IN BETWEEN CURING AND COUNTING: PERFORMATIVE EFFECTS OF EXPERIMENTS WITH HEALTHCARE INFORMATION INFRASTRUCTURE

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1 Financial Accountability & Management, 23(3), August 2007, IN BETWEEN CURING AND COUNTING: PERFORMATIVE EFFECTS OF EXPERIMENTS WITH HEALTHCARE INFORMATION INFRASTRUCTURE SIGNE VIKKELSø INTRODUCTION Modern healthcare is in transformation with the introduction of new medical technologies, evidence-based medicine, quality indicators, private healthcare providers, and new financial models. The introduction of New Public Management (NPM) with new accounting models, management, and market mechanisms contributes substantially to the transformation of healthcare, although its concrete effects have been disputed. Some find that core medical practices and principles are unaffected by new accounting tools (Jacobs, 1995 and 2005; Lapsley, 1999; and Berg and Timmermans, 2003), whereas others find substantial effects (Chua and Degeling, 1991; and Kurunmäki, 2004). Many studies argue that the autonomy of medical professions is simultaneously challenged and supported (Lapsley, 1993; Doolin, 1999; and Aidemark, 2001) just as NPM poses both opportunities and risks for management (Hepworth, 1996). Furthermore, NPM is no stable program but varies from country to country with different effects (Christensen and Lægreid, 2001; and Osborne and McLaughlin, 2002). There is, however, general agreement that NPM concepts and principles are accompanied by demands for more data on healthcare activities and for information systems to accumulate and process data. The shift from government funding through fixed grants to prospective payment for services and to contracts rests, for example, on detailed registration of provided services in order to allow managerial calculation and regulation of costs, utilization and competitiveness (Bloomfield, 1995; and Carey and Burgess, 2000). Also, the ambition to monitor and regulate cost-effectiveness and clinical effectiveness has led to growing concern for data on clinical quality (Chua and Degeling, 1991; Harrison, 2004; Berg et al., 2004; and Flynn, 2004). Also, hospital mismanagement has become associated with lack of accountable data (Pettersen, 1999). In general, accounting has acquired a wider role than mere control of cost: costs are to be linked to clinical effectiveness and to quality of care, and are presented on a national basis, for scrutiny and benchmarking and where budgets are aligned with clinical responsibilities (Lapsley, 2001, p. 348). The author is from Copenhagen Business School. Address for correspondence: Signe Vikkelsø, Department of Organisation and Industrial Sociology, Copenhagen Business School, Kilen, Kilevej 14A, 4, DK-2000 Frederiksberg, Denmark. ssv.ioa@cbs.dk, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. 269

2 270 VIKKELSØ This also implies a growing demand for IT systems to process clinical data for managerial purposes such as resource allocation, efficiency analyses and budgeting (Bloomfield and Coombs, 1992), for the construction and dispersion of clinical guidelines, and for the assessment of performance against quality indicators (Wiener, 2001; and Berg, 2004). In the light of the new types of accountability and data demand, it has been suggested that NPM is only one element in a new rationality of governance. Thus, Power argues that the growth of quality assurance techniques and philosophies is a central element in an emerging audit society (Power, 1997). According to Power, audit is more than a set of techniques to describe and assess the performance of an organization. It is a whole program of pervading performance standards and greater accountability, which works to produce a subtle kind of governance: The pervasive feature of the new wave of audits is that they work not on primary activities but rather on other systems of control (...) this gives the audit a more remote assurance role than is often understood by the publics which they are intended to serve (Power, 1994, p. 6). Furthermore, Power points to the underlying premises for the audit society. In order to be auditable, organisations must be rearranged so that activities can be monitored or documented, that shared quality criteria exists or can be agreed upon, and that legitimate evaluators have access to relevant data. In terms of governance, these preconditions for the audit society are perhaps more important than the actual auditing activities: The most influential dimension of the audit explosion is the process by which environments are made auditable, structured to conform to the need to be monitored ex-post (ibid, p. 8). Hereby, Power introduces a research agenda other than the direct focus upon diffusion and implementation of NPM-programs. By following the projects concerned with making practices new public manageable or auditable, e.g., with categorising activities, introducing accounting routines, installing computer programs, educating users etc., we may find rather substantial transformations in practices and of practitioners. Describing and analysing these transformations may not only shed light on the groundwork that makes possible the diffusion and implementation of this new logic of governance. It may also add important details to the understanding of NPM and its consequences. This paper takes up the proposal of Power by exploring the establishment of a standard for electronic patient records, called GEPJ (known hereafter as the GEPJ-standard). The GEPJ-standard is an element in a larger attempt to build a Danish healthcare information infrastructure, which has gradually moved from being guided by a vision of a universal communication channel to one of performance auditing. The paper investigates the relationship between

