About the evaluation of computerised health care services: some critical points.

ABSTRACT

This article analyses the concept of productivity underpinning the implementation of an information-technology-driven virage ambulatoire, or shift to outpatient care, as a solution to the productivity 'crisis' in Quebec's health care system. This 'crisis' was diagnosed in the 1970s and based on expenditure trends. These trends were regarded by the State as an 'obstacle' to balanced budgets and more generally, economic growth. Into this situation stepped the IT-driven virage ambulatoire with a structural reorganisation following a productivist logic. Unrolled in the 1980s, this connected health care to the economistic discourses of the 1960s which were developed to boost productivity in a service- or information-based economy. The State thus came to draw on analytic categories, developed for a very particular mode of economic analysis, to produce a hospital restructuring program oriented around IT-based ambulatory care. The result was the reduction of health care's principles of clinical and therapeutic efficiency to the administrative imperatives of time, quantum, cost, and optimisation, all of which became variables to be controlled, and the placement of economic logics ahead of clinical imperatives. Quebec has thus moved to a neoliberal productivist system in which clinical and therapeutic effectiveness are subordinate to economic need.

KEY WORDS

sociology; healthcare; productivity; evaluation; Information-communication technologies; clinical practice

1. Introduction

In this paper, we present some of the key findings of research into the selection of an information technology-driven virage ambulatoire, or shift to ambulatory (outpatient) care, as a State response to a 'crisis' in Quebec's health care system. In particular, we sought to analyse this 'crisis' in productivity in the health system, and the recourse to computerised outpatient care as a solution. Our objective was to demonstrate that the notions underpinning an IT-driven virage ambulatoire were the consequence of a specific conception of productivity which reduced the public health organisations' and health care users' goals to economic ends; thereby obscuring perspectives on improving clinical and therapeutic efficiency organised around the quality of clinical practice and health services offered to the patients. In so doing, we sought to demonstrate an ongoing shift from Fordist-Keynesian health care, of the style which emerged in most industrialised countries in the 1940s and 1950s (Carre and Lacroix 2001), to a neoliberal productivist health care system in which economic logics subsume clinical imperatives. This shift appears incompatible with clinical and therapeutic efficiency or quality health care, and is of concern given the need to evaluate the 'impact' of health care computerisation, specifically the clinical benefits of telemedicine for patients (Bonneville 2005).

We discuss this process in three steps. First, we outline some of the methodological choices made in undertaking this work. Second, we summarise the major findings of the research. Third, we demonstrate the epistemological shortcomings of the concept of productivity used in evaluating the quality of medical work--that is, its clinical and therapeutic efficiency--in the context of information communication technologies (ICT)-oriented restructuring.