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Stabilization and Destabilization Processes at Work in Digital
Infrastructures: The Co-Functioning of Architecture and
Governance
Joan Rodon, ESADE Business School, Barcelona
Ole Hanseth, University of Oslo
Abstract
Digital infrastructures (DIs) are characterized by fluidity and openness to number and types
of users and limitless possibilities for re-combinations of digital artifacts, while at the same
time having closed and static structures that give them continuity. This paper studies this state
of tension of DIs by focusing on the interactions among the existing and new socio-technical
components as they connect and disconnect across time and space. In those interactions
components exercise their capacities to affect and be affected by other components and this
leads to tensions. This paper captures this permanent state of tension of DIs with the notion of
stabilization. Against this backdrop, socio-technical components of DIs become involved in
processes that extend the existence of the DI through time (stabilization processes) and
processes that allow the DI to change and exist outside the current scales (destabilization
processes). To illustrate this notion, we apply to a longitudinal case study of a DI sponsored
by a regional healthcare service administration of Spain. We demonstrate how the dynamics
of this DI are characterized by cascades of processes of destabilization followed by re-
stabilization and vice versa. Further, our account reveals that DI evolution occurs at different
levels of scale and that stabilization processes at one scale trigger destabilization processes at
other scales. The paper adds to the literature on DI by providing a more integrated model
seeing DI evolution as the interaction between processes of stabilization and destabilization
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which are conditioned by the co-functioning of the architecture and governance structure of
the DI.
Keywords: digital infrastructure, stabilization, evolution, architecture, governance
1. Introduction
In many domains we observe a proliferation of digital infrastructures (DIs) that ubiquitously
become the basis for the operation of individual organizations and entire sectors, and the
emergence of digital innovations (Yoo et al. 2010). Such DIs are complex socio-technical
systems that grow over long time scales by integrating and extending existing installed bases
(Grisot et al. 2014; Hanseth and Lyytinen 2010). DIs are not built from scratch but grow
“conservatively through mutation and hybridization, rather than outright break with the past”
(Blanchette 2012; p. 33). They are “always an unfinished work in progress” (Edwards et al.
2009, p.365). Against this backdrop, prior studies emphasize that a challenge for the
management of DIs is how to make them evolvable (Gawer 2014).
DIs change over time in ways not captured by existing models of the (long term) evolution of
ICT solutions (Reimers et al. 2014). Accordingly, Reimers et al. (2014) suggest that a
promising route to study evolution consists of conceptualizing it through tensions between
components that destabilize the DI. In particular, a first stream of research has empirically
illustrated that the management of DIs involves recurrently dealing with tensions that result
from the complex interactions between socio-technical components (Tilson et al. 2010).
Another stream of literature studies how configurations of two core components of DIs
(namely, architecture and governance structure) condition the evolution of DIs (Henfridsson
and Bygstad 2013). In this paper we will follow Reimers et al.’s (2014) request for research
into new models capturing the evolution of DIs by integrating both streams of research. The
two research questions addressed in this paper, therefore, are: 1) how do the recurrent
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tensions of DIs determine their evolution?; and 2) how do the interactions between the
architecture and governance condition those tensions?
To address these two research questions we conducted a longitudinal, in-depth qualitative
case study of a DI sponsored by a regional healthcare service administration of Spain
covering a 14-year period from 2000 to 2013. This paper adopts an ontological approach that
describes the DI as in-process, becoming, and ever-changing. Our findings conceive the
evolution of DIs as a set of interacting processes of destabilization –that disrupt existing
relationships among components of the DI and/or create new ones– and re-stabilization –that
bring more homogeneity and persistence to the DI. Those processes in turn are shaped by the
interactions between, or co-functioning of the DIs’ architectures and governance structures.
The remainder of the paper is structured as follows. First we review existing research on the
evolution of DIs followed by our analytical framework: Assemblage Theory. In section four
we are introducing our research setting and overall research approach. The paper then
presents the narrative and analysis for the case study. The paper concludes with a discussion
of the findings and reflection on the contributions of our paper.
2. Research on the evolution of DIs
Literature on the evolution of DIs has focused on two main research problems. First, there is
a stream of research that has shown that evolution is conditioned by two constitutive
components of DIs, namely, architecture and governance (Ciborra 2000; Hanseth and
Bygstad 2014; Henfridsson and Bygstad 2013; Tiwana et al. 2010). Tiwana et al. (2010)
advocate for thinking in terms of co-design and co-evolution of DI architecture and
governance. The alignment between DI architecture (in terms of decomposition, modularity,
and design rules) and its governance structure (in terms of decision rights, control
mechanisms, and ownership) shapes the evolvability of DIs at diverse timescales (Tiwana et
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al. 2010). While governance is understood as the lever to reduce behavioral complexity (i.e.,
the difficulty to predict the aggregate behavior of the DI’s components), architecture is a
lever that tackles structural complexity (i.e., the complexity derived from the multiple and
unclear connections between the components). Henfridsson and Bygstad (2013) review 41
cases of DIs and identify three self-reinforcing mechanisms (innovation, adoption, and
scaling) that explain evolutionary outcomes. They find that the decentralized control and a
loosely coupled architecture triggered all three mechanisms, while the adoption and scaling
mechanisms were also triggered in cases based on a centralized control and loosely coupled
architecture.
Research on the complexity of DIs has also noted that the traditional approaches for
controlling and managing the development and implementation activities, which are based on
hierarchical organizing and decision rights with project management controlling the whole
activity on the top, and a tightly coupled architecture have proved inadequate due to the
number and heterogeneity of actors (Ciborra 2000; Constantinides and Barrett 2014; Hanseth
and Ciborra 2007). van Schewick (2010) and Hanseth and Lyytinen (2010) show how the
combination of a layering and end-to-end architecture and a governance structure based on a
loosely organized network of actors have contributed to the successful evolution of the
Internet. Finally, in their research about ten DI initiatives in the Norwegian health care sector,
Hanseth and Bygstad (2014) find that an approach that combined a centralized architecture
and a centralized control structure was most successful for establishing new and innovative
DIs, while a decentralized architecture and decentralized control were crucial for further
development of innovations on the DI after it was successfully established.
A second stream of literature has revealed that DIs are characterized by tensions that need to
be balanced (Edwards et al. 2007; Ribes and Finholt 2009). For instance, balancing the
retention of important elements over extended periods of time with the transformation of DI
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with respect to other important elements (Baldwin and Woodard 2009; Henfridsson and
Bygstad 2013; Reimers et al. 2014); the stability brought by the installed base to enroll new
actors and services with the flexibility to leverage unbounded growth of actors and services
(Hanseth et al. 1996; Tilson et al. 2010; Tiwana 2014; Wareham et al. 2014); the autonomy
of independent actors to seek generativity through distributed control with the centralized
control that enables that generativity to be played out in their own interest (Nielsen and
Aanestad 2006; Tilson et al. 2010; Tiwana et al. 2010; Wareham et al. 2014); the logic of
generative and democratic innovations and the logic of infrastructural control (Eaton et al.
2015); the collective identification of actors to reduce undesirable variance toward
contributions to the social good of the ecosystem with individual identifications that increase
desirable variance to encourage explorative and entrepreneurial responses (Wareham et al.
2014); the top-down demands for integration with the persistent, bottom-up reliance on the
installed base of systems and practices (Hepso et al. 2009); and the sensitiveness to local
contexts with the need to standardize across contexts (Rolland and Monteiro 2002; Silsand
and Ellingsen 2014). These studies usually conceptualize these tensions as a duality; that is,
these tensions are seen as interdependent, complementary, mutually enabling, and constituent
of one another (Tilson et al. 2010; Wareham et al. 2014). For instance, flexibility and
variability are achieved by means of the stability granted by standards as the latter enable
novel recombinations of digital components of DIs. Likewise, “stability can be bolstered only
by allowing flexibility…. [variation] at the edge and across layers bolsters the stability of
infrastructures” (Tilson et al. 2010, p.754).
Tilson et al. (2010) capture this duality with a conceptual model which depicts evolution as
dependent “on the definition and placement of control points… as well as on the ways they
are challenged by the dynamics of generativity” (Tilson et al. 2010, p. 755). Later, Tilson et
al. (2012) provide a validation support for this model with the cases of Apple’s iOS and
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Google’s Android. Reimers et al. (2014) study the balance of persistence and transformation
of DIs by focusing on changes occurring at the level of individual practices and of
constellation of practices. Reimers et al. (2014) conduct a case study of the evolution of
electronic ordering systems in the Australian pharmaceutical distribution industry over a
period of 30 years, and show how those systems gradually moved from closed and
proprietary, to quasi-open systems as a result of the appearance of new practices and the
mutual adjustment of practices. Overall, both models conceive DIs as being open and fluid
due to the tensions among the socio-technical components of DIs, while at the same time
having closed and static structures that give them continuity. However, we still have a gap in
our understanding of the relationship between the tensions to which DIs are subjected and
that shape their evolution. This is the void this paper fills. Before doing so, we draw upon
assemblage theory, as developed by DeLanda (2006), to make two related ontological
considerations of DIs which prior literature has not made explicit.
