved in medication processes in pursuit
of a common concern for medication therapy safety. Thus, like the City Square, the Medication Plan
exemplifies our notion of living infrastructure, as displayed in Table 2.
Finally, we should briefly return to our comments at the beginning of the paper about the traditional
conception of infrastructure as a material coordination system and relate them to the notion of living
infrastructure. We will simply note, as discussed in the previous section, that when an infrastructure
becomes tokenized, colonized or mechanized the productive tension between the regions of life lived
there closes down. The infrastructure is no longer a site that holds open practices as distinctive and
productive regions of life lived to the full: at most, only a mere material coordination mechanism for
coordinating the transactional elements of existence remains.
Table 2. Our conceptual framework, the City Square and the Medication Plan compared
Concept
Definition
The City Square
The Medication Plan
Concern
A concern defines that
aspect of human existence
with which the infrastructure
deals
The concern is living a good life in a
city
The concern is medication
therapy safety
Region
Regions are distinct aspects
of the concern they are
distinct ‘locations on a map’
of the concern.
The regions are the institutions of
town life religion, state,
commerce, and education/culture
The practices involved with
medication medical,
pharmaceutical, patienthood,
regulatory
Opening
An opening is the
establishment of productive
distinctions between the
regions of the concern
The establishment of distinctions
between spiritual, corporal,
individual and social aspects of a
good city life
The establishment of productive
relations between distinct
practices involved in medication
processes
Site of an
opening
Where an instance of an
opening takes hold
The lived-in city square that
provides the conditions of an
opening between church, town
hall, market and school to happen
An actual in-use Medication Plan
sustains a productive opening
between physician, pharmacist,
patient, and regulator/insurer
The
happening
of opening
How an opening arises, is
kept open, and continues to
be productive
The city square as an opening
happens through various on-going
dialectical processes, which could
be documented for any particular
city square
The Medication Plan as an
opening happens by: taking hold
through a dialectic of the already
familiar and the not yet familiar;
being held open through a
dialectic of self and other; and
remaining productive through a
dialectic of resistance and
accommodation
15
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Introduction: World, Being, and StyleThe Work of Art as Manifesting a WorldThe Work of Art as Articulating a Culture's Understanding of BeingHeidegger: Artworks as Reconfiguring a Culture's Understanding of BeingConclusion: Can an Artwork Work for Us Now?
Ereignis. In A Companion to Heidegger
  • R Polt
Polt, R. (2005). Ereignis. In A Companion to Heidegger, edited by H.L. Dreyfus and M.A. Wrathall, Malden, MA: Blackwell.
Geschichte der Pharmazie: Von den Anfängen bis zum Ausgang des Mittelalters
  • R Schmitz
Schmitz, R. (1998). Geschichte der Pharmazie: Von den Anfängen bis zum Ausgang des Mittelalters, Bd. 1: Eschborn: Govi-Verlag.
Interorganisationale Informationssysteme in der Distribution pharmazeutischer Produkte in Deutschland
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Wagner, T. (2005). Interorganisationale Informationssysteme in der Distribution pharmazeutischer Produkte in Deutschland. In Fallstudien interorganisationaler Informationssysteme --Ergebnisse aus vier Branchen und vier Ländern, edited by K. Reimers, T. Wagner and A. Zenke, Göttingen: Cuvillier Verlag, pp. 43-78.