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Abstract

Against the background of the increasing importance of digitization in health care, the paper examines how medical practitioners who are involved in the development of digital health technologies legitimate and criticize the implementation and use of digital health technologies. Adopting an institutional logics perspective, the study is based on qualitative interviews with persons working at the interface of medicine and digital technologies development in Switzerland. The findings indicate that the developers believe that digital health technologies could harmonize current conflicts between an increasing economization of the health care system and professional–ethical demands. At the same time, however, they show that digital technologies can undermine the demand for medical autonomy, a central element of the medical ethos.

Keywords

Digital health digitalization institutional logics qualitative social research profession market orientation

The promises of digital health

Hopes that digital and algorithm-based technologies will provide significantly improved methods of gaining knowledge (Kitchin, 2014; Mayer-Schönberger and Cukier, 2017) and contribute to a more comprehensive understanding of the world are proliferating in the health care system, and not just since the global corona pandemic. In view of ageing societies and the increase in chronic diseases, such as diabetes, developed industrial nations in particular are confronted with rising health care costs and the need for welfare state intervention (Lupton, 2018: 31). Against this background, hopes for digital health technologies to achieve more efficiency in the identification of diseases are growing (Raghupathi and Raghupathi, 2014). In addition, digital health technologies are meant to extend existing knowledge about health and illness. Connected to digital health, then, is the hope “to accelerate clinical discovery, generate data, monitor long-term outcomes of personalized interventions, or contextualize data obtained in clinical settings, [which] makes them a new and important complement to traditional clinical trials and established forms of medical knowledge production” (Sharon, 2017: 103). In the health care system, digitized data acquisition and the use of digital health technologies thus promise to bring about an institutionally anchored process optimization and efficiency increase as well as, ultimately, the establishment of a fairer and more sustainable health care system (McLoughlin et al., 2017: 14). Digital health technologies thus respond to a variety health system crises (Hogle, 2016; Schüll, 2016; Sharon, 2016).

As in other areas of society, the beginnings of digitization in the health care system can be traced back to the 1950s, when repetitive accounting tasks were taken over by computers and the input of payroll data was automated. In the 1970s, the development of health informatics began and electronic hospital systems became standard. Characteristic of the current phase of digital health is the continuous interaction and exchange of information between institutions and systems. The specific feature of digitalization is not simply that analogue information is translated into digital formats, but the move toward networked devices (Curran, 2020: 244). In accordance with the vast amount of hard- and software, the very general term digital health (also electronic or e-health, mobile or m-health) may refer to very different technologies, practices, and institutions. Digital health technologies are used in data-driven medical research (Big Data, Internet of things, artificial intelligence), biobanks as part of public health care, patient monitoring and sensory surveillance (wearables), electronic patient records, web-based patient–doctor consultations, internet platforms for information exchange, algorithm-based diagnostics, virtual reality, or personalized medicine. Digital Health is thus far from being limited to the needs and practices of modern self-questioning and self-optimization. In view of the numerous practical applications of digital technologies in the health sector, Deborah Lupton (2018: 1) defines digital health as follows:

The term ‘digital health’ refers to a wide range of technologies directed at delivering healthcare, providing information to lay people and helping them share their experience of health and illness, training and educating healthcare professionals, helping people with chronic illnesses to engage in self-care and encouraging others to engage in activities to promote their health and wellbeing and to avoid illness.

Following this definition, different dimensions of digital health can be identified. However, both in public and scientific discourse, the effects of digitalization in the health care system remain controversial. Different positions and arguments about benefits and constraints express the ambivalence of these developments.

A first dimension is represented by e-health technologies such as telecare and telemedicine. These are mainly used to overcome long distances and to move away from “classic” location-based primary care (Andreassen et al., 2018: 37). The demand and hope associated with telecare are to respond to the patient’s need for home care and to increase patient safety (Finch, 2008; Gale and Sultan, 2013). However, it seems problematic that the increase in technological equipment in private rooms can reinforce the perceived dominance of physical suffering (Oudshoorn, 2012) and also change the division of labor between professionals (doctors, nursing staff) and laypersons (family members) (Andreassen et al., 2018). Contrary to the expectations of health management and political decision-makers, digitization is not leading to a reduction in work, but rather to an expansion of informal work and dependencies on the social environment (Nicolini, 2007; Roberts et al., 2012).

A second dimension of digital health refers to the gathering of extensive personal data and the corresponding evaluation methods. Particularly in preventive disease control and oncology, deep learning methods, artificial intelligence, and Big Data promise both more efficient diagnosis (Raghupathi and Raghupathi, 2014). For example, deep learning procedures already exists today and provide more accurate predictions about types of breast cancer through computer tomography images and distinguish between good and malignant findings (Bennani-Baiti and Baltzer, 2020). A Smartwatch, for example, which measures the heartbeat around the clock, can alert if it detects abnormal heartbeat patterns. In addition to all these advantages, however, the risk of increasing surveillance is discussed particularly critically (Zuboff, 2015). In addition, mixing and combining “voluntarily” provided data (lifestyle, fitness data, consumption data) with clinically collected data (heartbeat, genetic diseases) can exacerbate existing inequalities (Beer, 2009; Mau, 2019) and thus promote discrimination against marginalized groups and individuals (Lupton, 2018: 130).

