The health care state in the information age

THE HEALTH CARE STATE IN THEINFORMATION AGE

RICHARD FREEMAN

The computerization of the medical record has important implications for thegovernance of health care, and the importance of health care means that changeswrought there are indicative of changes in government as a whole. This paperdraws on work in public policy, medical sociology and studies of science and tech-nology, as well as on cross-national empirical research in Britain and France. Itdescribes the recent development of information policy in health care as an exercisein state-building, realized specifically in the governance of the health professions.The paper concludes with a discussion of what is both new and not so new in theform and extent of state power which emerges.

INTRODUCTION: THE PATIENT RECORD

To consult a doctor is to enter a specialized set of communications: symp-toms are reported, diagnoses given, referrals made, prescriptions issued.The production, recording and exchange of information is an intrinsicaspect of what it means to be a patient or a doctor. Of course, such com-munications both express and reproduce social relations; in many instances,too, they are mediated by a third party. For the consultation itself is predi-cated on a further set of elaborate administrative communications: at aminimum, these have to do with the registration of entitlement (of thepatient) and arrangements for payment (of the doctor).

The information that health care administrations (including hospital,health authority, insurance fund and different levels of government) collectand produce in the ordinary course of their activity serves to define andshape functions, identities and relationships. The medical record, forexample, serves as a certificate of entitlement, as an accounting mechanismand as a way of organizing medical practice. By the same token, to controlthe form and content of medical information, in both its clinical and admin-istrative aspects, is to control much of the business of health care. And forsomething more than a decade, medical information has become the subjectof intensive and sustained government attention, both in Britain and else-where.

The purpose of this paper is to identify and interpret developments inthe governance of health care implicit in the computerization of the medicalrecord. It draws on work in public policy, medical sociology and studies

Richard Freeman is in the School of Social and Political Studies, University of Edinburgh and theInstitution for Social and Policy Studies, Yale University.

Public Administration Vol. 80 No. 4, 2002 (751–767) Blackwell Publishers Ltd. 2002, 108 Cowley Road, Oxford OX4 1JF, UK and 350 Main Street,Malden, MA 02148, USA.

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of science and technology: these shape some of its methodological preceptsas well as its substantive concerns. From studies of social and public policy,and especially from cross-national, comparative work on health policy,comes an appreciation of the contiguity of health care and the state. Thefinance and delivery of health care is for the most part regulated (if notdirectly provided) by the state, and the regulation of health care constitutesa major part of government business as well as public spending. In otherwords, in advanced industrial countries, the nature of the state is definedto a significant degree by and through health policy activity (Moran 1999;Freeman 2000).

This means, in turn, that in so far as information technology changeshealth care or government, it changes both. Studies of IT in public adminis-tration point variously to radical and minimal, positive and negative effects.IT provides opportunities for enhanced participation in decision makingand service delivery by employees, clients and citizens, as well as forincreased surveillance by managers and government. This conflict has beendescribed as being one between openness and effectiveness, while policyimplementation is likely to demand some kind of trade-off between the two(Demchak, Friis and La Porte 1998). The situation is further complicated bythe contingent, uncertain relationship between the deployment of infor-mation technology in large public sector organizations and the continuingevolution of new public management (Dunleavy and Margetts 2000). Theunderlying issue concerns the extent to which government is being transfor-med by technology: is it that new instruments are being used to pursueordinary goals within established parameters or are such instruments fac-tors in realizing what is better described as a post-modernization of govern-ment (Zuboff 1988; Bellamy and Taylor 1997; Frissen 1999)?

From science and technology studies comes a complementary insight thatsocial relations – including relations between states and societies – are notsimply inherent in but are formed through technology. A classic statementis Winner’s example of the tomato harvester, which for him is ‘not merelythe symbol of a social order that rewards some while punishing others; itis in a true sense an embodiment of that order. % The issues that divideor unite people in society are settled not only in the institutions and prac-tices of politics proper, but also, and less obviously, in tangible arrange-ments of steel and concrete, wires and transistors, nuts and bolts’ (Winner1980, pp. 127–8). For the purposes of this paper, the essential point is thatthe detail is constitutive of regime: it embraces both macro and micro andis a vital way of connecting the two.

