The unfolding of discursive struggles in the context of Health Information Exchange

Abstract

Projects that aim to improve Health Information Exchange (HIE) are often hampered by long, drawn-out discussions. Among other things, there is considerable debate on the role patients should have in the process of exchanging health information. The argument of this doctoral thesis is that it is helpful to approach discussions on HIE as discursive struggles: processes during which actors struggle with an interplay of multiple discourses. By articulating discourses and stimulating communal reflections, actors can be empowered to work with their differences in ways they find helpful. In pursuit of the above, Critical Discourse Analysis (CDA) is used to identify different discourses and the relations between them, such as discourses of patient-centeredness and discourses of policy-making. But more than this, the author develops a generative version of CDA. Those who study discourses are allowed to explore how they can transform discursive struggles into productive dialogues. The latter is a radical departure from traditional approaches to discourse analysis, which are mainly focused on understanding power relations and conflicts. The focus on generative inquiry is made possible by the meta-theory of relational constructionism, which can be seen as a particular version of social constructionism. Relational constructionism centres relational processes as they produce multiple local realities. Among other things, the meta-theory of relational constructionisms allows the researcher a) to let go of a detached stance, b) to set aside the usual separation of fact and value, c) to do something other than search for potentially universal truths, and d) to de-centre the interests and quality criteria of science communities. In other words, by embracing relational constructionism, researchers are allowed to engage with discursive struggles over HIE as reflexive practitioners; to have multiple communities (not just science communities) influence the what, why and how of their research efforts, and to centre ethics and local usefulness as quality criteria. In this thesis, the author reflects on her own engagement with discursive struggles over Health Information Exchange in the Netherlands. This way she explores how the process of studying discourses can contribute to their unfolding. Among other things, she underlines the importance of allowing engaged unfolding (in contrast to planning our inquiries), appreciating diversity, being sensitive to how processes of inquiry influence power relations, and stimulating reflexivity. The author argues that a reflexive orientation towards both the process and content of conflicts over HIE increases the likelihood that we make these conflicts tolerable or even productive. All readers are invited to join the dialogue on the unfolding of discursive struggles over HIE. So we can make healthcare a healing environment for patients that benefits from the generative possibilities of inquiries.