3 HEALTHCARE INFORMATION INFRASTRUCTURE 271 the changing visions, the features of the GEPJ-standard, and the concomitant redefinitions of healthcare. Analysing tensions, translations and innovations implied in the construction process, it discusses the performative effects of these innovations in order to explore Power s thesis. The research is conducted on the basis of the methodology of actor-network theory, which is presented in the section below. It is suggested that actor-network theory is well suited to exploring the deep and often subtle transformations of practices implied in making things auditable. Also, it sensitizes us to the way auditing programs are themselves changed by these processes. The empirical section describes the construction of the GEPJ-standard by following the changing visions of healthcare information infrastructure and the building of the standard. The paper points to critical moments where the purpose, focus and granularity of the GEPJ-standard are translated, and to the concomitant modifications in visions of performance auditing and in definition of healthcare practice. In the final section, the paper discusses these reconfigurations in the light of Power s thesis. It is argued that negotiation and transformation of information infrastructure is central to the way something becomes constituted as the object of performance auditing, and that this may be of greater importance than the direct control it affords. It is also argued that the processes of making healthcare auditable are characterised by experimentation, conflicts and dilemmas in which programs of performance auditing are also subject to controversies, dilemmas and transformations. THEORETICAL FRAMEWORK AND METHOD Often, information infrastructure is conceptualised as a channel enabled by information technologies, rules, and regulations through which information flows to relevant parties: Information infrastructure (the mix of telecommunications networks, computing hardware and software, and services required for the efficient transmission of information, together with the related policy, legal, and institutional framework) (Barbu et al., 2001, p. vii). However, this universalist notion of information infrastructure has met critique. Thus, Star argues that an infrastructure is not a uniform or universal structure, but must analytically be treated as a relational property (Star and Ruhleder, 1996), i.e. as a situated effect of a specific set of relations in which one person s infrastructure is another s topic, or difficulty (Star, 1999, p. 380). Nor is information infrastructure to be seen as something which is built or designed from scratch. On the contrary, a new infrastructure is always integrated into and thereby extending others (Ciborra and Hanseth, 1998). The present study sets off from this relational view of information infrastructure and draws on actor-network theory, which holds as a basic tenet that any phenomenon emerges as an effect of relations between heterogeneous networks. Neither technology nor humans are distinct and definable entities, but are

4 272 VIKKELSØ fundamentally entangled in networks. They gain their specific qualities through these relations (cf. Latour, 1992; and Akrich 1992). The concept of translation is central in order to understand how qualities emerge and change. Its basic point is that whenever an entity, human or non-human, is removed from or added to a network, the characteristics of the network, as well as the specific entity, are subtly or radically changed; they are translated (Latour, 1991; and Callon, 1986). A technology may be designed to bring about certain effects. However, its actual capability is determined by the specific network it enters. Attempts to control something at a distance, e.g., through information infrastructure, rely upon involvement of referential or representational artefacts and technologies (e.g., codes, schemes, databases, indicators, rules and regulations) through which the network becomes controllable (Bloomfield and Vurdubakis, 1997). Yet each step of reference also entails a translation in which something is lost and something is gained, and in which both the attempt to control and the network is transformed (Latour, 1999). Accordingly, information infrastructure allows various types of control at a distance, but is not a purely instrumental structure. Moreover, it should be viewed as a compromise between instigators of control and objects of control. If we want to investigate such translation processes (e.g., the establishment and effects of information infrastructure) we should not make a priori definitions, but follow empirically the way in which entities are connected and transformed, and look for the effects arising from this. This theoretical stance implies that we cannot determine in advance whether, and how, a new technology affects practices. Accordingly, we should neither adopt the view that accounting tools are decoupled from organizational core operations (Meyer and Rowan, 1977; Brunsson, 1989; and Lapsley, 1999) nor that they colonize these. Likewise, we should bracket any normative pre-conceptualisations and empirically explore what is performed by a particular standard (Berg and Timmermans, 2003) or accounting concept (Bloomfield, Cooper and Rea, 1992). The present case rests on empirical research conducted in The aim was to explore the co-construction of visions of information infrastructure and features of the GEPJ-standard, with three specific questions guiding the data generation: (a) How did the GEPJ-standard develop from version to version in terms of overall purpose, and in terms of specific structure and features? (b) What kind of reactions did the versions encounter? and (c) How was healthcare practice and healthcare data defined and redefined throughout the versions? Data was generated through document study and interviews. The document study comprised relevant white papers, memos, statements, system version documentations, press articles etc. that were gathered, coded, and analysed. The interviews were conducted with key persons involved in the GEPJ-project at different organizational levels (covering the National Board of Health, Copenhagen Hospital Corporation, and involved hospitals) and with persons representing evaluators of the GEPJ-standard (consultants, clinicians, researchers). In total ten persons were interviewed.