3. Assemblage Theory
The first consideration regards the nature of relations among components of DIs. DIs cannot
be solely defined by relations of interiority, meaning that a DI is a cohesive whole premised
on the aggregation of multiple socio-technical components each filling a specific purpose
within the DI and not having existence outside the DI. In fact, an analytical focus on the
relations of interiority limits the possibility of accounting for the dynamics of DIs in relation
to their outside environment and for the roles and functions that components can play outside
the DI to which they belong. The necessary relations that form a DI are partly constituted by
the existing practices and actors, technological capabilities, architecture, and so forth, as well
as by the relations that these components have with other entities that are exterior to or in the
surroundings of the DI. Accordingly, DIs are not seamless totalities but wholes whose
components are characterized by their relations of exteriority (DeLanda 2006), meaning that
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the boundaries of the DI are open as new socio-technical components connect and disconnect.
That is, the relations between components are only contingently obligatory. A component
develops a function based on the relations with other components but it has existence outside
those relations. For instance, a mobile DI such as iOS or Android compromises multiple
heterogeneous socio-technical parts –e.g. telecom carriers, OEM, content providers, APIs,
SDKs, app developers, apps, legal contracts, app users, and so forth– that might participate in
other DIs –e.g. OEMs might manufacture devices for diverse DIs, app developers might build
an app for several DIs. The autonomous parts together form more or less permanent DIs. By
looking at a DI as involving relations of exteriority allows us to foreground ongoing
processes of composition and decomposition. Moreover, this focus on the relations of
exteriority shifts the attention from the inert properties of component parts to their capacities
to interact with (or to affect and be affected by) other components. And this leads us to the
second ontological consideration.
Any component of a DI is equipped with properties and capacities. While the properties are
intrinsic to the component, the capacities are relational and exercised in the interactions
between components (DeLanda 2006). Properties are always there, but capacities need
something –a catalyst– to be triggered. For instance, the fact that a digital product is modular
(a property) does not mean that it will become generative (a capacity) per se. Generativity,
which refers to an “overall capacity to produce unprompted change driven by large, varied,
and uncoordinated audiences” (Zittrain 2006, p.198), is dependent for instance on how the
modular product interacts or is combined with other digital products, which are sometimes
layered upon one another, and how those digital products are contextually appropriated and
used (Yoo 2013; Yoo et al. 2012). To illustrate, Google Maps (which is modular) becomes
generative as Nikon’s myPicturetown app integrates with it so videos and photos can be
mapped to the locations where they are shot. That is to say, the generative capacity of a
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digital product does not simply depend on its modularity (a property) but also on the
interactions of multiple components that exercise their capacities and which may be either
internal or external to the digital product. Allowing for possibility of non-linear complex
interactions between components is relevant when studying the emergence and evolution of
DIs (Hanseth and Lyytinen 2010), but if the components are fused into wholes with only
relations of interiority, that possibility disappears. Hence, the fact that the multiple socio-
technical components of DIs exercise their capacities as they connect and disconnect across
space and time makes DIs be in a state of permanent tension.
In order to study the relation between tensions and DI evolution, this paper uses the notion of
stabilization, which we adapt from DeLanda (2006). By stabilization we broadly refer to the
processes that increase the internal homogeneity of the DI giving it an identifiable boundary
and produce more or less permanent articulations between the socio-technical components of
DIs that ultimately extend their existence through time. This occurs e.g. through the
standardization of the practices, meanings, and roles of actors, the establishment of
architectural control points that centralize the control structure, or the sorting processes that
exclude certain roles. For instance, the tight centralized control that Apple has on the iOS
ecosystem (Tilson et al. 2012) is an example of a highly stabilized DI. Such a centralized
control standardizes and excludes some uses and business models for app developers.
Alongside stabilization, any shift in the relations among components of a DI can also create
tensions that trigger destabilization processes. Destabilization processes work in the opposite
direction disrupting the order of the DI by means of increasing a DI’s heterogeneity and
fragmentation, promoting the geographical dispersion of components, and dissolving the
borders between components of the DI. For instance, the sponsor of a DI might decide to
open it by creating an API or an SDK that encourages 3rd-party developers to innovate in new
applications and services that ultimately blur the boundaries of the sector. Social networking
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technologies like twitter, Facebook or Whatsapp are another example of destabilizing forces
as they blur the spatial boundaries of social interaction by eliminating the need for physical
co-presence and increasing geographical dispersion. Destabilization processes, which usually
remain relative meaning that they retain the possibility for re-stabilization, allow DIs to
change and exist outside the scales at which they were formed.
Of course any component of a DI can participate in both processes of stabilization and
destabilization by exercising different capacities and inducing changes in the relations
between components (DeLanda 2006). For instance, incremental and additive changes to an
API of a DI are made to favor the extension and continuity of the installed base (stabilization)
while at the same time attract new components –e.g., new apps, new users– that destabilize
the DI.
In short, we suggest that DIs are always in tension responding to continuous destabilization
processes counter-balanced by re-stabilization processes. Destabilization at a certain scale of
a DI tends to be followed by re-stabilization at the same or another spatiotemporal scale and
vice versa. In that respect, the processes of destabilization and re-stabilization allow us to
view tensions – e.g., continuity and change, control and autonomy–, which characterize
evolution, as related.
4. Method
In order to illustrate how DIs recurrently go through processes of stabilization and
destabilization, and how those processes are conditioned by the co-functioning between
architecture and governance, we conduct a longitudinal, in-depth case study (Yin 2009) about
an electronic prescription digital infrastructure (EPDI) for the public health service in the
autonomous region of Catalonia, Spain. The empirical case covers 14 years (from 2000-
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2013). Before we present the details of the data collection and analysis, we provide some
background of the Spanish model of pharmacies of which the EPDI became a component.
4.1. The Spanish model of pharmacies and the infrastructure in-place
The model of pharmacies in Spain compromises multiple components operating at different
scales. At the lower scale, there is the pharmacist; a health agent who exercises its
professional practice in community pharmacies or hospital pharmacies by dispensing of
drugs, production of patient-specific preparations, and other pharmaceutical care tasks (e.g.
health promotion, tracking patients’ medication record, checking drug interactions, etc.). In
order to practice pharmacists must be registered in the College of Pharmacy of the province
where they practice.
Community pharmacies are private healthcare establishments of public interest. Pharmacies
are the only health establishments authorized to dispense prescription-only medicines and
over-the-counter medicines to the general public. Medicines in Spain are publicly funded.
Until 2012 medicines were provided to pensioners for free; working age people paid 40% and
those suffering from chronic illnesses paid 10% of the cost of medicines. Pharmacies are
privately owned, and only pharmacists are allowed to own a community pharmacy. One
pharmacist or a group of pharmacists can own only one pharmacy. Pharmacy chains are not
allowed forms of ownership. The establishment of pharmacies is regulated responding to
demographic and geographic criteria in order to guarantee a homogeneous access of the
services to citizens. Regulations are defined at the national and the autonomous community
levels. While the central government is in charge of the general coordination of
pharmaceutical care and of matter related to pharmaceuticals such as registration, each
autonomous community organizes the planning of the pharmacy system.
In the autonomous community of Catalonia, the main actors that constitute the field are: the
Catalan Health Service (CHS), the Catalan Council of Pharmacists (CCP), the four Colleges
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of Pharmacists (which coalesce into the CCP), the community pharmacies, pharmacists, and
trade associations of pharmacies. The CHS a public body that guarantees the right of health
care protection for all citizens in Catalonia. The CCP is a corporate and public legal entity
that represents the interests of all pharmacists in Catalonia, as well as the interests of
community pharmacy owners and ensures that regulations are respected.
An important stabilizing component of the model of pharmacies is the agreement between the
CHS and the CCP for the provision of services. The agreement establishes and regulates a
relational framework between the CHS and the CCP with regard to the conditions by which
pharmacists provide pharmaceutical care, invoice according to the contract economic
regulations, temporary fund the dispensed drugs and health products, continuously deliver
health care information to the CHS, do health promotion and disease prevention, and perform
pharmaceutical surveillance and security alert management of drugs and health products to
the population served by the CHS.
A core practice of pharmacists is the dispensing of drugs which interacts with other practices
(e.g. prescribing, invoicing) and actors (e.g. physicians, patients, CCP, CHS) and involves
flows of information, patients, money, and so on. The functioning of the prescribing,
dispensing and invoicing before the digitalization was as follows (see Figure 1). Once the
physician had decided the drug treatment for a patient the latter was given a paper
prescription. Physicians used clinical workstations to generate the prescriptions and printed
them. The patient took the prescription and her individual medical card to the community
pharmacy, where the drug was dispensed. Then pharmacists stored and signed those paper
based prescriptions. Pharmacists used a pharmacy management system (PMS) for tasks such
as the management of sales, inventory, or purchasing orders. Periodically, pharmacies
grouped the paper-based prescriptions they had dispensed in a given period of time and sent
them to the CCP. The CCP then checked all those prescriptions, scanned them, forwarded the
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scanned and paper prescriptions to the CHS, and handled the invoicing for pharmacies. In
particular, the CCP submitted a single invoice to the CHS. So, the CCP, not pharmacists, was
the one in charge of invoicing the CHS. The CHS reimbursed that invoice to the CCP who
checked for errors and finally paid pharmacies according to the signed prescriptions they had
previously sent.
In this scenario, the information about patients’ drug use was fragmented in the diverse
systems of the multiple health providers and pharmacies either electronically or in paper.
