IMPLEMENTING INNOVATION IN THE SERVICE RELATIONSHIP: HOW MANAGING
CHANGE IN FRENCH HEALTHCARE COMPLEX SYSTEM?
THE CASE OF THE PERSONAL HEALTH RECORD (PHR) PROJECT
----------------------------------------------------------------------------------------Habib Johanna
CEROG- Public Management Institute
Paul Cézanne University, Aix-Marseille III,
21 rue Gaston de Saporta, 13100 Aix-en-Provence
France
Email : johanna.habib@univ-cezanne.fr
----------------------------------------------------------------------------------------Scotti Nelly 
CEROG- Public Management Institute
Paul Cezanne University, Aix-Marseille III,
21 rue Gaston de Saporta, 13100 Aix-en-Provence
France
Email: nelly.scotti@univ-cezanne.fr
----------------------------------------------------------------------------------------
Johanna Habib is a doctoral student in Management Science at. Paul Cézanne University, CEROG Public Management Institute, Aix-Marseille III, France. Her researches are focused on Innovation,
Knowledge Management, Organizational Learning and complexity.
 Nelly Scotti is a doctoral student in Management Science at Paul Cezanne University, CEROG Public Management Institute, Aix-Marseille III, France. Her Investigation lines are focused on Public
Management, Service Relationship and Healthcare Organizations.
Abstract
Our paper is focused on the implementation of the Personal Health Record (PHR), an innovation in the
French healthcare system. This national experimental project provides the public health insurance
users with a secure electronic medical record, under their own control.
This paper attempts mainly to identify the specificities of the management of innovation in the service
relationship and to provide some evidence about the key elements which favour or block the process
of general and deep change in the healthcare system.
First, the results show that innovations in the service relationship induce us to turn a particular
attention about three essential aspects of change: technical, cultural and relational dimensions.
Second, the case analysis reveals that several elements of Project Management seem overriding to
generate change in the healthcare systems and to facilitate the generalization process of innovative
approach. These Project Management dimensions are gathered in three themes: the diversity of
interests, the contours of project and the project piloting.
Afterwards, the empirical research confirms the relevance of the Service Relationship concept to
apprehend the PHR innovation particularities and of Complex Adaptive System framework to
understand innovation and change processes in the public system.
Finally, we discuss the implications of these findings for research and practice and also make
recommendations to encourage change opportunities in the process of implementing innovation in the
service relationship.
Key words
Innovation, Service, Relationship, French Healthcare System, Complex Adaptive System, Qualitative
Approach.
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Introduction
Increasingly, public organisations are becoming aware of the importance of Information Systems to
manage their relationships with users. Most innovations in the public sector are currently focused on
the “service delivery process” and “service relation”. After the movements of managerial rationalization
of work and decentralization of competencies, the public service modernization took a new direction:
the way of “service” for the users, characterised by a set of themes as processes reorganization, new
technologies diffusion, development of electronic services, work’s polyvalence, reception training...
However developing and implementing an innovation in the service relationship within public systems
seems complex. In fact, this kind of innovation, focused on users’ needs, implies major
transformations in organizational processes and configurations of interaction.
Our paper is focused on the implementation of the Personal Health Record (PHR), an innovation in the
French healthcare system. This national experimental project provides the public health insurance
users with a secure electronic medical record, under their own control. The PHR is available on-line
and contains all relevant medical information required for healthcare patients. It intends to improve the
healthcare quality through an easier healthcare patient access to the medical information and through
healthcare professional coordination and information-sharing. Yet, if the PHR seems expected by
users of French healthcare system, its appropriation by healthcare professionals seems more
problematic. This innovation necessitates that the healthcare system changes its culture, work
modalities and interrelationships…
This paper attempts mainly to identify the specificities in the management of innovation in the service
relationship and to provide some evidences about the key elements which favour or block the process
of general and deep change in the healthcare system.
In this aim, the theoretical framework is built on a review of innovation and service relationship
management theories and Complex Adaptive System (CAS) literature in order to propose a relevant
and effective approach to change management in healthcare system.
We use a classical case study methodology (Eisenhardt, 1989, Yin, 1994) based on a qualitative
investigation (Miles and Huberman, 1984) and a combination of different collection methods –
interviews with healthcare experts (key actors of PHR project), non-participant observations of
workgroup sessions, and analysis of strategic documents. The used methodology allows exploring the
external and internal change drivers.
Our research intends to answer the following questions:
- What are the specificities of innovation in the service relationship?
- How grasping is the change in the complex healthcare organizations?
- What are the key dimensions to implement innovation in the service relationship within the
complex Healthcare system?
1. Innovation in the service relationship
1.1 The concept of service relationship
1.1.1 from particular characteristic to complex process
Goffman (1961) introduced the concept of service relationship in an essay about psychiatric hospitals.
According to Goffman (1961), the service relationship between two persons allows to understand the
institutions (for example psychiatric hospital) in which the relationships are formed. The author doesn’t
consider service relationship out of a specific professional context. In fact, the notion of service
relationship relies on interaction. The customer’s (or user’s) participation constitutes the foundation of
this specificity and establishes the service relationship. The active part of the customer consists in the
production of data that the agent, the professional will be able to translate into relevant information for
the service situation.
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However more and more the service relationship is becoming automated and doesn’t need human
contact even if human interaction is often necessary to complete or to help customers and conceive
the concept of service relationship. By way of illustration, in French post offices or in the new projects
in French hospitals, machines are set up to buy the television service, to select the channels and to
take the remote control. In these cases of relation automatization, organizations used Medias like
computers and software with specific interface in accordance with the kind of service. To obtain the
best service relationship, the agents who have to use the technical interface (software, machine…),
have to know and master it (having been trained). This induces that the service relationship activity is
based on the agent’s technical expertise and on the customer’s trust towards the agent (Goffman,
1961). Sometimes when agents don’t receive sufficient training and are not acclimated to the
technological change, the media can become a difficulty and act as interference within customers’
interaction.
In parallel, Goffman (1961) makes apparent a distinction between different levels of verbal exchange
in the service relationship. He discerns: a technical part linked to the technical competence of the
agent (informational interaction), a “contractual part” (about frame, shapes of the unfolding of the
service delivery process) and a sociability part (greetings). De Bandt and Gadrey (1994) submit a
widening of Goffman distinction and strengthen operational interaction, the most important part even
though it is reduced for some situations. This extension included information/data collection,
advice/guidance or assistance.
This proposal of De Bandt and Gadrey (1994) to use this concept to account for service delivery
enhanced the first theoretical frame. “The service relation is a specific kind of producer-consumer
relationship” (De Bandt and Gadrey, 1994, p.14)
The concept of service relationship is defined by “the connexion modality between the suppliers and
the customers about the object of the request.” (De Bandt and Gadrey, 1994, p.24). They observe in
concrete service relationship existence of cooperation in the conception, realization and control of the
service delivery process between actors of the “service offer” and those of the “service request”. The
examination of service relationship concrete situations shows this cooperation is always accompanied
by a variable uncertainty. If we can know about means committed by the two parts to deliver the
service, we can’t foresee the final result (for example: customer’s satisfaction) (De Bandt and Gadrey,
1994).
Moreover, we can consider the service relationship as “an experience within the experience”. The
notion of service defines as an experience. The “servuction model” (Eiglier and Langeard, 1988) points
to the decisive part played by contact agents in the production of service, as one of the three elements
that are part of the organization.
