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The Digitalization of Healthcare

TheDigitalization
ofHealthcare
Electronic Records and the Disruption
of Moral Orders
Ian P. McLoughlin
Karin Garrety
Rob Wilson
with
Ping Yu
Andrew Dalley
1

3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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Oxford University Press in the UK and in certain other countries
© Ian P. McLoughlin, Karin Garrety, and Rob Wilson 2017
The moral rights of the authors have been asserted
First Edition published in 2017
Impression: 1
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Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.

Acknowledgements
The origins of this book lay in the unlikely surroundings of the Crown Casino
Complex on Melbourne’s South Bank in early December, 2009. It was here
that Karin Garrety approached Ian McLoughlin (they were attending a con-
ference at the time rather than placing bets) about an idea she had for a
research study of why national electronic health record projects, such as one
that had recently got into trouble in Australia, tended to fail. Over the ensuing
months it was decided to broaden the scope of the research to look at
what appeared to be a more advanced but just as problematic experience in
England. This added Rob Wilson, who had an intimate knowledge of the
events in England, to the team. He was also joined by Andrew Dalley, a
medical practitioner who had been involved in health informatics in Austra-
lia, and Ping Yu, an Australian health informatics researcher. A funding appli-
cation (in a way like placing a bet) to the Australian Research Council (ARC)
was made and (against the usual long odds) funds were won for a three-year
project. This commenced in 2011 and was entitled‘Generating Insights for
the Future: A Retrospective, Comparative Study of Attempts to Implement
Large Scale Electronic Health Record Systems’(ARC Discovery Project
110100084).
We would like to acknowledge the support of the ARC and, since our
‘winnings’were somewhat less than requested, the generous assistance of
other parties as well. We therefore thank our respective institutions—in par-
ticular the University of Wollongong, which hosted the project and supported
a sabbatical period for Garrety that enabled her to work on the research and
conductﬁeldwork in the UK. We would also like to thank the University of
Newcastle upon Tyne, whose International Visiting Professorship scheme
enabled McLoughlin to undertake research interviews in the UK and the
university’s Business School for supporting Wilson to visit Australia for the
same purpose.
We would also like to express our gratitude to the people—who must remain
anonymous—in Australia and England who agreed to be interviewed during
our research, many of whom played prominent roles in the highly public
and politicized projects concerned. Likewise, we also express our appreciation
for the invaluable work of Scott Burrows, Kieren Diment, Richard Ross, Kerry

Ross, Ingeborg Van Teeseling, Gregor Zelle, Nabi Zaher, Kirti Mishri, Nick
Booth, Mike Martin, Rick Iedema, and Ellen McLoughlin, who provided
research and other much-appreciated assistance, critical comment, or valuable
insight at various points along the way. Thanks are also due to participants
(some of whom had played a signiﬁcant role in events in each country) in a
dissemination workshop held at the Monash University Prato Centre in Tus-
cany, Italy in September 2013. The sometimes combative debate and discus-
sion did much to encourage the line of argument concerning the disruption of
moral orders that we present in what follows. Finally, as ever, we thank our
families for their forbearance as we again spent many a long hour playing at
the‘academic casino’.
Acknowledgements
vi

Contents
List of Figures ix
List of Tables xi
List of Abbreviations xiii
Introduction 1
1. Digitalizing Healthcare:‘Dangerous Enthusiasm’or‘Disruptive
Innovation’?10
2. The Troubled History of Implementing EHRs 23
3. Moral Orders and Justiﬁcation in the Division of Medical Labour 41
4. The Development of a National EHR in Australia I: Trials,
Tribulations, and Uncertainty 58
5. The Development of a National EHR in Australia II: The Struggle
over‘Personal Control’ 78
6. The Development of a National EHR in England: The Summary
Care Record 98
7. Boundary Objects: Building EHRs at National and Local Level 119
8. Conclusion: Moral (Re)Ordering and Rethinking
the Electronic Record 140
Appendix 1.Research Design and Methods 157
Appendix 2.Other Sources Not Cited in Text 161
References 165
Index of Names 187
Subject Index 191

List of Figures
1.1. Proportion of Australian population aged over 65, 1974–2055 12
1.2. United Kingdom population aged under 16 and 65 and over, 1971–2031 12
2.1. Dimensions of EHRs 24
5.1. PCEHR system architecture 84
7.1. Relationship between boundary object and user acceptance 136

List of Tables
2.1. Opt-in/out models of consent 27
2.2. National EHR project comparisons in selected nations 30
3.1. Orders of worth 49
4.1. Key events in the development of a national EHR in Australia, 1986–2008 59
4.2. The HealthConnectproject key events, 2000–563
5.1. Australian national EHR policy key events, 2007–16 79
5.2. NEHTA/PCEHR project key events, 2010–16 80
6.1. UK national EHR policy key events 99
6.2. NPfIT/SCR project key events 100
7.1. Boundary objects in the four EHR cases 125
A1.1. EHR case study interviews 159
A1.2. Primary care practice proﬁles 159

List of Abbreviations
AHMAC Australian Health Ministers’Advisory Council
AMA Australian Medical Association
ANF Australian Nursing Federation
APF Australian Privacy Foundation
BA Business Architecture
COAG Council of Australian Governments
DOHA Department of Health and Ageing (Australia)
EHR Electronic Health Record
EMR Electronic Medical Record
ERDIP Electronic Record Development and Implementation Programme
(England)
EU European Union
FPC Federal Privacy Commissioner of Australia
GDP Gross Domestic Product
GP General Practitioner
HCN Health Communications Network
HIC Health Insurance Commission
HITECH Health Information Technology for Economic and Clinical Health Act
(USA)
HRSCFCA House of Representatives Standing Committee on Family and Community
Affairs
HSCIC Health and Social Care Information Centre (England)
ICT Information and Communication Technologies
LSP Local Service Provider (England)
MyHR MyHealthRecord
NAO National Audit Of ﬁce (UK)
NCRS National Care Record Service (England)
NEHRT National Electronic Health Records Taskforce (Australia)
NEHTA National E-Health Transition Authority (Australia)