From medical sociology comes a body of work which specifically con-siders the medical record. The landmark study is Garfinkel’s (1974): in post-ulating ‘good’ organizational reasons for ‘bad’ clinical records he notes that‘the crux of the phenomenon lies % in the ties between records and thesocial system that services and is serviced by these records’ (p. 114). Heath(1982) shows how the record works to preserve the general practice consul-

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THE HEALTH CARE STATE IN THE INFORMATION AGE 753

tation and Berg that it is ‘a fundamental, constitutive element of medicalpractice’ in the hospital (Berg 1996, p. 499). As he goes on to explain, it isnot neutral but transformative, mediating the relations that act and workthrough it: it is ‘one of the ways power differences are materially consti-tuted’ (Berg 1996, p. 512). Because the record is ‘a distributing and collectingdevice: work tasks begin and end there’, it can be argued that it effectivelygenerates the terms of existence of both patient and clinic: ‘(T)he act ofrecording . . . enacts the organization’ (Berg and Bowker 1997, pp. 519,524). The medical encounter is governed, it can be said, both in its processand the terms on which it is undertaken, by the information required toproduce it.

The empirical work on which this paper is based consisted in studies ofthe nature of medical and related record-keeping in Britain and France. Therecord is taken to include all information stored in such a way (on paper;in electronic format; in health care settings; in local, regional or nationaladministrative centres) that it can be retrieved and/or exchanged by healthcare personnel (professional, paraprofessional and administrative staff), aswell as by patients themselves. The point was to capture the ensemble ofdocumented information, at once legal, medical and financial, throughwhich the medical encounter is constructed. The research interest lay notin the detail of any given patient’s medical history but in what might bedescribed as the informational architecture of the record. What is at issuehere and in what follows is the nature of the information required of, byand about both provider and user of health care, as well as the natureand implications of technological innovation. My investigation sought toestablish types and patterns, ‘standard operating procedures’ in health carepractice and administration. These are necessarily simplifications of whatis self-evidently a varied, complex domain. According to country (andsometimes locality) and context, there are often important exceptions to thepatterns described here, notably for children, for some older people andfor some low-income groups. Data were gleaned from interviews and sitevisits, and from government and other administrative regulations, guide-lines and policy statements.

In any comparative research design, there are two logics at play. One isthat of experimentation and the control of variables, of hypothesis testingand explanation. The other, which is the more active here, is that of explo-ration and description, of illustration and definition. Comparison makes itpossible either to identify a phenomenon by seeing it repeated in a differentcontext or to understand what it is by learning about what it is not. PhilipStrong’s account of conducting research in the US as well as the UK inorder to understand The Ceremonial Order of the Clinic has served as a model:he used cross-national comparison to address the problem of ‘how to noticesignificant absences, how to discover what might have been there butinstead was systematically excluded?’ (Strong 1988, p. 235; see alsoStrong 1979). In this instance, preliminary research based on a number


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of countries suggested that Britain and France, while holding somemajor background variables constant (for example, the extent of public fin-ance of health care and its concomitant state regulation), were likely togenerate the most revealing analytic contrasts. Differences in the adminis-tration of the NHS in England, Scotland, Wales and Northern Ireland meanthat some of the terms and procedures considered here differ across theterritory of the UK. Whitehall statements apply in the first instance toEngland. Where stated, they apply to England and Wales. However, it isnormal for equivalents to be produced in the other countries of the UKas well.

The paper begins by describing respective health systems in generalterms, and then by reconstructing what amounts to the status quo ante ofmedical record-keeping. This is a heuristic device, an archaeology of a spe-cific practice visible now only in traces. It is necessary, however, in orderto explicate the nature and significance of recent change.

HEALTH CARE GOVERNANCE AND MEDICAL RECORD-KEEPING

In France, health care is funded by a universal but limited system of com-pulsory insurance. This is provided by a system of occupation- and area-based funds; 80 per cent of the population is covered by the Caisse nationaled’assurance maladie des travailleurs salaries (CNAMTS, usually CNAM), whichis divided into regional and local units. CNAM is a self-governing ‘techno-structure’ (Pomey and Poullier 1997) controlled by unions and employers;it regulates the health insurance system. The government health portfoliotends to change with each change of administration and is currently subor-dinated to the Ministry of Employment and Solidarity. Insurance contri-butions are paid by employers and employees. Hospital bills are settleddirectly between insurance fund and provider, the majority of which arein the public sector. In ambulatory care, payments are made as reimburse-ments of fees, and cover approximately 70 per cent of the cost to the patient.In France, patients are free to choose and change a doctor as they wish,though most stay with one they know. Referral from one doctor to anotheris frequent although not normal; patients may also seek a second opinionfor their complaints. Doctors in ambulatory care are self-employed, andmay be either generalists or specialists; most (approximately two-thirds,with some variation according to gender and specialty) are in solo practice.