A third dimension is reflected in political and management discourses. Accordingly, political decision-makers and industry associations emphasize the “transformative” effects of digital technologies in the health care system, as they do regarding other economic areas (McLoughlin et al., 2017: 18; Topol, 2015). They argue that “disruptive” innovations like digital health can reduce the currently hardly manageable and complex organization of hospitals that derive from high administrative costs (Christensen and Grossmann Jh Hwang, 2009: 419; McLoughlin et al., 2017: 19).

Given the complexity of discourses and positions between “hype and hope around the digitization of healthcare” (Wachter, 2017) and the warnings of a “dangerous enthusiasm” (McLoughlin et al., 2017: 17–18), this article tries to find a middle ground, adopting neither the first nor the latter view. I assume that institutional and structural change—as often proclaimed to be triggered by digitalization—has always been grounded normatively. Negotiations in the field of digital health mobilize shared knowledge and values, which become empirically verifiable especially in conflicts. The relationship between digitalization and health is documented in the attitudes of developers, who inscribe these attitudes as cultural values into technologies and translate them into programs (Dourish and Gómez Cruz, 2018; Mützel et al., 2015). In this sense, digital health technologies are “sociocultural artefacts: that is, their meanings and uses are underpinned by tacit assumptions, norms, meanings and values. Digital technologies are the products of human decision making across a range of actors, carried out in specific social, cultural and historical contexts. Digital technologies are invested with their makers’ established ideas and beliefs about the human body, health, medicine and human behavior” (Lupton, 2018: 2).

To find out what digitalization in the health care system is about and how the actors construct it in everyday action, I thus ask: How do medical practitioners and doctors who are involved in the development and implementation of digital health technologies legitimate and criticize the implementation and the use of these technologies? Accordingly, the arguments and visions of those people who are most involved in the development of digital technologies are at the center of this paper. They act at the interface between public health care and the market, between technology and profession. In their everyday practice, they are confronted with the challenge of mediating between the old logics of the health care system and the constraints and benefits of the digital. These “institutional entrepreneurs” (Hardy and Maguire, 2008) play an essential role in the meaningful construction of digital health by plausibilizing social discourses of digitalization in the health sector and dealing with emerging contradictions. At the same time, as members of the medical profession (radiology, internal medicine), they have sufficient influence to assert their views, attitudes, and mediations between “digital” and “health.” Thus, the analysis of these views, attitudes, and mediations also provides information about political and professional–ethical interests as well as current transformations in the current health care system.

Institutional logics, digitalization, and the Swiss health care system

By asking how the development and implementation of digital technologies in health care is legitimized, a central role for institutional change is attributed to the actors and their actions. Following the perspective of institutional logics (Friedland and Alford, 1991; Thornton et al., 2012), the following assumes that individuals and organizations generate meaning, organize time, and space in their everyday practice, which in turn affects the reproduction of everyday life (Thornton et al., 2012: 2). Accordingly, this perspective is based on cultural heterogeneity and examines values and normative orientations as a basis for “institutional logics in action” (Lounsbury and Boxenbaum, 2013: 5). It assumes that modern societies are characterized by varying, ideal-typical institutional orders. In these, comprehensive cultural beliefs structuring the perception of the actors and guiding decision-making (Marquis and Lounsbury, 2009: 799). Furthermore, by conceptualizing society as an “interinstitutional system,” the Institutional Logics perspective takes as its starting point not only one source of rationality, but different rational orders. These, in turn, are characterized by specific logics that guide and make sense of actions and processes in a given area. Central to the approach is thus the conceptual distinction between different logics that shape the perception and construction of legitimacy by the actors. Institutional logics are socially constructed, historical patterns of material practices, beliefs, values, convictions, and rules according to which individuals produce and reproduce their existence, organize time and space, and give meaning to social reality (Thornton et al., 2012: 804). Each order is based on a set of practices (structural), interpretation schemes (symbolic), and ideal-typical principles (normative) that structure the preferences, modes of action, and design of organizations. Thornton et al. (2012), for example, state that institutional logics define norms, values, and beliefs; they structure the perceptions of actors in organizations and thereby contribute significantly to the establishment of an understanding of what can and may be formulated as legitimate strategic interests and decisions. To this extent, shifts and changes in institutional logics can have a direct impact on what is considered problematic (Thornton et al., 2012: 82). Against the background of the broad impact of digitization, the question arises how digital–technological innovations affect the established logics of the health care system, how they challenge or change them. At least it can be assumed that newer technologies such as wearables or algorithm-based decision systems have different effects than documentation systems, patient records, or other forms of information and communication technologies. Whereas these previous efforts were aimed at automating and optimizing documentation, Digital Health aims to link people and technologies in a more concrete way and to replace human decision-making.

In total, seven historically bound and ideal-typical orders—family, community, religion, state, market, profession, business—refer to different criteria that give structure to the actors’ actions. They differ in root metaphors, sources of legitimacy, sources of authority, sources of identity, basis of attention, normative foundations, strategic foundations, informal control mechanisms, economic system (Thornton et al., 2012: 56). Within complex societies, these orders fulfill different social functions and solidify different values, goals, concepts of justice, and faith. For example, the institutional order of religion focuses on explaining the creation of the world; while in the order of the family, social relations are transformed into reciprocal and unconditional obligations to ensure the reproduction of family members. In contrast, the task of the state order is to transform political, social, and economic issues into consensus or majority decisions. Legitimacy in the community order is founded on the unity of goals and the common belief in trust and reciprocity among the members, while in the corporate order it is the position in the market that determines the legitimacy of entrepreneurial action. The order of the profession is metaphorically reflected in the relational network and constitutes its identity from the membership in professional associations and federations. In contrast to the order of the market, in which legitimate action depends on prices, the order of the profession justifies all those actions that are comprehensibly based on expertise and knowledge. Correspondingly, the assignment of status in the professional order is based on membership of reputable groups and personal expertise (Thornton et al., 2012: 44).

