While we agree with Berg,34 that what counts as success in healthcare information infrastructures is tricky to define; we would argue that the Danish General Practitioners Database was a success-ful information infrastructure, which then ended up as a total failure due to reverse synergy. Our concept of reverse synergy is challenging the dominant idea in contemporary information infra-structure literature concerning healthcare, where studies continuously argue how adding new actors adds new potential value, and where failures are often seen as misalignment between actors, which could have been mitigated.4,5 We argue that in our case the situation was not about lack of alignment, but rather the underlying concern held by core actors related to the uncertainty for how fundamentally incompatible agendas were introduced. Our case demonstrates that connecting new actors uncritically to an information infrastructure can have serious consequences for the existence and further development of it. Clearly, information infrastructures transform over time, and we do not argue for isolation and closure. Rather, we bring to the surface how potential conflicts about the ontological structure of an infrastructure introduced through political measures; encourage key participants to resist. In our case, resistance came in terms of a lawsuit and local workarounds fighting what was seen as political strong agendas forced top-down, but in other cases resistance might take different forms, which is why future research should investigate similar cases in other parts of the world such as the United Kingdom35 and Scotland.36 In turn, by comparing and analyz-ing multiple cases, we might then be able to identify strategies of how to avoid reverse synergy.
Our purpose is not to suggest strategies for reducing risks of resistance. Rather, our case demon-strates costs of reverse synergy being corrosive to the ontological inertia initially built into the infrastructure. Our article unpacks the oft-missed cost of misaligned actors and conveys the funda-mental idea that adding new actors, agendas, or purposes risk having serious consequences for existing successful information infrastructures.
Acknowledgements
Earlier versions of this paper were presented at the 5th International workshop on ‘Infrastructures for Health Care: Patient-Centered Care and Patient Generated Data’ in Trento June 2015; and at the ‘Knowledge Infrastructure’ workshop held in Seattle in December 2015. We are grateful to all participants who have made comments and especially to David Ribes, Ola Hanseth, and Stephanie Steinhardt for their comments and discussion. We would also like to thank the anonymous reviewers for insightful comments and suggestions as
well as the people who lent us their time to be interviewed for this paper. Finally, we want to extend a special thanks to David Randall for discussing the initial scope of the project over a cup of coffee and to Charlotte Lee for her constructive comments and contribution in critically discussing the argument in earlier versions of this paper.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Notes
i. Documents include the following:
1. OECD (2013) OECD reviews of health care quality: Denmark. Available at: http://www.oecd.org/els/health-systems/ReviewofHealthCareQualityDENMARK_ExecutiveSummary.pdf (accessed 13 April 2016).
2. Kristensen TG (n.d.) DAMD-opfinder: Striden er vel konsekvensen af vores succes. Available at: http://
www.altinget.dk/artikel/damd-databasens-opfinder-det-er-vel-konsekvensen-af-vores-succes
3. Lægeforeningen (n.d.) Yngre læger og PLO-forhandlingerne. Available at: http://www.laeger.dk/portal/
page/portal/LAEGERDK/Laegerdk/Y_L/Overenskomst/ALMEN_PRAKSIS/
4. Practicus (2013) Data til kvalitetsudviklings- og forskningsprojekter fra Dansk AlmenMedicinsk Database (DAMD). Available at: http://www.practicus.dk/flx/artikler/?m=showArticle&aid=243 5. Rasmussen LL (2006). Bekendtgørelse om indberetning af oplysninger til kliniske kvalitetsdatabaser
m.v, 21 December. Available at: https://www.retsinformation.dk/Forms/R0710.aspx?id=11046
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https://doi.org/10.1177/1460458216655188 Health Informatics Journal 2018, Vol. 24(1) 54 –65
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