In the UK, health care is delivered through a public system, the NationalHealth Service (NHS), and is funded predominantly out of general taxation.In England, health policy is the ministerial responsibility of the Departmentof Health (DoH), while the operation of the service is managed by the NHSExecutive. Local administration is the responsibility of Health Authorities.Hospital and community services are provided by independent publicagencies (Trusts). Importantly, a clear distinction is made between care pro-vided in hospitals by specialists and in local practice by generalists (generalpractitioners, or GPs). GPs are independent contractors to the NHS, and



most work in group practices. All UK residents have the right to registerwith a GP. They pay no charges for consultations; charges for prescriptionsare paid to the pharmacist when and where they are submitted. Except inemergencies, access to specialist and hospital care is by GP referral only.

Across those countries studied, information is collected and used in dif-ferent ways at different times as a patient interacts with an office-baseddoctor. Three principal stages can be defined: registration, recording theconsultation (which may also result in referral and/or prescription), andbilling and remuneration.

In France, patients register with a sickness insurance fund, normally astatutory caisse primaire, and are issued with a carte d’assure social, which istypically a small fold-over document carried in a wallet. It carries an IDnumber which is used for a variety of other official purposes, includingemployment and taxation. The British patient registers with a doctor; in themajority of cases, in effect, this means with a group practice. A practiceaccepts a patient onto a doctor’s list (the list is the basis of the payment ofGPs by capitation) and in turn registers that patient with the local healthauthority. The health authority then issues a small yellow registration card,the ‘National Health Service Medical Card’ to the patient; the card containsan NHS number. In England and Wales, the NHS Central Register holdsbasic personal details (but no clinical information) of all patients registeredwith a GP.

The record of the nature and outcome of the consultation, the medicalrecord – known in France as the ‘dossier de suivi medical’ (usually simplythe ‘dossier’) and in the NHS colloquially as the ‘notes’ – is kept in paperform in cardboard envelopes or folders. In England, this envelope is knownas the ‘Lloyd George’ (in reaching a pay settlement with panel doctors in1912, the then Chancellor introduced a requirement for them to keep rec-ords [Honigsbaum 1979, p. 94]). This folder holds brief written records ofconsultations; any lab results, as well as referral letters and responses tothem; it tends to be thicker than its French counterpart, and appears to beviewed more noticeably as a sine qua non of medical practice. Records aretransferred when a patient registers with a new practice; for example, as aresult of a change of residence. In France, the record may be transferredon referral, but not if a patient simply chooses to consult a new doctor.

In France, at the end of a consultation, the physician gives their patienta note of treatment or care, the feuille de soins, which serves both as anitemized bill and a form on which to claim reimbursement. It is a four-part,fold-out document, containing a minimum of information to be completedby the patient. The patient pays the doctor, (usually) writing a cheque asthe doctor completes the feuille. The reimbursement payment to the patientis then made by cheque or bank transfer within a few weeks.

In this way, the health care domain in France is circumscribed or perhapseven defined by matters of finance. The ‘system’ is one of payment forhealth care, not of the provision of health care, and this system is ‘owned’


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by labour unions – by virtue of their government of the funds – rather thanby the state. Registration appears to confer status and entitlement: the carteis a record of the immatriculation of the assure. In the NHS, it is the doctorand the local practice which appears central: patienthood is governed pro-fessionally rather than administratively. The organization of health care inEngland appears to be both more whole as well as more paternalistic. TheFrench patient, on the other hand, enters a partial, segmented world; inFrance, the patient themselves appear to do much of the work of integratingthe system. A patient consultation ends with a symbolic exchange ofpapers, while the English patient may or may not be given a (paper)prescription.

INFORMATION POLICY IN HEALTH CARE

A concern with information management in health care emerged at aroundthe same time in both Britain and France. It was predicated upon a complexset of problems which became manifest in the course of the 1970s, andwhich constituted a new ‘moment’ in health policy, meaning both a tem-poral unit and a new dynamic in political relations between those whoregulate, use, provide and pay for health care (Freeman 2000). As in mostEuropean countries, just at the point at which access to health services hadbeen effectively universalized, the ambition of government, the authorityof professional medicine and the affordability of the system itself, all cameto be challenged.

In this study, the information issue presented in slightly different waysin different countries, reflecting differences in health system configuration.In France, two strands can be discerned: the introduction of an obligationfor physicians to keep records, and the modernization of the payment sys-tem. Only the second of these was explicitly related to the availability ofnew technology. In Britain, computer technology seemed to offer an opport-unity for the rationalization of existing, established practices of health careinformation-gathering. In time, both countries were to float ideas for a per-sonal health and medical record to be held by patients, though the emphasisof subsequent policy has been to capture treatment episodes recorded byproviding physicians and hospitals. Policy makers in both countries havebeen confronted by severe implementation problems and these have beenmet by a progressive assertion of government authority.