NHHRC National Health and Hospitals Reform Commission (Australia)
NHIMAC National Health Information Management Advisory Council (Australia)
NHS National Health Service (UK)
NHSIA National Health Service Information Authority (England)
NIB National Information Board (England)
NPfIT National Programme for Information Technology (England)
OBS Output-Based Speci ﬁcation
OECD Organization for Economic Cooperation and Development
PCEHR Personally Controlled Electronic Health Record
PHR Personal Health Record
QDGP Queensland Division of General Practice
R&D Research and Development
RACGP Royal Australian College of General Practitioners
SCR Summary Care Record
SEHR Shareable Electronic Health Record
SHA Strategic Health Authority
SHS Shared Health Summary
UHI Unique Healthcare Identi ﬁer
WHO World Health Organization
List of Abbreviations
xiv

Introduction
Digitalizing Mr Jones’s Health
Edward Jones is a retired coal miner living on his own in north-east England.
He is a non-insulin dependent diabetic with coronary heart disease. During a
consultation with his general practitioner (GP), Mr Jones agreed to have an
electronic health record (EHR) created as part of his overall care plan. This
allows information about Mr Jones’s medical conditions to be made available
to other healthcare providers, for example to ambulance services and hospital
medical staff, if an emergency were to occur. In addition, Mr Jones is able to
use a portal to add information of his own to the record from his home
computer such as details of his next of kin and what to do in the event of
an emergency.
Some months later Mr Jones is at home and starts to experience severe chest
pains. He calls‘NHS Direct’, a 24-hour telephone helpline established in
England in 1998 and now discontinued. A patient advisor accesses his elec-
tronic health record, which shows clinical information and details about his
domestic circumstances. The patient advisor calls an ambulance and with
Mr Jones’s agreement informs his next of kin to let her know he is on the
way to hospital. As the ambulance is called, the paramedics on board are
automatically passed key information from Mr Jones’s record relevant to the
emergency (such as his current medications and any allergies) in order that
they are fully informed before they arrive at his home. Similarly, at the
hospital emergency department, test results from his most recent visit as an
outpatient to the cardiovascular department are automatically made available
to the medical team on duty from the hospital’s own patient record system.
Further, any interventions the paramedics make on the way such as blood
pressure checks or other test results are immediately uploaded to the hospital
systems on arrival. As Mr Jones is wheeled into the emergency department, the
receiving medical team already has at its disposal a care pathway populated
with key clinical information about his condition, even down to printed labels

to attach to his test samples once taken. Of great comfort to Mr Jones and his
family is the knowledge that wherever this emergency might have occurred in
England, all the necessary information would have been available to the
clinicians in exactly the same way.
The above events formed part of a scenario developed at the turn of the
twenty-ﬁrst century to depict one possible way in which a national electronic
health record system might change healthcare, clinical practice, and the
experiences of patients. Around the world, the pastﬁfteen years or so have
seen major policy,ﬁnancial, and other investments aimed at realizing visions
of fully integrated national systems of electronic health records that enable
safer, higher-quality, patient-centred healthcare. The purpose of this book is
to try and explain why such visions have largely remained works ofﬁction.
Digital Health and Electronic Records
Healers began keeping idiosyncratic notes on patients’symptoms in ancient
times. However, it was only in the early twentieth century that concerted
efforts were made to regularize record-keeping through standard paper forms
(Reiser, 1991a, 1991b). During the 1990s paper records—normally kept in
buff-coloured envelopes named in the UK after their instigator in the early
1900s, Lloyd George (see front cover), began to be replaced by computerized
records, especially in primary care (Purves, 2002; Brennan, 2005). Such
examples of the digitalization of healthcare (sometimes referred to as e-health)
have increasingly joined other new health technologies, such as human
genetics (e.g.‘tissue engineering’and stem cell research), as a means by
which healthcare systems and the institutions which comprise them might
be transformed and overall population health improved (Webster, 2007).
Whilst having no precise deﬁnition, digitalization is normally taken to refer
to a cluster of informatics technologies which can be‘used for monitoring the
individual—such as bio-sensors or tele care; telemedicine deployed for diag-
nosis (through imaging/ultrasound) and therapeutic purposes; and informa-
tion systems used to manage clinical data about patients’(Webster, 2007: 6).
EHRs are a key example of attempts to use information and communication
technologies (ICTs) to record and exchange clinical data.
This is particularly so when the intention is to share information recorded
in digital form across organizational and other boundaries (for example,
between primary care and hospitals, or between clinical specialisms dealing
with the same patient); when it is envisaged that this will occur not for single
episodes of care but as a longitudinal record of an individual’s interaction with
healthcare systems; and when this is attempted at a national scale and is
intended in some way to provide patients with new access to and control
The Digitalization of Healthcare
2