That meant that the CHS had only a retrospective and partial view of patients’ treatments. It
could find out about those issues only when pharmacies invoiced but not when physicians
prescribed or pharmacists dispensed. The EPDI would target this fragmentation and
heterogeneity of systems.
Figure 1: Flows involved in the paper-based prescribing, dispensing and invoicing.
4.2. Data Collection and Analysis
Our empirical data is based on a 5-year data collection effort (mid-2008 to end-2013)
covering the period 2000-2013. Thus we focused on retrospective and real time data events.
We gathered these data from a variety of sources, including interviews, archival records, and
ethnographic observations to triangulate the data obtained (Yin, 2009). Between 2008 and
2013 we conducted 20 in-depth semi-structured interviews with key informants involved in
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the EPDI from its genesis in 2000 until 2013. Those interviews were conducted in three main
periods: May – August 2008, January – May 2010, and February – May 2013. We identified
interviewees by applying the snowball sampling technique (Miles and Huberman 1994); that
is, identifying subjects for inclusion in our sample by referral from other subjects. All the
interviews were recorded and immediately transcribed after they concluded.
In the first period (May – August 2008), by then the EPDI was being piloted, we started
interviewing the project leader (a CHS executive), and then we moved to representatives of
two of the main user representatives of the EPDI: healthcare providers and pharmacies. At
that time, two healthcare providers participated in the pilot and we interviewed subjects from
both providers that were actively involved in the project: IT staff and the CIOs, primary care
physicians, primary care pharmacy coordinators of the healthcare providers, and community
pharmacists. Likewise, on the side of community pharmacies we interviewed members of the
CCP who were involved in the project, and the pharmacists that were part of the pilot. We
also interviewed external consultants that had participated in the project from its early stages.
In this first period questions were more open, and sought to understand interviewees’
opinions concerning the project, the role they played, the decisions they had made concerning
the EPDI’s design and the project’s organization, the events they thought were most critical
since it started, and the expected outcomes.
In the second period (January – May 2010), by then the EPDI was in the last phase of its roll-
out, we put the focus on the side of the pharmacists and the CHS. We conducted interviews
with the current vice-president of the CCP and the former one, who had been in charge of the
project, pharmacists that were using EPDI, and the CHS executive who was the project
leader. Three of the informants had already been interviewed in the first period. In these
interviews we sought to check the informants’ opinions during the first period of data
collection (3 interviewees were the same), evaluate the design, pilot and roll-out decisions
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and the current outcomes of the project, and understand how the EPDI was influencing the
work and role of pharmacists, the CCP, and the CHS.
Roll-out was officially completed on June 2010. Three years later (February – May 2013) we
started the third round of interviews. We interviewed the general IT coordinator of the
Department of Health, IT manager of the CCP, pharmacists, and a provider of pharmacy
management system (PMS). All the informants had been in their positions since 2007 when
the EPDI was piloted. In these interviewees we sought to understand the changes and
adaptations to the EPDI, and its impact on pharmacists, the CCP, the CHS and PMS vendors.
Besides interviews we attended half-day workshops about the EPDI that were organized by
the CHS on 2008, 2009, and 2010. All the agents involved in its design, implementation and
use participated in those workshops. During these workshops we had multiple informal
conversations with 16 participants. Those conversations enabled us to collect more data and
check our understanding and assumptions about the EPDI. Another very relevant source of
data was archival records: presentations, workshops recorded in video, mailing lists, meeting
minutes, internal reports, and press articles. Overall we gathered more than 500 archival
records talking about the EPDI in Catalonia from 2000 to 2013. The collection and analysis
of these archival records started in May 2008 and lasted until 2013. Those archival records
became the main source of evidences while in other case cases were used as a complementary
to the evidences obtained in the interviews and the workshops. Finally, from 2010 one of the
authors periodically did on-site observations on how pharmacists used the EPDI, the changes
that they made on their practices, and their perceptions on the EPDI.
This corpus served as the basis for our data analysis in this paper. The data analysis
proceeded in four phases. In the first phase, we started our data analysis by constructing an
initial timeline of key events from 2000 to 2013 (see Appendix 1). We then created a thick
descriptive narrative of the case (Langley 1999). That narrative presented the formation and
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evolution of EPDI and the flow of activity particularly from the perspective of two of the core
actors in project: the CHS, and the CCP. In the second phase, we identified four major
tensions that were salient during the genesis, design, roll-out, operation and evolution of the
EPDI. Next, we reanalyzed that narrative around those four tensions and coded them aiming
to identify destabilization and re-stabilization processes as well as the components involved
in those processes. In the fourth phase, we examined how those components were related
with the EPDI’s architecture and governance regime, and in turn, how they conditioned the
destabilization and re-stabilization processes.
In the following section, we present three tensions and their associated destabilization and re-
stabilization processes.
5. Findings
We will here present our findings organized along three tensions: between centralized control
and local autonomy, between stability and change of pharmacies’ practices, and between the
evolution of the EPDI and the flow of financial resources. Each of these tensions can be seen
as interactions between different assemblages: between central government and the pharmacy
assemblage, between the digital technology and pharmacies’ practices, and between the
overall EPDI assemblage and external ones. Further, each of the tensions was dominant in
different phases of the evolution of the EPDI; accordingly the presentation of these tensions
also represents to a large extent the evolution of the EPDI throughout its history.
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Tension 1: Balancing centralized control and autonomy of actors at national and
regional scales
In 1999, the Spanish Ministry of Science and Technology started a project called PISTA1 that
aimed to promote the use of telecommunication networks to improve the delivery of services
to citizens, and to leverage the potential of data analysis. One of the initiatives of the PISTA
project aimed at establishing a national Spanish electronic prescribing solution. This initiative
would target the fragmentation and heterogeneity of prescribing and dispensing systems that
were in-place. Several stakeholders were invited to the project: governments of the
autonomous regions2, the representatives of the diverse professionals involved in prescribing
and dispensing –i.e., the Colleges of Physicians and the Spanish Council of Pharmacists–,
and patient associations. On April 2001 a first draft of a requirements analysis was delivered.
Following a top-down approach, the PISTA project delivered in 2002 a conceptual model for
a common Spanish electronic prescription DI and a roadmap for its implementation. It was a
one-size-fits-all model based on a centralized architecture that the Spanish Council of
Pharmacists objected to from the very beginning. They argued that the main goal of the
central government was simply to control the pharmacists’ practice and to reduce public
expenditure on drugs, rather than the use of IT to develop the pharmacists’ professional
practice and improve the quality of their services (Cordobés, 2002). For instance, pharmacists
complained that the government’s model did not allow them to do pharmaceutical care
because pharmacists did not have access to the database of pharmacological treatments, and
the central database only stored those drugs that were funded by the National Health Service.
Further, the model did not account for the interaction between physicians and pharmacists, it
1 PISTA stands for Promoción e Identificación de Servicios Emergentes de Comunicaciones Avanzadas (Promotion and Identification of Advanced Communication Services) 2 The governments of the autonomous regions involved were Catalonia, Madrid, Basque Country, Canary Islands, and Asturias. Other regions such as Andalusia and Valencia were not involved but they were already developing their own electronic prescription infrastructures called Siglo XXI and Gaia respectively.
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did not include the invoicing process, and the pharmacist was assigned the role of a drug
dispenser only. PIST arrived, then, at a design of a national solution. I.e. the design was
stabilized even though there was no strong consensus.
Finally, because Spain has a decentralized health care system in which the autonomous
regions are in charge of organizing the planning of the pharmacy system, the diverse
autonomous communities started their own electronic prescription projects from 2004. From
the outset, these regional projects adopted the design guidelines proposed in the PISTA
project. In the case of Catalonia, by mid-2004 the Catalan Health Service (CHS) set the
foundations for building an electronic prescription digital infrastructure (EPDI) that sought to
improve the efficiency of the Catalan health system by streamlining patients’ access,
containing drug expenditures, and reducing prescription and dispensation errors due to lack
of coordination between the agents involved. To achieve those goals the CHS needed a real-
time, holistic view of patients’ treatments. This involved doing changes to existing practices.
For instance, physicians would not make individual prescriptions anymore but medication
plans that would last up to one year; that in turn, would eliminate the need for co-presence of
patients and physicians in the prescribing process and would reduce the number of patient
appointments with primary care. Patients would pick up medicines at any pharmacy
according to a concrete temporal window thus avoiding that patients accumulated more drugs
than necessary. Pharmacists would remotely access the content of prescriptions thus avoiding
misinterpretation of prescriptions. The CHS would have the information about acts of
prescribing and dispensing in real-time and would have the capacity to influence both acts for
instance by forcing the prescription of generics.
From the outset of the project, the CHS as sponsor of the project was at the center of its
governance structure, and it initially set two central requirements for the EPDI. First, all the
data —i.e., prescriptions, dispensations, invoices, patients, drugs, health providers,
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physicians, pharmacies, pharmacists— should be integrated and accessible online by the
diverse stakeholders —physicians, pharmacists and the CHS. Second, the processes of
prescribing and dispensing should run in real time; that is, any drug could be dispensed at any
community pharmacy in Catalonia immediately after it was prescribed, regardless of the
location of the prescribing physician. To fulfill these requirements, the CHS proposed, in line
with the PISTA guideleines, a CHS-centered architecture consisting of a central system
owned and managed by the CHS (called SIRE) that contained an integrated database with all
the data (see Figure 2). On the one side, the health providers3 would have to interconnect
their systems with the SIRE. On the other side, pharmacists were expected to connect directly
to CHS’ system, all using the same application for the dispensing and invoicing processes.