In France, CNAMTS’s difficulties with processing claims data were recog-nized in the early 1970s, though it took a decade and more to develop pilotprojects based on the use of microprocessor cards to hold and capture data.Following the introduction of prospective budgeting in 1984, public hospi-tals were given a new degree of organizational autonomy in the collectionand processing of systems data in 1989, and a hospital medical record wasintroduced in March 1992. An obligation for doctors in local practice tokeep records was agreed in principle as part of routine negotiations withgovernment in October 1993. These were to be legal documents, distinct



from the ad hoc notes a doctor might ordinarily keep; they were also to bethe legal property of the patient who would entrust them to the consultingphysician. Subsequent legislation set out a further intention to link patientremuneration to the presentation of a new and separate document, the car-net medical, which was to be kept by the patient and was intended to informthe different doctors a patient might consult of his or her medical history.A requirement to keep records was included in the doctors’ conditions ofservice issued in September 1995. At the same time, it was becoming clearthat data capture on the part of the health and medical professional wasto become the effective point of entry to a networked electronic health infor-mation system. The Carte de Professionnel de Sante (CPS), which made poss-ible the secure exchange of information between health care professionals,began to be developed by a public-private partnership formed in 1993,while SESAM-Vitale, a patient-based card system for electronic processingof reimbursement claims, was piloted by a consortium of insurers in1994–1995.

In the later part of the decade, policy development both intensified andbecame frustrated by mismanagement and technical failure. Showing someimpatience with achievement thus far, and in the context of more generalconcern at the relationship between France’s social security system and itseconomic performance, the French government included the modernizationof health service information in a package of administrative reforms, thePlan Juppe, which was agreed in 1995 and implemented in a subsequentministerial regulation in April 1996. In the interests of the ‘clinical manage-ment of health spending’, health care professionals were to be able todeliver claims to insurers electronically by the end of 1998. Patients wereto be issued with the Carte SESAM-Vitale by the end of 1999, with a pro-vision that later versions would also carry medical information. In October1996, however, a review committee, chaired by Charles Rozmaryn, thengeneral manager of France Telecom, pointed to the considerable technicaldifficulties inherent in the programme and criticized its management atthe same time. The committee recommended that a strategic policy unit becreated, which should be directly answerable to the minister: the ConseilSuperieur des Systemes d’Information de Sante (CSSIS) was formed for a three-year term in January 1997. The CSSIS was quick to emphasize two centralconcerns for policy: the SESAM-Vitale project and the construction of anintegrated health information network, the Reseau Sante Social (RSS) (CSSIS1997, 1998, 1999). A further critical report by a former head of the hospitaldepartment at the Ministry of Health, Jean de Kervasdoue, then declaredthat the chances of the SESAM-Vitale system working reliably remainedremote. The government then announced that technical cooperation was tobe supported by a new Mission pour l’Informatisation du Systeme de Santelocated in the ministry itself (Secretaire d’Etat a la Sante 1997). In 1998, thebroader public interest was expressed in the formation of a parliamentary


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committee (the Mission d’Information) to monitor information policy in thehealth system.

In Britain, the formation of an NHS/DHSS Steering Group on HealthService Information (the Korner Committee) in 1980 is taken to mark thebeginning of a formal interest in information gathering in the NHS (Masonand Morrison 1985). The service-based demand for information thenincreased rapidly in the mid-1980s, following the introduction of generalmanagement at unit level and above as recommended by the GriffithsReport of 1983. In 1988, the NHS Executive launched a Hospital InformationSupport Systems Initiative (HISSI), which piloted the use of integrated com-puter systems in acute care and led to a later R&D programme to developan electronic patient record. The Executive’s Information ManagementGroup (IMG) published a new Information Management and TechnologyStrategy in 1992, recognizing that the introduction of what was known asan ‘internal market’ in the NHS required a new intensity of data collectionand processing. This envisaged a system of common classification andcoding to enable the capture of clinical data, a dedicated network of admin-istrative registers, and the introduction of a new NHS number for patients(Keen 1994a and 1994b). The new NHS number was in widespread use inEngland and Wales by mid-1997 (NHS Executive 1997). While NHS patientshad always been accorded a number on registration, this was now replacedby a unique 10-digit identifier. Its purpose was to make data computer-compatible, to improve its accuracy and accessibility, and to enable linkagebetween records kept at different sites.