over their health data. A report by the European Union (EU) in 2011 claimed
that digitalized records with this kind of functionality were the‘Holy Grail’of
e-health policy in so far as they would provide patients with‘an account
of his/her diverse encounters with the health system as recorded in a variety
of medical records maintained by various providers such as GPs, specialists,
hospitals, laboratories, pharmacies etc.’(Stroetmann et al., 2011b: 31).
The scenario involving Mr Jones (developed to assist in the development of
a prototype EHR in a regional pilot project in England—see Chapter 7) is based
on the often articulated view that the implementation of national EHR sys-
tems allows the delivery of‘the right information at the right place at the right
time’(Department of Health, 2001: 28). This is regarded as particularly import-
ant in cases such as an emergency admission or the management of long-term
chronic morbidities, the incidence of which is rising in many countries in the
context of ageing demographics. This view is based on the assumption that the
paper-based recording and sharing of information too often result in frag-
mented and inefﬁcient services which are prone to error with detrimental
effects on the safety and quality of care. In contrast, making healthcare records
electronic renders health information mobile, easy to access and exchange,
and above all able to‘travel with the person’as he/she moves around the
healthcare system (Christensen et al., 2009: 142). Moreover, EHRs are an
essential enabler of the‘disruptive innovation’required to bring about a
‘low-cost, high-quality healthcare system’(Christensen et al., 2009: 143).
However, despite the promises, in practice attempts to implement national
EHR systems have been‘plagued by delays, escalation of costs, scope creep,
and technical glitches including catastrophic system crashes’(Greenhalgh
et al., 2009: 730). The technical challenge of designing new systems and
connecting them to diverse legacy systems has proven problematic in many
jurisdictions, whilst the resulting systems have more often than not been
regarded as neither useful norﬁt for purpose by clinicians (Greenhalgh et al.
2009; NHS England/US Department of Health and Human Services, 2016).
Having said this, there is some evidence that EHRs implemented in smaller
countries, or in larger countries at regional and local level, are, relatively
speaking, more successful (see, e.g., Hayrinen et al., 2008; Aanestad and
Jensen, 2011; Stroetmann et al., 2011a; 2011b; Greenhalgh et al., 2009; 2013;
Lluch and Abadie, 2013; Kierkegaard, 2015a; 2015b; Bowden and Coirea,
2013). There is now an emerging realization that, whatever the hopeful prom-
ise and rhetoric around the potential beneﬁts of electronic health records, the
beneﬁts are not being realized in practice. As the failures and disappointments
mount, some are beginning to doubt the hype and ask whether the supposed
beneﬁts ever will be realized (e.g. Tehune et al., 2009; Mensink and Birrer,
2010; Karsh et al., 2010; Hyssalo, 2010; Murray et al., 2011; Wachter, 2015;
Rosenbaum, 2015). Like many other attempts by the state to transform its
Introduction
3

workings and improve the delivery of public services through digitalization,
the outcomes in healthcare may well be turning out to reﬂect what are in fact
‘dangerous enthusiasms’on the part of policy-makers and others (Gauld and
Goldﬁnch, 2006).
Indeed, even where EHR systems of more limited scope and scale have
been implemented, it has been claimed that healthcare staff are still‘dis-
tracted’from the‘human side of medicine and nursing’by the new tasks that
EHRs generate, such as data entry, searching, and veriﬁcation (Gagnon et al.,
2012). Acceptance of EHRs by patients and some clinicians has also been
questioned by signiﬁcant broader objections about privacy, conﬁdentiality,
and data security. Here concerns have focused upon the implications of
centralizing sensitive medical information in large national databases whilst
at the same time broadening the possibilities for this information to be
accessed by a wide variety of healthcare professionals, whilst also of course
opening up these data to possible cyber theft and abuse (see e.g. Carvel, 2007;
Cresswell, 2011).
Explanations of why EHR projects are so problematic are many and varied.
One theme is that those in charge of national EHR projects seriously neglect
many of the contingencies that affect implementation and adoption
(Greenhalgh et al., 2010, 2011) whilst their policy sponsors,‘caught at the
heart of institutional webs’, are incapable of developing anything more than
a‘simplistic view’of the problems that emerge (Sauer and Willcocks, 2007:
196). The building and implementation of EHRs, especially at a national
scale, clearly involve many stakeholders from diverse backgrounds who have
different interests and priorities. As a result, the reality of what is happening
is always subject to multiple views and open to conﬂicting interpretations
(Currie and Guah, 2007; Boonstra et al., 2008). When trying toﬁnd com-
promises and solutions, there is, it appears, rarely one clear idea of the way
forward that interested parties can agree on.
EHRs in Australia and England
The healthcare systems of Australia and England provide two of the most
signiﬁcant examples of attempts to design and implement large-scale national
EHRs. Our choice of these countries as the focus of our research was, of course,
inﬂuenced by available funding and our own networks which enabled
access into potentially sensitive research areas. However, there are also more
substantive reasons why a comparison between the Australian and English
experiences is instructive. For example, as a former colonial outpost of the
British Empire, Australia’s healthcare system, like many of its other institu-
tions, reﬂects a common heritage in that basic care in both countries is free at
The Digitalization of Healthcare
4

the point of need. However, healthcare provision is organized and funded
quite differently. As a federation (or commonwealth), responsibilities for
healthcare in Australia are distributed across six states and two territories.
The UK has a more centralized system in the form of separate National Health
Service (NHS) organizations in England and the other three constituent coun-
tries of the union (Scotland, Wales, and Northern Ireland). In Australia
primary care is funded through the commonwealth, while public hospitals
are managed by state and territory governments, funded throughﬁxed grants
provided by the federal government. In England funding allocated to the NHS
covers primary care as well as public hospitals.
The strategy, operations, and performance of both health systems are never
far from political, policy, and public concern. Australia’s fragmented arrange-
ments have been consistently criticized but, as students and observers of the
system have noted, have remained remarkably impervious to several attempts
at reform over the past few decades (Macklin, 1991; Lewis, 2005; Armstrong
et al., 2007; Hurley, 2009; Richardson, 2009). The NHS has, almost since its
inception in 1948, been criticized for being inefﬁcient and fragmented, espe-
cially at the intersection of health and social care, and has increasingly been
subject to reorganization and attempts by government to rein in costs and
improve the allocation of resources (e.g. Commission on the Future of Health
and Social Care, 2014). In both countries investment in e-health and a
national EHR have, since at least the turn of the century, been seen as essential
elements in attempts to modernize and transform their increasingly troubled
healthcare systems.
In Australia the federal government claimed that‘electronic health records
have the potential to save lives, time and money and make the health system
more efﬁcient’and, moreover, would‘drag the management of health records
into the 21st century’(Roxon, 2011). Two attempts to develop a national
health record have been undertaken since 2000. Theﬁrst project, called
HealthConnect, was abandoned in 2005. A more recent attempt involved the
introduction of a national personally controlled electronic health record
(PCEHR), rebranded in 2016 asMyHealthRecord. To date the PCEHR is reported
to have cost about 1.5 billion Australian dollars (Gartrell, 2015). The system
went live in 2012. However, following disappointing take up by consumers
and clinical opposition, the project is currently stalled pending further trials.
In England, a national electronic health record was described in the late 1990s
as the‘cornerstone of a modernized health service’bringing about‘better,
safer, cheaper and more integrated’healthcare (Greenhalgh et al., 2009: 730,
citing Department of Health 1998). In pursuit of these objectives £10 billion
was initially invested (the actual costs rose signiﬁcantly) in what at the
time was billed as the world’s largest civilian IT project—the NHS’s National
Programme for Information Technology (NPfIT). The core component of this
Introduction
5