However, in reality, these institutional orders and logics never appear in their raw form. Rather, they meet in certain fields and influence those fields as well as organizations and the actions of individuals. For example, the institutional constellation of the hospital sector and other health care organizations is characterized by the effectiveness of several logics. Both professional, welfare–state orientations as well as market logics and managerialism informed by business administration, as reflected in the case-based lump-sum system since the 1990s, are associated with different expectations that constitute the specific rationality of the hospital sector (Wolf, 2013). In the context of an increasing dominance of managerial logic, however, a decline in the importance of professional logic in the medical and nursing professions has been evident for several decades (Scott et al., 2000).

In Germany, Austria, and Switzerland, the “DRG” (diagnosis-related groups) per-case flat rate system in particular has contributed to a strengthening of market logic and managerialism. It groups similar medical cases for lump-sum compensation of the hospital, which has increased the interest of private investors in the hospital sector (since this type of remuneration makes both profits and losses more likely) and thus triggered the emergence of a market, in which hospitals compete for patients. While the related reforms were implemented in Germany in 2004 and in Austria in 1997, the DRG Swiss was introduced relatively late, in 2012. As in the neighboring countries, it also aims to reduce costs in the hospital sector. In all countries, the widespread introduction of economic mechanisms is accompanied by the reorganization of work, a reduction in the number of health care facilities and acute care beds, shortened lengths of stay, increasing rehospitalization, and a growing need for ambulatory aftercare (Tuch et al., 2018: 43). In addition, a large number of public hospitals in Switzerland were separated from public administration and transferred to private institutions in the early 2000s. The application of the so-called New Public Management ultimately led to the flexibilization of working conditions, especially in nursing, and to the strengthening of managerialism, which makes it more difficult to implement medical and nursing professional ethics in practice (Gemperle, 2014). Despite national specifics and different political and legal regulations, the introduction of New Public Management in Germany, Austria, and Switzerland has led to a continuous economization of all functional interrelationships of the health care systems since the 1990s (Schultheis and Gemperle, 2014).

However, a special characteristic of Switzerland is that the entire population has been covered by obligatory insurance since the 1990s. However, more than 60% of health care costs are covered by households themselves. Direct payments to the health system are therefore twice as high in Switzerland as in Germany and the USA and three times higher than in France. This type of “private welfare state” is intended to encourage people to avoid “unnecessary” expenditure and to invest responsibly in their own health (Streckeisen, 2013: 36). In contrast to the German health care system, in which the majority of the population is insured by law and the amount of contributions is based on income, Swiss policyholders pay a flat-rate insurance rate, which applies to everyone regardless of income (Streckeisen, 2013: 37). Swiss employers do only pay little contribution to the employees’ insurance and flat-rate insurance rates are not based on the individuals’ income. Accordingly, Switzerland is characterized by an already highly privatized welfare state structure. A population focused on personal responsibility and self-help is a prerequisite.

Although medical professionalism and welfare state orientation are coming under considerable pressure from these marketing tendencies, they are not disappearing. Even if they are institutionalized to varying degrees, the orientation of the welfare state is legally reflected at least in the public duty of care. However, this has created a “double reality” in the health care sector between economic efficiency and good care (Becker et al., 2016). This complexity of orientations provokes a continuous change that needs to be handled by the actors. In doing so, they do not simply adapt to new circumstances, but actively engage in negotiation processes that can also lead to conflicts (Lawrence and Suddaby, 2013). The result is a complex situation in which actions are based on multiple logics, but at the same time this provokes contradictions and conflicts in organizations. This provides easier access for new actors, as they take up contradictions and propose new solutions. Currently, developers of digital health technologies are among the new actors who are contributing to strengthening the logic of the health care system. However, the ideas and attitudes associated with the digitalization process are not only translated but also transformed and communicated with the established logics of the health care system. Such mediation can be seen where digital technologies strengthen the already pronounced orientation of personal responsibility. Here, so-called self-tracking can be seen as an important external influence. For example, a shared attitude among many self-measurement experts is to avoid loss of control by taking personal responsibility for controlling health-related well-being through measurement. This attitude is—as already described above—in line with Swiss health policy discussions in which a high value is placed on autonomous and responsible health action. Here, the increase in personal responsibility through digital technologies goes hand in hand with the promise of making national health systems more sustainable financially and physically. Independent, digitally measuring patients play a central role in this reorganization of the health care system. Tamar Sharon (2017: 101) notes that a greater emphasis on individual health responsibility, as well as a healthy lifestyle, has already become an important factor in reducing illness and costs. This manifests an understanding of health in which individual action contributes to the well-being of the entire population. The case of the Swiss health care system is particularly interesting because the use of digital technologies corresponds to its generally very liberal and private health care system. This is also reflected in the digitalization strategy, which has been successful to date. Despite federal structures a regulatory framework has been created that encourages the actors to participate, for example through competitive incentives (Baas, 2020: 316). That is reflected, for example, in the establishment of numerous regional initiatives and the creation of a central coordination office for digital health—Ehealth Suisse.¹ In terms of digital health strategies, Switzerland is becoming a role model for other countries (Baas, 2020: 315).