In our research, the meaning of service relationship comes from Goffman’s contribution crossed with
De Bandt and Gadrey’s. We define service relationship as an interaction that needs cooperation
between actors and constitutes a service experience not only for agents but also for users.
1.1.2 The key conditions of service relationship
First, the service relationship profession requires various and complex competencies. The service
relationship induces competencies of which the beneficiary of service is deprived. All service
relationships unfold in a specific place that constitutes for the agent as well as for user a “meeting or
encounter point”. For the agent, this place represents a workspace he has to control to facilitate
activities he has to lead. The service relationship profession requires wide and various competencies.
From the workspace control to the perceptive abilities, agents have to build the diagnostic and to
formulate the request of the user explicitly, to be careful and listening to the public, to be didactic. The
major part of its occupation consists in translation from user language to the agent’s language level
and after that, in machine language, to collect and record information in the computer. It concerns to
decode the request of the user and to encode it in a specific language of the software. More and more,
this contact personal has also to develop management conflict abilities.
Finally, the contact agent is a “sense worker” (Habermas, 1997).
Then, the public service relationship relies on the users’ listening. Indeed in public services, the
reflection around the service relationship is not new and is more often characterised by a strategic
belief than by actual implementations. Service relationship then being mostly a slogan, to the point of
sometimes loosing all meaning (Weller, 1998). “Service relationship is liable to serve as an example,
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not in the sense where it would represent a kind of formula to be replicated, but where it would put at
stake the connections between the various dimensions of work.” (Ughetto and al., 2002, page). Public
organizations are concerned about serving their users better. (Weller, 1998). Numerous means are
invested to improve the public service relationship. Public managers have become aware of the
importance of contact agents and approach the problems of the service relationship and more
particularly the wicket henceforth like a strategic point in their service delivery. “Personalization of
processing, hybridization of “back office” with “front office”, the contact with agents, the emergence of
administration control devices, the application of quality control and contentment proceedings of users
contribute the wickets to be changed into important places of production and arbitration, whereas they
just constituted annex of bureaucratic structure.” (Weller, 1998, p.3)
Changes and evolutions of public services are focused on the user. In that extent, “service
relationship” became a reference for managers. In order to analyse these evolutions, research reports
have been developing new concepts and methods, as the model suggested by Erving Goffman (1961)
about “tinkering trades”. These references give a better understanding of the whole complex activities
of public servants and of the organizational framework in which they daily accomplish their work. But it
also underlines moral troubles and abusive political implications of such a reference, when the expert
servicing model is introduced into administrative institutions.
1.2 Innovate in the service relationship: What does it mean?
1.2.1 The concept of innovation
If the concept of innovation refers traditionally to the development of new products and services, it
covers different elements and viewpoints according to the disciplines and the selected analysis level –
individual-oriented, structure-oriented, and interactive-oriented or systems of innovation oriented
(Johannessen and al, 2001). In this research, the concept of innovation is defined as “the
development and implementation of new ideas by people who over time engage in transactions with
others within an institutional order. […] A new idea, which may be a recombination of old ideas, a
scheme that challenges the present order, a formula, or a unique approach which is perceived as new
by individuals involved.” (Van de Ven, 1986, 590-591). This definition offers a holistic view of
innovation (new ideas, people, transactions and institutional context) and apprehends implicitly
innovation as a learning and change process.
The approach advocated here considers:
First: innovation as a learning interactive process in which the participants improve their knowledge
and their know-how by exchange and experimentation (Harkema, 2004; Baets, 1998). It concerns a
sense making process that takes place in a specific social and institutional context (Weick, 1995) and
brings about large structural relations between organizations; departments, services, and work groups
with several different skills.
Second: we assert that the innovation process cannot separate from the organizational change
concept. Innovation induces systematically a dynamic of change. It seems in fact difficult and not
relevant to mark out a fundamental distinction between innovation and change (Van de Ven, Angle &
Poole, 2000). In a systemic and interactionist view, the analysis of the innovation process implies
necessarily the study of change process which is connected with the development and implementation
of newness and a change in collective representations which constitutes a point of leverage for
innovation process.
1.2.2 How situating innovation in the service relationship: A third way between organizational
and technological innovations?
First of all, we must define the concepts of organizational and technological innovation in order to
clarify the concept that we develop in this research: innovation in the service relationship.
Technological innovation is generally considered the development and/or introduction of a new
product or procedure which touches fundamental knowledge, techniques and methods within a
specific business area (Temri, 2000). Often technological innovation relies on the evolution of scientific
knowledge which is connected with the needs of market. This kind of innovation produces licenses
and develops more frequently in the R&D department of one or several firms. Naturally, the
development of technological innovation can cause organizational change and/or innovation.
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The term 'organizational innovation' refers to the creation or adoption of an idea or behavior new to the
organization (Daft 1978; Damanpour and Evan 1984; Damanpour 1996). This kind of innovation
allows modifying more or less radically working methods of agents within organizations” (Charreire,
2003). Organizational innovations essentially concern management practices, work organization,
decision-making process, etc. According to David (1996), organizational innovations have in common
“the fact that the process linked with their introduction within organization concerns at once the
relationships and the knowledge”. The relationships embody the whole contacts between entities
within the organization and the knowledge regards the whole individual and collective knowledge
within the organization. For instance, the introduction of project management into an organization
modifies both relationships – especially the hierarchical relations between actors or groups of actors –
and the way to create new knowledge.
This definition could be appropriated to innovation in the service relationship if the external dimension
(customers or users) was included. In fact, if innovation in the service relationship combines the two
characteristics of organizational innovation (change in the relations and the modalities of knowledge
creation), its main specificity relies on an external dimension: its customers or users. Moreover, this
third way to innovate implies generally a technological component (Habib, 2007). We can consider the
innovation in the service relationship required by a holistic and complementary perspective with the
characteristics of technological and organizational innovations. PHR innovative project studied in this
research demands to take into account both its internal dimension – change in the French Health Care
operating and working–, its external dimension – change in the relationships between healthcare
professional and users– and finally, in its technological dimension – appropriation of new technological
tools and change in the social professional practices (De Sanctis and al, 2003). To study an
innovation, customers or users, necessitates finally to consider technological and organizational
innovation as mutually dependent.
1.2.3 Innovation in the public service relationship: the predominant role of Information System
Modernization of public services is mainly centered on users. In order to simplify its steps and facilitate
the relationship between public organizations and citizens, the essential lines of French reform is
based on the best information for users and an internal reorganization of public services limiting the
bureaucratic approaches. There is a need to rehabilitate the role of reception centers of public
services, that is to say, to turn a particular attention to the agents’ management in contact with the
users. At the present time, the reconfiguration of the agents’ work in contact with users in terms of
service relationship is favorable to innovative approaches based on Information System – i.e.
administration, e-government, e-democracy, computerization of administrative documents,
geolocalization, etc…
This is explained in particular by the backwardness of the public sector in relation to the private sector
in the IS area. Indeed, when the private sector develops bottom-up innovation by the use of
technologies analysis, the public sector tries to adapt its work organization and its services to ITC
evolution.
In other terms, public managers attempt to grasp the opportunities of ITC through the development of
IS implementation. It seems indeed that IS in the public sector is able to ameliorate the representation
and accessibility of users and more generally the performance and quality of service providers by a
best rapidity, flexibility and transparency. Moreover the development of IS innovative approaches
requires a transverse dynamic of change that could allow to limit the bureaucratic and hierarchical
tendencies of public organizations.