5 HEALTHCARE INFORMATION INFRASTRUCTURE 273 MAKING HEALTHCARE AUDITABLE THROUGH AN IT-STANDARD During the last decade Danish healthcare information infrastructure has moved from being viewed as a technical subfield to a key factor in healthcare governance. In this process, standards and system integration have become central issues. Thus, the National Board of Health in 1999 began the construction of a national standard for electronic patient records; the GEPJ-standard. However, this project turned out to be rather complicated, and the purpose and features of the GEPJstandard underwent several reversals. Notably, the initiative became intertwined with two other policy initiatives: a pathway-oriented national patient register and a national IT strategy. In this section, I outline and analyse the series of events related to the construction of the GEPJ-standard. First, I describe the way visions of healthcare information were translated as the ambition of the GEPJ-standard was linked with the two other policy initiatives. Second, I point to the way the changing visions were socio-materially inscribed in the successive versions of the GEPJ-standard, and how the versions were later evaluated. The purpose of this two-layered analysis is to show how national policies and institutional interests, and practical realisation of the standard were co-constituted in a heterogeneous and antagonistic network of both large-scale organizational and individual actors. In order to provide an overview of this rather complicated network, let me start the description by presenting a figure of the major actors of the construction process: Figure 1 Important Actors in the Construction of the GEPJ-standard and their Mutual Conflicts Department of Health Informatics Department of Health Economics Ministry of Health National Board of Health Independent consultants Vendors GEPJ-standard EPJ Observatory Vejle Region Confederation of Danish Regions Copenhagen Hospital Corporation Clinicians in rhus Hospital Note: The figure shows the variety of important institutional and individual actors, who have been directly or indirectly involved in the successive construction and evaluation of the GEPJ-standard. Some of these actors were directly criticizing each other.

6 274 VIKKELSØ An Emerging Vision of Healthcare Information Infrastructure The Danish healthcare system is highly decentralized, compared, for example, to the National Health Service in the UK. Hospitals are owned by 13 counties (united in the Danish Regions Confederation) which are also responsible for their operation and financing, predominantly through regional taxes, but also through national activity-based funding regulated by DRG-codes. 1 The hospitals have to comply with certain national rules and regulations, but each region has a high degree of autonomy regarding the organization and operation of services. The National Board of Health is predominantly an advisory institution, which supervises and documents health services, plans certain specialized functions, and advises on regional and local healthcare. This structure of governance makes space for local innovation, but little national coordination. However, the role of the counties has been contested, and recently (after the termination of the case study) the 13 counties have been fused into five regions with less autonomy. Thus, growing ambitions of increased national governance mark the contours of the following case. Separate Visions Electronic patient records have been present in Denmark for some decades as local, bottom-up initiated projects. However, gradually electronic patient records became a national and public issue. In 1994, the first national IT-strategy for Denmark was presented (Ministry of Research, 1994). Here, electronic patient records were envisaged as a central means to making healthcare more efficient and to support coherent patient trajectories. This vision was confirmed in two subsequent reports (Ministry of Research, 1997; and Ministry of Health, 1997). In order to reach this goal, the strategy argued that a standard for electronic patient records should be developed, and in 1996 the Action Plan for Electronic Patient Records ( Action Plan ) was released, suggesting a gradual standardization process in order not to interfere too directly with the autonomy of the Danish Regions, which own and operate the hospitals (Ministry of Health, 1996). In parallel with the growing interest in the GEPJ-standard for electronic patient records, an ambition of expanded central registration of patient data had emerged. Since 1977 the Danish National Patient Register had gathered patient data reported from the hospitals in order to monitor and study the pattern of diseases in the Danish population. However, during the 1990s dissatisfaction with the register was articulated, addressing its inability to produce statistics to permit assessment on patient pathways, i.e. the bundle of distributed activities related to a patient trajectory. In 1997 the National Board of Health presented the idea of replacing the existing register with a new pathway-oriented register, called F-LPR (known hereafter as F-LPR) (National Board of Health, 2000). In the following years the ambition for the GEPJ-standard would be combined with

