Share or Perish: Mutual Trust, Usable Knowledge and Efficiency Gains in the Governance of e.Health Programs

This study aims to contribute to the research agenda on collaborative efficiency by investigating the key-factors and mechanisms enabling coordination, cross agency learning and efficiency gains within the governance of digital infrastructures. We focus on coordination mechanisms developed within the healthcare system digitization and dematerialization programs to achieve cost savings. A challenge for e-health advocates is the ability to reconcile managerial purposes (ICT solutions, cost cutting, efficiency) with substantive purposes (clinical risk reduction, healthcare appropriateness) in a context of multi-level governance. Focussing on the analytical framework by the ACF and by the literature on bounded rationality (Simon, 1983; Scharpf, 1994; Pelligra, 2007), we use cooperative efficiency as both a dependent and independent variable: as a result of trust structure within the governance networks (Sharpf, 1994), and as an explanatory factor of the role played by competent and professional brokers or fixers with the aim of producing usable knowledge and solving problems in the implementation (Elston, 2014; Majone, 1989; Lindblom and Cohen, 1979; Weiss, 1980). If mutual trust can enable actors to play a cooperative game (Aumann and Maschler, 1961), how this is linked to the institutional framework and the role specific fixers/brokers play in driving and managing cross agency learning? (Weiblen, Sabatier and McQueen, 2009) The second section illustrates some basic concepts and the research design. The third section illustrates the legal framework for the healthcare digitalization and compares the key characteristics of the governance networks and implementation of the Electronic Health Records in the twenty Italian regions. The fourth section provides an analysis of the healthcare digitization programs in the Veneto Region before and after the creation of Arsenàl.IT, a regional voluntary consortium designed by all the Venetian LHAs and the HTs. In the final section we discuss the empirical findings and the theoretical implications in comparative perspective.