The ITC possibilities of communication and exchange invite to redefine the role of users and citizens in
front of public services. The passive representation of users is not any more appropriate to the
knowledge economy. These logics, impacting nearly the whole French public services, seem to
particularly be present in the healthcare system. In the following PRH case presentation, we try to
underline the stakes linked with the computerization issues.
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2. The Personal Health Record case
2.1 The PHR context and stakes
2.1.1 The issue of Healthcare System Computerization
In the French Healthcare system one of the difficulties is to reduce the gap of the computerization
between liberal clinicians and public hospitals. The origins of this problem are, first, the different levels
of information system investment, and second, “the appetence” of the clinicians for this topic.
If the liberal clinicians are computerized to a great degree (between 80 and 85%), only 40 to 60%
among them use a digital file and few use an opened patient record, sharing the same software.
Regarding public hospitals, only 30% of them have an efficient information system. The information
system investment corresponds to 5% of the total hospital investments.
The PHR was created to provide all public health insurance beneficiaries with a secure electronic
medical record, under their own control. The record will be accessible on-line.
It will contain all relevant medical information required for patient care. It is intended to improve the
quality of healthcare by facilitating coordination and information-sharing between healthcare
professionals.
The purpose of the PHR is to make patients able to provide healthcare professionals with the
information needed for their care.
The PHR will prevent possible errors due to healthcare professionals knowing which other healthcare
professionals the patient has seen or what treatment he is under. This record will serve as the
interface for healthcare professionals, providing them access to the medical information they need
(hospital discharge reports, biological analyses, x-rays, medication provided by a pharmacist) and
share the data that a given healthcare professional seems helpful to other healthcare professionals. It
is also a mean of preventing redundant procedures.
2.1.2 The PHR stakes for the key actors
PHR Stakes for patients:
The generalized computerization of information systems is supposed to improve the relationship
between physicians and patients.
The main stake is to provide healthcare continuity to the patient. This centralization of the medical
information is supposed to make progress in the quality of diagnosis by providing online decision tools
and by helping the development of communication between the health professionals.
PHR stakes for clinicians:
The aim of the PHR is to improve practice of medicine by various tools especially assistance decision
tools (for example: data basis about medicines, access to frame reference of good experiences),
access to medical knowledge confirmed and developing teamwork and network.
This project aims to expand the city-hospital network and link the town medicine and hospital sector,
which is the main stake of the PHR.
PHR stakes for public health:
The main stake, from the point of view of public health, is to improve public policies by means of better
health defence against epidemic and environmental peril by an improved knowledge of health
condition of the population and the progression of transmissible disease.
The benefit expected is the strengthening of a health watch plan thanks to circulation of vertical
information and an improved epidemiological knowledge of the French population.
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2.2 The PHR content and Project Owner
2.2.1 The PHR Content
Foremost, the Personal Healthcare Record is a legal obligation according to articles 3 to 5 of the law
concerning health insurance of August 13th 2004. The original idea was to set up a tool enabling us to
centralize the patient’s personal health data, available for some medical personnel, respecting
personal ownership of medical information.
The first ambition of PHR is quality healthcare enhancement, which normally involves economic
support. All health insurance cardholders will be able to open a PHR starting on 1 July 2007– in
theory. The PHR will be created by the patient electronically, on an access portal. The PHR access
portal can be described as a virtual reception centre. If the patient does not have internet access,
approved public service providers will provide free access points on their premises.
The PHR belongs to the patients who control the access rights. Healthcare professionals will have
access to specific information, depending on their profession. The PHR will not be open to
occupational physicians, or when a supplementary health insurance policy is taken out. Similarly, the
site hosting services will not have access to PHR.
For home use, a secured procedure, with login and password, is being prepared. The PHR will be
handled by a State-approved healthcare data hosting service. This means that it meets public security
requirements. The hosting service will not have access to the content of the PHR.
The PHR will contain the last name and commonly-used first name, birth date, information used to
identify personal physician and any information needed for healthcare coordination. At this stage,
based on public consensus-seeking efforts on the MPR draft decree, the said information is defined as
follows:
-
General medical data: personal medical and surgical histories, previous use of specialised
medical services, recognised allergies, intolerances and vaccine history.
Healthcare data: results from biological tests, reports from diagnostic and therapeutic
procedures, diseases and treatment underway, etc.
Imaging data: both reports and images: x-rays, IRM, etc.
Each piece of information listed in the PHR will be dated, signed and its author identified.
Doctors and healthcare professionals will supply the PHR only with the patient‘s personal approval.
Health information will be entered solely by healthcare professionals. However, there will be room for
personal statements so that the patient can talk about his health condition.
The patient is allowed to hide medical information in his PHR, except from the healthcare professional
who wrote it.
2.2.2. The Project team
To design the PHR, a public organisation for the “Personal Health Record” (GIP-DMP) was
established in spring 2005. It represents healthcare professions (doctors, pharmacists, hospital
workers, midwives, dentists, academics, healthcare establishments, etc.) and patients.
The latter will soon be more widely-represented. The GIP was first asked to conduct experiments and
design the national deployment procedure.
The GIP-DMP will steer the entire project, to the called timetable or by the law.
The Grouping’s responsibilities will include the following:
-
-
Maintaining relations with representatives of healthcare professions and patient associations
regarding the personal medical record; informing healthcare professionals and the general
public about the personal medical record;
Determining which personal healthcare data, regarding prevention, diagnosis or healthcare,
will be listed in the personal medical record and making it possible to monitor such aspects as
healthcare procedures and services, pursuant to Article L. 1111-8 of the Public Health Code;
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-
-
Determining the access and the hosting conditions of the personal medical record, whether in
terms of viewing or making changes to the personal medical record, and conditions for
passing on information from the healthcare data categories in the personal medical record.
Steering and monitoring the implementation of experiments with the personal medical record
on the 17 pilot sites.
Designing and producing, as applicable, the supporting IT systems for the personal medical
record.
Steering and implementing the extension of the personal medical record to the entire
population.
If GIP-DMP is the project owner, other members are implicated in the PHR project: national
government agencies, public health institutions, public health insurance bodies, hosts selected by GIPDMP to experiment PHR (for example Cegedim-Thalés, D3P, France Télécom – IBM, etc…)
The experimentation of PHR took place last year, from June to December 2006. This step has been
headed by the GIP DMP with six hosts with different offers and 17 pilot sites spread over 13 regions.
1500 liberal healthcare professionals, 68 private and public health organizations and 37 health
network have been taking part. The aim of this step was to create 30.000 PHR for real patients and to
connect all the hospitals involved. The members of this experimentation have been set up to a secure
process, online data service certificates to guarantee the experimenters’ patients data security and
confidentiality. If the date of PHR generalization was set up in July 2007, the project current difficulties
delay this new stage.
The budget dedicated to implementing the PHR system amounts to 1.2 to 1.5 billion €, to be used from
2006 to 2010. It is part of a broader healthcare information systems budget in the amount of 2.3 billion
€. By better informing all of the practitioners treating a single patient and by fostering better familiarity
with and monitoring of the said patient, the PHR will make it possible to downscale healthcare costs.
For instance, 15% of all medical procedures are redundant and generate 1 to 1.5 billion € in costs per
year. Likewise, some 128 000 hospitalisations occur each year, due to drug interactions (iatrogenisis),
generating 283 million to 472 million € in healthcare costs.
