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A Sociohistorical Approach: Moving Closer Together Through Detachment from Care Practices

To analyze the conditions surrounding the introduction and spread of connected objects in healthcare (i.e. connected digital objects), we considered it necessary to avoid developing an approach focused solely on this innovation. Instead, we chose to recontextualize it by situating connected objects within a broader dynamic and a longer timeframe, not only within the healthcare sector, but more broadly within the field of health. To this end, we adopt a communicational perspective that accounts for a recurring theme in discourse: the modernization of healthcare as a promise of better health outcomes, whether through production, prevention, monitoring or support for care.

To describe the conditions for integrating this type of technology, our first step is to adopt a broader lens and revisit the 1980s to understand how what we term "moving closer together through detachment1" emerged and evolved.

Next, we examine how, during the 2010-2020 decade, connected objects - in a broader sense - became part of, extended, challenged or failed to align with this process.

Finally, we explore how connected objects reinforce this process of moving closer together through detachment - notably by introducing more sociotechnical mediations - limiting the production of sensitive data while aligning with a usage-based logic that gradually took shape during the development of remote health services.

What should be understood by "moving closer together" through "detachment"? It is the promise of remaining as close as possible to the patient while care practices and health organizations simultaneously withdraw, establishing a sociosanitary distance from bodies and individuals.

What is proposed here is, in a sense, a sociological interpretation that combines "moving closer together" and "distancing" in healthcare - highlighting the role of digital communication. It should be noted that this concept emerged from research conducted with our colleague Robert Panico and was later explored in a French follow-up publication titled "Informationalization in Healthcare or Moving Together through Detachment? Elements of an Analysis of the Economic and Organizational Management of Healthcare Distance" (Carré and Panico 2003). That study sought to describe "the terminological indeterminacy that arises from the combination of two terms that appear both contradictory and simultaneous: beyond the spatial metaphor, it is a matter of interrogating this semantic ambiguity." (Carré and Panico 2003, p. 102).

There were two objectives to this research. On the one hand, we deliberately posed a somewhat provocative question about detachment, taking a contrarian stance towards a reform agenda which, under successive governments, aimed to link system modernization with improved access to care and closer proximity to healthcare through the territorial reorganization of health services and the new coordination of healthcare providers centered around the patient. On the other hand, we sought to examine a less frequently discussed aspect of modernization - less celebrated because it is more pragmatic - namely, cost control, which is now less of a taboo, as the rationalization of actions and increased oversight of care practices have become standardized.

1.1. The shift to ambulatory care: digitalized as a structuring framework

Faced with rising public healthcare expenditures, which in France account for nearly 10% of GDP2, public authorities, among others, came to view the sector as in need of reorganization to restore order, as it was becoming ungovernable (Julien et al. 1987). At that time, public authorities began to adopt a stricter, accounting-based logic, leading to a more quantitative and enduring vision (Morel 1997), which has only grown stronger. This drive for reorganization centered around what became known as the "Bostonian" model, and the following series of objectives: hospital closures or consolidations, fewer doctors, shorter hospital stays, increased patient involvement and expanded outpatient surgery, among others.

All of this was captured in the term "shift to ambulatory care," which rested on four key pillars (Carré and Lacroix 1999): the establishment of technical networks in the healthcare sector; the creation of a computerized patient record, initially shared, then more recently integrated into an online personal health account; more collaborative care pathways involving healthcare professionals; and finally, increased patient autonomy and task externalization. These developments encouraged the entry of new actors into the healthcare field, allowing for short-term experimentation and the gradual rollout of remote services (e.g. remote monitoring, remote consultations, tele-diagnosis, etc.).

Here, the concept of remote services should be understood in a broad and generic sense, often situated at the intersection of market-based and non-market-based models (Carré 2001). These changes are thus part of a dual process: the implementation of healthcare administration and oversight3 through the establishment of sociotechnical mediations between healthcare providers and patients.

The sociosanitary crisis, as Carré and Lacroix (2001a) remind us, is politically driven. The arguments put forward are not based on a need to respond to malfunctions in the healthcare sector, but rather stem from the view that health costs (i.e. budgetary concerns) are too high and, as some claim (specialists, experts, public authorities), threaten to slow France's economic growth and competitiveness. As a result, budgets must be cut and streamlined4. The solution is imposed without public debate, and implemented through the technical networks of healthcare actors.

Four communicational strategies will be implemented, more or less chronologically:

- de-singularizing the healthcare sector to make it more ordinary, with the aim of treating it like any other sector - allowing comparisons that highlight its lower productivity;

- assigning individual responsibility to healthcare actors, using approaches that induce psychological discomfort to promote personal changes in attitude or behavior. In other words, individuals are held accountable, particularly in cases of medical nomadism or excessive medication use;

- imposing regulations, sanctions or threats to incentivize those who are reluctant to comply;

- promoting telemedicine. This final point highlights technical achievement and noble goals - such as improving healthcare quality, humanizing medicine and enhancing patient autonomy - while downplaying less acceptable, more industrial or labor-intensive goals that are harder to justify to the public and healthcare professionals.

1.2. Innovation and technology: the position given to digital ICT

The healthcare sector, and particularly hospitals, is a major driver of innovation in our societies, adopting emerging technologies across many disciplines (surgery, radiology, hematology, among others). It is worth noting that hospitals were among the first institutions to computerize their administrative systems and exchange data electronically. These technical innovations extend traditional methods of examining the human body while also improving and streamlining them to enable more accurate diagnoses, as seen in the evolution of radiography, particularly ultrasound, MRI and CT scans.

These tools have gradually become diagnostic aids (expert systems of varying complexity), but a key shift occurred at the turn of the 21st century with the rise of digital information and communication technologies (ICTs). Their introduction began to influence not only care delivery but also administrative and financial systems (healthcare economics), and even served as communication tools - through secure messaging platforms, digital portals and other interfaces - between institutions, professionals and patients.

All of this has had a significant impact on operating methods, team dynamics and modes of cooperation, progressively integrating into patient interactions. The phenomenon intensified throughout the 2010s and particularly during the Covid-19 pandemic.

Thus, digital information and communication technologies hold an important position in health modernization, since they are both the result of reform; modernization requires digitization and the use of networking by stakeholders and, in turn, they drive reform by introducing new actors and strategic logics that were, until recently, foreign to the healthcare sector.

According to public authorities at the time, the goal of these techniques, among others, was to reshape the delivery of care around the patient, ensuring the closest possible proximity (Carré and Panico 2003). This process of social digitization even extends beyond traditional care settings (clinics, hospitals) to reach medical practices where community-based medicine is provided.

The modernization deemed necessary thus encourages networked healthcare, enabling information exchange and the expansion of so-called remote services, contributing to a new vision of care access and practices, in which health becomes integrated into the so-called digital society.

All of this is accompanied by the slogan...