However, institutional logics are by no means structurally bound. When integrated into other social fields, they are either reshaped, adapted, or can provoke conflicts (which in our context, may point to possible limits to the institutionalizability of digitalization). When it comes to the digitalization of health, in addition to the logic of digital self-measurement, a traditional logic is also at stake. For example, studies on the installation of telecare technologies in private rooms have observed a change in working relations and professional ethics, which is particularly evident in the field of ambulant care. While proponents of e-health and telecare technologies focus on enabling a “therapeutic alliance” between caregivers and patients by dissolving established knowledge asymmetries (Neff and Nafus, 2016; Ruckenstein and Schüll, 2017), Pols (2014) shows that, contrary to the assumptions of political decision-makers, digital technologies such as telemedicine have contrary effects. They do not strengthen the patients’ autonomy and self-management but in fact increase the need for physical proximity to medical staff (Andreassen et al., 2018). In addition, a recent study of the digitalized and data-intensive Danish health care sector showed that digital data communication not only creates new forms of control but also can undermine the scope for professional judgment.

Contrary to beliefs in the emergence of a “deliberating health knowledge” and an “expert patient” (Andreassen et al., 2018; Henwood et al., 2003), digitalization does not lead exclusively to a reduction in work, then, but rather to an expansion of informal work and an increase in dependence on the social environment (Nicolini, 2007). The importance of autonomous health action is also reflected in the health policy discussion. Here, the increase in personal responsibility through digital technologies is connected to the promise of making national health systems more sustainable, both financially and physically. In this reorganization of the health system, independent patients who digitally quantify themselves play a significant role. As Tamar Sharon (2017: 101) argues regarding personalized health care and self-tracking: “[A]n increased emphasis on individual responsibility for health and healthy lifestyles [is] an important contribution to diminishing the burden of disease and financial costs […]. In this sense, to be engaged in one’s health is, ipso facto, to be engaged in the health of the population. Indeed, this is why the empowerment of individual patients and citizens is key.”

From the perspective of institutional logics, these conflicting and contradictory discourses, debates, and scientific findings about digital health technologies must be reconciled in order to develop effective action-guiding orientation. How institutional change takes place depends on the motivational force that the respective logics develop within a field (Kern, 2014: 325; Thornton et al., 2012: 62). In terms of generating agreement and willingness to act for new beliefs, values, identities, and norms and to deal with contradictions, so-called institutional entrepreneurs represent the driving forces of institutional change (Lok, 2010). They initiate a series of material and discursive interventions that can bring about a change in actor relations and collective action (Hardy and Maguire, 2008). Through convincing legitimization work for the digitalization of health, the developers of digital technologies create the normative basis for handling the structural complexity that these technologies once again bring into organizations, serving “as a filter for interpreting and responding to strategic issues and environmental changes” (Glynn, 2008: 418; Kodeih and Greenwood, 2014: 9). In addition, they are intermediaries between the state and the market and between medicine and technology, so they face with the daily task of mediating the order and organization of the health care system through digitalization. In this way, they contribute to the legitimization of the new idea and create a normative basis for coping with structural complexity, as digital technologies will once again bring to organizations.

In order to address the question of what significance digital technologies have in general, it is first necessary to understand how they are plausible as meaningful innovations for the health care system (especially since the health care system is already based on a large number of technical systems). The following analysis of the interviews focuses on the question of how the actors link digital health to the characteristic logic of the health care system. Against this background, the article asks how institutional entrepreneurs of digital health mediate the logic of digitalization with the key logics of the health care system—market and profession.

Data and method

As described above, normative orientations and the evaluations they result in are central for the transformation and stabilization of institutional logics in organizational fields. To a certain extent, such normative starting points for structural and institutional change are expressed in everyday negotiation processes. Therefore, this explorative case study is based on 15 interviews with persons from different areas of digital health care in a Swiss hospital. Three of the people interviewed have no medical background but work in a project that aims to make the hospital’s internal processes accessible for Big Data analysis. Nevertheless, they are of great importance in the context of the study, as they check the ideas and plans of the medical professions for their feasibility and, if necessary, modify them. The selection of the interviewees was based on “theoretical sampling” (Glaser and Strauss, 2010), in order to identify as many aspects of the field of investigation as possible. Therefore, I invited those interviewed to give me advice about other people who might be interesting for my questions. This includes medical personnel with digitalization tasks in hospitals, clinical developers, and Big Data analysts, as well as developers of virtual reality programs and applications in medicine. Although these people are dealing with different aspects of digitalization, a common ground is their close connection to the structures of primary health care. The purpose is not to represent the logics of action completely. It is rather an explorative approach that intends to identify specific problems in the mediation of digital and health and to point out central negotiations that characterize this relation.

One remarkable aspect of the sample is the gender composition. Apart from one female mathematician, the sample is male. This may have to do with the fact that the higher positions in medicine are still held by a majority of men. It can also be assumed that access for women in the digital technology sector remains difficult. Although this is not the research question, it must nevertheless be reflected here that this constellation can also have considerable effects on the development and implementation of digital health. The group-specific mentality studied here does not reflect the perspective of other professional groups nor that of female developers and physicians.