3. The contribution of complex adaptive system theory to grasp innovation
implementation in the French Healthcare System
3.1 French Healthcare System: A complex adaptive system?
The terms of the complexity theory cover many fields and disciplines of academic research and so,
they are characterized by an important diversity and a large multidisciplinary. The main theories
classified under this label of “complexity theory” are, according to Stacey and Al (2002), chaos theory
(Lorenz, 1972; Ruelle, 1991), dissipative structures theory (Prigogine and Stengers, 1984) and the
theory of complex adaptive systems – CAS – (Gell-mann, 1994). Among the latter, CAS theory is the
most commonly used in Organization Sciences, notably owing to the fact that it is easy transposable.
3.1.1 CAS Overview
A CAS is made up of multiple interconnected and non-linear elements and numerous interdependent
agents– individuals, groups and/or organizations – in interaction (Holland, 1995). The agents interact
with each other, their behaviour are adaptive. They act locally according to their own functioning
process. There is no global and fixed plan. The relations between agents are self-organised locally.
“Entities’ adaptation is guided by the search of local interests and not by a mutual purpose to the
whole agents” (Thiétart, 2000). The action processes evolve continuously by learning, adaptation to
external influences, mutual and spontaneous interactions, etc. If the agents have autonomous and
independent behaviours and act with their individual schemas, they are mutually dependent on the
system. It seems important, in fact, to underline the highly connected nature of agents’ relationships in
an adaptive system. The complexity of the system is produced by these multiple interactions between
agents that can lead stable states as well as instable states. The system, understood as a whole that
differ from the sum of the parts in interaction, is dynamic and non linear. The environment variations
and changes and the agents’ capacities of adaptation, memorization and learning are so many
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elements that make the behaviour of the system unpredictable. CAS generates emergent behaviours
and self-organization. Thus, a CAS is dynamic and adaptive because their agents have the capacity to
experiment and explore with new actions, to reconstruct and modify their mental schemas, to adapt
and learn from their experiences and from experiences of other agents as well as the variations and
changes in their environment. “Their ability to learn and adapt is underpinned by self-organizing
behaviours, including exploration and experimentation” (Carlisle and MacMillan, 2006). After, this
general CAS overview, it appears interesting to synthesize its main characteristics.
3.1.2 CAS Characteristics
First, a CAS has a dynamic behaviour because of the presence of numerous heterogeneous agents,
their interdependence, and their capacities to learn and adapt their behaviours according to the
changes of their environment. Therefore, A CAS is constantly changing.
Second, a CAS is a highly interrelated system. The variables and agents in the CAS operating are
large in number, interdependent and connected in complex and non-linear ways. Besides, numerous
factors influence the system operating and the interrelations between variables and agents.
Third, a CAS operates simultaneously at many different independent scales (individual, group and
organization). If each individual agent acts in an independent way, the agents’ interaction and
adaptation (to each other) locally allow the emergence of group or organizational behaviours.
These levels are both interdependent and connected with each others. Thus, they show regularities
or similarities as well as irregularities and differences.
Fourth, a CAS can evolve at the edge of chaos. Feedback loops – positive and negative – produce
both periods of stability and periods of instability and chaos in the operating system. To survive and
optimize the system, the agents, which evolve in an open environment, adapt and change their
behaviours. In a CAS, equilibrium and stability can generate the death of the system.
A CAS takes turns with order and disorder stages. The edge of chaos, a stage of moderated instability
or “creative destruction”, fosters the appearance of emergent processes like change, creativity or
innovation. In this perspective, Stacey (1995) compares creative and innovative act to a process that
goes away to equilibrium, accepts disorder and uncertainty, self-organizes and adapts itself through
learning.
Fifth, a CAS is a self-organized and emergent system. The multiple interaction of agents and elements
in the system produce new global patterns. Especially, when the system is situated at the edge of
chaos, a bifurcation process allows the system self-organization and the emergence of new operating
models and new behavioural rules. This change comes from an internal dynamic, as well as the
influences of the external environment. New global patterns can be generated by small changes.
Many works, especially in Management Science, have shown that organizations can be considered
and therefore modelled as a complex adaptive system (Stacey 1993, 1995, 1996; Thiétart et Forgues,
1995; Cheng et Van de Ven, 1996; Brown et Eisenhardt, 1997; McKelvey, 1997; Boisot et Child, 1999)
and more precisely as a CAS (Gell-mann, 1994, Stacey, 1996, Anderson, 1999).
“A wide range of organizational theorists and practitioners have argued that
organizations are complex, non-linear systems whose members (agents) can
shape their present and future behaviour through spontaneous self-organizing
which is underpinned by a set of simple order-generating rules” (Burnes, 2005,
81)
Nevertheless, if complexity theory considers organizations as CAS (Gell-mann, 1994) it seems
essential to note, following Stacey (1996) and Chiva (2004), that human CAS have many distinctive
characteristics in comparison with biological CAS. In human systems, the agents – individuals – are
affected by emotions and feelings that influence interaction processes. The individuals are, besides,
able to think in a systematic way, to prioritize their goals, or also for instance, to implement power
strategies (Chiva, 2004). Thus, human CAS seems more complex than biological CAS. It is advisable
to be prudent in the application of this theory to the organizations. So, the first step consists in
checking the relevance of analogy between a CAS and the French Healthcare System.
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3.1.3 CAS Transposition to French Healthcare System
Cilliers (1998) defines many attributes characterizing the CAS. In introducing and detailing these main
attributes, we will show why innovation processes can be perceived as a CAS and so, can be
modelled with this theory.
Table 1: Application of CAS theory to the French Healthcare System
Large number of elements
The French Healthcare System is made up of numerous agents (individual, groups and organizations) and is under the influence of numerous
parameters
These elements interact dynamically
These agents (individual, groups and organizations) interact in order to develop their activities and to defend their own interests.
Many interdependent actions combine in the French Healthcare System
Interactions are non-linear
Theses interactions are complex (actors’ games) and unpredictable by nature (the actions convergence is not predetermined)
There are feedback loops in these interactions
Interactions generate many feedback loops which allow agents to adapt their actions according to the actions of others. There is no global plan
but a general interdependence of local plans.
The system is open
Agents seek information and knowledge in the French Healthcare System environment. They learn and adapt their behaviours according to
variations of external environment.
The system operates far from equilibrium
The implementation and diffusion of innovation in the French Healthcare systems cause exploratory and chaotic behaviours, conflicting events
and provoke a stage of disorder, situated far from equilibrium (Stacey, 1995).
The system has history
The French Healthcare system is embedded in a specific history and organizational culture. Agents implement the concept of innovation
according to their particular context, i.e. social and institutional built.
Source: Adapted of Cilliers, 1998.
These different elements exhibits that the French Healthcare system model according to the CAS
theory is perfectly conceivable. The system’s characteristics allow us to better understand the dynamic
of innovation implementation and the emergent organizational change. In other words, to consider the
healthcare organizations as professional complex adaptive systems (Anderson and McDaniel, 2000) is
similar to an heuristic approach to explore the relationships between agents and their emerging
patterns, in order to frame how to manage change and innovation. It seems, in fact, essential to focus
on the relational network between the organizational agents and their mutual adjustments and
interactions within the environment dynamics.
3.2 Implications to explore organizational change in French Healthcare System
Ideas from the complexity theory emphasise on the emergent nature of change. Change comes from
continuous interactions between the agents in the system (Brown and Eisenhardt, 1997).
“Emergent change consists of ongoing accommodations, adaptations and
alterations that produce fundamental change without a priori intentions to do
so. Emergent change occurs when people re-accomplish routines and when
they deal with contingencies, breakdowns, and opportunities in everyday work.