Over the next few years, increased information flows brought some con-cern over efficiency and confidentiality. A number of executive and inde-pendent investigations of different aspects of information policy wereundertaken, some arguing for better management of information in thehealth service; some scrutinizing and criticizing various misconceivedattempts to do so (Audit Commission 1995a, 1995b, 1997; NHS Executive1996a, 1996b; National Audit Office 1996a, 1996b, 1998). In 1997, theincoming Labour administration issued a health service White Paper inDecember (DoH 1997), followed within the year by a new information strat-egy statement, Information for Health (NHS Executive 1998). This took upthe theme of modernization developed in the White Paper and describednew initiatives, including a National Electronic Library for Health and NHSDirect, a telephone and Internet-based advice service for patients. Infor-mation for Health set out plans for the continuing development of the elec-tronic patient record as well as for an electronic health record, and heldout the prospect of a patient-held summary record using smart card tech-nology. Its emphasis was on the integration of health service information,for which an appropriate infrastructure, including software and networksystems (by now known as NHSnet), were to continue to be enhanced. Inrecognition of some of the failings of policy making in this area (see above),the Executive’s IMG was disbanded and replaced by a new Information



Policy Unit; one of its functions was to oversee the work of a new NationalHealth Service Information Authority formed in April 1999. From 1 October2000, GP terms of service were amended to remove the obligation on gen-eral practitioners to keep paper records and to permit them to rely solelyon electronic forms (NHS Executive 2000).

GOVERNMENT, HEALTH CARE AND INFORMATIONTECHNOLOGY

The deployment of information and communications technology in thehealth sector is part of a more general reformation of the public sectorwidely referred to as the ‘reinvention of government’ (Osborne and Gaebler1993; cf. Heeks 1999). For all that, what is strikingly new about new tech-nology should not obscure the extent to which information policy is anexercise in the normal politics of health care. As an instance of state-building, its significance lies as much in what is familiar about it as in thechange it represents.

What is described in the French case as the informatisation of health careis undertaken by ‘corporate rationalisers’ as against ‘dominant pro-fessionals’. The terminology is Alford’s (1975), used to account for the inter-play of structural interests in health care. These are loose and changingcoalitions of public officials, professional leaders, industrial concerns, fin-ancial administrators and unit managers on one hand and doctors on theother, their position reinforced by their exclusive access to medical knowl-edge. They tend to be supported by patients and protected as often as notby instutional inertia. Where health care has come to be paid for by thirdparties, this is the essential logic of its politics. Corporate or collective inter-ests lie in universalization, standardization and minimum cost; professionalinterests in clinical autonomy, local decision-making and maximumearnings. On most issues, different organizational interests are likely to bemobilized at different times in different countries, though their underlyingstructure is the same.

In Europe, third-party payment for health care is mandated and regu-lated by government. What is interesting, however, is that the increasingpolitical significance of health care, in terms of public spending, employ-ment and welfare entitlement, has been barely matched by the administrat-ive capacity of government to regulate it effectively (Freeman 2000). Whatwas accepted for a long time as an arena of ‘private government’ has onlyrecently come to be challenged by thoroughgoing reform. This means that,in health care in Europe, the reinvention of government was always likelyto be a process in which government would be reinforced. Information tech-nology assisted and accelerated a state project of long standing. And likesimilar such projects in previous eras, it has drawn on other kinds of insti-tutional resource and been promoted and expressed as ‘cultural change’.

Health care information policy in both Britain and France is framed bya degree of national myth-making and image management. Where the


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Department of Health argues that the NHS ‘must embrace multi-channelcommunications and ensure that the strength of a revitalised NHS brandis recognized not only nationally but also internationally’ (DoH 2001, 4.3),the French Ministry claims that one of the principal benefits of com-puterized health information is to guarantee ‘la perennite du systeme fran-cais d’assurance maladie’ (MES 2001). The first of the five ‘work areas’ ofthe NHS Executive’s Information Policy Unit is introduced as follows: ‘Themain challenge facing the implementation of Information for Health is oneof cultural change’. In France, the CSSIS (1999, p. 26) comments more nega-tively, but to the same effect: ‘. . . on doit insister sur les idees suivantes: –le culture medicale francaise (sic) n’a pas accorde au dossier de sante laplace centrale qu’il merite . . .’.

