The Digitalization of Healthcare: Electronic Records and the Disruption of Moral Orders

Citation

Birkland, J. (2019), "The Digitalization of Healthcare: Electronic Records and the Disruption of Moral Orders", Journal of Enabling Technologies, Vol. 13 No. 1, pp. 51-52. https://doi.org/10.1108/JET-03-2019-071

The Digitalization of Healthcare: Electronic Records and the Disruption of Moral Orders explores why efforts to launch national electronic health records (EHRs) have failed to bring the cost savings and health benefits promised by governments. Central to the authors’ argument is such failure which is due to the disruption of moral orders that such technologies create.

EHRs involve a diversity of stakeholders, from healthcare providers to politicians, policy makers to healthcare administrators, healthcare consumers to advocacy groups. However, it is not just the economic and technical concerns among these groups that must be managed when such systems are planned and implemented; but also the moral concerns. Drawing on the work of Hughes (1963), the book argues that EHRs are not just technical artifacts, but instead are a key aspect of the moral ordering of healthcare; acting as a disrupter in the existing ordering.

Moral orders represent the responsibilities and norms that are present among a group of individuals, including among a certain profession. The Digitalization of Healthcare identifies four important moral orders which interact in the healthcare environment: the domestic, industrial, market and civic. The domestic moral order places value in caring for the ill within the family; in this order, families are seen as the rightful caretakers. Order and efficiency are valued in the industrial order. The market moral order values cost and price. The final moral orders are: the civic, values democracy, engagement and equality. All of these orders are in tension with one another, and EHRs do not recognize all of these moral orders. A reason why such systems have failed is because they do not manage the conflicts between these moral orders and understand that EHRs act as a reordering force, disrupting the very moral centers of the environments they enter.

The Digitalization of Healthcare begins by explaining the motivations surrounding EHRs (Chapter 1) and the difficulties in their implementation (Chapter 2). These first chapters ground the book in the history of EHRs and introduce the main theoretical perspective of the book: that EHRs impact the moral orders in healthcare (Chapter 3). The middle chapters of the book examine case studies of implementations of national EHRs in Australia (Chapters 4 and 5) and England (Chapter 6); and also address several smaller scale EHR systems at the regional level in these two countries (Chapter 7). These case studies integrate data from government documents (including evidence presented to parliamentary bodies and policy documents) and interviews of informants involved at all levels of the implementation process (providers, users, and policy makers). The final chapter (Chapter 8) integrates these cases, drawing similarities and examining how EHRs disrupted the moral orders in each case study. Several sets of appendices are provided, including sources not cited and a detailed methodology.

Authors of The Digitalization of Healthcare hail from the UK and Australia. Ian P. McLoughlin is a Professor of Management at Monash University (Melborne, Australia), focusing on e-health, innovation in healthcare and digital government. Karin Garrety is an Honorary Fellow at University of Wollongong’s School of Management (Wollongong, Australia), studying people’s interactions with information security, technology and organizational change. Rob Wilson is a Professor of Information Systems Management at Newcastle University (Newcastle upon Tyne, UK), specializing in public service innovation, with a particular interest in the role that systems, data, and information play in organizations and relationships.

The EHR case studies created within The Digitalization of Healthcare are fascinating reading. They clearly lay out how different moral orders and stakeholders interacted to create EHRs – and why these EHRs so often fell short of their lofty goals. Each case is well constructed, drawing on various data sources to create a smooth and accessible narrative. They are a particular highlight of the book. The model of moral orders proposed by McLoughlin, Garrety and Wilson is insightful and applicable to many situations beyond healthcare in understanding why (and how) systems and technological innovations often do not meet our expectations. One criticism of the book is that the solutions to managing the moral orders (Chapter 8) could be more thoroughly outlined. Specific tips, gleaned from the case studies, for managing these conflicting norms and responsibilities would be helpful to the practitioners, policy makers and politicians who will be interested in this overall very accessible book.

Scholars who work in e-health will be interested in the theoretical perspective of moral orders created by McLoughlin, Garrety and Wilson. Graduate students working in e-Health will find the EHR case studies helpful in not only informing their work on digital healthcare, but also as a model to replicate when writing their own case studies. The book is also of value to healthcare practitioners, providing insight into how different moral orders impact innovation in their field. Finally, policy makers and politicians who are interested in advancing national policies regarding e-Health would benefit immensely from reading The Digitalization of Healthcare. It is clear from the case studies presented, those involved in such policy decisions often lack a thorough understanding of the various factors involved. The Digitalization of Healthcare provides not only a framework for understanding these factors, but suggestions on moving forward in creating systems that work.