Much of this change goes unnoticed, because small alternations are lumped
together as noise in otherwise uneventful inertia…” (Weick, 2000, 237)
In other words, change occurs spontaneously when connectivity and interdependence between agents
(people and groups) are large enough. In this perspective, the management of change consists first on
creating interdependences between actors and groups in order to foster a convergence of actions, a
local coordination allowing self-organization of system. Accepting the principles of emergence and
self-organization in the complex system leads to rejecting the logic of intentional change, global plan
and top-down.
Emergent change induces to develop skills of managing disorder and uncertainty as well as to
encourage experimentation, diversity of views, creative actions, improvisation and deviant behaviours.
The focus of organisational change interventions in a complex view moves away from ‘planning
10
change’ into ‘facilitating emergence and self-organization”. So, how fostering to self-organization is the
complex system?
According to Gell-mann (1994) self-organization occurs when the system stands at the edge of chaos.
This stage of moderated instability or “creative destruction” encourages the appearance of emergent
processes like change, creativity or innovation.
This stage of ‘edge of chaos’ is facilitated by five factors (Eigen and Schuster, 1979 ; Juarrero, 1999 ;
Kauffman, 1993 ; Ingber, 2000 ; Andriani, 2001) :
1) Multiple interactions between agents
2) Multiple interactions between agents and their external environment
3) Numerous information and knowledge flows
4) Large cultural diversity among agents
5) Equilibrium between formal and informal structures (of exchange) within organizational system
After this explanation of theoretical foundations and of the PHR project, it seems that empirical study
must search for answers to the following question: Do factors facilitating a state at the edge of the
chaos, in the CAS theory, influence the organizational change required for implementing the PHR
innovation in the French Healthcare System?
In this objective, a qualitative methodology based on the single case of PHR has been designed.
4. Research methodology
4.1 Case study methodology
This research intends to explore the process of innovation in the service relationship in the specific
case of French Healthcare System. A single case study has been chosen in order to propose a depth
investigation.
According to Yin (1994), a single case may be relevant 1) to confirm or test a theory, 2) to represent a
unique or extreme case or 3) to observe a phenomenon that was previously inaccessible to the
academic community. In our research, this is the second situation that justifies the single case
relevance.
Yin (1993) identified three main types of case studies: Exploratory, Explanatory and Descriptive. The
PHR case study is an exploratory one. This type of case studies can be considered as a prelude to
some social research and data collection aims to precise the research questions. Moreover, an
exploratory case study requires selecting the case according to the conceptual framework in order to
maximize the research process and the relevance of first results.
In parallel, our case study has been designed on a multi-level analysis: actors, groups of actors and
the interaction between them (the system). Feagin, Orum, & Sjoberg, (1991) state that: a case study is
an ideal methodology when a holistic or systemic view is required for understanding a social process.
This implies to use multiple sources of data. In other terms, the case provides an exhaustive collection
of data.
The PHR case study allows us to examine the resistances and issues to change (linked to the
innovation implementation in the French Healthcare System), and to identify the external and internal
change drivers.
4.2 Data collection and analysis
Case study research requires a delicate data collection to control the data authenticity. The PHR case
study has been designed in using a combination of different collection methods (Stake,1995). We
have made a qualitative investigation (Miles and Huberman, 1984).
11
First, the collection of primary data includes:
- Centred interviews (20 interviews of one hour each) with the PHR keys actors. The healthcare
experts interviewed were mainly: Information System Managers in public hospitals, Executive
Managers of main structures in charge of the PHR implementation, Ministry of Health PHR
project manager, heads of pilot department in the PHR experimentation, etc.
- Non-participant observations, especially during the workgroup sessions of the PHR key
actors. These meetings allowed monitoring the PHR experimentation and identifying the main
issues of project. However, in most cases, these work sessions were not for the unique
subject of the PHR, but more generally the computerization of public healthcare system.
Second, we organized a collection of secondary data (Weick, 1993) through:
- A set of strategic documents explaining the project stakes, the stages of implementation, the
actors, the first lessons of experimentation, etc. These documents come from diverse sources:
internal documents to PHR project, documents written by main pilot structures, strategic
document of the Ministry of Health or the Parliament, etc.
- A set of newspaper articles in periodicals, medical magazines, specialised press, etc.
This collection method provides a data triangulation and a robust chain of evidence (Miles et
Huberman, 1984).
The data analysis had been a qualitative one through a thematic content analysis (Bardin, 2001) and
had been achieved with the assistance of Nvivo (qualitative data analysis software) in order to
organize the verbatim in categories of themes and under-themes. Our data analysis may be
characterized as a method of categorical aggregation (Stake, 1995).
5. Research findings : the main points of blocking
5.1 Technical aspects
5.1.1 A lack of communication and a compartmentalization approach
The PHR project represents for the hospital’s personnel (medical, paramedical and administrative) a
new further project to carry out which adds to their workload. Moreover, the PHR is a legal obligation
for hospitals and is like a constraint “for us it is impossible to free up time and staff to work on this new
project”, said a manager hospital, “We already have important inner restructuring projects that mobilize
some agents. Our challenge is to make coherent inner projects with national obligation projects”. This
quotation raises two main problems of the PHR project. First, we can observe a lack of communication
around the PHR. One of the actors interviewed who have taken part at the experimentation said “One
of the main difficulties is the mobilization of personal and experimentation is very difficult to launch if
you do not have a minimum of good will. The PHR project and more particularly the experimentation
has been done in a confidential way without a real national communication campaign even though this
step of the project could impact 3000 hospitals. ”
In spite of the major stakes of the PHR project and the obligatory nature of the project, the numerous
partners didn’t invest in communication campaign to mobilize hospital personal, to explain the project’s
goal and perspectives to prepare and organize the implementation and the experimentation step. This
confidential aspect poses a real problem in the project appropriation by everyone who has to act in it.
Second, as the PHR project was not introduced for the personal, they do not realize the stakes and
the extent of this innovation. This lack of communication makes tough the mobilization and creates a
compartmentalization approach of the project. Each part tries to understand what is expected and how
to integrate these new activities to the other or the PHR project is a transverse project with global
finalities. “There is a hiatus between the global vision wished by the authorities and the work oriented
vision of each actor.”
12
5.1.2 The illusion of the interoperability: “On the track of a standard…”
At this time the PHR is not a sustainable and perennial tool. It is complicated to supply and a lot of
technical aspects are still not solved.
The main stake of the PHR project is the interoperability to provide a national healthcare record
available in hospitals like in general practices and supplied by all the clinicians, to improve the health
condition’s knowledge, diagnosis and to develop a data exchange. Today one of the problems is the
national identification norm and compatibility of the formats between the hosts.
Main actors of the PHR project neglected the reflection about the patient identification norm. A major
part of the hospitals try to run over this problem, for example in a pilot site “We do not know everything
about the PHR project. We know we have to be the best on the patient identification and on the
professionals’ identification.” This quotation illustrates the problem of compartmentalization on the
national territory and the lack of preliminary reflection, anticipation of the main technical problem.
Another important obstacle is data security and confidentiality. According to an information system
manager “One of the main problems is the identification and the confidentiality and security of the data
contained in the PHR.” Some hospitals, not necessarily experimental ones, have foreseen the
identification problem and have been forming alertness identification units. According to the security
expert in the PHR project, it deplores the following; “We have had to standardize the identification
methods before the launch of the project”. For another actor “The technical part [of the PHR project]
isn’t complex because it is a high tech rather than because there is no standard to implement”. This
absence of standard is emphasized by the multiplicity of hosts involved in the project. Indeed, six
different hosts have been selected to develop software for this project.