Modernization, especially of government, was a strong theme of the Blairadministration which was returned in 1997. It was the key term of the NHSWhite Paper (DoH 1997), and was developed at length in a further WhitePaper published a little over a year later, called simply Modernising Govern-ment (Cabinet Office 1999). What it means for health services to ‘modernize’,apparently, is that they should work as efficiently as business systems,employing comparable administrative and managerial tools, and prove ascapable as other services of satisfying customer or user preferences. Infor-mation for Health cites advances in personal banking (NHS Executive 1998,2.48); Building the Information Core refers to holiday booking (DoH 2001,3.3). However, some of the more criticized failings of NHS policy have beenthose to do with business practice (NAO 1996a, 1996b, 1998). The Frenchgovernment, by contrast, could turn to a normal practice of state–industrycollaboration. Both the CPS and SESAM-Vitale cards were developed bypublic-private consortia or groupements, while the contract to develop theRSS network was awarded to the private telecommunications giant,CEGETEL. Nevertheless, governments in both countries have faltered inthe realization of health care IT projects, both seeking to retrieve their pos-itions by asserting centralized control.

Policy in both Britain and France has become increasingly subject to min-isterial direction and both countries have established dedicated agencies forits coordination at the highest level (see above). For powerful institutionalreasons, this has gone further in Britain than in France. As far as its regulat-ory autonomy and coherence is concerned, the NHS Executive benefits fromthe incorporation of the medical profession into what is an effective monop-sony. In France, government must overcome the quasi-autonomy of organi-zations charged with health finance and the radical separation of paymentfrom provision. In effect, these have become the object of its attention: infor-mation policy in the insurance-based system is as concerned with theadministration of billing as with clinical procedure.

The most powerful of the common denominators which operate acrosscountries, meanwhile, is the sense that information technology is designedto improve the management of health care, whether by professionals or by



administrators. Yet the domain which the ‘corporate rationalizers’ are seek-ing to occupy is defined by an extraordinary complexity and a bewilderingrate of change. In this context, policy statements serve as critical acts ofsense-making, as attempts to provide coherence and fixity in a fluid andcontested environment. That is to say that a more significant commondenominator may be the erosion of common sense. Medical records are nolonger an element of everyday practical wisdom: what was formerly com-mon sense – part of the local knowledge of the practitioner – has becomepublic policy. What are the defining terms of these new patterns of thought?What kinds of activity do they make possible and what kinds do theyexclude? What are the ends to which new forms of control are being exer-cised?

GOVERNING THE MEDICAL ENCOUNTER: THE RECORD IN THENETWORK

Information policy in health care has two principal elements: the com-puterization of the medical record and the construction of electronic com-munications systems or networks known as intranets (NHSnet and theFrench RSS). These networks serve two functions: they facilitate theexchange of information between health care agencies, staff and adminis-trators, and they also redefine the boundaries of the health system, demar-cating it as a specific domain of authorized expertise. Because new flowsof communication raise new questions about confidentiality, much workhas to be done to ensure that networks are secure. The reduction of thesystem’s internal differentiation depends on increasing its external differen-tiation or separation from its environment. Intranets are at once the canalsand railways of the new health care state as well as its re-equipped naviesand customs officers. As the CSSIS (1999, p. 41) puts it, ‘. . . le RSS est unlieu securisee de communication entre professionels de sante, un territoirereserve d’echange’. As in the industrial era, defence and communicationsare the public goods provided by government to support a changingeconomy.

Networks offer the prospect of the integration of health systems, a long-standing goal of government since its entry into the field. Network-basedcommunication is intended to overcome divisions between specialist andgeneralist, between community-based and hospital-based provision,between payer and provider, and between health care and social care. NHSdocuments continue to reiterate an original ambition to provide health care‘from cradle to grave’, the archaic phrase alternating with its contemporaryequivalent, ‘seamless care’. Crucially, however, integration depends onstandardization: successful communication is dependent on a common lan-guage. Network-based communication in health care requires the commoncoding and classification of professional activity, as well as a standard rep-resentation of the patient (the permanent patient identifier). Both thera-


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peutic codes and patient numbers are embedded in – i.e. carried by – theelectronic medical record.

The patient record, that is to say, is as significant as a medium of com-munication as much as its object. Exchanges – between health care pro-fessionals, and between professionals and administrators – are conductedthrough the record as much as on or about it: ‘Achieving integrated careis a key national policy objective. For professionals from different organis-ations to provide an integrated care service to their individual patients andclients, they require comprehensive and easily accessible person-basedrecords as the basis for communication’ (NHS Executive 1998, 2.28). Thecontent of the record, meanwhile, in both of the study countries, remainsuncertain and contested. The NHS Executive (1998, 2.9ff, 2.72) acknowl-edges that there is no agreement on the content of the proposed ElectronicHealth Record (EHR). For the French CSSIS, ‘Si le fait de placer le patientau centre des episodes de soins est evident, il faut constater qu’il estaujourd’hui difficile d’obtenir un consensus sur le contenu du dossierinformatise et, par ce biais, des processus de soins’ (CSSIS 1999, p. 12). Therecord can be presented as the keystone of policy development – ‘pierreangulaire des systemes d’information’ (CSSIS 1999, p. 4) – even while thenature of the information it carries is unclear. What is important about therecord is not its content but the connections it makes.

