Infrastructure revisited: ethnographic case study and (re)theorization of the ‘installed base’ of healthcare IT (Preprint)

BACKGROUND Star defined infrastructure as something other things “run on”; it consists mainly of “boring things”. Building on her classic 1999 paper, and acknowledging contemporary developments in health technologies, services and systems, we developed a new theorization of health information infrastructure with five defining characteristics: a) a material scaffolding, backgrounded when working and foregrounded upon breakdown; b) embedded in systems and relationships (becoming real in relation to organized practices); c) collectively learned, known and practiced; d) patchworked (incrementally built and fixed) and path-dependent (influenced by technical and sociocultural legacies); e) institutionally supported and sustained (e.g. embodying standards negotiated and overseen by regulatory and professional bodies). OBJECTIVE Theoretical objective: to explore what health information infrastructure is and how it shapes, supports and constrains technological innovation. Empirical objective: to explore the challenges of implementing and scaling up video consultation services. METHODS Ethnographic case study. We collected a total of 450 hours of ethnographic observation, over 100 interviews and about 100 local and national documents over 54 months. Sensitized by the characteristics of infrastructure, we sought examples of infrastructural challenges that had slowed implementation and scale-up. We arranged data thematically to gain familiarity before undertaking a theoretically-driven analysis informed by strong structuration theory and neo-institutional theory. RESULTS We describe three sub-cases of scale-up challenges in our main study site, all of which relate to “boring things”: selection of a platform to support video-mediated consultations; replacement of desktop computers with virtual desktop infrastructure [VDI] profiles; and problems with call quality. In a fourth sub-case, configuration issues with licenced video conferencing software limited spread of the innovation to another UK site. In all four sub-cases, a number of features of infrastructure were evident, including intricacy and lack of dependability of the installed base; interdependencies of technologies, processes and routines, such that a ‘fix’ for one problem generated problems elsewhere in the system; the importance of collective learning and design-in-use; the constraining effect of legacy systems; and delays and conflicts relating to regulatory and professional standards, especially around clinical quality and safety. CONCLUSIONS Innovators and change agents who wish to introduce new technologies in health services and systems should a) attend to materiality (e.g. expect bugs and breakdowns, and prioritize basic dependability over advanced functionality); b) take a system and relational (as opposed to isolated tool or function) view of the technological artefact; c) train teams on the job, bring clinicians and technologists together and nurture communities of practice; d) innovate incrementally with attention to technological and socio-cultural legacies; e) attend not just to standards but to where these standards come from and what priorities and interests they represent, and whether there is sufficient leeway for them to be appropriately adapted to different local conditions. CLINICALTRIAL The two studies reported here, VOCAL and Scaling Up VOCAL, are registered on the UK National Institute for Health Research Central Portfolio Management System (CPMS IDs 18470 and 43013).