project was a national summary care record (SCR). The NPfIT was abandoned
following much acrimony during the project’s lifetime in 2010, but the much-
delayed SCR survived.
These problems and setbacks notwithstanding, politicians and policy-
makers in both countries remain committed, if not enthusiastic, about the
beneﬁts of e-health and national EHRs. For example, a new Federal Minister of
Health in Australia has recently spoken of the‘great digital health revolution’
and the potential of mobile technologies to place the future‘literally in the
palms of the consumer’(Ley, 2015a). Similarly, in the UK aFive Year Forward
Viewfor the NHS in 2014 set out a vision to be achieved by 2020 of a‘paperless
NHS’with‘fully interoperable electronic health records’that patients would
be able to access and‘write’to online and through‘wearable’and other
devices (NHS, 2014a: 32; NIB, 2014).
Health Records and the Disruption of Moral Orders
In this book we take up the challenge of those who have suggested that the
ethical and moral dimensions of the digitalization of healthcare have yet to be
properly addressed. According to Greenhalgh et al. (2010), for example, there
are two alternative narratives which seek to justify the worth/unworthiness of
national EHR systems. Theﬁrst‘holds that centrally-stored electronic summa-
ries, accessible by patients and authorized staff, are linked with unassailable
common goods like choice, empowerment, quality, safety, efﬁciency and
personalized care—and that the“tipping point”for their widespread adoption
is imminent’(Greenhalgh et al., 2010: 5). The second‘depicts policymakers as
seduced by a vision of technological utopia, professional leaders as obsessed
with standardization, the public as largely disengaged, and the government
as extending electronic surveillance into intimate parts of citizens’lives’
(Greenhalgh et al., 2010: 5).
At the core of implementing EHR systems is the need to address moral and
ethical issues. Speaking in the Australian context, for example, Fry et al. (2014)
argue that these challenges remain unresolved, in particular in relation to
clarifying the range of concerns at issue, the positions and interests of key
stakeholders, and the vexed question of how, when building and implement-
ing a national EHR system, such concerns can be resolved in a consensual way
(Fry et al., 2014). However, at present, in most instances the development and
implementation of national projects‘typically occurs with a greater focus on
the technical issues, to the detriment of considering key ethical questions’(Fry
et al., 2014: eb35). In consequence there is a need to lay‘a clear framework
for discussing and integrating ethical concerns in the design and development
The Digitalization of Healthcare
6

[if] the trust, and therefore the usability, of any shared system’are to be
achieved (Fry et al., 2014: eb35).
It is our contention that in order to explore the difﬁculties that national
EHR projects have encountered, the continuing justiﬁcations offered for their
pursuit (often in the face of stakeholder discontent, if not outright oppos-
ition), and how different and counterposed viewpoints can be accommo-
dated, we need to understand the medical record in a deeper way than
might atﬁrst appear necessary. As Berg and Harterink observe, whilst‘on a
superﬁcial level’medical records might be regarded as‘mundane’artefacts,‘on
closer inspection they prove to be a surprisingly multi-layered technology’
(Berg and Harterink, 2004: 15). Rather than being‘mere’repositories of infor-
mation, medical records reﬂect and structure the relationships through which
medical work is carried out and are a manifestation of both a technical and,
critically, a moral division of labour. In this sense medical records have and
continue to play pivotal roles in what we shall term the moral ordering of
healthcare. As the idea of digitalizing the paper-based record has become a
major policy objective for governments around the world, one consequence
has been that the moral orders that have underpinned the medical division of
labour have been disrupted.
The key actors concerned include, of course, medical professionals, both as
individual clinicians but also as represented by a variety of professional bodies,
who occupy a privileged position in the medical division of labour. However,
doctors since the middle of the last century have had to take into account the
views and interests of a wide variety of other stakeholders. These include
politicians and policy-makers concerned with achieving public value and
reforming healthcare systems to achieve this; managers and administrators
who play an increasingly prominent role in the co-ordination and control of
healthcare organizations; patients as the‘consumers’of health services and
advocacy groups established to represent their collective interests who have
rising expectations concerning the quality and safety of care and the nature of
the patient experience; private-sector suppliers and other intermediaries who
offer‘business solutions’aimed at delivering government plans to modernize
health services; and privacy advocates, watchdogs, and other bodies con-
cerned with the implications of the increasedﬂow and sharing of information
for privacy, civil liberties, and data security.
All these actors occupy particular positions in the medical division of
labour. However, this division of labour is not just economic and technical.
It is also one underpinned by moral orders which provide justiﬁcations for
particular distributions of rights and responsibilities, which are in turn linked
to the detection and management of risks. As such, attempts to transform
healthcare using digital technologies do not just potentially disrupt estab-
lished business models and their associated work routines. They also challenge
Introduction
7