One of the principal elements of successful state-building is the establish-ment of a national or official language. In a 1996 paper for the NHS, JamesRead, Director of the NHS Centre for Coding and Classification, suggestedthat its various systems – which included Read terms, ICD classificationsof diseases, OPCS classifications of surgical procedures and HealthcareResource Groups/Health Benefit Groups – could be collectively describedas ‘the “language of health”, an essential element of the electronic clinicalrecord’, enabling ‘more effective and efficient healthcare delivery’ (Read1996, abstract). This is by way of saying that the medical record does forthe health care state what was previously done for the state as such by theelementary school and the radio. It has been made the vehicle of commonstandards of communication. Its purpose is to erase the dialects of classand region of different professional groups and the different local agenciesin which they work.

Compare now the French project: ‘Ainsi le dossier de sante du patient,qui etait une collection de dossiers par metiers – ou par professionnel –etablis principalement a des fins de memorisation, va evoluer vers undossier partage, donnant potentiellement acces a l’ensemble des donneesrelatives au patient. Il devient a ce titre un outil de communication entreles differents intervenants qui apportent et coordonnent leurs competencesautour du patient’ (CSSIS 1998, p. 1). With repetition, it becomes clear thata second, equally subtle but perhaps even more significant manoeuvre istaking place here. The individual patient is being separated from the indi-vidual physician: the patient is being made accessible to multiple agents at



multiple sites. For the replacement of the paper record by an electronic oneintegrates formerly separate documents kept by different staff working indifferent facilities: ‘Wherever a patient is treated, there is a record of thattreatment. These are "organisational records" and at present they are, in themain, paper records. New technology gives us opportunities for makingthose records safer and available for other health professionals’ (DoH 2001,4.4). The effect of this is to erode the individualized relationship betweenpatient and physician which is perhaps the central construct of liberal medi-cine – whether la medecine liberale or its Anglo-Saxon equivalent (and afurther indicator of this separation is the way in which the record isdescribed: the CSSIS is explicit in preferring a vocabulary of health ratherthan medicine [CSSIS 1998, p. 1], while NHS nomenclature – ElectronicPatient Record, Electronic Health Record, Patient Health Record – avoids,if it does not deny, explicit association of the record with the doctor).

Decreasing control of the record by the individual physician is mirroredin its increasing control by the organization of which he or she is a part.That is to say, these processes of separation and standardization make themedical encounter (which is what the record is a record of) more amenableto government. One of the principal justifications of the new informationpolicy in both countries is the opportunity it creates for enhanced clinicalgovernance, or medical audit (for an early comparative study of infor-mation and audit in health care, see Develay, Naiditch and de Pouvourville1995). As the NHS Executive puts it in Information for Health, ‘EPRs andEHRs provide the source of the base anonymized and aggregated data tosupport the clinical audit process’ (NHS Executive 1998, 4.25). In France,the convention which agreed the medical record was primarily concernedwith the introduction of references medicales opposables, sets of guidelinesaccording to which treatments deemed medically useless might be excludedfrom the list of procedures covered by statutory insurance schemes. Butthe underlying significance of the record is as the vehicle of treatmentcoding: ‘The successful development of the EPR and EHR requires a com-mon coded clinical vocabulary to facilitate reliable and accurate electroniccommunication of clinical information, with nationally and internationallyconsistent activity analysis.’ (NHS Executive 1998, 3.16, cf. CSSIS 1998, 2.2b).In theory, there is no more than a contingent relationship between the elec-tronic record and the coding of medical practice: it is possible to code paperrecords, just as it is possible for the electronic record to be constructed asfree text. But the effect of entering data on the electronic record by meansof codes creates the potential for clinical activity to be counted, and thento be assessed and manipulated. In practice, then, it is not that the qualityagenda forms a backdrop to recent developments in information policy butrather that audit and the record – or at least the ambitions that policymakers have for them – are mutually constitutive.

