4. Institutional choice and path dependency
Stephen Darlington
E‐health systems have the potential both for social control( Zola 1972; Hodgson 2006) and service transformation. Social control is where power‐relationship ratios heavily favour the state / government and to some extent healthcare providers. Service transformation is important as public sector providers improve their efficiency and effectiveness. Combined with increased citizen interaction and desire the latter can shift power relationship ratios towards patients and healthcare providers and away from the state. This may lead to an increase in satisfaction with e‐health systems for most stakeholders most of the time. The choice of e‐health system may therefore be crucial in determining rights respected and affected, service delivery outcomes and stakeholder satisfaction.
Stakeholder rights that are respected in an opt‐in e‐health system include: initial consent, initial choice to join, assurances of privacy, and fairness. Opt‐in e‐health systems, such as Australia’ s PCEHR, give both patients and healthcare providers the most choice. Both parties must choose to join for the meaningful transfer of medical information to take place. The path dependencies of patients being able to choose what information goes into their PCEHR, and which healthcare providers may access what information, clearly shifts power relationship ratios towards the patient. Patients have more control over both events and outcomes than they had previously and their privacy rights are strengthened. They are also able to make different decisions from one another yet still be satisfied with the e‐health system and thus see it as fair.
However, rights that are affected, such as the portability of medical records and the ownership and use of medical information, may reduce the utility of the system. In systems where healthcare providers are not salaried employees, but operate as a business, commercial issues arise of ownership, access, and cost. For example, a patient requesting their records be transferred to a competing healthcare provider might find that their current healthcare provider considers those records the property of the medical practice and may refuse the transfer request or charge for it. The question then becomes one of transactions within a commercial exchange. When a patient pays for a diagnosis who owns the professional opinion of the healthcare provider and the medical test results that provider ordered? Are those records transferrable? Who decides and who pays? Resolving these issues is critical for both effective patient and healthcare provider participation and positive system utility. Expected cost reductions and improved service delivery will be less likely to occur if some stakeholders refuse to participate because they see their rights being negatively affected.
Opt‐out e‐health systems have the practical effect of reducing real choice to those who know they have such a choice and have the inclination and ability to navigate the system in order to realize their choice. Patients are automatically enrolled in the e‐health system and must follow its rules and procedures unless they choose to opt‐out. This was the case with the UK’ s National Health System Summary Care Record( SCR). Patient concerns included the difficulty of opting out, privacy and accuracy of their records, and a lack of government consultation about the whole process( Porter 2010). Lack of choice reduces stakeholder control of events and outcomes shifting power relationship ratios towards the state. Power‐relationship ratios can also favour healthcare providers if they institute systems that automatically enroll patients. For example, this may happen on hospital admission with the expectation that patients will follow the rules and procedures as they are treated within the hospital’ s system. It may be very difficult for patients to opt‐out of such systems with the practical result being the imposition of a mandatory system in all but name unless patients have the resources and capability to voice dissatisfaction or exit the system. Therefore, rights both respected and affected in optin systems are likely to be more contested in opt‐out systems unless stakeholders habitually engage with, and display satisfaction for, the institutional system of rules and norms.
Mandatory e‐health systems imply imposition, universal coverage and an absence of patient choice and privacy rights. While initial system structure may be a result of stakeholder negotiation, once institutionalized e‐health system rules, procedures and norms dictate the role of rights and establish power‐relationship ratios. Therefore power, and control over events and outcomes, is likely to aggregate in the hands of the major healthcare providers and the state. Utility is likely to be prioritized as the path most likely to achieve goals of improved service delivery and lower cost. The rationale for universality and utility is advances in technology have produced the opportunity for e‐health systems to efficiently and effectively deliver outcomes that support key state goals in a way that was not possible in the past. The opportunity cost of not doing so is seen as high especially in an era of aging populations and rapidly rising healthcare costs. For example, identifying a target group susceptible to a certain disease within the system makes it much easier to notify, monitor and
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