7 HEALTHCARE INFORMATION INFRASTRUCTURE 275 the ambition for the F-LPR, resulting in an emerging vision of health information infrastructure as an all-encompassing governance tool. Combining and Translating Visions The vision of the F-LPR had already been anticipated in the Action Plan. Here, electronic patient records were described as tools for improving healthcare quality by providing data as the basis for rational planning of patient pathways, resource allocation, and systematic evaluation of treatments. To fulfil this role, the GEPJ-standard required some basic qualities: it should promote electronic patient records that should be cross disciplinary; present data in a problemoriented way; provide flexible communication tools; and finally be integrated with other hospital systems (Ministry of Health, 1996, p. 8). Moreover, the Action Plan suggested standardization of healthcare terminology and clinical pathways, of technical interfaces between information systems, and of a minimum dataset for electronic patient records (ibid, p. 76). The establishment in 1997 of the 6 th Office in the National Board of Health strengthened the merging of the vision of the GEPJ-standard with the F-LPR pathway vision. In the following years, the 6 th Office engaged in two particular projects decisive for the development of the GEPJ-standard: the launch of a model for F-LPR, and the formulation of a national IT-strategy for the hospital services. The F-LPR pathway model was launched in 2000, presenting the vision of pathway registration as an old ambition, now possible to realize due to the emergence of patient administrative systems and electronic patient records (National Board of Health, 2000). The purpose of pathway registration was to make possible statistical analyses of patients total use of the hospitals in relation to specific diseases. Data should be provided by registering all clinical activities related to a patient in relation to a pathway diagnosis (e.g., a diabetes patient may be treated in both a medical and an eye-clinic for different health problems in relation to the disease). If the patient should contract a new, unrelated disease, a new pathway diagnosis is made. Moreover, the model employed the principle that treatment of disease is a process, in which symptoms lead to a diagnosis that motivates specific interventions, which finally lead to a cure or optimal alleviation of the illness (the diagnosis may be modified during this process). Activities must be reported according to this process-model, so any patient pathway is registered as a head diagnosis and a series of rationally motivated interventions. The process-model had two major implications. First, data types were redefined, so that in principle all data were events in a time-line. For instance, mode of discharge, which previously designated the termination of a patient contact, changed to referred to, thereby linking data from the first health service contact to data on subsequent health service contacts related to a specific diagnosis. Thus, any health activity would be registered as an opening, postponement, continuation or closing of a specific part of a patient pathway. Second, new

8 276 VIKKELSØ types of data were introduced. Previously, only selected activities should be registered (e.g., surgical operations). In the F-LPR pathway register all clinical interventions (e.g., prophylactic programs and nursing) had to be registered with codes for procedure, executor, booking, booker, and state of intervention (i.e., booked, started, cancelled, interrupted or accomplished). These changes signified a move to a causal framework for patient registration, where any data entry is motivated by a previous entry and must be followed up by another (except when a pathway is closed). Accordingly, F-LPR afforded whole new types of health statistics and analyzes: (a) surveys of patient groups and comparison across regions or treatment types in order to find the best and relatively most efficient types of treatment (ibid, p. 85); (b) detailed performance statistics for specific hospitals and wards; (c) statistics on the consumption of hospital services by different types of diseases, allowing DRG-rates to be based on pathway diagnoses; and (d) refinement of waiting-time statistics. These capabilities required that considerably more data were registered. However, the National Board of Health promoted a vision of automated registration, whereby data entered in the electronic patient records were automatically transferred to the pathway register. This would integrate record keeping and registration for healthcare statistics into one activity, and thus integrate the visions of the GEPJ-standard and the F-LPR pathway register. The only requirement was that electronic patient records were restructured so that data could be automatically pulled from selected data fields. The launch of two new IT-strategies for healthcare would pave the way for the achievement of this vision. A Vision of Governance The National Strategy for IT in Hospital Services was presented in 1999 (Ministry of Health, 1999) based on the work of a group consisting of representatives from the Ministry of Health, the National Board of Health, the Danish Regions, and the Copenhagen Hospital Corporation. The strategy continued the focus of the 1996 Action Plan while simultaneously introducing the new requirements. First, the hospital information systems should be integrated through the development of a standardized data model: Uniform structuring of content is a prerequisite to the exchange and understanding of data between different IT-systems, to the integration of systems, and to usage of data for all relevant purposes, including clinical research and quality development (Ministry of Health, 1999, p. 6, author translation). Second, the strategy stressed the need for process-oriented records, i.e. records that are problem-oriented, follow uniform documentation principles based on clinical guidelines, and are shared cross-disciplinarily. Third, the strategy proposed the establishment of a National Patient Index, which through automatic reports from the hospital information systems, collects basic information on present and previous patient pathways (ibid, author translation).