Figure 2: CHS-centered architecture for EPDI.
This CHS-centered architecture outlined a scenario in which the EPDI was portrayed as a tool
to control the administrative processes of pharmacists. Second, while on the side of
physicians the CHS-centered architecture preserved the interaction model between health
providers and the CHS by allowing health providers to keep their internal systems and
practices and only forcing them to create a communications module with the central server of
the CHS, it disrupted the existing order of the field of pharmacy as it bypassed the traditional 3 Health providers are those organizations that provide health services to the people insured by CHS. These services are hired by CHS and managed through contracts. There are two main kinds of health services: primary healthcare services and specialized healthcare services. At the time of the project, there were 36 health providers.
19
central position of the CCP in the invoicing process (Figure 1). Pharmacists perceived the
bypassing of the CCP as a weakening of their role and position in front of the CHS. It opened
the door for the CHS to set bilateral agreements with pharmacists in the future. Moreover,
that design made the deregulation of the field of pharmacy easier as the CHS would have
more control. Deregulation would be a key destabilizing force that would threaten the role
and identity of pharmacists as it would open the door to new entrants (e.g., pharmacy chains)
that would not be so much under the influence of the CCP –i.e., the CCP would be detached
from the day-to-day practices of pharmacists. Finally, the fact that the architecture excluded
the CCP also affected its revenue model. Besides the membership fees from pharmacists, an
important source of the revenue for CCP had been the invoicing process as pharmacies paid
for the processing of the paper-based prescriptions.
Based on these weaknesses of the architecture, the CCP proposed changes, turning the CHS-
centered architecture into a dual one (see Figure 3) consisting of a private network that would
interconnect all the pharmacies plus a central server, called SIFARE, that replicated the data
of the CHS’s SIFARE server that pharmacists needed —i.e., prescriptions, dispensations and
data catalogues. The CCP would own the private network and SIFARE. Pharmacies would
not have a direct access to SIRE but instead to SIFARE through the private network and the
SIFARE would synchronize in real time with the SIRE. This dual architecture mirrored the
existing structure of the model of pharmacies, and was also aligned with the discourse of the
CCP that linked the architecture with the professional development of pharmacists that relied
on shared services and strategies. The CHS reaction to this alternative architecture was
initially very negative. They were seriously afraid that this architecture represented serious
risks regarding the achievement of their two main objectives. However, after some
negotiations between the CHS and CCP, the dual architecture was approved and the
governance structure for the project was redefined to involve two main committees: a
20
steering committee, and an executive committee later called follow-up committee, in which
diverse members of the CHS, CCP, health providers and other stakeholders were present4.
Moreover, on September 2005 the CHS and the CCP signed an amendment to the
pharmaceutical agreement which established the clauses for the development of the pilot for
the EPDI, and made explicit the role of the CCP (ANNEX, 2005). That is, the amendment to
the pharmaceutical agreement reified and consolidated the architecture and roles of actors
previously defined. At this point in time, the idea of a National DI resulting from the
interoperability of diverse regional DIs that followed the design guidelines defined in the
PISTA project was fading away.
Figure 3: Dual architecture for EPDI.
To summarize – the CCP challenged and managed to destabilize the design proposed by CHS
which was based on the guidelines from the PISTA project. A main reason for this was that a
solution based on this design had capacities to interact with the pharmaceutical sector in and
could destabilize existing practices of the CCP and pharmacies and the relations between the
CHS and the pharmacies in ways the CCP found unacceptable. The CCP and the CHS
managed to reach agreement about a new architecture and governance structure. This dual
architecture and governance structure have stayed stable, at least up to now.
4 This organizing structure was still running in 2013. The steering committee meets every quarter, and the follow-up committee meets monthly. Likewise, working groups are created when new domains of study are required (e.g. prescribing and dispensing by active ingredient, prescribing and dispensing of narcotics, professional filters, communication to population, analysis of legal requirements).
21
Tension 2: Balancing stability and change of pharmacists’ practices
On the side of pharmacists, the CCP decided that SIFARE should be as transparent as
possible for community pharmacies so that they would not be forced to discontinue the use of
the existing pharmacy management systems or use an additional system for dispensing (as
would have happened with the initial design proposed by the CHS, see Figure 2).
Accordingly, in 2005, the CCP created an advisory committee for technology and
communications which brought together the CCP and the pharmacy management systems
(PMS) vendors. The members of the advisory committee met every quarter to discuss about
the EPDI’s status and agree on new requirements and services and the pace for implementing
them. Under this governance structure the CCP revamped a recognition program for PMS
vendors. The program defined a minimum set of functional and technical requirements that
PMS should fulfill, and homogenized the behavior of PMS vendors and pharmacists in terms
of access to and use of EPDI. Moreover, PMS vendors should be able to integrate their
solutions with SIFARE in a way that minimized the changes to the practices of pharmacists.
The CCP developed a set of web services for SIFARE and an API (see Figure 4). Those
vendors who passed the recognition program got an API from the CCP to interconnect their
PMS solutions with SIFARE5. The API enabled the dispensing and invoicing practices to run
partially at the pharmacies and at the CCP. In particular, the API kept some degree of
freedom for pharmacists about how they should perform their work (destabilizing capacity)
while at the same time all the pharmacies sent the same information to the CCP’s server for
checking purposes (stabilizing capacity).
5 Out of the more than 35 PMS vendors that operated in 2004, only 9 got the recognition and remained in the market. Five PMS vendors got the recognition in 2005, one in 2007 and three in 2008.
22
Figure 4: EPDI’s architecture finally implemented.
These architectural components created new dependencies among the actors – CHS, the CCP,
PMS vendors and pharmacies. The CHS developed and maintained a set of SIRE web
services to be used by the CCP for dispensing and invoicing. The CCP created the SIFARE
web services and an API for PMS vendors (see Appendix 2 for more details on the relation
between SIFARE Web services and the API). With that API, PMS vendors had to adapt their
applications to prescribe electronically, and install and configure the new version of the PMS
in pharmacies.
Other components that contributed to the stabilization of the EPDI were the security model
and the private network for pharmacists. The EPDI’s security model was defined by the
Catalan Certification Agency (CATCert).6 In this model, the CCP acted as a Registration
Authority ensuring that any digital certificate would be bound to the pharmacist to whom it
would be assigned in a way that assured non-repudiation. That is, this security model
conferred the CHS and CCP more control over pharmacists’ practices thus reducing
undesirable actions from the latter. Regarding the communications, pharmacies would be
connected through a virtual private network (VPN). The CCP signed an agreement with a 6 The CATCert is a governmental agency that was set up in 2002 in order to implement and roll-out the digital signature in all the Catalan governmental institutions and provide services to those organizations ensuring that the electronic transactions fulfill the legal guarantees.
23
telecom provider. That agreement homogenized the service and price conditions for all the
community pharmacies, regardless of their location or size. Each pharmacy would have an
asymmetric digital subscriber line and a backup integrated services digital network line to
connect to the central server of the CCP—the SIFARE7. On May 2008 the pilot was
satisfactorily completed. Overall, the pilot had involved 70 physicians, 56 pharmacies and
17,000 patients, and 314,500 prescriptions had been dispensed.
The EPDI continuously went through destabilization and re-stabilization processes
throughout its roll-out. Those processes were triggered by accelerations and expansions, and
decelerations and compressions of flows of actors (e.g., new physicians and pharmacists
using the EPDI, PMS vendors passing the recognition program, patients migrated into the
EPDI); information services (e.g., medication plans, dispensations, invoices, digital signature,
web apps, CHS-independent services); technological resources (e.g., processing capacity of
the web, application and database servers, of pharmacists’ computers, bandwidth of the VPN,
software bugs); and skills and capacities (e.g. skills and capacities of pharmacists to adopt a
new service, and of PMS vendors to adapt their solutions to a new API). For instance, as new
physicians started using the EPDI, new patients were migrated to the EPDI, and new
pharmacists were trained to start using the EPDI. This in turn, considerably increased the
number of transactions and at some points collapsed the capacity of the technological
infrastructure which had to be adjusted. That is, destabilizing events marked the transition to
a re-stabilizing work such as an increase of the processing capacity of the application servers,
database servers, and pharmacists’ computers, and the bandwidth of the VPN; the setting up
of a technical office and help-desk service to support pharmacists in resolving technical
problems and performing a baseline audit to check whether pharmacies were ready for
electronic prescription; the creation of an e-newsletter to inform pharmacists about the roll-
7 From 2012 some pharmacies started setting up 3G back-up connections.
24
out and the launch of new services; and the upgrading and corrective maintenance of the
software applications running on SIRE, SIFARE and PMS.
The rollout was completed during the third quarter of 2010. At that time all the pharmacies
were using the EPDI. On August 2010 the electronic prescriptions dispensed accounted for
50% of all the prescriptions being billed. On November 2011 an average of 385,222
prescriptions were dispensed electronically daily. This accounted for more than 75% of all
the prescriptions being billed. The CHS estimated that the EPDI had saved around 5,100,000
(patient) visits to primary care centers for collecting prescriptions. During 2011 the CHS
decided to extend the rollout of the EPDI to the specialized care, and in 2012 to the geriatric
residences, and home care. None of these rollouts entailed making significant changes to
SIFARE, PMS or the pharmacists’ routines. Early 2013, 83% of prescriptions dispensed in
pharmacies were electronic.