Nr.	Position/medical domain	Digital–technological field	Age	Gender
Int. 1	Chief physician/surgery	Virtual reality	46–65	M
Int. 2	Chief physician/internal medicine	Implementation, strategy, sensor development	46–65	M
Int. 3	Assistant doctor/internal medicine	Mobile technology, sensor technology	20–35	M
Int. 4	Senior physician/radiology	Big Data analyses, development of algorithms	36–45	M
Int. 5	Medical specialist/radiology	Big Data analysis, natural language processing	20–35	M
Int. 6	–	Data scientist/mathematician	20–35	W
Int. 7	Senior physician/radiology	Development mobile technology	46–45	M
Int. 8	–	Data Scientist/Informatician	20–35	M
Int. 9	Assistant doctor/internal medicine	Big Data analyses	20–35	M
Int. 10	Medical specialist/radiology	Big Data analyses, development of algorithms	36–45	M
Int. 11	Assistant doctor/internal medicine	Big Data analyses, development of algorithms	20–35	M
Int. 12	Medical specialist/internal medicine	Development virtual reality	36–45	M
Int. 13	Medical specialist/radiology	Sensor development	36–45	M
Int. 14	–	Data scientist/mathematician	36–45	M
Int. 15	Assistant doctor/[–]	Sensor development	20–35	M

The interviews usually lasted 60–90 minutes and were mostly conducted on the premises of clinical facilities between March and September 2018. In accordance with research ethics, all information on persons, organizations, and companies was deleted from the transcripts. The semi-structured interviews focused on descriptions and evaluations of certain technologies, the development of digital health, and personal attitudes toward it. The interview guide only served as an orientation and the flow of speech was interrupted as rarely as possible. In general, questions were kept open and adjusted to the topics of the interview. Special attention was paid to ensuring that the respondents did not just present their knowledge and interpretations in theoretical terms, but also justified them and made subjective assessments. The way in which interviewees legitimized or criticized technologies revealed the underlying shared knowledge base, which could serve as a starting point for changing institutional logics.

For the analysis of this shared knowledge and the shared positions, the documentary method of interpretation was chosen. Going beyond qualitative content analysis (Mayring, 2010), the documentary method not only captures subjective opinions and experiences but also aims at reconstructing socially shared but implicit knowledge (Bohnsack, 2014: 33ff.). The basic methodological assumptions of the documentary method can be traced back to Mannheim’s sociology of knowledge, ethnomethodology, symbolic interactionism, and Pierre Bourdieu’s cultural sociology. As Mannheim has already stated, sociality must first be established in interaction and communication (Mannheim, 1964: 91–154). In this respect, he proclaims that reconstruction and interpretation must not simply take note of actors’ perceptions, but must follow the creative process of producing perceptions in order to gain access to unknown spaces of experience or in German “Erfahrungsraum” (Bohnsack et al., 2010: 105; Mannheim, 1980: 227) and its underlying patterns (Bohnsack, 2014: 57; Garfinkel, 1961). The goal is to identify collective (life) orientations and realities based on mutual understanding.

The particular advantage for investigating digitization in the health care system is its distinction between communicative (socially generalized) knowledge and conjunctive (non-public milieu-specific) knowledge (Bohnsack et al., 2010: 22) which is accessible in a two-step empirical analysis. The first one provides information about societal “objectified” knowledge and is closely linked to support common sense theories (Nohl, 2012: 49). In contrast, the second one is part of everyday practice. While communicative knowledge is accessible to most members of society, conjunctive knowledge remains limited to specific milieus and must be made accessible by interpretation. The core of this empirical reconstruction is not, as is usual in other qualitative procedures, a system of categories. Rather, by comparing minimally contrasting cases—here: persons working at the interface of the medical profession and digital technologies—the foundations of a group-specific and collective mentality are reconstructed (Bohnsack, 2014: 61).

Empirical findings

Market organization as a source of legitimacy and delegitimization

The analysis of the interviews with people working in the field of software and strategy development shows first that digital networking between different areas of care is considered to be very important. In all interviews, the advantages of digital patient information and documentation systems are emphasized, as they enable a more efficient handling of internal hospital procedures and processes.

Whereas “until a few years ago”² as one respondent said, “you still received faxes that you couldn’t track and things often got lost,” digitally networked information systems allow you to have all the information on the respective patient available “at one click.” The advantages of digital networking and the possibilities of data storage are also often associated with the daily workload of nursing and medical staff. This is reflected in statements such as “pointless documentation can be minimized [through networking digital technologies],” “one no longer has to search for paper patient files,” “tests are not done twice or three times,” “consultation notes are not lost so easily.” The focus here is on reducing “useless” medical work steps. The consensus is that clinical work currently lacks efficient processes, which leads to additional burdens, for example in nursing. A vision of digital health emerges that is highly critical of the current organization of the health care system, which has been made more cost-efficient through numerous reforms that share an orientation toward business management principles. From the interviewees perspective technologies like the Swiss “elektronisches Patientendossier” (electronic patient dossier) could also help to put the patient in the center of the health care system again. They tend to think that the shift in emphasis from welfare claims to economic rationalities ought to be readjusted if not corrected (Becker et al., 2016). In this sense, information and communication systems not only benefit working conditions but also promote a new, noneconomic perspective on patients. In this context, the efficiency mechanism is thus redefined as a critical point of reference. One interviewee pointedly expresses this when he says:

Such systems [such as electronic patient systems] help us to make our work more efficient. If we save costs, that is just good. However, at the same time, that does not mean that we must save money anywhere else [for example personnel costs]. The technologies already take care of that. I click here and I have all the information I need right here and I can see what the nurses have done. On the other hand, I directly get the findings from the pathology department. […] In the past, many consultations were simply lost. (Int. 2, 99–105)

Through the legitimization work of the developers, efficiency in the context of digital technologies is linked to the fundamental norm of care and community and thus acts as a limit to market processes. Similar to John Maynard Keynes in his 1930 essay “The economic opportunities for our grandchildren,” the interviewed medical developers also assume that technological innovations and the associated increases in productivity will solve economic problems and improve the “quality of life”—in this case, the “quality of care” (Keynes, 1930). However, the reference to the efficiency-enhancing effect of patient information systems and information and communication technologies in general is not sufficient to justify the use of these technologies. The respondents do not believe that the use of these technologies alone effectively reduces the workload resulting from the general economization of the health care sector. These goals can only be achieved in combination with other “newer technologies like wearables to gather more data,” as one of the respondents put it. Wearables and health trackers can once again correct the negative consequences of economization, the interviewees believe:

In recent years, the health care system has really been strongly oriented towards economic indicators, but the people involved have been forgotten. I believe that technologies such as those we are developing [sensor technologies and wearables] can contribute to making people more visible again—patients, but also employees. And not just as a key figure. (Int. 3, 98–141)

Paradoxically, the market logic here is of particular importance for the originally intended correction of the effects of economization. The implementation of digital technologies like Wearables and the liberation of extensive health data brings with it a decisive competitive advantage that will provide future generations with economic wealth. One employee of a clinical Big Data project is clearly in favor of a more extensive gathering and sharing of personal health data:

Basically, there is no use in prohibiting the gathering or analysis of data. And I think it’s actually a pretty good idea to make data freely available and then use it with all kinds of technologies. Because probably the society that makes its data most widely available will be the one that benefits most from this next wave of progress and will be the most prosperous in thirty years. Those who are extremely restrictive in their use of data will perhaps even be significantly less affluent than today. And I say that if I want to act in the interest of citizens and patients, I have to make data available freely so that people can be part of this wave. Otherwise, in ten to twenty years time, you may be on the margins. (Int. 4, 1002–1009)

Indicative for other interviews, the inevitability and necessity of the digitalization of health and health care are stressed here. In the interest of the common good and prosperity, “you have to go along with it, because otherwise you will be marginalized.” They feel that “they must go into this competition for data,” as another Interviewee puts it, “because competition also drives innovation.” In this respect, market logics provide an important basis for legitimization. This shows that the positive effects of digital technologies—especially those that contribute to greater efficiency—are only discussed and legitimized against the background of other pro-competitive technologies such as Big Data or Machine Learning, which partially undermines the original legitimacy of the market logic. In view of the importance of the market in the context of digital health, an ambivalence arises from the benefits of efficiency-enhancing technologies and the simultaneous need for economic profitability. In addition to the reduction of work steps and processes and enhancing market leadership, legitimizing arguments focusing on efficiency also refer to possible reductions in financial costs. However, in contrast to more traditional cost-cutting measures, these are not at the expense of clinical staff or patients.

According to the interviewees, digital technologies respond to the “orientation dilemma” (Bode, 2010: 204) resulting from the introduction of the DRG flat rate per case system. By linking efficiency as a mechanism for enabling a caring or welfare-oriented logic with business logics of cost reduction, digital technologies harmonize the conflict, but without prioritizing either logic. The delegitimization of market logics in public health systems is linked to the idea that digital technologies free up time and financial resources, which has a direct impact on patients and their well-being. Thus, there is a shared view that the use of digital technologies, especially in clinical care, can reactivate the “lost idea of care,” as one member of a clinical digitalization project puts it exemplarily.

It is apparent that the use of digital technologies is not sufficiently legitimized by exclusively pointing to financial arguments. Ultimately, as one developer of AI health care technologies describes it, the reduction of financial expenditure through digital technologies must always be justifiable with regard to the patients’ well-being and the benefits that patients derive from the use of these technologies. All interviewees share this view; it documents a central cultural difference between digitalization in the health care system and so-called disruptive innovations in the private sector. One developer expresses this differentiation well by referring to a fundamental orientation of medical professionals:

But the whole thing only makes sense if it has an effect on the patient. And not just because drones are cool or because you can make a bunch of money using them. The technology must always have a use case, must always meet the patients’ needs. There are a lot of things that could be improved in the health care sector, but I would say 99 per cent of doctors are not looking for profit. The daily work shifts take long enough, and because we know quite a lot of patients, their stories and sufferings, we want to improve things. (Int. 2, 365–372)

Profession as a contested source of legitimacy

The mediation between the market and care through digital technologies described above corresponds to the idea of stabilizing the reciprocal relationship with patients by means of a more extensive collection of personalized health data. In addition to ICTs and patient documentation systems, a newer generation of technologies is being highlighted in this context. While the use of these “older technologies” strengthens the efficiency of processes and procedures in such a way that they are regarded as the basis of a critical countermovement of personnel against the economization of the health care system, sensor technologies such as wearables and health tracker aim to enable patients to take personal responsibility. Here, too, the key vision is to use more data to strengthen the patient’s position as the linchpin of care. According to the respondents, the use of smartwatches and the collection of corresponding tracking data could enable a more “patient-driven rather than supply-driven development” within health care. Here, too, the use of digital technologies and the generation of nonclinical personal data sets is legitimized against the background of the general well-being of patients; sensory monitoring, the interviewees believe, would allow for “putting the patient back in the center.” This idea is linked to the goal of regaining “trust in the relationship with the patient.”