9 HEALTHCARE INFORMATION INFRASTRUCTURE 277 The strategy comprised a series of initiatives, among other things delegating to the National Board of Health a central role in developing a problemoriented structure for electronic patient records based on patient pathways, a plan for the development of a shared terminology system for healthcare, and a requirement specification of the F-LPR pathway register. Through these initiatives the strategy reversed the order of priorities in the Action Plan. Where technical standards were previously put to the fore, the key priority now became a restructuring of the records, so that every clinical activity would be documented in a standardized (i.e. problem-oriented, codified, disease-specific) way as an event in a patient pathway. This reversal of visions for healthcare information infrastructure was further promoted by the IT-strategy for year (Ministry of the Interior and Health, 2003). Here, it was stated that an: Effective use of data in healthcare requires coherent use of digital information technology (ibid, p. 11, author translation). Electronic patient records were no longer only tools for effective communication and cooperation in healthcare, but also for supporting and documenting systematic quality insurance of healthcare services. The strategy should support a prioritizing of IT-employment in healthcare (...) being a tool for better administration and governance of healthcare (ibid, p. 14, author translation). Hereby, health information infrastructure becomes framed as an all-encompassing tool for healthcare governance, positioning electronic patient records as instruments of performance auditing. Realizing the Vision The IT strategy became a starting point for the practical construction of the GEPJ-standard. However, the construction process was no simple instantiation of the vision, but characterized by conflict, experimentation, and redefinition of basic entities in healthcare. During the construction of the successive versions of the GEPJ-standard, the vision of healthcare information infrastructure moved from being all-encompassing to being more and more focused on specific types of performance auditing. Below, I describe the changes from version to version. Establishing the Foundation for Pathway-Oriented Records It was agreed that the National Board of Health should develop and test the GEPJ-standard, and in 2000 a small project group of primarily doctors, nurses, and people with a background in medical informatics was established. In GEPJstandard Version 1 (National Board of Health, 2000b), the GEPJ-standard had a fourfold purpose; namely to afford clinical support, data exchange, quality control, and legal documentation of the patient treatment. It remained optional as to how clinical data could be recorded (e.g., chronologically or problemoriented, that is, under a pathway diagnosis). However, in GEPJ-standard Version 2 (National Board of Health, 2002) the influence of the F-LPR-vision had become evident. The purposes of GEPJ

10 278 VIKKELSØ Figure 2 The Process Model of Electronic Patient Records Diagnostic consideration Evaluation Diagnosis Goal Result Planning Plan Execution were now reduced to two: to establish a standard for communication between healthcare information systems and to promote highly structured machinereadable records. Problem-oriented structuring of data was now obligatory and should follow a process model illustrated in Figure 2. The underlying principle was, in accordance with the IT-strategies, to facilitate automatic transfer of data from electronic patient records to the F-LPR pathway register. Moreover, a broader diagnosis-concept was introduced, where a diagnosis was no longer confined to a formal medical diagnosis, but could cover anything health related. This would allow all kinds of healthcare activities to be registered and, hence, monitored and measured. The GEPJ-standard was backed up by several other initiatives. The IT Strategy for declared that all future electronic patient records should follow the GEPJ-standard. This demand was accompanied by the establishment of the National Concept Council with the commission to standardise concepts and terminology in healthcare. Furthermore, the GEPJ-project group declared that the existing national healthcare classification system had significant flaws and that a preliminary analysis shows that SNOMED CT 2 forms a suitable basis for a Danish clinical terminology (National Board of Health, 2004, p. 3). Also, the Copenhagen Hospital Corporation initiated the project Clinical Content, which aimed at developing standard care plans and documentation standards for electronic patient records, in order to assist clinicians in practising the process-oriented record-keeping. And finally, an evaluation-program 3 for the GEPJ-standard was launched.

11 Mixed Evaluations HEALTHCARE INFORMATION INFRASTRUCTURE 279 From August to October 2004, three evaluation reports were published presenting mixed conclusions about two different GEPJ-prototypes that were both built upon the GEPJ-standard Version 2. Rather than questioning the process model underlying the GEPJ-standard, the first report suggested that obstacles in the prototypes could be solved by introducing the more elaborate SNOMED CT classification system, by standardizing the record content through diseasespecific care plans, and by developing better user interfaces (EPJ-Observatoriet, 2004a). The second report concluded that adding standard care plans to the process-model would offer more intuitive support of clinical work (Mediq, 2004, p. 12, author translation). It also pointed to the need for developing a better classification selector, additional codes, sub-sets (i.e. limited options for choosing codes), and rules for the combination of codes. The report concluded that problem-orientation, terminology, and clinical content were still the three basic elements in future electronic patient records. The third report focused on the GEPJ-standard s ability to transfer data between systems, thereby enacting a silent shift in evaluation criteria towards automatic transfer to the F-LPR pathway register. Whereas the original aim was to test exchange of data between two GEPJ-based record systems, the report evaluated the data transfer from GEPJ-based systems to the F-LPR pathway register. The report suggested that a test-service for measuring the ability to transfer data to F-LPR should be developed in order to support the future harmonization of GEPJ-based systems. Also, it proposed that mnemonics be developed to help clinicians properly record the relation between diagnoses and interventions (EPJ-Observatoriet, 2004b). Direct approval of the GEPJ-standard Version 2 came from the Copenhagen Hospital Corporation (H:S). Where other regions in the preceding years had introduced different electronic patient record systems, H:S had decided to wait for the GEPJ-standard to be developed before it would build and implement a shared GEPJ-based electronic patient record in the Copenhagen Region. In 2004 H:S published a call for the tender of a clinical notation module to be used throughout the Copenhagen Region (25,000 users). The tender material required strict adherence to the coming Version 3 of the GEPJ standard. Open Conflict In December 2004, the GEPJ-standard Version 3 introduced a distinction between normative and informative documentation, i.e. between obligatory and optional clinical registration (National Board of Health, 2004b). The regions and other key actors were asked to comment on Version 3, and this elicited quite direct scepticism except from the Copenhagen Hospital Corporation. One tenderer (vendor) pointed to problems in the relationship between clinical concepts and the categories of GEPJ (CSC, 2004). One region could not accept

