Project Overview

How can public and private actors construct appropriate laws, rules and norms to exploit the promise of HIT, while avoiding the dangers?

In recent years, proponents have touted various HIT innovations as remedies for a wide variety of healthcare ills, from geographic inequities, to paperwork costs, to medication errors, to fragmented case management. Recent estimates suggest, for example, that computerized order-entry alone could reduce medication errors enough to save thousands of lives and billions of dollars annually -- and other technologies possess equally impressive potential. Yet, despite such benefits, HIT adoption has been slow and uneven, lagging far behind the penetration of IT into many other sectors of the economy.

In part, this may reflect the fact that, while these new systems promise to improve the timeliness, accuracy, efficiency and rigor of American healthcare, they also threaten to disrupt the sector’s established order, raising the specter of new forms of competition, coercion, surveillance and inequality. Consequently, as new HIT comes on line, professions, organizations, social movements and public authorities vie for control, each pursuing its own distinctive vision of healthcare's “inherent” technical, economic, clinical, and ethical “imperatives.”

In this climate, an even-handed understanding of real-world governance dynamics is crucial. Broadly speaking, “governance”, refers to the ways in which individuals, organizations and societies manage interdependence and sustain cooperation in the face of vulnerability. For new CITs to surmount such vexing challenges as standardization, trust, and accountability, policymakers must develop effective governance systems both within individual healthcare organizations and throughout the healthcare sector as a whole. Within each organizational setting, decision-makers face the problem of crafting a practice regime that reconciles shifting technical and regulatory pressures with the daily work of medicine. Meanwhile, at the level of the sector as a whole, decision-makers face the problem of crafting a regulatory regime that promotes sound IT practices across a wide range of organizational settings, each with its own structure, culture, practices and politics.

Unless researchers develop solid theoretical frameworks and reliable empirical data to inform governance at both levels, much of the new technologies’ potential could be squandered in political stalemate -- or, worse yet, subverted by ill-advised policy choices.

Yet, despite the likely importance of governance mechanisms in determining the fate of healthcare IT, few broad-based empirical investigations of these issues currently exist. Professional associations and consulting firms occasionally conduct pragmatically-oriented surveys of IT budgets and the like, but such studies seldom examine non-technical governance structures or underlying causal mechanisms. Medical sociologists and health policy researchers, for their part, generally treat IT as being too peripheral to the "core" enterprise of medicine to merit sustained attention. And investigations of economic and legal governance outside the healthcare arena rarely consider the distinctive issues that emerge in the context of overlapping professional jurisdictions, significant public-goods problems, intense civil-liberties concerns, and extensive state involvement -- all of which characterize healthcare IT.

Consequently, although impending HIT developments hold the potential to transform American healthcare, we currently lack both the conceptual and the factual infrastructure to address responsibly this crucial area of policy concern.

The HITS project seeks to fill this gap in our knowledge.