the moral orders which underpin healthcare practices and relationships. By
increasing the mobility, transparency, and availability of information (and
associated risks), digitalization has signiﬁcant implications for the established
rights, relationships, and responsibilities which deﬁne the intentions and
identities of participants in healthcare, including patients. This calls into
question what Boltanski and Thévenot (2006) refer to as the‘orders of
worth’that participants use to justify their positions and challenge those of
others in public discourse and debate. Orders of worth in healthcare are often
in tension. For example, arguments that prioritize cost-effectiveness and
efﬁciency can clash with those that hold individualized care, even when
time-consuming and expensive, as the ultimate value. As we will see, the
digitalization of health records has thrown some of these tensions into even
sharper relief, exposing the public justiﬁcations and positioning of key stake-
holders to‘tests of worth’(Boltanski and Thévenot, 2006).
Research Sources and Book Outline
In exploring these issues we draw on original research that aimed to provide
insights for those engaged in trying to develop, implement, and use digital
technologies in order to improve healthcare systems. The project was designed
as a comparative study of attempts to develop national EHR systems in
Australia and England, but mindful that smaller-scale projects have been
relatively more successful and that there may be signiﬁcant learning from
making comparisons in this respect as well, we also studied two strategically
signiﬁcant regional EHR projects which were superseded by their national
counterparts. Theﬁrst was a regional project in south-east Australia which
produced a working system linking GPs with local hospitals, and the second a
pilot project conducted as part of a demonstration project intended to inform
the ultimately ill-fated NPfIT programme.
For each case we conducted a retrospective, multilevel, and longitudinal
investigation of the policy development, implementation, and outcomes of
the projects. This involved a detailed analysis of documentary sources, includ-
ing policy statements, responses to ofﬁcial consultation exercises, evidence to
parliamentary committees, and so on over the pastﬁfteen years; in-depth
interviews with over thirty key informants, many of whom were involved in
inﬂuential and strategic positions as‘insiders’within the projects studied; and
a small study of the views of healthcare providers and users‘on the ground’in
two primary care clinics in Australia (technical details of the research design
and methods are provided in Appendix 1 and a selective sample of documen-
tary sources consulted in Appendix 2).
The Digitalization of Healthcare
8

In what follows our aim is to move beyond simple linear models to explain
change and their taken-for-granted assumptions about the impact of digital
technologies and the need for organizations to adapt to them or face dire
consequences (see, e.g., Tang et al., 2006; Lluch, 2011; Blumenthal, 2011;
Zieth et al., 2014). In this deterministic view there is one path forward to the
goal of widespread digitalization, which can be reached only if we are able to
identify troublesome obstacles and overcome or push them aside. Experience
to date would suggest that there is a need for a better understanding of the
nature of what is involved. There is much we can learn from past implemen-
tations and, where problems have occurred, help avoid similar mistakes and
errors in the future. However, such insights will need to go further than
improving the way projects are managed, systems designed and developed,
and the perceived human and organizational‘barriers’to their implementa-
tion overcome. Our aim in this book is to probe much more deeply into these
issues by examining the manner in which the moral orders underpinning the
medical division of labour are being disrupted by the electronic record.
In Chapter 1 we outline the drivers of policy interest in digital health and
explore the arguments that in pursuing their objectives policy-makers are
prone to‘dangerous enthusiasms’and conversely that healthcare is on the
cusp of signiﬁcant disruptive innovation. In Chapter 2 we address key deﬁn-
itional issues and examine the troubled history of the implementation of
EHRs. In Chapter 3 we present the moral orders framework and in the follow-
ing four chapters we put these more conceptual arguments to the test through
a detailed empirical analysis of the experience of building and implementing
national EHRs in Australia and England. In Chapter 4 we consider Australia’s
ﬁrst attempt to build a national EHR in the form of HealthConnect, a project
which was abandoned in 2005. In Chapter 5 we consider the fate of its
successor, an ambitious and novel introduction of a‘personally controlled
electronic health record’, and in Chapter 6 we consider the experience in
England in the form of the NPfIT and SCR. In Chapter 7 we use the concept
of‘boundary objects’to examine the problems associated with engaging
stakeholders in building EHRs in our national case studies and two antecedent
regional projects and introduce the idea of EHRs as health information system
infrastructures. In Chapter 8 we draw the threads of our argument together
and set out the case for rethinking the nature of‘the record’and the moral
orders upon which the rights, relationships, and responsibilities that enable it
to function are based.
Introduction
9

1
Digitalizing Healthcare
‘Dangerous Enthusiasm’or‘Disruptive Innovation’?
In this chapter we consider the motivations behind the often very signiﬁcant
investments that governments have made in e-health in general and EHRs in
particular. In the following chapter we look in more detail at the fate of some
of these projects and the challenges that have arisen. Our aimﬁrst, however, is
to explore two propositions concerning the policy andﬁnancial investments
that governments have and continue to make in developing national EHRs.
Theﬁrst argument, in part fuelled by broader experiences of public invest-
ments in ICT, suggests that such policies can reﬂect a‘dangerous enthusiasm’
on the part of politicians and policy-makers that exposes signiﬁcant weak-
nesses in the ability of governments and their agencies to manage large-scale
ICT projects. The second argument takes a different tack and explores the
signiﬁcance of EHRs as a key component of the ‘disruptive innovation’
required to transform healthcare systems so that they can cope more
effectively with the challenges they face. Ironically, the idea of‘disruptive
innovation’is sometimes appropriated by policy-makers as part of their
‘enthusiastic’rhetoric. However, disruptive innovation theorists are critical
of the idea being appropriated in this way, and as we argue in the following
chapters, the‘disruptions’heralded by e-health do not necessarily enhance
efﬁciency and effectiveness. Before we consider these issues, we outline the
challenges confronting healthcare systems and why the digitalization of
healthcare is seen by policy-makers as a way of addressing them.
Wicked Problems and the Reform of Healthcare Systems
By the early 2000s it was increasingly evident that healthcare systems around
the world were facing new and potentially calamitous challenges, which