Furthermore, nonclinical data (e.g., fitness, lifestyle, and geodata) could complement the previously “incomplete clinical recording” of the health status of patients, so that the human being—as one interviewee put it—is no longer reduced to “one parameter.” Digital technologies would then be legitimized not only in the light of their monitoring function, which makes an individual’s state of health continuously observable, but also especially with respect to the possibility of including patients as subjects in health care. In the discussion about so-called Patient reported outcomes,³ the development of a new quality standard in the health care system is becoming apparent, which emphasizes the relationship with patients and their satisfaction with treatment. The fact that such digital (mobile) data collection instruments dissolve the spatial separation between the clinic and the private life of the patient is not perceived negatively by the interviewees. A clinical software developer expresses the importance of digital technologies for establishing a collaborative relationship between patients and health care institutions as follows:

With such sensory devices, we have more than all the parameters that could ever be collected in a hospital, so as a doctor I am much closer to the patients, even closer to their everyday lives. Moreover, all that is made possible with just one of those things you put around your arm. At some point, it does not matter whether you have it in the hospital or outside. This opens up completely different possibilities of health. You simply know in advance because you can see the signs, for example if someone slips into a depression because he is only at home. This brings you much closer to the patient than before when you only had laboratory tests and so on. (Int. 2, 195–201)

From the perspective of the respondents, a key benefit of digital health technologies, then, is that they overcome the limitations of traditional examination and analysis methods and strengthen the relationship between data-giving patients and medical science. In return for their health data and a decrease of privacy, patients receive faster and better diagnostic procedures. And medical science benefits because the “all-encompassing measurement” enables a consolidation of medical expertise and the “conservation of knowledge in algorithms.” Here, digital technologies serve, among other things, to reduce uncertainty, especially in the diagnosis of rare diseases. Two of the respondents put this as follows:

The doctor can then assess the patient as a whole. No lab test, no X-rays, no blood work can do this. The algorithm features not only 10, but 30 pieces of information. That allows the doctor to see the bigger picture. (Int. 7, 305–308)

This really is the jackpot. It is terrific for internal medicine and rheumatology. And especially when it gets more complicated, for example with rare diseases, which people with thirty years of professional experience have only seen once or never before. These are not bad doctors, but you just cannot always remember everything. And that is of course sensational, such an algorithm, which has learned the knowledge of a hundred thousand doctors at once. (Int. 2, 396–405)

At this point, however, a break in legitimacy becomes apparent. While the possibility of a more comprehensive diagnosis is clearly viewed positively, the respondents are sceptical when it comes to the use of Big Data analyses in medical research and health care. Specifically, they criticize a scenario in which decisions on therapeutic treatments are made solely on the basis of algorithmic analyses. Accordingly, they see themselves confronted with a specific dilemma: not only is information about the state of health and illness of those being treated multiplying, but so are the possible options for action. Although digital measurements and algorithm-based analysis procedures are intended to reduce uncertainties caused by varying and more extensive sources of knowledge, the very same technologies and analysis in fact provoke uncertainties about the conception of health and illness:

Every day more data is being collected, data we just did not have before. But what’s the point of having your heart rate checked around the clock? Because the danger is, if for some reason the data point to a pathology, you have to decide: Is it a correct measurement or an incorrect measurement? And even if it is “pathological,” what do you do with this? In atrial fibrillation, for example, if I find out that many more people have atrial fibrillation; do I give them all blood thinners? I think that would be wrong. That is the danger—before all this, nothing happened whatsoever, simply because we didn’t know it in the first place. (Int. 7, 215–223)

In view of the increasing number of options for action, then, medical practitioners are confronted with the challenge of not only collecting data but also deciding on their usefulness for therapeutic treatment. This is the conclusion of an employee of a clinical software development project:

Certainly algorithms can reduce uncertainties in medicine, but they do not relieve a doctor of the decision […]. You have to use this mountain of data to make good decisions, not to no longer feel responsible. (Int. 3, 989–993)

This scepticism corresponds to general reservations about the decision-making capabilities of algorithms as they are discussed in the media and in research. A respondent employs an analogy to express his fears:

Digitalization in the health care sector is similar to driving a car. Sure, there is Tesla and they drive autonomously, but they are always causing accidents. Sure, the technology will improve at some point, but the question for the entire medical profession, for politics and ethics: Do we actually want autonomous medicine? Or do we prefer to have a downsized version, which features a lane departure warning system [LDW], and cruise or speed control, but does not make you just sit passively in the car. In case of an accident, you want to get active yourself. You react to the error message: Oh, the LDW is complaining; or: Oh, the wheel is vibrating. It’s more like an interaction: I notice the error message and can check if it really is the case. In the worst case, go to the patient and ask. So more like a support tool. (Int. 5, 407–427)