Tensions between the stability and change of pharmacists' practices remained as the CCP
launched new services independently of the CHS (see years 2011 to 2013 in appendix 1). The
rationale for those services was consistent with the role of the EPDI as an opportunity to re-
professionalize their practice (as seen in previous tension). To do so, the CCP leveraged its
ownership over certain elements of the architecture (the SIFARE and the VPN). On the one
hand, the CCP developed web apps for pharmacists (e.g. tools to support the invoicing,
management of alerts, management of users, management of digital signature, etc.). On the
other hand, the CCP launched new services to pharmacists through PMS vendors by
extending the API for PMS. The idea was that the PMS should be the entry door for
pharmacies to those services. For instance, at the end of 2011 the CCP announced the
“paperless pharmacy” project which entailed leveraging the SIFARE and the VPN to digitize
some paper-based procedures (e.g. recipe and narcotics books). Until then although most of
the PMS electronically stored those documents, pharmacists still had to periodically print
25
those documents and carry them physically to the Department of Health. With this project
pharmacists would keep using their PMS but that information would not only be locally
stored at the PMS but also at SIFARE. Then pharmacists would electronically sign and
submit that documentation that was stored at SIFARE to the Department of Health. This
“paperless pharmacy” project homogenized and reorganized some of the activities and flows
of data of pharmacists (e.g., the case of recipe and narcotics books) aiming to generate
efficiencies. Those data would not be stored in the pharmacists’ local computers or on paper
anymore, but centralized in the CCP’s server. To achieve its purpose, the CCP required the
cooperation and involvement of PMS vendors who had to adapt their solutions to the new
services. Accordingly, in 2013, the CCP worked on a new recognition program for PMS
vendors more oriented to technical aspects and tied to professional services. For instance, in
the case of pharmaceutical care, the CCP had already defined a protocol, and wanted that all
PMS vendors implemented that protocol, not its own one each. This new recognition program
was a component that further helped strengthen CCP’s ties with PMS vendors and this in turn
increased the degree of conformity of PMS. The new services also had the capacity to
reinforce the role of the CCP as a service provider for pharmacists.
Tension 3. Balancing the expansion of the EPDI and the compression of flows of
financial resources
A recurrent destabilizing force of the EPDI was its cost; in other words, the need for a steady
flow of financial resources to fund the infrastructure. On the side of the CCP, there was a
need to invest in the technological infrastructure comprising SIFARE and the VPN. The idea
was that the reduction of cost related to the processing paper-based dispensations for
invoicing (e.g. scanning and checking of dispensations) would cover the costs of the new
technological infrastructure of the CCP. But in any case the CCP searched for alternative
26
sources of funding. For instance, in 2008 they received funding for the VPN from the Center
of Innovation and Development of the Catalan Government.
On the side of individual pharmacies, they had to invest in the connectivity services to the
VPN, upgrading their PMS, the digital signature systems, swipe cards, and swipe card
readers. In 2008 the CCP reached an agreement with a Spanish bank. For those pharmacies
having an account in the bank with a minimum balance, the bank would pay part of their cost
of the connectivity and provide them with their digital certificates and swipe card readers for
free8. In 2010 the CCP received some financial support from the Department of Health of
Catalonia that was distributed among pharmacies. Moreover, a condition for PMS vendors
passing the recognition program was that they had to cover the costs of adapting their PMS to
interconnect with SIFARE as well as the costs of upgrading the PMS for their customers.
The economic crisis in Spain, which started in 2008, became another major destabilizing
force for the EPDI, particularly from 2010. As a result of the pressure from the EU to reduce
the deficit, the Spanish Ministry of Health and Social Security decreased the prices of public-
funded drugs and the margins of pharmacies. Second, the central and the regional
governments approved new taxes in 2012 by which citizens had to partially pay the drugs in
the pharmacy. Those taxes stimulated a fall in drug consumption and the pharmaceutical bill
dropped (see Appendix 4). Third, the financial tensions between the Spanish government and
the regional governments had also a destabilizing effect on Catalan pharmacies. The
autonomous regions, Catalonia among them, lost direct access to financial markets and the
Spanish government became the only source of funding for the regions. The Spanish
government leveraged that new scenario to put pressure on the autonomous regions in order
to reduce the deficit. Then from 2010 the CHS started committing repeated defaults to
8 In 2012 the funding agreement with that bank was still in force and the number of pharmacies benefiting from it had remained constant (around 1,300). As an example the total contribution of the bank was 373,680€ and 520,132€ on 2008 and 2012 respectively.
27
pharmacists. In short, as a result of the economic crisis there was a deceleration of the flows
of invoices, reimbursements, and funding that destabilized the EPDI.
The Catalan pharmacists faced those destabilizing events by leveraging again its ownership
and control over certain components of the EPDI. One initiative was the “paperless
pharmacy” project (already described in the previous section), which reduced the cost of
paper-based processing costs of pharmacists. Another relevant re-stabilizing event move was
the setting up by the CCP of a company called TICFarma in 2011. TICFarma offered
telecommunication services to the same pharmacies and pharmacists. With TICFarma, the
pharmacists (as a collective) increased its bargaining power in front of telecom providers.
TICFarma managed to: (1) reduce the connectivity costs for pharmacists, and (2) launch new
telecommunication services for pharmacists. Moreover, the CCP used TICFarma’s profits to
pay the cost of the technological infrastructure consisting of the SIFARE and the VPN.
Through TICFarma the CCP also reinforced its role as a service provider for pharmacists.
Likewise, the CCP mobilized a collective action of pharmacists to search for alternative ways
to fund the pharmacies and to put pressure on the Catalan government through measures such
as claiming the default interests judicially, organizing a campaign to collect signatures among
citizenship in defense of the pharmacies, and two general closures of the Catalan pharmacies
on October 25th 2012 and November 7th 2013. Overall, that reaction of the CCP increased the
cohesiveness and resilience of the pharmacists as a collective, and in turn, it re-stabilized the
EPDI.
6. Discussion
6.1. Stabilization and destabilization processes at work
The previous section has empirically depicted three main tensions around the digitization of
the paper-based prescription infrastructure in Catalonia from 2000 to 2013. The first tension
28
illustrated the need to balance the interests of the National government towards an integrated
National DI with those of the regional governments and other lower-scale collectives (e.g. the
pharmacists) on keeping control over the installed bases of systems and practices. Moreover,
the first tension also illustrated the balancing of the interests of the Catalan Health Service on
administrative and centralized control over the activity of pharmacists with the interests of
pharmacists on keeping their autonomy over their professional practice. The second tension
illustrated the need to balance the stability with the change of pharmacists’ and PMS vendors'
practices. The third tension illustrated the balance of pharmacists' needs to invest on a robust
infrastructure with their diminishing revenues from public-funded drugs.
These empirical results do not pretend to be an exhaustive list of tensions that extend the ones
reported by prior DI literature (Hanseth et al. 1996; Reimers et al. 2014; Tilson et al. 2010),
or to theorize about the mechanisms that balance those tensions (Wareham et al. 2014).
Rather, our results illustrate the idea that DIs are always in tension responding to continuous
processes of stabilization and destabilization. In broad terms, the digitization of the
prescribing, dispensing and invoicing processes involved a progressive disruption of the
existing ordering of the paper-based prescription infrastructure (i.e., freeing up existing
relations between the diverse components: physicians, patients, pharmacists, invoices,
documents, roles, legacy systems, and so forth), and subsequently rearranging and
recombining some of those components, as well as assembling new ones. Our narrative of the
digitization speaks of continuous processes of destabilization and re-stabilization which
provided the DI with both change and endurance, respectively. Our account has highlighted
the balancing acts of the CCP to overcome the tensions.
Stabilization and destabilization processes are related in different way. For instance, in our
case there are many examples of sequences of processes where destabilization is followed by
re-stabilization and also examples where a stabilization process triggers a destabilization
29
process. A typical example of the latter is that when one version of the EPDI stabilizes, this
triggers an adoption process which destabilizes the existing practices in pharmacies (which
again is followed by re-stabilization). In such cascades of processes there are also feedback
loops and self-reinforcing processes (Hanseth and Lyytinen 2010; Henfridsson and Bygstad
2013). The adoption of the EPDI contributes both to its stabilization and destabilization.
Adoption of the EPDI implies that it grows in number of computers and software modules
and this increases the costs of switching to a new version, i.e. it stabilizes the EPDI. At the
same time, growth in number of users of the EPDI generates more traffic which again implies
that after some time the EPDI must be upgraded to handle this growth, i.e. destabilizes the
EPDI. Further the stabilization of the EPDI triggered the generation of ideas about new
services that could be added to the EPDI. When such add-ons are adopted they again
contribute to both the stabilization and destabilization of the existing EPDI. We also see that
in principle independent processes interact and strengthen or weaken each other. For instance,
the financial crises triggered a number of different processes at various levels, all contributing
to destabilizing the EPDI in terms of constraining the funding of its operations.