Actually, the project began too early, whereas experts didn’t deal with the main preliminary problems
like the identification of patients and standard conceptions for national territory. This lack of preliminary
work has been creating great confusion and a dilution of the PHR project goals.
The question remains on how to share information between different hospitals through national
territories with different hosts and different formats? How to promote interoperability where there is
diversity and multiplicity of software and versions of the project?
5.1.3 A innovation project: the necessity of training for the change
In spite of the numerous structures involved in this project, none of them have considered training for
the change. No organized training to prepare personnel has been decided by the decision-making
structures. In an experimental site, a manager has to organize training without taking time to prepare
it: “We organized a part of the training for the physicians and it is a heavy step that we haven’t
anticipated.” This time dedicated to the training organisation would have come to PHR project team
because they hold competencies and knowledge to manage change. The PHR project would have
required a national training plan to introduce a new culture around a specific population. Indeed, the
project impacts medical personnel, clinicians and administrative agents and each group has its
practices, habits and has to incorporate this new tool to their work. The information system manager of
a French hospital noticed: “We are worried about how to inform administrative personnel of the
necessity of accurate patient data collection. According to me it was of utmost importance before
beginning the experimentation. Furthermore it is important to locate and to mark identification-high-risk
units like emergency services where the identification patient is fussy.”
Training for change represents a strategic step in the implementation of this kind of innovation in the
service relationship. PHR project’s owner would have had to create training sessions for different
populations involved and diffuse the computerization culture not only to the experts like information
system manager but also to the other levels of hospitals.
French hospitals are bicephalous, composed of medical personnel (paramedical, physicians…) and
administrative agents who often have bureaucratic practice. It is necessary to coach the change to
restrict resistances to the change.
13
5.1.4 The PHR project: a new workspace
The implementation of new software modifies work conditions and requires a specific acquisition of
new reflexes and new behaviour. In contact management, agents are stressed and submitted to an
important uncertainty (De Bandt and Gadrey, 1994). The setting up of a new technological tool
represents a supplementary stress for them. To deliver a service relationship in good conditions the
agents need to control their workspace. The set up of new software means for agents a new stress to
manage and they need time to be self-confident when they work with this new technological tool to
give information to people or to answer their questions.
The software is considered like a support, a mean to be more efficient when agents inform users. If it
becomes unfriendly, it modifies the way service relationship is delivered and users begin to complain.
The PHR project represents a modification of the technological workspace of agents, not only for
paramedical and medical staff but also for the administrative part like the hostess at the front desk and
administrative entrance where patients have to present paperwork for the healthcare insurance and
mutual company. “This category of agents is a small and very delicate group. When something is
changed in their workspace it is essential to explain the reasons and the benefits for their everyday
labour. Otherwise, they have the ability to go on strike since they are unionized.” 1
This extract shows the specificity of contact agents who work in an unsure environment and how the
smallest change in their environment creates a stress and may disrupt all of the hospital management
by producing sick leaves or a strike.
We can suggest working in task groups with concerned agents to present the PHR project and the
impacts of this project on the work conditions. We consider this is not a training phase or an
information step but a specific communication dedicated to the contact agents who have to represent
the hospital in front of users and patients. This suggestion concerns the ergonomic aspects in the PHR
project. When we modify the workspace we change marks and for some agents it corresponds to an
additional stress in their workspace.
5.2 Cultural aspects
5.2.1 For the clinicians
The PHR project modifies the medical and the clinician’s culture. People are accustomed to thinking of
clinicians as wise men who are able to cure all illnesses. They are considered like a God who holds
the supreme knowledge and is able to control life and death. In their diagnosis clinicians are aware of
this authority and are the owners of their diagnosis and of their data. First because they use jargon
and make decisions for which they are responsible and second because as usual the clinician keeps
his memorandum and the patient examinations in his practice.
The PHR project transfers the authority of the patient data from the clinicians to the patient himself.
With this centralization of the health data in a virtual space, the patient becomes the owner of his
health condition. Symbolically the clinician loses the control of his knowledge, his expertness and
especially of his data.
Moreover, the PHR changes the patient into a client who can compare the diagnosis between different
clinicians. Clinicians have to not only write the diagnosis and their memorandum in the PHR but also
make it public so that another clinician can read and reconsider it. This sharing of the diagnosis is a
revolution in the field of medicine.
Another aspect in the PHR project is the possibility for the patient to hide information. This functionality
allows the patient to hide some data from clinicians, which can be very dangerous for their diagnosis
as they need all the information in order to make vital decisions.
This revolution in the positioning of the clinicians is not considered by the managers of the project
groups. This cultural change needs to be presented to the clinicians because they may be resistant to
this project. For example, the results of the first experimentation show that only 23% of the clinicians
declared to sustain the PHR. One of the perspectives to consider for the PHR managers is to give
value to the medical stakes of the PHR program for the clinicians to obtain a conjunctive involvement
from hospital clinicians and city clinicians.
1
IS manager of a Public Hospital
14
5.2.2 For the medical staff
The PHR represents “another form”, even though it is digital, to fill out by the medical staff. It
corresponds to a bureaucratisation of their job. French nurses complain of numerous documents they
have to fill out when they take care of the patients and according to them this bureaucratic aspect of
their job is at the expense of the human aspect of it.
Moreover, the nurses have evolved in an oral culture. In the hospital units they have some staff
meetings to inform the night team and the day team about the patients’ conditions. With the set up of
the PHR, nurses will have to write with precision and to develop their written culture.
“One of the bigger problems of the PHR implementation is not the technical aspect but the supplying.
This part of the job concerns the medical and paramedical staff for the medical aspect as well as the
administrative agents for the administrative part. 2”
The transition from an oral culture to a written culture represents an important change in the work
routine of the nurses as with the PHR they now are supposed to be conversant not only with people
but also with the software.
Unfortunately we can observe that “clinicians and administrative managers are involved in the PHR
experimentation but nurses and administrative agents are reluctant and very cautious. They grasp the
PHR like an overburden in their daily work and not like a tool.” 3
This quotation underlines the lack of communication about the PHR and the cultural change that the
PHR represents. Another IS manager of a public hospital adds “We are conscious of the circulation
issues because we are working on them but the medical and paramedical staff do not take part in
these brain-trusts.” Finally we can notice that the PHR project managers did not consider the diversity
of the cultures that coexist in the hospital and adopted a point of view that corresponds to their
approach. In spite some efforts to involve clinicians and medical personnel, the PHR project
conception remains an IS project that complicates the cultural integration for the “non-specialists”.
We can observe that the large majority of the persons involved in the PHR project come from an
information system culture and are used to set up this kind of project but they are not able to translate
the technical aspects into medical or administrative stakes. The PHR implementation difficulties
indicate the cultural gap or the “cultural shock” between nurses who want to stay with the patients to
take care of them, clinicians who want to be owner of their diagnosis and their expertness and the
administrative agent who want easy software to type in patient information. This centralization of the
health information disturbs the habits and culture of each part and gives patients ownership over their
body and information about their health condition, without the knowledge.
5. 3 Project Management issues
Some aspects of Project Management equally increase the resistance to change of healthcare actors.
We present, in this second part of the results, the three main dimensions linked to PHR project
management and we show how these block the PHR process deployment and could cause the future
failure of this innovation.