many theorists have characterized as falling into the category of so-called
‘wicked’problems (Head, 2008a; Showell, 2011; Ferlie et al., 2013; Shaw and
Rosen, 2013; Australian Public Service Commission, 2007). While‘tame prob-
lems’arise in situations where causes and effects, and therefore solutions, are
relatively well understood, wicked problems and their causes elude easy def-
inition. They emerge in complex environments with many interacting and
interdependent elements. Wicked problems appear intractable and can
endure without agreements around‘solutions’for decades, whilst‘solutions’
that are tried often generate new problems of their own (Rittel and Webber,
1973; Head, 2008a). Because of this complexity, it is difﬁcult to discern with
any certainty what works and what does not, and recurrent rounds of reform
are typical as successive governments seek to remedy the negative conse-
quences of previous changes (Paton, 2014).
In the case of healthcare, despite rising proportions of gross domestic prod-
uct (GDP) being spent on its provision, services are struggling to cope with
changing patterns of disease, inequalities in access, ageing populations, and
increasing expectations among patients concerning the safety and quality of
the care they receive. Ironically, perhaps, the most signiﬁcant factor in
increasing pressure on healthcare systems is a consequence of their success.
In most developed countries, people are living longer (OECD, 2013a). This is
due, at least in part, to changing patterns of disease which are in turn the result
of improved hygiene and nutrition, public health campaigns, and advances in
healthcare treatments. Conditions that were once often fatal, such as prema-
ture birth, spinal and head injuries, HIV and other immune disorders, strokes,
diabetes, heart disease, and cancer, are now to some extent survivable and
manageable.
However, these advances in prevention and treatment, combined with
falling birth rates, have in turn contributed to another problem—a so-called
‘demographic time bomb’. According to the United Nations, for example, the
world is experiencing a‘unique and irreversible process of demographic tran-
sition that will result in older populations everywhere’(<http://www.un.org/
en/globalissues/ageing/>). As a result, people aged 60 years or over have
increased from 9.2 per cent of the global population in 1990 to 11.7 per cent in
2013. By 2050 the proportion of the global population over 60 will be 21.1 per
cent and the number of older people will exceed the number of younger people
for theﬁrst time in human history (United Nations, 2002, 2013). In Australia a
recentIntergenerational Reportprojected the number of Australians aged 65 and
above will double by 2054–5, whilst the proportion aged 85 and over, less
than 1 per cent of the population in 1974–5 (80,000 people) will be nearer to
5 per cent (2 million) (Commonwealth of Australia, 2015: viii) (see Figure 1.1).
TheKing’sFundreports that at the foundation of the NHS in 1948, just under
half of the population in England died before they reached the age of 65,
Digitalizing Healthcare
11

whilst ofﬁcial statistics predict that by 2030 one inﬁve of the nation’s citizens is
expected to be aged over 65 (Oliver et al, 2014: 7; House of Lords, 2013) (see
Figure 1.2).
Ageing populations are expected to exacerbate the worrisome and decades-
long trend of rising healthcare costs that threaten the sustainability of existing
systems. In 1970 the average percentage of GDP spent on healthcare by
Per cent
25
20
15
10
5
0
1974–75 2014–15 2054–55
25
20
15
10
5
0
Per cent
65–84 85 and over
Figure 1.1.Proportion of Australian population aged over 65, 1974–2055
Source: Commonwealth of Australia, 2015
Under 16
Projections
Millions
65 and over
18
16
14
12
10
8
6
4
2
0
1971 1981 1991 2001 2011 2021 2031
Figure 1.2.United Kingdom population aged under 16 and 65 and over, 1971–2031
Source: House of Lords, 2013
The Digitalization of Healthcare
12

developed countries was 5.3 per cent. By 1980 thisﬁgure had risen to 7.0 per cent
and by 2010 had grown to 9.4 per cent beforeﬂattening out, partly as a conse-
quence of the globalﬁnancial crisis (OECD, 2013a; 2015). The trend of rising
costs is also evident in Australia and the UK. Whilst Australia’sspendinghas
hovered around the Organization for Economic Cooperation and Development
(OECD) average, it is predicted that public spending on healthcare per person will
double between 2015 and 2055 (Commonwealth of Australia, 2015). In England
spending has until recently remained below the OECD average. However, in the
ﬁrst decade of the new century it has increased to average levels of GDP (OECD,
2013a). One reason for this rise was a perception among policy-makers that
underfunding of the healthcare system, including underinvestment in informa-
tion systems, had reduced its capacity to cope with the challenges of chronic
disease and an ageing population (European Observatory on Health Care
Systems, 2002; Wanless, 2002).
In keeping with their‘wicked’character, the underlying reasons for the
rising proportion of national expenditure being spent on healthcare are com-
plex. They reﬂect the rise in chronic long-term conditions as populations age,
the fact that individuals increasingly have co-morbidities whose interactions
are difﬁcult to manage, the mounting cost of drugs and medical equipment for
diagnosis and treatment, and increasing public expectations of high-quality
healthcare that is effective and safe (OECD, 2015). Moreover, whilst expend-
iture has increased, there is no clear and direct relationship between such
increases and the health outcomes that result. This is particularly evident in
the United States, where, despite spending 17.7 per cent of GDP on healthcare
in 2010, the Commonwealth Fund recently ranked that nation last or close to
last on a range of measures spanning quality, access, efﬁciency, and equity,
compared to eleven other developed nations spending between 9 per cent and
12 per cent (Davis et al., 2014). In comparison, Australia and the UK spent
under half that of the US per capita as a percentage of GDP but scored far better
on most health outcome measures. However, it is notable that the UK, like the
US, scored badly in relation to indicators of healthy lives amongst the popu-
lation, having, for example, much higher death rates from diseases‘amenable
to medical care’(Davis et al., 2014: 9). Findings such as these have fuelled an
increasing perception amongst policy-makers and others in many countries
that the quality and efﬁciency of healthcare need to improve, both to improve
the returns from expenditures being made and to enhance the capacity to
cope with the looming demographic time bomb.
Against this backcloth, improving healthcare systems is not easy. The past
few decades have seen policy-makers endeavouring toﬁnd ways of transform-
ing healthcare systems in order to make them more responsive to patient
needs and deliver services that are less fragmented and wasteful (Flood,
2000; Twaddle, 2002; Department of Health, 2000; European Observatory
Digitalizing Healthcare
13

