Infrastructure Innovation in Health Care – The Example of Automatic Drug Dispensing in Germany
Klein S, Schellhammer S
Comprehensive medication management for polypharmacy patients has been recognized as a key area of health care in need of improvement and innovations: it affects a growing number of patients, has huge financial implications and ties into broader issues such as patient health and medication safety, medication records, coordination across different medical specialists, cooperation between medical doctors and pharmacists. It fits the characteristics of an infrastructure as a constellation of practices. Given the prevalence of national regulation, we have been studying the public discourse about improving medication management in Germany over the course of the past 10 years. Specifically, this paper investigates the development of an initiative to introduce industrial automatic dose dispensing (ADD), i.e. the large scale production of patient specific blister packs for solid oral medicines, as an infrastructure innovation in the German healthcare system. We trace the arguments of both opponents and proponents of this innovation and theorize the outcome so far. ADD has been introduced in a number of countries, namely Northern Europe, the Netherlands; the US, Canada, Japan and Australia (Bell et al. 2013). While some of the effects of ADD are contested, overall it has been positively assessed. Since regulatory preconditions for the industrial creation of ADD in Germany have been put in place, trials were run by two industrial ADD operators. Additionally, a number of smaller blister centers have been set up by pharmacies at a regional level. Yet, in contrast to other countries, Germany still lacks a regulatory and reimbursement framework to facilitate routine use of ADD at a national level. The goal of this paper is to provide explanations for the impediments of infrastructure innovation in the field of medication management and to illustrate ways of theorizing that can be transferred to other areas as well. Actors in the health care sector have sided either with the opponents or proponents of ADD as a solution to medication management. Due to this situation, we find that attempts to introduce ADD as a solution to existing problems with medication management are unlikely to succeed on a national level anytime soon. Our analysis of the discourse that unfolded over the last years reveals a number of challenges characteristic for infrastructure innovation: (1) The ADD initiative illustrates the tension between design and emergence in infrastructure innovation. (2) Digital disruption (or disruptive innovation) plays a major role in explaining the reluctance for infrastructure innovation. (3) Infrastructure innovation as institutional innovation relies heavily on collective action. As such the discourse is characterized by the forming of coalitions striving to frame the debate and gain ownership of meanings. Yet, the complexity and dynamics of infrastructure evolution put tight constraints on our ability to forecast the impacts of particular designs. Our explanation thus rests on two pillars: the contested issues in the public debate illustrate different approaches of sense making and framing among opponents and proponents of the solution. At the level of institutional innovation we can interpret the debate as part of a political process to facilitate or inhibit regulatory changes. The chapter is structured as follows: The next section explains the rationale for innovating medication management in Germany. The third section introduces the theoretical lenses and explains the methodological approach. Section four provides an overview of building blocks of the key ADD proposal and a timeline of events from 2003 - 2013. The fifth section reconstructs the discourse on medication management during the named period. The discussion section brings theoretical lenses and findings together.
information infrastructure; practice theory; medication management; compliance