5.3.1 The lack of Interests Diversity Management
The French Healthcare System is made up of a multitude of actors, groups and institutions with
different interests and strategies. Implementing a radical innovation needs to manage this diversity of
interests reflecting various cultures, professions, expertise, etc… especially when it concerns an
Information System Project with a transverse perspective. In PHR´s case, GIP-DMP did not take into
account this diversity in the project management. The different categories of health actors have
practically never been associated in the project conception although this stage is essential to obtain
2
3
Executive Manager of the MAINH (the National Support Mission of Health Investment.)
IS manager of a Public Hospital. This hospital took part of the experimentation step.
15
actors’ support and mobilization. According to MAINH 4 representative: “There are different
professional views about this project as PHR integrates objectives and speeches that, in the short
term, appear antinomic. Today, we take orientations that leave numerous questions in suspense.”
The main interest in the diversity approach for the PHR concerns the duality: cost/quality.
For Government, Social Security and health insurances, PHR represents an opportunity to structurally
change the health system in order to make it more effective and efficient. In other terms, PHR replies
to a “productive requirement” of cost savings. For patients and health professionals PHR should
improve the coordination of medical care as well as the general quality of care. PHR, in this logic, is
similar to an information exchange support allowing the development of communication networks
between health professionals and the continuity of cares between several health establishments. The
aim is to create collaborative informal networks operating on horizontal communication. We could
qualify this second approach of “sharing logic”.
These two points of view seem in complete opposition and block the PHR deployment. “Today
clinicians suspect the general strategy of cost reduction behind PHR and block its diffusion. Some
criticize the project in public meeting, in press and in their institution or in front of the patient.” 5. The
economic perspective of PHR aiming to control the costs of health services is perceived by clinicians
as a monitoring of health activities and a control method of daily practice. It reflects a top-down
perspective of implementation: PHR is “a centralized proceeding of medical work which must increase
our productivity”6. Moreover, this predominance of cost savings logic causes another problem: the one
of PHR inadequacy with medical practice which reinforces the resistance to change of liberal and
hospital clinicians.
If naturally the financial interest of PHR seems particularly interesting in view of the health system’s
current spending, this one can not justify the project validity for health professionals and for patients.
PHR implementation requires health professionals’ adhesion about its prior objectives. For the time
being, we are far from that and the dialogue does not seem to be in search of it. To illustrate this
difficulty, the “Midi-Pyrénées” regional union of liberal clinicians removed itself from PHR
experimentation because it considers that its advices were not taken into consideration by the heads
of the project.
To overcome these difficulties, it seems essential that GIP-DMP associates more with the different
health actors involved in PHR implementation in order to obtain a dialogue about PHR objectives and
consequently the mobilization of the health system. Through the setting up of PHR team project, it
appears necessary to gather, as much as possible, the different professional cultures (clinicians,
auxiliary nursing staff, administrative staff, IS staff, executive staff, etc.). The aim is to create value
through the diversity of culture, profession, practice, expertise, etc. The contradictory logics and the
tensions linked to interest diversity could be beneficial to innovative and performance approaches
around PHR if different views of information and collaboration are organized and are anticipated in the
project management (Andriani, 2001, Habib, 2006).
For the time being, in the complex health system, the diversity of interests seems to block change
because it is not managed at the different levels of project action.
5.3.2 The “blurred contour” of PHR Project
The second dimension that causes problems to PHR innovation is the lack of delimited contours to the
project. We observe through the analysis of experts’ interviews that PHR project mingles with other
projects associated to strategic axis of healthcare organizations’ computerization. By the way of
illustration, the Information System Managers of Public Hospitals merge in practice PHR project with
the issues of Emergency Computerization, Interoperability IS, Vital card new generation 7, Health
Professional Card, Patient or Professional Identification, etc. In other terms, the content of PHR project
being not clearly defined, the key actors involved do not know how tackle PHR project. “In my hospital,
we have decided to approach PHR with the Professional Identification issue. We are aware of limits of
this scope but the priority lines of PHR are not explicit”8. “In terms of regional objectives, this is not
clear. We are some difficulties to grasp the coherence of planed actions. We wish to know the prior
4 The MAINH is the National Support Mission of Health Investment. This organization is a support structure that supports central
administration and the cabinet of ministry, ARH and hospitals. The latter is accountable of animation, consolidation of data and
communication.
5 Executive Manager of GMSIH (the Organization for the Modernization of French Hospital Information Systems)
6 Extract of interview with a hospital clinician.
7 Vitale card is an electronic claims submission consisting to simplify and accelerate exchange between health care
professionals, patients and health insurance.
8
IS manager of a Public Hospital
16
aims. During the meetings of ARH9, this one evokes several aims, several questions, several solutions
… but we do not know what the immediate target is: The PHR or more simple things like the health
network?”10 This lack of Project delimitation is also underlined by a Senate Report in 2007 which
reveals that the main piloting authority, The PHR project owner (GIP – DMP), can not yet answer to
essential questions about PHR: What is the PHR content? What must be the operating principles
(local, regional or national)? What is the global cost? What is the PHR cost for the main actors and
structures of healthcare system, etc…?
This “deliberate vagueness” gives the feeling to the expert interviewed that “the PHR for the time being
is only in the speech”. This feeling is reinforced by the unrealistic planning of PHR actions which set
the PHR generalization in July 2007. This produces multiple local actions without coordination and
leads, in some cases, to the demobilization of key actors’.
Besides, it seems important to consider that PHR for health organizations is similar to an external
project that is a governmental requirement. With very few exceptions (i.e. the cancerology institutions),
PHR is not necessarily in observance with the general strategy of health organization and especially
with the program of computerization. This implies that there is not an automatic convergence with
internal or local projects. Thus we observe a duality between these two perspectives: external vs.
internal projects and top-down vs. bottom-up approaches. Often in the cases studied, we note that
local actors give preference to local projects of computerization (notably because theses projects are
financed on their own budget) and neglect the national PHR project. If the PHR project was better
delimited and the prior objectives more clear, it seems that local actors could integrate PHR easier in
their local initiatives. “We wish to transform the top-down approach of PHR into an assistance to our
local projects but at the present time we do not know how realize it. The content of the PHR project is
too vague.”11
In terms of managerial implications, it appears that the PHR project must clarify its prior objectives to
facilitate the local initiatives in order to focus on the same objective (convergence of local initiatives)
and to avoid the demobilization of health actors. Moreover, it seems interesting that piloting instances
take into account these dualities - external vs. internal – top-down vs. bottom up – because the PHR
project can not be implemented as a law. This important IS project requires transversal approaches
and participative management at each level of action.
5.3.3 The failings of Piloting
Several problems of piloting now obstruct the deployment of PHR. We intend, in this part, to explain
why the current piloting of the project is not adapted to the IS project implementation and to enhance
some possible solutions.