12 280 VIKKELSØ the definition of clinical pathways in GEPJ and found the relationship between diagnoses and interventions too complicated and labour-demanding (Fyn Region, 2004). And the Confederation of Danish Regions stated, the standard is still subject to significant uncertainties (Danish Regions, 2004, p. 1), recommending that the GEPJ-standard Version 3 should only work as a pre-standard. Two additional evaluation reports were published, supporting the previous scepticism of GEPJ Version 2 still without directly questioning the process model. The first report evaluating the clinical usability of Version 2 concluded that staff had not been properly educated and that the prototypes were not clinically satisfying. It suggested that teaching materials and guidelines should be developed in order to allow professional groups other than doctors to make diagnoses, and that standard care plans should be developed in order to offer concrete, clinical decisions about operational, purposeful registration (EPJ-Observatoriet, 2004c, p. 77). The second report was a follow-up to the evaluation of data transfer (EPJ-Observatoriet, 2004b), now with a more negative assessment (EPJ- Observatoriet, 2004d). It described serious problems with data transfer to the F-LPR pathway register: the process model was difficult to understand, resulting in complex and excessive documentation of clinical events. Moreover, business rules of the systems were too restrictive and there were mapping problems between the prototype and the integration platform. The report advocated a reduction of obligatory data fields and that the integration platform, rather than the record-system should be modified to handle data extract and reporting. A Modified Program of Performance Auditing Concurrent with these reports, an independent consultant published a damning critique, arguing that the original goal of standardization, and data exchange between electronic patient records, had been bypassed, and that the GEPJstandard Version 3 was inflexible and far too detailed (Olsen, 2004). The report gave rise to heated debate in the press, but the National Board of Health argued that the critique was based on misconceptions of the GEPJ-standard. Soon after, however, two conflicting evaluations were published. The first (EPJ-Observatoriet, 2005) was a follow-up to the evaluation of the initial clinical trial of GEPJ (EPJ-Observatoriet, 2004c). In that report, clinicians pointed to serious problems with overview of patient cases, concluding that the GEPJmodel is too loose and unspecific (EPJ-Observatoriet, 2005, p. 18). However, the authors of the second report questioned the validity of the clinicians conclusions, due to serious deviations from the original test program and to an unsatisfactory prototype. Also, they argued that clinicians should acknowledge that the GEPJstandard does not contain any support (e.g., guiding dialogue boxes) regarding documentation in electronic patient records a matter that should be developed within the context of an emerging national project inspired by a project in the Copenhagen Hospital Region called Clinical Content of Electronic Patient Records. As a retort to this undermining of clinicians opinion, Århus Region

13 HEALTHCARE INFORMATION INFRASTRUCTURE 281 published an alternative report (Bossen et al., 2005), arguing that the negative clinical evaluation of the GEPJ-model could not be explained as problems in the prototype: the GEPJ model does not support daily clinical work, but entails much extra work and critical lack of overview of patient care and treatment (...) these problems cannot solely be attributed to the design of the prototype or to clinicians lack of skills (ibid, p. 4, author translation). In the press, a number of conflicting assessments of GEPJ were presented through interviews with proponents and opponents among clinicians. Another growing critique of the GEPJ-standard Version 3 was that it would not be able to support DRG-accounting. This was already stated in an assessment of the GEPJ-standard from Vejle Region (Vejle Region, 2004), but now another department of the National Board of Health, the Department of Health Economics, joined the critique, complaining that the pathway principle would conflict with the existing DRG-system, the national payment-system for interregional patients, tariff financing, and allocation of national pools based on data on patient contacts from the LPR. In May 2005, the GEPJ-standard Version 4 was launched (National Board of Health, 2005) now introducing two substantial changes: the number of obligatory data fields was significantly reduced, and the principle of pathways was softened so that data could be entered without being tied to a pathway diagnosis. Nevertheless, the responses to the new version were again mixed. The Copenhagen Hospital Corporation subscribed to the standard. Yet two other regions stated that they found the GEPJ-standard much too complex and uncertain, especially regarding the notion of pathway and the obligatory dataset (Fyn Region, 2005; and Århus Region, 2005). The National Board of Health declared that it would now suspend further development of the GEPJ-standard in order to let the regions begin the work of developing GEPJ-based systems. In August 2005, the National Board of Health set up a project group to work on the translation of SNOMED CT from English into Danish. Also, it was decided to establish an electronic patient records-coordination board consisting of the regions and central health authorities, which should take decisions on proposals to change or expand GEPJ and incorporate the results from the Concept Board and Clinical Content projects. Just recently, however, the Copenhagen Hospital Corporation cancelled its contract with the tenderer, meaning that a key actor in the development of a GEPJ-prototype was now in retreat. DISCUSSION The construction of the GEPJ-standard has been an element in a series of reforms of healthcare information infrastructure which, I have argued, can be seen as attempts to make healthcare auditable. By following the construction process, I have shown that this has been a rather complicated and controversial