on Health Care Systems, 2002; OECD, 2015). It is in this context, no doubt
motivated by the transformations enabled by digitalization in other sectors of
the economy and society, that policy-makers have turned to digital technolo-
gies as a‘solution’to the problems facing healthcare.
The Policy Case for E-Health and EHRs
Policy interest in the digitalization of healthcare remained sporadic until the
1990s, when the promise of networked computing prompted renewed think-
ing about the role of what would become labeled as‘e’or‘digital’health.
A landmark report published in 1991 by the Institute of Medicine in the US
concluded that technology had reached a stage that would allow the devel-
opment of what it termed the‘computer-based patient record’, which, accord-
ing to the report’s authors, had the potential to transform medical practice
(Dick and Steen, 1991). Signiﬁcantly, the report also stated that the full
realization of this potential would require much more than the‘simple auto-
mation of the current patient record’(Dick and Steen, 1991: v). New practices
that make full use of the capacity of a computer-based record system to gather,
exchange, and manipulate information would need to be developed. More-
over, in addition to improving the quality and availability of patient data, and
streamlining administration, such a system could also be used to capture
‘relevant, accurate data necessary for provider and consumer education, tech-
nology assessment, health services research, and related work concerning the
appropriateness, effectiveness, and outcomes of care’(Dick and Steen, 1991: 7).
In the light of the interest that the report generated, it was reissued in 1997 with
an updated preface and progress reports (Dick et al., 1997).
Fuelled by such ideas and the promise of the emerging Internet, the 1990s
saw much activity on the policy front. In England, Australia, and elsewhere
policy-makers began to envisage using digital technologies to create regional
and national health information networks that would drive systemic reforms.
Similarly, governments in these and other countries introduced incentives to
stimulate the uptake of computers in clinical settings (Brennan, 2005; Doupi
et al., 2010). By the end of the decade, policy-makers around the world had
begun to translate these aspirations into strategies aimed at widespread digit-
alization of healthcare, including nation-scale EHR systems (Ceusters et al.,
1996; Iakovidis, 1998). As a result the new millennium saw a further steady
stream of policy documents in many nations advocating the introduction of
national EHRs alongside other e-health technologies such as electronic pre-
scriptions, telemedicine (the use of broadband and teleconferencing equipment
to facilitate long-distance consultations), and health information portals as
ways of transforming healthcare (see Chapter 2). International bodies such as
The Digitalization of Healthcare
14

the OECD, European Union (EU), and the World Health Organization (WHO)
also supported and initiated policy-thinking, often emphasizing the need for
cross-national learning, standardization, and collaboration across borders
(see, e.g., European Commission, 2004; WHO, 2004; OECD 2013b; 2010).
Despite the global dimensions of this activity there is a striking degree of
similarity in the arguments put forward in these policy documents. The health-
care sector is typically presented as an‘information-intensive’industry, whose
problems can be attributed to deﬁciencies in the storage and exchange of data
(see, e.g., European Commission, 2004). It is claimed that EHRs will be more
accurate, legible, and easily moved and shared than their paper counterparts.
Errors will be more readily detected and corrected. Tests will not have to be
repeated because paper results have been lost or are stored elsewhere. With
EHRs at their disposal,‘clinicians will have at theirﬁngertips all of the infor-
mation needed to provide the best care’(Department of Health and Human
Services, 2008: iii). Prompt access to EHRs at a national level will also enable
‘seamless’care when citizens consult multiple providers, travel, and/or require
emergency or after-hours attention. People will‘be spared the ritual of repeating
their name, address, previous and recent medical history to every [provider]
they have to deal with’(Department of Health, 1998: 24). EHRs and related
technologies such as telemedicine will also improve access to care and specialist
services for people in remote locations. Citizens’ability to electronically access
their own health data and information about how to manage their conditions
will empower them to care for themselves, thereby reducing cost to govern-
ments. Healthcare providers will also be able to improve their diagnostic and
treatment skills by consulting online repositories of useful information, such as
best-practice guidelines. Finally, the digitalization of healthcare will enable
healthcare administrators to audit clinical activities and outcomes, and to use
these data for more effective planning and evidence-based treatment.
The potential capacity of e-health technologies to help overcome informa-
tion deﬁcits in healthcare may seem self-evident enough, especially when the
impacts of digitalization in other sectors of the economy such asﬁnancial
services and online retailing are considered. However, it is important to take
another inﬂuence into account, namely that of think tanks, consultants,
researchers, and others that provide advice to governments. Such advice is
increasingly signiﬁcant as politicians and policy-makers look to‘evidence’to
guide and legitimate their decisions and actions (Head, 2008b). However, the
‘evidence’regarding the effects of digitalization on healthcare has been prob-
lematic. E-health technologies are still novel, and their impacts on the quality
and efﬁciency of care are still active areas of investigation (Nguyen et al., 2014;
RAND Corporation, 2014; Brenner et al., 2015). Researching the effects of
digital technologies is also complicated by the fact that health outcomes are
inﬂuenced by many factors in addition to the availability (or not) of electronic
Digitalizing Healthcare
15