First, we remark that too many structures are implicated at the central level in the PHR project and its
piloting. For example, at the governmental level, four ministerial directions – “hospitalization and cares
direction”, “Social security direction”, “health direction” and “research direction” – intervene in the PHR
project management. Each direction has created a “PHR cell” and leads its own actions without
coordination with the other directions. That is explained largely by the traditional competition between
these ministerial directions. It is the same logic for the structures involved directly in the PHR
deployment – Mainly the GIP-DMP (PHR project owner), the MAINH (National Support Mission of
Health Investment) and the GMSIH (Organization for the Modernization of French Hospital Information
Systems). If these structures have officially definite missions, nevertheless in reality they act in similar
directions and develop a large confusion about the piloting organization. “It is difficult to understand
the role of each institution. For example, last week I was present at two meetings with the same
actors. First a meeting about the emergency computerization project (which is managed at central
level by the MAINH and the GMSIH and at regional level by the ARH) and second a meeting about
PHR experimentation with the same partners. More or less the two meeting revolved around the same
subjects.”12
The analysis of expert interviews reveals the stacking of structures without clear functions and
missions, the lack of continuity between these central structures of piloting (ministerial directions and
PHR structures), and the responsibilities are weakening. Generally speaking, we observe the absence
9
Regional Agency of hospitalization
IS manager of a Public Hospital
11
IS manager of a Public Hospital
12
IS manager of a Public Hospital
10
17
of structure having a sufficient visibility to pilot the project in a general view and to assure the
coordination of local actions about PHR or its key axis.
At the regional level – intermediary programming –, we note the absence of regional instance to
federate the local initiatives. For the time being, the PHR management does not plan the regional
piloting. In some regions, the ARH (Regional Agency of Hospitalization) that plays the role of
coordinator but the implication of this structure differs from a region to another. In other cases, the
local health networks assume the coordination role. At last, in other regions, no other structure invests
in this mission. The absence of a regional reference poses mainly a problem in terms of knowledge
mutualization and synergy effects between the local structures embedded in the PHR experimentation.
Without coordination, the local structures can not exchange information and expertise about the
project. And that is all the more prejudicial with the absence of PHR project prior objectives and the
investment realized by local structures in different axis of PHR. Several actors interviewed speak
about “a wasting of resources, means and energy”.
Finally, at the local level, the GIP-DMP has chosen to base essentially the PHR experimentation and
generalization on the university hospitals in neglecting the mobilization of the small public health
organizations and the liberal health professionals. If this option can be justified in relation to the PHR
technical difficulties and the implication need of structures with a high level computerization and IS
expertise, it is not necessarily the best choice to create a participative local dynamic around PHR.
Indeed, the interviewed experts underline the difficulty for hospital clinicians to invest time in the
communication and/or creation of a PHR. Thus, the non-association of small public structures and
liberal clinicians blocks the process of PHR. Notably because these actors could play an important role
in terms of communication with patient and the opening of records and more largely in the change
process of health complex.
The entirety of these piloting problems reflect a lack of interactions between actors implicated in the
PHR project at each level of action (central, regional and local) and between these different levels.
The lack of interactions – in internal as well as in external – do not allow the information and
knowledge exchange required to develop the PHR project. At last, the main structures of piloting
approach the project with an inefficient top-down management that does not authorize a balance
between formal and informal structures. These located elements, according to the CAS theory (Eigen
and Schuster, 1979; Juarrero, 1999; Kauffman, 1993; Ingber, 2000; Chiva, 2004), block the “edge of
chaos” phase and the deep change process needed by PHR deployment.
To favour the change linked to PHR, we suggest the following axis:
-
-
-
At the central level, it seems relevant to reinforce the visibility of the project owner (GIP-DMP)
so that a unique central structure pilots the PHR. In this end, we recommend the creation of
PHR team project common to GIP-DMP, GMSIH and MAINH and which integrates the key
actors of central directions. This team project, attached to GIP-DMP, could be a legitimate
instance of PHR piloting.
At the regional level, it appears interesting that a structure federates the local initiatives.
However, the analysis shows that there is no preferential regional structure (ARH, University
Hospitals, Health network) to assume this responsibility. Besides, if some experts pointed out
the ARH for this mission, it seems difficult to constrain the implication of AHR in PHR project
management. To remedy the regional piloting problems, we advise that in each region the
GIP-DMP team project appoint a regional representative in charge of the creation of a regional
committee project. This committee, in associating the representatives of the main heath
actors13 implicated in PHR deployment, could facilitate a participative project management,
reinforce coordination and expertise exchange between local actors as well as between them
and central actors, and increase synergy effects.
At the local level, it seems judicious to initiate a dynamic of actors’ interdependencies through
a better role sharing and the association of a large majority of health actors. In a similar
perspective we suggest the creation of local project committees (in coordination with the
regional committee) in order to incite the local health actors’ mobilization and to organize the
main PHR actions in the territory. The aim is to favour the emergence of local actors’ network
and of the dynamic of implication.
13
Representatives of ARH, University Hospitals, Public and Private hospitals, health structures, liberal clinicians, auxiliary
nursing staffs, administrative staffs, chemists, Patients’ associations, etc.
18
These elements should be accompanied by a general communication about PHR. Indeed, for the
present time, no communication campaign around PHR has been realized towards health
professionals and patients. Now without communication about PHR (its stakes, its benefits, its content,
the patients’ right, the role of health professionals, etc.), the dynamics of mobilization needed to PHR
deployment seems difficult to emerge.
Figure 1 : The Piloting of PHR
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Regional committee of PHR project
Regional committee of PHR project
Representatives of regional health actors
Representatives of regional health actors
PHR team Project
Common to GIP-DMP, GMSIH,
MAINH and ministerial directions
Regional committee of PHR project
Regional committee of PHR project
Representatives of regional health actors
Representatives of regional health actors
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
Local
committee
These suggestions could move PHR deployment from a top-down to a bottom-up approach, increase
the interactions at all actions level and between each of them and integrate the key conditions of
change in the complex health system. In fact, the findings are consistent with the suggestions coming
from the CAS approach which looks at the healthcare system as a complex adaptive system. Thus,
the change required by PHR deployment should be managed in a participative and dynamic way with
a particular focus on: the diversity of actors involved, the multiplication of interactions and information
19
flows and a balance between formal and informal structures of exchange. About this last point, the
PHR piloting through the creation of team or committee projects at each action level seems particularly
well adapted to respect this balance and foster the success of innovation diffusion.
Conclusion
The PHR project is a national project which concerns every public hospital. This project aims to make
easier the generalization of the computerization in the health sector. The main objective is to centralize
the health information in a single file which gathers all the medical information and medical
examinations.
This new way to collect information represents a real revolution in the clinician’s culture and more
particularly in the way to consider the patient and the clinicians. We may name this a cultural
revolution because the PHR project corresponds not only to a change in the way to manage the
service relationship in the health sector but also in the way to approach the physical relationship to the
medical practitioner. Furthermore, we should point out here the passage from a bureaucratic approach
of data processing to a ‘pure’ information system approach. However, the experiment and the
conviction that the logic of the project management is most effective in such a context haven’t
specifically guided the experimentation step of the project. A specific project management is more
adapted to this kind of information system project.
This project approach is better adapted to the context and the technical constraints specific to the
management of the information systems, however, the PHR project concerns all the French population
and not a specific population. Project management and training are the main axis to implement a
major scale project as the PHR. The transition and the change from an all powerful clinician to a
diagnosis shared between clinicians needs a specific organization to change management and
mobilize key actors.
The diversity of the professional culture is one of the neglected aspects which raise the complexity to
find an agreement between the different actors and their own logic and interests about the kind of
information that they have to supply the PHR. Even if all the actors of this project pursue the same
goal: to provide the best possible service to the users.
To achieve this goal each part looks to protect its interests (work conditions, power, workload…). This
compartmentalization is the result of a lack of communication and a lack of consistency in the project
management.
Implementation of a new tool is always viewed as a revolution, when it concerns health in a public
context founded in bureaucratic culture, the change management and the research of sense for each
part of the project is essential to the achievement of it.
20
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