14 282 VIKKELSØ process, in which visions and features of the GEPJ-standard have undergone significant reversals, and where the further destiny of the GEPJ-standard is most uncertain. In this light, the GEPJ-standard may be viewed as a failure for the installation of new logics of governance. However, the project has had important effects over and beyond the standard. Thus, it has been an occasion for other important innovations and redefinitions of healthcare, which constitute clinical practices as auditable objects and which are likely to outlive the GEPJ-standard. In the following, I will point to these innovations and redefinitions and to their performative effects on healthcare. Starting from a situation of disjointed local electronic patient record projects and with visions of a pathway-oriented patient register, the Danish central administration took the initiative to establish the GEPJ-standard in order to afford exchange of all types of data between healthcare actors. However, gradually a more focused vision emerged, where the main purpose of information infrastructure was to provide data for research, management, and quality control. This vision became inscribed in the GEPJ-standard through the introduction of uniform terminology, codes, standard patient pathways, and problem-oriented structure. During the construction process, however, the vision was challenged from two angles: from clinicians who found the GEPJ-standard too complicated and labour-intensive, and from the administrators of the DRG-system who objected to the pathway-principle. As a compromise, the GEPJ-standard Version 4 kept the problem-orientation, but loosened the pathway-principle and the granularity of performance documentation. Thus, eventually the GEPJ-standard became a compromise between programs of quality control, management information, and ultimately of case-mix funding with no guarantee that it would be clinically useful. Figure 3 shows the changing focus and purpose of the GEPJstandard. The construction of GEPJ is temporarily postponed, and key partners are in retreat from building GEPJ-based prototypes. It is an open question as to how it will further develop, and whether it will attain a status as a de facto standard. One option is that DRG will be directed towards clinical pathways and thereby allow path-oriented records and registers (Carey and Burgess, 2000). Another, is that the GEPJ-standard will never be implemented and that electronic patient records will keep most of their current structure. However, as argued by Power, the most significant effects of new governance technologies may not be their actual performance, but the steps that are taken in order to configure practices toward auditability. In this respect, the GEPJ-project may prove to have important consequences independent of the subsequent career of the standard. Thus, the GEPJ-project has been an occasion for introducing innovations that seem to be generally accepted by most actors in the field as basic elements of a future healthcare information infrastructure: the principle of problemorientation as rational problem solving; the incorporation of quality standards, comprehensive, fine-grained classification systems; increased codification of activities; and expanded central registration of patient data.

15 HEALTHCARE INFORMATION INFRASTRUCTURE 283 Figure 3 The Standard s Shifting Enactment of Health Care Information Infrastructure DRG National Patient Register Clinical Practice X Electronic patient Record Clinical Practice Y Pathway-oriented Patient Register Evidence based Medicine Key: The information infrastructure originally intended with the GEPJ-standard (Version 1). The information infrastructure gradually being promoted in the GEPJ-standard (Versions 2 and 3). The information infrastructure ultimately being performed through the GEPJ-standard (Version 4). These uncontroversial innovations are not simply a means to better or expanded auditing of healthcare performance. Rather, they work to redefine healthcare in particular ways. Let me point to these redefinitions, some of which have also been noticed in other studies. First, the increased use of diagnostic codes and classifications in records works to label diseases as clearly demarcated categories of health problems to which particular treatment regimes and clinical pathways are tied. Health problems that cannot easily be categorised will be harder to document in the record and, hence, harder to solve, since the record plays an increasingly pivotal role as a coordination mechanism between professions, organizational units and shifts (Winthereik and Vikkelsø, 2005). Second, the patient becomes divided into a number of diagnoses, each of which becomes somewhat tractable through the record data but leaves the patient black-boxed as a unity and relational identity. This framing of disease as a demarcated pathology may work so as to produce a sense of rational control, allowing multiple statistical analyses of the relationships between specific