We also see different kinds of destabilizing process. Some processes have the character of
more sudden incidents which immediately cause a breakdown of an assemblage (the EPDI,
pharmacies’ practices, etc.) and its restructuring and re-stabilization. This happened, for
instance, when serious software errors were detected. Other destabilizing processes have the
character of accumulation of destabilizing elements, but where change of the assemblage is
not happening until the number of destabilizing elements has reached a certain threshold.
This is typically the case with the adoption process where each new user of the EPDI
represents a destabilizing element, but where each element has no direct effect until the
threshold is reached. For instance, as the number of physicians and prescriptions going
through EPDI increased, the processing capacity of the servers and the bandwidth of the VPN
30
had to be scaled; otherwise, there would be more disruptions in the prescribing and
dispensing applications. At a certain threshold of disruptions (in terms of number or
duration), physicians and pharmacists perceived that they could not exercise their
professional practice, and accordingly, they temporally reversed the use of the EPDI. As
more physicians discontinued the use of the EPDI, the less value pharmacists saw in using the
EPDI.
6.2. Interactions between assemblages
The stabilizing and destabilizing processes through which the EPDI evolves are the outcome
from the interactions of the multiple heterogeneous components (or assemblages) –e.g., CHS,
CCP, PMS vendors, pharmacies, services, APIs, transactions, norms, economic crisis, laws,
banks, and so forth– characterized not by their properties but rather by capacities to interact,
i.e. relations of exteriority. In those interactions components exercised their capacity to affect
and be affected. Moreover, by conceiving the DI as characterized by relations of exteriority
we have shown that the DI is subject to tensions from its surroundings. That is, the DI is not a
static object; rather it is in-process, becoming, and ever-changing. The DI is not a whole with
clear boundaries, but an open-ended grouping of heterogeneous components (Hanseth &
Lyytinen 2010) that over time have established more or less durable relationships with each
other and the whole. Components enter into the whole via contingent relations. In other
words, the components of a DI are open to various “plugins” that can change at any time thus
rendering the degree of stabilization of a DI precarious and hence its evolution unknowable in
advance. In short, we consider that the notions of relations of exteriority and (de-
)stabilization offer a conceptual tool for grasping the dynamics and tensions characterizing
DIs and following them through space and time.
Another characteristic of our narrative about DI evolution is that it describes things and
events occurring at different levels of scale (pharmacy, collective of pharmacists represented
31
by the CCP, regional DI, and national DI) and the bottom-up movements of scales that lead to
the emergence and evolution of the DI. For instance, on the side of pharmacists (at a lower
scale), the multiple installed bases of pharmacies were articulated together through
components such as SIFARE, API, VPN, recognition program, agreement with a bank, and
so forth. Similarly, on the side health providers, the multiplicity of physicians' installed bases
was assembled. Then both assemblages (pharmacies and health providers) were articulated
together through SIRE, web services, regulations, security model, and so forth, and
synthesized into the EPDI. However, this bottom-up assembling process has not yet occurred
at the national scale since the multiple regional DIs are still not interoperable. Due to
differences among regions in terms of availability of resources, installed base of systems and
practices, and political interests and priorities, the several regional projects that were
underway followed their own design guidelines. Moreover, for these regional projects
interoperability across regions was not a priority. This definitively destabilized the vision of
the central government about the standardization and interoperability of the prescribing and
dispensing processes across Spain. That is, while the initial outcome of the PISTA project
destabilized the regional installed bases, the subsequent stabilization of those regional DIs9
ended up destabilizing the National DI. Yet at the European scale there has been an initiative
called epSOS10 which aimed to interconnect diverse National Contact Points supporting
electronic prescribing and dispensing. In the case of Spain, the regions of Andalusia,
Catalonia and Balearic Islands participated in the project. So in Spain, epSOS provided the
opportunity for interoperability across regional DIs without having to go through a National
DI. That is, some of the regional DIs were articulated into a European scale bypassing the
national scale. Overall, this study provides empirical evidence to support the idea that the 9 By the end of 2014 (15 years after the PISTA project was initiated) twelve out of seventeen regional DIs were stable (in the sense that in those regions 75% of the prescriptions were done electronically, and 100% of pharmacists used the DI for dispensing and invoicing). 10 Smart Open Services for European Citizens (www.epsos.eu) project run from July 1st 2008 to July 31st 2014.
32
existence of a DI at one scale depends on the stability of the DI at a lower scale and that any
DI emerges and evolves through bottom-up movements.
6.3 The co-functioning of architecture and governance
This section discusses how the co-evolution and co-functioning of the architecture and the
governance regime conditioned the processes of destabilization and re-stabilization processes
(see Table 1 for a summary of the properties of the architecture and governance structure).
As shown in the first tension, the architecture and governance regime were not static but
changed during the design of the EPDI (between 2004 and 2005). There was a process of
disaggregation in which the initial integral centralized architecture and the top-down
governance structure shifted to a dual one and middle-out approach respectively. The integral
CHS-centered architecture and the top-down governance structure were important conditions
in the simultaneous stabilization of the DI at the regional scale and destabilization of the DI at
the scale of pharmacists. With this integral CHS-centered architecture pharmacists could be
monitored, analyzed, and profiled by analytics in which the central database controlled by the
CHS would govern the constitution the subject (the pharmacist) as a crucial instrument of
control at a distance. So the control over the profession would reside away from pharmacists
in the central database and the analytics would be performed only by the CHS (government).
Moreover, the integral CHS-centered architecture involved a change in the relation between
CCP and pharmacists; the CCP would be detached from the day-to-day practices of
pharmacists such as dispensing and invoicing.Therefore, this configuration of architecture
and governance represented a powerful destabilization of pharmacists’ practices.
Then as a result of the re-stabilizing work of the CCP, that configuration of architecture and
governance shifted to a dual architecture (figure 3) comprising two central nodes (SIRE
controlled by the CHS, and SIFARE controlled by the CCP) and a middle-out approach
comprising a steering committee and follow-up committees that went toward bringing closer
33
the needs of health providers, government, pharmacists, Colleges of Physicians, and the CCP.
In the dual architecture both nodes (SIRE and SIFARE) stored very similar data and run
similar applications. Data would remain centralized residing in the servers of both the CHS
and the CCP thus conferring real-time visibility over the data to the CHS. At the same time,
the fact that data and applications would reside in the CCP’s server (SIFARE) also meant that
the CCP would be able to implement services that could enhance their professional
development.
Moreover, the middle-out approach to governance and the dual architecture altered the
organization of interdependencies. In particular, the CHS devolved the responsibility over the
design, development and operation of diverse parts of the EPDI to the CCP. That created two
centers of activity (governance’s property): the CHS and the CCP. The CCP would be in
charge of building the private network for pharmacies, developing the SIFARE, and
promoting EPDI’s use among pharmacists. Because the CCP would mobilize resources,
material (e.g. money) and expressive ones (e.g. legitimacy) for pharmacists, it was perceived
as a catalyst for the success of the project.
Overall, the configuration comprising the dual architecture and the middle-out approach to
governance supported the re-stabilization of the DI at the regional scale and the scale of
pharmacists. Yet a side effect of this configuration was the potential increase of the
heterogeneity within pharmacists, which would further destabilize the DI on their side.
Tension 2 shows how this side effect was minimized with a decoupling of one of the central
nodes (SIFARE) from pharmacists’ PMS. This decoupling increased the degree of
modularization of the architecture on the side of pharmacists. The functionalities of SIFARE
were decomposed into loosely coupled components and the interface specifications for how
PMS should interact with SIFARE were codified through web services. This way the CCP
was able to incorporate gateways (e.g., recognition program, API) that facilitated the
34
integration of PMS vendors. Hence, those gateways respected and kept up the multiple
practices and systems of pharmacists, as well as accommodated the number and frequency of
new services sponsored by the CHS to the interests and capacities of pharmacists and PMS
vendors. In that respect, the architecture became modular in production (Baldwin and Clark
2000), adding stability to the installed base of pharmacists while at the same time giving them
space for certain autonomy and new innovations. This shift to a loosely coupled architecture
between the central node (SIFARE) and pharmacists (PMS) was also accompanied by new
components that further decentralized the governance structure (e.g. advisory committee
between the CCP and PMS vendors, and the adjustments to the recognition program). This
governance structure enabled the CCP to keep the control over pharmacists and PMS vendors
(stabilizing the EPDI) while at the same time delegated some roles and responsibilities to
PMS vendors and by doing so, stimulated that some decisions could be taken in a more
decentralized manner (destabilizing the EPDI). Moreover, this configuration of architecture
and governance allowed the EPDI to grow autonomously on the side of pharmacists without
the need for a CHS-centered control.
Finally, tension 3 shows how the destabilization and re-stabilization processes associated
with the expansions and compressions of flows of financial resources were conditioned by a
combination of components of the dual architecture and the middle-out governance structure.
