Representative Participation in a Large-Scale Health IT Project

User involvement is widely recognized as best practice in the development of information technology (IT) systems. In large-scale IT projects, the involvement of users and other stakeholder groups is typically in the form of representatives, as opposed to the direct (in-person) participation characteristic for smaller projects. The potential new sharing of power that representative participation entails vis-à-vis direct stakeholder involvement, and the implications of such a shift, are an important discussion in the context of participatory design. This paper extends and adds to previous work on this subject. Drawing on stakeholder interviews conducted as part of a case study of an electronic health record implementation project in Norway, this paper seeks to describe and analyze problems that can arise with representative participation in a large-scale project. Our focus is on an observed decline of interaction between health professionals participating actively in the project and their advisory units consisting of colleagues without a formal project role. The paper describes how the project's structural arrangements might explain this decline. The paper also describes how the participating health professionals' involvement of the advisory units at regular intervals early in the project (broad involvement) was replaced by more ad hoc and competence-oriented approaches (narrow involvement). We further use the organizational structure of democracies as the basis for two analogies, (I) participants-as-political-representatives and (II) participants-as-technocrats. The observed decline in interaction between the participating health professionals and their advisory units can be seen as a transition in role from user representative to technocrat. Generalizing from the case, we suggest that (1) a project's structure strongly affects the possibilities of participating users to consult other users (e.g., non-participating colleagues) about issues concerning the design solution, (2) a project's structure conditions the role of participating users and who, or what, they represent, and (3) representative participation requires rethinking a project's structure.