What's Behind the 'Digital Front Door'? Building a digital care infrastructure in a fragmented healthcare system

With alarming demographic and workforce developments in healthcare systems globally, digital health innovations are often heralded as solutions. Despite promises, empirical work points towards the complexity of such endeavours. Various sources of fragmentation complicate scaling up local initiatives and collaborations between different care institutions. In this paper we take fragmentation as ontological reality and conceptual starting point. Mobilizing literature on sociotechnical infrastructures and alignment work, we follow how a hospital-based innovations programme developed a digital care infrastructure in a major urbanized region. Combining these theoretical notions allows us to trace how digital infrastructure is 'done' in practice and continuously 'under construction'. Drawing on longitudinal ethnographic methods (observations, interviews and document analysis) conducted over an extensive period of time (17 months), we examine how various actors involved in a digital innovations programme try to build a digital infrastructure in a healthcare system characterised by fragmentation. We focus on how actors within the programme attempt to align social, technical, organisational and professional elements within the fragmented context. Our approach allowed us to identify five types of alignment work: narrative, internal, organisational, regional, and technical alignment work, and address emerging tensions and interactions between them. We argue that by using this more granular and comprehensive typology, and through conceptualizing infrastructures as moving targets, we can better appreciate the complexity and variety of alignment activities that support 'the' digital transformation in healthcare.