For the object of information policy – which is the subject of the record,too – is not the patient but the health care professional and what he or she


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does. The stated rationale for the new information strategy in the NHS is‘supporting patient care’ (NHS Executive 1998, p. 2); in France, the first offive reasons for computerizing health care information is ‘Pour ameliorerla prise en charge individuelle des patients’ (MES 2001). In both instances,the focus is apparently the patient, but effectively the professional; as faras the patient is concerned, the electronic record serves as something of apromissory note. More direct appeals to the patient interest include claimsabout the reduction of travel and delays in the NHS (NHS Executive 1998,p. 5), and of administrative form-filling in France. The first stated objectiveof the SESAM-Vitale system is to simplify the reimbursement procedure forsickness insurance claims: ‘Avec les feuilles de soins electroniques (FSE),l’assure n’a rien a remplir, ni a coller (vignettes), ni a poster, ni a affranchir:c’est une economie d’un milliard de francs par an pour les malades’ (MES2001). Nevertheless, the fundamental logic of policy statements is that thepatient will benefit because the professional will work better. It thenbecomes arguable that one of the key functions of the record is to enrol thepatient in the governing of the profession.

THE HEALTH CARE STATE IN THE INFORMATION AGE

The essential argument of this paper is that information policy in healthcare can be thought of as a kind of state building. What is happening isthat government is defining and defending new administrative territory,building an infrastructure which will enable new and sophisticated kindsof social and economic activity to take place. This is why what is going onin Britain and France is taking place at European level, too: a EuropeanCommission Technical Committee (TC251) is now concerned with stan-dardization in health information and communications technology. Forwhat appears to be required by technology in fact constitutes an act ofgovernment. And what is crucial in this is that health service informationhas become both object (something to be managed) and instrument(something to manage with) of government. Policy in this area is quin-tessentially a set of communications about communications: what concernsgovernment, to use Foucault’s phrase, is the ‘conduct of conduct’.

Some of the policy statements analysed here have something of the qual-ity of science fiction. They describe a technology which even until recentlywould have been thought incredible, or literally fantastic, and use it toinvoke a vision of a better world. It is of course a truism of studies of sciencefiction that it reveals more about the contemporary mind than future reality,and so it is here. But what is interesting about many of these documentsis their traditionally modern cast: they are concerned with the provisionof welfare according to industrial standards of efficiency as well as thestandardization and surveillance which these entail. The application of newinformation technology in health care frequently appears as a totalizingproject: in France, it has occupied government at the same time as accessto supplementary insurance schemes has been universalized, from January



2000, via the couverture maladie universelle; in Britain, the NHS InformationAuthority has become concerned that numbers be issued to new-bornsbefore medical intervention takes place (NHSIA 2000). All of this is muchmore akin to the electrification of the Soviet Union than travels in hyper-reality.

An important qualification must be made, in that what is beingannounced as a new informational order remains fractured and incomplete(cf. Mennerat 1996). Government is not a single, focused agent; itencounters resistance and is dependent on the compliance of powerful thirdparties. EPR projects continue to be beset by technical difficulties of interop-erability and ethical concerns about confidentiality and information priv-acy. Whether or not health care records should provide limited information,enable access to information stored elsewhere, or in themselves constitutean entire medical history remains to be resolved. What is interesting aboutthis is that in neither country was the content of the paper record legallydefined, and this in turn reinforces a sense that it is the form not the contentof the record which is really significant. In this way, while the record hasbeen assigned a critical role in the consolidation of the health care state, itremains also to some degree chimerical. In part, this is because it has apolitical function as a rhetorical space or ‘floating signifier’: in mediatingbetween competing professional, managerial and government projects, it issomething akin to Gallie’s ‘essentially contested concept’. At the same time,however, it can be both critical and chimerical because what matters is notjust the information it contains, but the connections it makes: the record istruly a ‘space of flows’.

What government has established, however, is that the patient record isno longer simply a resource on which the medical practitioner draws toaccount for what he or she has done, both to other practitioners and, overtime, to him – or herself; it is becoming the means by which the systemaccounts for itself. The electronic medical record is the means by whichpractice is made amenable to management, and as such is a mechanism ofthe continuing collectivization of the medical encounter.

ACKNOWLEDGEMENTI am grateful to the Faculty of Social Sciences, University of Edinburgh, forfinancial support in preparing this paper; to the Centre de Documentation,CNAMTS, Paris, for access to material and to Bruce Guthrie and Gerardde Pouvourville for invaluable advice. Earlier versions were delivered tothe ECPR workshop Policy, Discourse and Institutional Reform (Grenoble,April 2001) and to an ESRC research seminar Governing Medicine: ‘ClinicalGovernance’ in UK Public Health Institutions (Manchester, September 2001).

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Date received 24 January 2002. Date accepted 1 July 2002.


The health care state in the information age

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