Towards new challenges for innovative management ... - Erima - Estia

II. The challenge in France: How to cross frontiers in an overlycompartmentalized
Healthcare system?
According to V. Fuchs, the main challenge faced by American medicine is “to devise a system of
medical care that provides ready access at a reasonable cost” (Fuchs, 1998). In France,
however, the challenge points to an old and deep tension between the concerns of liberty and
equality. The French health system struggles to choose among individual and collective
interests, while also addressing a vital need for data for decision making (Fuchs, 1998).
As in many other developed countries, an over-compartmentalization of activities is often seen as
a primary cause of high cost and weak quality in the France’s health system. Indeed, France’s
health system suffers a particularly worrisome case of compartmentalization, between the Health
Ministry (“Ministère de la Santé”) and Health Insurance (“Assurance Maladie”), between large,
« hospitalo-centric » hospitals and primary care, and between specialists and general
practitioners. Within the hospital structures themselves, there is added compartmentalization
between doctors and other professionals (e.g. nurses), and among treatment, care and social
goals. The patient is said to be torn between rival services of public or private hospitals, between
different health providers and between professions that are often in conflict. Each profession
rivals to defend its own specificity and power.
In the hospital, Glouberman and Mintzberg (2001) distinguish four separately-working worlds,
symbolized by four Cs: Cure, Care, Control, and Community. Cure relies on physicians, Care
depends on nurses, Control and administration are entrusted to managers, and Community
concerns boards and trustees. However, France is not alone. In the USA, Shortell et al. (1996)
highlight an excessive fragmentation, claiming that an integration of these various components is
imperative to each of them. The goal is to improve the quality of care and to contain (or better yet,
to cut) costs. Better information management is the key to reinforcing co-ordination among all
actors involved in the care delivery process.
According to the Fieschi report (2003) the individualistic French mindset makes it difficult to build
a culture of information and evaluation or assessment. The key challenge is first how facilitating
information exchange then information sharing and in the long run collective producing of
information for improving management and building innovative cooperative practices centred on
patients in an idea of management by processes (quality and traceability).
III. The specificity of health data
Health and medical patients’ data is uniquely personal, and demands rigorous measures of
confidentiality (privacy). It is subject to restrictive legislation, such as the “Health Insurance
Portability and Accountability Act” (HIPAA) in the United States, the “Commission Nationale de
l’Informatique et des Libertés” (CNIL) in France (in conformity with European Union directives), or
the “Commission d’ Accès à l’Information” in Québec (Canada).
The aim of such legislation is to assure property, access, storage and responsibility in using
patient’s data. Solutions vary according to different national contexts. Sometimes conflicts arise
between different legislation measures, such as that between individual States in the US and the
American Federal Government (Bourret, 2004).
IV. Innovating information tools in a networked health system
According to Grimson (2000): “The present inability to share information across systems and
between care organizations…represents one of the major impediments to progress toward share
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