16 284 VIKKELSØ diseases and clinical activities However, as argued by Chua and Degeling, it poses a series of managerial and societal problems, as it helps to obscure disease as an ecological, industrial, and social phenomenon. Policies based on a fragmented understanding of disease will inevitably lead to implementation gaps and policy deficits (Chua and Degeling, 1991). Third, records move towards being registration sheets for executed interventions and compliance with clinical standards rather than being tools for clinical decision-making and coordination. Consequently, the medical profession will subtly have managerial logics inscribed in their practice. The effects of this are uncertain. It may give rise to a hybridization of the medical profession (Kurunmäki, 2004) with stronger clinical focus on resource management due to the coupling of diagnosing with DRG-accounting, and stronger clinical disciplining according to quality standards. It may also give rise to work-arounds (e.g., entering default codes in obligatory data fields in order to reduce the time spent on record-keeping) and shadow-records, which allow clinicians to evade the rigid structure of formal records in order to accomplish their clinical work. This would leave it up to a sub-group of clinicians to actively take part in the managerial and administrative responsibilities, leaving the values and practices of the profession protected (Jacobs, 2005) and creating new spaces for clinical autonomy through construction and choice of DRG-categories (Bloomfield and Coombs, 1992). The above transformations point towards a more accountable healthcare in which detailed and systematic registration of activities allows new types of monitoring, analyses, and control. In this way, the GEPJ-standard paves the way for increased clinical governance (Flynn, 2004). However, what becomes auditable are only those aspects of healthcare which are rendered visible and measurable through the electronic patient records. How patients are actually handled by the healthcare collective and how patients experience this handling will not be elicited in the new information infrastructure. This point is close to Michael Power s thesis that the growth of performance standards, accountability tools, and NPM management principles in healthcare signify a change from medical audit as a learning process and as professional self-reflection to a more programmatic type of governance directed towards control of control systems (Power, 1997). In the present case, the introduction of problem-orientation, disease-specific standard for care and documentation of care, SNOMED CT, and expansion of the patient register are important new control mechanisms that may perhaps not afford more direct monitoring and control of healthcare practices, but primarily control from a distance by formatting technologies for clinical decision-making, communication and collaboration. However, the GEPJ-case also shows us that making healthcare auditable requires more than simply inserting representational artefacts between clinical practices and various clinical databases and management information systems. It opens up a process marked by deep tensions within the healthcare field about the categories, structure, granularity, scope, and format of records and of databases,

17 HEALTHCARE INFORMATION INFRASTRUCTURE 285 in which concerns for quality control, cost control, professional autonomy, coordination of clinical pathways, medical education, and legal matters are negotiated and transformed. Performance auditing is no uniform program with specified objects and agents, but can take on many forms and purposes. Moreover, actors may have quite different interests in performance auditing, where, for example, concern for clinical quality may conflict with concern for resource allocation. What specifically is made the object of performance auditing emerges as the outcome of actor-network dynamics around the reconfiguration of information infrastructures. This also explains why performance auditing is not easily defined but comes in a variety of forms (Behn, 2000). Making something auditable entails co-constitution of object, ambition and information infrastructure of performance auditing. In healthcare, information infrastructure is an analytically interesting site for exploring what, with inspiration from Knorr Cetina, can be termed the epistemic machinery of governance and its substantial effects on practices (Knorr Cetina, 1999). Research into the role of information infrastructure in healthcare has already pointed to the multifaceted nature of clinical use of information (Ellingsen and Monteiro, 2003a; Clarke et al., 2003; and Winthereik and Vikkelsø, 2005) and to the difficulties in integrating clinical information systems (Ellingsen and Monteiro, 2003b; and Monteiro, 2003). Important questions would be how the introduction of accounting tools and auditing programs affect the ecology of knowledge in healthcare? How information infrastructure simultaneously affords accomplishment of daily tasks and the control of these from a distance? And how practices and practitioners change through these processes? Actor-network theory is well suited to explore the processes through which something is made auditable, since it explicitly centres on the heterogeneous engineering, tradeoffs, and translations implied in creating new capabilities. Focusing on these dynamics helps us to understand how the implementation of new programs of governance is not simply a matter of persuasion, raw power and ingenuity. It is a contested, transformative process in which both practices and programs of governance are changed and respecified. NOTES 1 Diagnosis-Related Group (DRG) is a system to classify hospital cases into approximately 500 groups expected to each have a certain hospital resource use. DRG-codes are assigned by a grouper program based on International Classification of Diseases (ICD)-diagnoses, procedures, age, sex, and the presence of complications or co-morbidities. The DRG-system is managed by the National Board of Health as part of a national case-mix management system, which is used in hospital services to settle accounts of interregional patients, to calculate municipal co-financing, distribute the Government pool in relation to tax financing, and as a tool for analyzing costs and activities on hospitals. 2 SNOMED CT (Systematized Nomenclature of Medicine) is a system of standardized medical terminology, developed by the College of American Pathologists. It began as a classification system for pathology in 1965 and was later fused with the British Clinical Terms SNOMED CT as a multi-axial classification system, which affords a varied and detailed coding by combining codes from different axes.

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