"I do not see the point of using the system". Understanding a Broken Policy Knot in the Primary Care Sector

This paper explores the implementation of a policy promoting new cooperative practices in the primary care sector. Through a two-year multi-sited ethnographic study of Multi-Professional Healthcare Centers (MPHCs) and their coordination mechanisms, we highlight the gaps between the coordinative protocols that prescribe how these structures operate, and the certified Health Information System (HIS) that has been defined by public authorities to support the new practices. These gaps make us say that the policy knot - that entangles policy, practice, and design - broke. To understand why, we studied the biography of the certified HIS and identified that it is based on the practice of general medicine only. Without simply concluding that public policy has failed because of the system's shortcomings, we reveal the human effort involved in compensating for the HIS's inability to support the articulation work required for multi-professional coordination. Based on this empirical contribution, we offer the policy-oriented technological frame as a concept to make sense of IT in public health, and the congruence loop as a guideline to avoid the breakage of a policy knot.