The CCP further leveraged its control over some architectural components (SIFARE and the
VPN) and its position as representative of pharmacists, all of which were obligatory passage
points (Callon 1986) for the CHS, pharmacists, PMS vendors, and telecom providers, to
undertake a series of actions. One of those actions was the creation of TICFarma, which
emerged at the nexus of a series of destabilizing flows related with the economic crisis. For
instance, delays by the CHS in the reimbursement of the pharmacists’ invoices (a slowdown
of the speed of flows) combined with a lack of alternatives for funding pharmacies (Spanish
35
banks limited the credit to companies), and with the reduced margins of drugs that led some
pharmacies to limit the diversity of drugs that they dispensed11 (volume reduction of flows of
public-funded drugs and invoices). Before TICFarma, the infrastructure built by the CCP (for
pharmacists) had been mainly financially supported by the same pharmacists through a
percentage of the invoices. With TICFarma that infrastructure would be also funded by the
telecom providers and the potential new services that could be developed (e.g. the paperless
pharmacy project). Hence, TICFarma helped to dampen the decelerations of those flows (e.g.,
payments, funding) by ensuring the continuity of use of the EPDI, and ultimately re-
stabilized the EPDI.
In short, we have shown how the interactions among the properties of the architecture (being
dual and modular) and the middle-out governance structure endowed the DI with the capacity
to evolve in a way that balanced the homogenization of practices with the stimulation of new
innovations. That is, the architecture and governance of the EPDI created a space in which
diverse flows of actors, information services, technological resources, financial resources,
and skills passing through the DI could more easily circulate.
Table 1: Properties of architecture and governance
Tension Architecture Governance
Centralized control and autonomy of actors at national at regional levels
From an integral centralized tight-coupling architecture comprising a single data base, and a single application for dispensing and invoicing,
to a dual architecture at the core that decoupled the two central nodes: SIRE and SIFARE).
From a top-down approach and centralized control structure (national and regional),
to a middle-out approach that brings together the needs of regional government (CHS), health providers, pharmacists (and the CCP), Components of the governance between CHS and CCP: 1) Amendment to the pharmaceutical agreement; 2) Steering & follow-up committee for EPDI; 3) Decree regulating the EPDI.
11 Some pharmacies stop dispensing some drugs (particularly the most expensive drugs) arguing that they could not afford funding themselves the drugs.
36
Stability and change of pharmacists
Modular architecture decoupling the CCP’s central node (SIFARE) from pharmacists’ systems (PMS). The CCP used gateways (not standards) such as recognition program, or API exposed in DLL to minimize disruption of installed base.
Platform-architecture on the side of pharmacists that allowed new innovations from the CCP (new data services, paperless pharmacy project) and from 3rd parties (PMS vendors).
New components of the governance between CHS and CCP: 1) Act for the roll-out; and 2) Security model (encryption of communications between SIRE and SIFARE; CCP as a Registration Authority).
Components of the governance between the CCP and pharmacists’ side: 1) Advisory committee between CCP and PMS vendors; 2) Recognition program for PMS vendors; 3) Agreement with telecom provider; and 4) Security model (digital certificate for pharmacists).
Extension of the recognition program for PMS vendors.
Expansion and compression of flows of financial resources
Dual architecture, and in particular the architectural control points: SIFARE and VPN.
Components of the governance between the CCP and pharmacist: 1) Advisory committee between CCP and PMS vendors; and 2) Redefinition of the recognition program for PMS vendors.
Foundation of the TICFarma company.
6.4. Towards a contingency theory of DI evolution
Our findings support previous research (reviewed in section 2) showing that DIs evolve
according to the way relevant tensions are managed and that the evolution of DIs is shaped by
the architecture and governance of DIs. But our findings extend previous research by
providing a more integrated model that depicts DI evolution as the interaction between
processes of stabilization and destabilization that are conditioned by the DI’s specific
configuration of architecture/governance.
We consider the EPDI’s specific configuration of architecture/governance as a fortunate
choice. It has been a key factor in the successful establishment and evolution of the DI. This
is of special significance because both the architecture and the governance structure are far
from optimal according to, if not directly contradicting, conventional Software Engineering
37
and IS development and implementation wisdom. The dual architecture introduced what was
seen as unnecessary redundancy and complexity. At the same time, the governance structure
where two governing units (CHS and CCP) worked to a large extent independently and
autonomously could be seen as representing a high risk for the fragmentation of the solution
to be developed. However, this configuration of architecture and governance structure was
well aligned with the structures of the user community which is characterized by two main
groups: pharmacies/pharmacists and health care providers/physicians. This configuration
supported the evolution of the DI into two loosely connected platforms which made it fairly
easy for the CHS and CCP to reach agreement about what and how data should be shared.
Moreover, this configuration enabled the CHS and the CCP develop additional services on
top of their platforms for their respective user communities. This conforms to the findings of
Constantinides and Barrett (2014) who suggest that a polycentric approach to DI governance
may support successful infrastructure development and scalability. We consider that the
configuration of architecture/governance identified in our study can be successfully replicated
in the development of shared DIs for user communities that are constituted by clearly
identifiable user groups.
In line with Henfridsson and Bygstad (2013) we suggest that we need to move towards
contingency theories (or mid-range theories) about the relations between specific
configurations of architecture and governance and how they fit specific kinds of DIs and
business sectors. We may move towards such a theory by combining our findings regarding
the performance of the configuration of architecture/governance in our case with others’
findings. This includes for instance, the Internet’s combination of end-2end architecture and a
governance structure composed of a huge loosely connected networks of individual
developers and development organizations drawing heavily upon the Internet itself for
coordination and information sharing (Hanseth and Lyytinen 2010; van Schewick 2010). The
38
smartphone centered ecologies based on platforms and “appstores” where individual actors
(e.g. Apple, Google) control the platform (Eaton et al. 2015; Tilson et al. 2012). Also
Henfridsson and Bygstad (2013) found that DIs characterized by loosely coupled architecture
and a governance regime based on decentralized control and where the three self-reinforcing
mechanisms (innovation, adoption, and scaling) were present, evolved successfully.
Moreover, they also found three successful cases characterized by a tightly coupled
architecture and a centralized control governance structure, where only adoption and scaling
mechanisms were present. Henningson and Hanseth (2011) studied the European Union
eCustoms initiative aimed to computerize and harmonize the diverse existing national DIs
and integrating them into a pan-European eCustoms DI. By drawing upon assemblage theory,
they depict the evolution of the eCustoms DI as dialectic between stabilizing and
destabilizing processes, and show how the loose coupling between the different national DIs,
combined with the tight-coupling of national DIs, and a governance structure characterized
by a classical hierarchical structure at the national level rather than at the European level,
shaped the evolution of the diverse DIs. The authors argue that while national DIs evolved
quite successfully, there was a fragmentation of the European eCustoms DI. In that sense, the
authors argue that the “eCustoms initiative have failed because they stabilized what should
have been destabilized (the exiting national DIs) and destabilized what should have been
stabilized (i.e. limit the growth and integration of additional systems)” (p. 17). Finally, in
their research on DI initiatives in the Norwegian healthcare sector, Hanseth and Bygstad
(2012, 2014) found that a configuration based on centralized architecture and centralized
control was most successful for establishing new and innovative DIs, while a decentralized
architecture and decentralized control were crucial for further development of and
innovations on the DI after it was successfully established.
39
The different DIs mentioned here are developed to support very different kinds of services
and user groups. Some of the initiatives aim at stimulating maximum innovations while
others aim at restructuring and harmonizing existing DIs. These are important parameters
when determining which stabilizing and destabilizing processes one want to generate in order
to make a DI evolve in desired directions and then which architecture governance
configurations can help achieve that.
7. Conclusion
This paper has explored the evolutionary dynamics of DIs. We have shown that DIs are
characterized by fluidity and openness to number and types of users and limitless possibilities
for re-combinations of digital artifacts, while at the same time having closed and static
structures that give them continuity. By drawing upon assemblage theory, this paper has
articulated a two layer model that conceives the evolution of DIs as a set of interacting
stabilizing and destabilizing processes which are conditioned by the co-functioning of the
DIs’ architecture and governance structure. Our account builds on and integrates the ongoing
debates in the literature which on the one hand study the influence of architecture and
governance in the design and evolution of DIs (Constantinides and Barrett 2014; Hanseth and
Bygstad 2014; Henfridsson and Bygstad 2013; Tiwana 2014), and on the other hand, which
depict DIs as characterized by tensions that need to be balanced (Hanseth et al. 1996; Ribes
and Finholt 2009; Tilson et al. 2010; Wareham et al. 2014). We suggest that further research
could investigate different dynamics around the processes of stabilization and destabilization
that characterize DI evolution, as well as other configurations of architecture and governance
in other settings that will extend our results.
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8. Appendix 1. Timeline of events
Next table presents a timeline for the events from 2000 until 2013.
Table 1: Timeline for the EPDI
2000
The Spanish Ministry of Science and Technology in collaboration with governments of the autonomous regions as well as the representatives of professional agents involved in the prescription and dispensation processes (physicians and pharmacists) starts working on the foundations for a common Spanish EPDI.
2001
The CCP leads a first pilot of EPDI, involving a hundred private physicians and 25 community pharmacies.
The CCP tries to extend this pilot to the public health but fails.
From October 1st, incorporation of the “individual medical card” to the dispensing process. This accelerated the process of computerization of Catalan pharmacies.
In parallel, the CCP, in collaboration with other professional colleges, sets up a company (FirmaProfessional) which issues digital certificates. Some pharmacies start using those certificates to send electronically their data for invoices or other kind of files to the CCP, or check online the data of patients’ individual medical cards.
2002 A first draft for a Spanish EPDI is presented. Since Spain has a decentralized health care system, the diverse autonomous regions are expected to start their own EPDI.