In view of fears of “being patronized by technology,” as one interviewee put it, a central conflict between the different effective institutional logics of digital health emerges. To be sure, digital technologies and the corresponding diagnostic and analytical procedures are being legitimized in terms of their cost-efficient effects, their function of mediating between (place-bound) health care facilities and the everyday world of patients, and the consequences this has on the relationship between all involved. At the same time, however, it has become apparent that the scenario of technologically induced therapeutic decisions runs counter to the ideal of individually attending to all patients in health care. The autonomy of professional decisions would thus be further reduced, and the hegemony of market logic would be confirmed after all. Much in this vein, some of the interviewees fear that

… at some point you will be held accountable if you didn’t use such an algorithm, and then were wrong about the diagnosis. (Int. 1, 564–571)

Despite all the promises associated with digital health technologies, then, medical expertise and professional ethics remain strong normative reference points in everyday medical practice. A partial resolution of the conflict, the interviews suggest, could be achieved by viewing technology as a “support system” that merely “assists” us humans. Thus, a senior physician who is also responsible for digital strategy development resolves the ambivalence that exists between the positive and the negative effects of digital health technologies by stressing his own decision-making authority (Carmel, 2013; Lupton, 2018: 119):

I want it to help me think, to help me integrate this, but I don’t just want to be given an answer and that’s it. No way. (Int. 2, 789–790)

Discussion and conclusion

In view of the increasing importance of digital technologies and the growing attention paid to the digitalization of health, in this article I have examined the question of how do medical practitioners who are involved in the development and implementation of digital health technologies legitimate and criticize the implementation and the use of these technologies. This group of experts is of particular relevance for investigating the ambivalences and challenges associated with digital health, as they have to mediate their own professional standards and the benefits of digital technologies every day. In this respect, they provide more general insights into the constraints and benefits of digital health. Proceeding from the perspective of institutional logics, the analysis provides insight into the positions and logics negotiated in the health care system.

First, it could be observed that the capacity to connect different patient information systems, departments, and facilities by means of digital technologies is a central concern for those working in health care. The respondents point out that the use of digital technologies can make every day clinical work more efficient and possibly correct the tendency towards an economization of the health care system. This finding is particularly interesting because digital technologies are here ascribed the ability of harmonizing contradictory instructions for action—in particular economic efficiency and care. Future research could focus on how these visions; these promises of ICTs in health care evolve. After all, there is still a risk that the freed-up time does not go toward more intensive patient care. In fact, it is conceivable that clinical personnel will have to additionally cover other task areas.

These hopes for digital health technologies are associated with the possibility of reactivating a general welfare orientation that places the patient and his or her well-being—not key figures and parameters—at the center of medical practice: the patients can be assessed in their “entirety” and treatments thus be improved. At the same time, however, an aspect of digital health comes into view here that remains controversial. While the use of algorithms in medical diagnostics is legitimized with respect to their function of “conserving” broad medical knowledge and making it accessible at any time, a certain scepticism regarding a possible “takeover” of technology is documented in the interviewees’ statements. The new possibilities for reducing uncertainties through a medicine based on varying data sources are clearly being perceived positively, but a complete handing over of responsibility is decisively rejected. A partial solution to this conflictual constellation consists in emphasizing professional ethic while allotting to technologies the role of an “assistant.”

In addition, it becomes clear that different technologies have different effects on the health system. This suggests that digitization is by no means a homogeneous external logic for the health care system. Rather, it shows that personal responsibility and professional logic are important prerequisites for digital technologies such as wearables or algorithms to be connectable—both positively and negatively.

It remains to be seen what further consequences the generation of ever larger amounts of patient data and the use of algorithms based on medical expertise will have. It could be assumed that with an increasing implementation of digital health technologies, the medical ethos will gradually lose its importance as a strong normative reference point. However, it is conceivable that critical physicians could establish a countermovement of sorts that counteracts an ever more data-driven medicine and does not lose sight of the inaccurate and the unplannable. In other words, future research should pursue the question of how medical professional ethics are being or can be maintained if not only the treatment process but also prevention is shaped by technology and data.

Further questions also arise with regard to other groups of employees and institutions in the health care system. Based on the findings of this paper, the question should be investigated whether the potential inherent in digitalization can actually be used to improve work, the quality of care, and health, and to mitigate the negative consequences of economization. It was shown that developers in particular voice such normative demands, which they translate at least partially into technology. The perspectives of medical developers—mostly men—then, are not only important for the scientific and public discourse about digitalization, but also for the design of future work, in which this group of experts will play an important role. As has been shown, developers are critical actors who bring their demands for professional action and professional ethics into the development process and who stand up for good work and the quality of care in their own way. If the digitalization of the health care system is not only to meet efficiency requirements, but also claims to justice, medical professionals’ demands and criticisms must be integrated into the development of technology.

Supplemental Material

sj-pdf-1-bds-10.1177_2053951721996733 - Supplemental material for “More like a support tool”: Ambivalences around digital health from medical developers’ perspective

Supplemental material, sj-pdf-1-bds-10.1177_2053951721996733 for “More like a support tool”: Ambivalences around digital health from medical developers’ perspective by Sarah Lenz in Big Data & Society

Supplemental Material

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Supplemental material, sj-pdf-2-bds-10.1177_2053951721996733 for “More like a support tool”: Ambivalences around digital health from medical developers’ perspective by Sarah Lenz in Big Data & Society

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This Project was partly funded by the University of Basel’s Institute of Sociology and the DFG Centre for Advanced Studies “Futures of Sustainability,” Hamburg University.

ORCID iD

Sarah Lenz

Notes

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