2004 The CHS sets the foundations for the building of an EPDI for the public health.
EPDI’s design is negotiated between the CHS and the CCP.
2005
During the first half of the year the EPDI’s design is approved.
The CHS defines the functional specifications for its system (called SIRE) and starts its development (which is outsourced to an IT services company, a joint venture of Telben and Accenture).
A governance structure for the project consisting of two committees (steering committee and executive committee) which involve all the actors (CHS, Health Providers, CCP, ….) is created. This governance structure is still valid in 2013. Obviously the role of the committees has changed throughout the phases of the project.
The CCP starts the development of its system (called SIFARE, which is outsourced to an IT services company, EDS which in May 2008 was bought by HP).
The CCP launches a recognition program for PMS vendors.
5 PMS vendors get the recognition.
The CCP issues an invitation to tender for the pharmaceutical virtual private network (VPN).
2006
The CHS completes a first version of SIRE (and its web services).
The CCP completes a first version of SIFARE (and the associated web service) and releases API 1 (for PMS vendors).
The CCP reaches an agreement with PMS vendors in order that the latter will assume the cost of upgrading their software for pharmacies.
Telefonica wins the tender to build the pharmaceutical VPN.
A pilot of the project starts and a first real prescription is done on April 2006.
44
The rollout of the VPN starts with the pharmacies that participate in the pilot.
Due to repeated technical problems and errors with SIRE, the CHS stops the pilot and starts a new version of SIRE to address those problems (the CCP hires a new IT services company, ATOS).
2007
1 additional PMS vendor gets the recognition.
The CCP gets a subsidy from the Center of Innovation and Development of the Catalan Government for the infrastructure
A new version of SIRE and SIFARE are completed on November.
At the end of the year the CHS resumes the pilot involving two health regions (in the provinces of Girona and Tarragona). The physicians of primary care services, pharmacies and patients are progressively added into the pilot, being physicians the ones who decide which patients must be prescribed electronically.
The rollout of the VPN continues among the pharmacies involved in the pilot.
2008
3 additional PMS vendors get the recognition.
On May the pilot is satisfactorily completed. The pilot has involved 70 physicians, 56 pharmacies and 17,000 patients, and 314,500 prescriptions have been dispensed.
The CHS starts the rollout of the EPDI during the 3rd quarter. The rollout consists of four phases each involving different health regions. The last phase (and health region) is that of Barcelona (that involves 2,200 of the 3,000 pharmacies in Catalonia).
The CCP reaches an agreement with a Spanish bank by which the bank will pay part of the cost of the connectivity for pharmacies as well as provide pharmacies with their digital certificates and swipe card readers for free.
On December the CCP creates an e-newsletter and a technical office to support pharmacies during the rollout.
2009
On January the CCP sets up a helpdesk to support pharmacists.
The CCP releases API 2 (for PMS vendors).
The last phase of the EPDI’s roll-out which involves the health region of Barcelona starts by mid-year
2010
On January the electronic prescriptions dispensed accounted for around 23% of all the prescriptions being billed.
The rollout of the VPN completes.
The Catalan Department of Health gives a financial aid to the CCP to support the connectivity of pharmacies
The CCP launches new web applications to support pharmacists (e.g. tools to support the invoicing, management of alerts, management of users, management of digital signature, etc)
The EPDI’s roll-out for all the primary care centers is completed during the third quarter of the year. All the more than 3,000 Catalan pharmacies are daily using the EPDI.
On August the electronic prescriptions dispensed accounted for 50% of all the prescriptions being billed.
2011
Due to some unsatisfactory response from the telecom provider (Telefonica), the CCP decides to extend the helpdesk services to include the monitoring of the infrastructure in order to detect failures before pharmacists realize. The aim is to minimize the impact of massive failure by acting in advance.
On November an average of 385,222 of electronic prescriptions are dispensed daily. The CHS
45
estimates that the EPDI had saved around 5,100,000 (patient) visits to primary care centers for collecting prescriptions.
The CHS does some pilots of EPDI in the specialized care and mental care.
The CCP sets up TicFarma (a business) to leverage the CCP’s ownership of the VPN, and hence its bargaining power in front of telecom providers to reduce the costs of telecommunication services (data and voice) for pharmacists. Apart from reducing the connectivity costs for pharmacists, with TicFarma the CCP also aims to launch new telecommunication services for pharmacists. With TicFarma the CCP seeks to transform all the pharmacies into a corporation which offers telecommunication services to the same pharmacies and pharmacists. Moreover, TicFarma’s profits are used to pay the cost of the CCP’s infrastructure consisting of the SIFARE and the VPN.
By the end of the year, the CCP announces the “paperless pharmacy” project. This project entails leveraging the SIFARE and the VPN to digitize some paper-based procedures (e.g. recipe and narcotics books) and interactions of pharmacies with the Department of Health. With this project the CCP will develop a set of web services and will release a new API for PMS vendors.
2012
The CHS starts the EPDI’s roll-out to specialized care. That rollout does not entail substantial changes to SIFARE or PMS.
The CHS integrates the paper-based prescriptions and dispensations into the EPDI
The Catalan government approves the “euro per prescription” tax by which patients will pay an additional euro for each prescription at the pharmacy. This new tax requires releasing new versions of the SIRE and SIFARE.
The CCP releases API 3 (for PMS vendors) to support the “euro per prescription” tax.
The Spanish government passes the co-payment act which entails that citizens will pay drugs based on their income. The calculation of the final amount and the payment will take place in the pharmacy when the patient picks the drug. This act entails making changes to SIRE and SIFARE.
The CCP releases API 4 (for PMS vendors) to support the so-payment act.
The CHS starts the roll-out in geriatric residences, and home care. Such a rollout does not entail any changes to SIFARE or PMS.
First closure of the Catalan pharmacists on October in protest for the repeated defaults of the CHS.
2013
The CCP redefines the recognition program for PMS vendors in order to include new professional services in line with the ones defined in the “paperless pharmacy” project.
The CCP releases API 5 (for PMS vendors) that supports the new recognition program.
The CHS works on new services that involve changes to SIRE, SIFARE and PMS –for instance, informing patients about the cost of treatments. Those changes are progressively incorporated in the new versions of SIFARE’s web services.
Second closure of the Catalan pharmacists on November in protest for the repeated defaults of the CHS.
46
9. Appendix 2. SIFARE Web services and APIs developed by the
CCP
A first version of the API was released in 2006 coinciding with the pilot. A second one was
released in 2009 before the massive roll-out in Barcelona. The third and fourth versions were
released in 2012 coinciding with two main regulatory changes, one from the Catalan
Government and another from the Spanish government; a fifth version which was to be
released by end 2013. The fifth API was launched in 2013 and included new professional
services (e.g. the case of the “paperless pharmacy” project).
List of SIFARE web services, their version and the corresponding API.
SIFARE Web Service API 1 (2006)
API 2 (2009)
API 3 (early 2012)
API 4 (oct.
2012)
API 5 (2013)
Calculate prescriptions that need to be dispensed v1 v3 v10 v12 v12
Look up next dispensation date v1 v2 v4 v5 v5
Insert dispensation v1 v1 v4 v6 v6
Insert paper-based dispensation v1 v2 v3
Delete dispensation v1 v1 v1 v2 v2
Delete paper-based dispensation v1 v2 v2
Look up dispensations made v1 v2 v4 v8 v8
Look up dispensations made by pharmacy v1 v1 v2 v4 v4
Look up paper-based dispensations made by pharmacy v1 v2 v2
Look up dispensations that need to be signed v1 v4 v7 v9 v10
Creation and signature of lots of prescriptions v1 v1 v1 v1 v1
Look up of contingent codes per pharmacy v1 v1 v2 v1 v1
Insert delayed dispensation v1 v1 v1 v3 v4
Block prescription v1 v1 v2 v2 v2
Create product reserve v1 v1 v2 v2 v2
Consult prescriptions v2 v2 v2
Consult generic alerts v1 v1 v1
47
Consult document associated to an alert v1 v1
Enable/Disable/Confirm reading of messages v1 v1 v1
Consult messages to pharmacists v2 v3 v3
Insert message v1 v1 v1
Consult required tax v2 v3 v4
Insert tax v1 v1 v1
Delete tax v1 v1 v1
Consult tax applied by pharmacy v1 v1 v1
Consult tax applied by citizen v1 v1 v1
Consult warning generated by the CHS v1 v1 v1
Consult document associated to a warning v1 v1 v1 v1 v1
Insert warning for the physician v1 v1 v1 v1 v1
48
10. Appendix 4. Evolution of pharmaceutical bill in Catalonia
Evolution of the pharmaceutical expenditure of the Catalan Health Service in the period 2004
to 2013.
Year Pharmaceutical expenditure in € (1)
Number of prescriptions
2004 1.135.994.555 88.349.827 2005 1.192.708.331 93.255.814 2006 1.240.916.916 95.908.647 2007 1.272.866.297 100.606.918 2008 1.364.946.036 107.207.365 2009 1.392.951.071 109.014.080 2010 1.386.379.728 112.320.893 2011 1.282.039.257 115.386.329 2012 1.136.101.523 110.619.114 2013 987.091.295 98.204.823 2014 1.009.847.263 100.053.114
(1) Aggregated period January -‐ September