data. Consultants and researchers tasked with providing evidence-based
advice to governments have had to rely on results from pilot programmes
and small, stand-alone electronic systems installed in speciﬁc hospitals or
clinics. They have also attempted to model the theoretical beneﬁts of possible
future implementations, based on assumptions about uptake, costs, and
impacts on adverse health events (see, e.g., Heard et al., 2000; Silber, 2003;
Bartlett et al, 2008; Deloitte, 2012a).
Having said this, the advice to policy-makers is almost overwhelmingly
supportive of the beneﬁts of digitalization of healthcare. However, while
some advisors are cautious and modest in their claims about potential bene-
ﬁts, others tend towards the grandiose and hyperbolic. An example of opti-
mistic caution can be found in a report prepared by academics Heard, Grivel,
Schloeffel, and Doust (Heard et al., 2000) for Australia’s National Electronic
Health Record Task Force. They noted that, at the time,‘the body of scientiﬁc
evidence demonstrating beneﬁts from the implementation of an EHR is not
overwhelming’(Heard et al., 2000: 15). Nevertheless, they concluded that,
‘the electronic health record (EHR) is a necessary tool for providing person-
centered and continuing healthcare safely and efﬁciently in the modern
information environment’(Heard et al., 2000: 1). At the other end of the
spectrum weﬁnd a‘case for e-health’presented to the European Commission
by a director of consultancyﬁrm Basil Strategies. Drawing on the‘best available
published data concerning e-health in Europe’, it concluded that‘e-Health is
the single most important revolution in healthcare since the advent of modern
medicine or hygiene’(Silber, 2003: vii).
Policy-makers have also, as one might expect, looked to models that estimate
the potentialﬁnancial beneﬁts from digitalization after costs have been taken
into account. It is beyond the scope of this book to interrogate the assump-
tions behind these models, but the impressive numbers that they produce
have become part of the discourse mobilized to legitimate e-health invest-
ments. In 2005, for example, an analysis by the RAND corporation in the US
found that interoperable electronic medical record systems could potentially
save the healthcare system more than $US81 billion annually (Hillestad et al.,
2005). Thisﬁgure was disputed (Himmelstein and Woolhandler, 2005), but
claims such as this were used to justify policies aimed at stimulating the
development and take-up of EHRs in the US (Thune et al., 2013). Estimates
produced for the Australian healthcare system have been more modest. In
2008 the Allen Consulting Group claimed that the increased productivity and
reduction in adverse events resulting from the introduction of a national EHR
would save the nation up to $AU7.9 billion over ten years. This sum quickly
made its way into policy and other reports advocating the development of
such a system (NHHRC, 2009b; see also Deloitte Australia, 2011: 21). More
recently, Deloitte (2012a) estimated that Australia would save $AU11.5 billion
The Digitalization of Healthcare
16

overﬁfteen years if a national EHR were implemented. This projection also
found more or less immediate expression in ministerial speeches justifying
government expenditures on e-health. However, it was also disputed, one inﬂu-
ential blogger in the e-health community called it‘an astonishing and just
unsupportable piece of nonsense’and a‘fraud on the populace’(More, 2012).
EHRs: a Dangerous Policy Enthusiasm?
The appeal of EHRs and of e-health more generally lies in the apparent
promise of digital technologies to provide, or at least enable,‘solutions’to
many of the‘wicked problems’faced by healthcare systems. Policy-makers
seem to assume that once the requisite legislation and technical safeguards are
in place, and the obvious beneﬁts of digitalization understood, then imple-
mentation of systems and uptake by intended users should be relatively
unproblematic. This certainly seemed to be the case, for example, in the
Institute of Medicine report cited above, which optimistically predicted that
with,‘proper coordination and appropriate resources’widespread digitaliza-
tion of healthcare could be achieved by 2001 (Dick and Steen, 1991: 152).
However, for some observers such views reﬂect a tendency for governments
and their advisors to be seduced by the promise of digital and other new
technologies toﬁx the difﬁcult policy problems that they face.
For example, in a study of e-government policy in New Zealand, Gauld and
Goldﬁnch (2006) refer to this tendency as a‘dangerous enthusiasm’. They
identiﬁed four interrelated and self-reinforcing aspects of this phenomenon
and the manner in which it shapes the perceptions and behaviour of policy-
makers. First,‘idolization’, that is, a misplaced belief in the transformational
potential of information technology, driven by the assumption that digital
data can‘transform the business of government’; second,‘technophilia’, the
tendency for policy-makers to be persuaded by ICT professionals who believe
that technology canﬁx the problems of service delivery; third,‘Lomanism’,
which refers (with due reference to Arthur Miller’s playDeath of a Salesman,
1949) to the art of sales representatives in selling the‘solutions’of technology
vendors to the public sector—doing little to cure public servants of their naïve
faith in technicalﬁxes; andﬁnally‘managerial faddism’, which consultants
and their clients easily fall prone to and which emanates from the prescrip-
tions, rational techniques, and tools of the‘guru of the moment’(Gauld and
Goldﬁnch, 2006: 17–18). Taken together, these enthusiasms appear to blind
policy-makers to the‘incredible complexity’involved in public sector
information-system projects. This complexity is manifested in such things as
difﬁcult-to-deﬁne project objectives, challenges of specifying requirements,
and delivering contracts to develop‘solutions’, issues of capacity and capability
Digitalizing Healthcare
17

of government and public entities to manage such complexity and to co-ordinate
the activities of organizations with diverse interests and cultures, all in the
context deﬁned by political contingency and high levels of public visibility
(Gauld and Goldﬁnch, 2006: 133–4).
Faced with increasingly wicked problems in healthcare, it is perhaps easy to
see how politicians and policy-makers might fall prey through the effect of
such enthusiasms to what has been termed‘solutionism’—a way of thinking
that‘presumes rather than investigates the problems that it is trying to
solve, reaching“for the answer before the questions have been fully asked”’
(Morozov, 2013: 6). For some this has been reinforced by a‘power loop...in
which consultants occupy inﬂuential positions in government and public
policy circles’that enable them to‘act as powerful agents’in developing
‘solutions’and the technology and expertise that are needed to‘deliver’the
promised outcomes (Horrocks, 2009: 110). The result, it seems, is a litany of
‘policy blunders’and high-proﬁle information-system project failures (Bacon
and Hope, 2013; King and Crewe, 2014). As we will see in the following
chapter, investments in national EHR systems in the healthcare sector have
seemingly provided many notable contributions to this phenomenon.
EHRs: A Disruptive Innovation?
In contrast to the rather pessimistic conclusion of the‘dangerous enthusiasm’
thesis, a more positive view of the promise of digitalization is provided by
the theory of‘disruptive innovation’. For some observers the challenges
facing the provision of healthcare are now well beyond what can be managed
through reforms aimed at improving existing systems and models for care
delivery. In this view, what is required is a far more radical restructuring of
healthcare akin to transformations that have occurred in other sectors of the
economy—a process which Clayton Christensen and colleagues term‘disrup-
tive innovation’(see, e.g., Christensen, 1997; Christensen and Raynor, 2003;
Christensen et al., 2009). In healthcare the need for innovation which
‘disrupts’current modes of delivery has been eagerly taken up by policy-
makers and other advocates of change (see, e.g., National IT Health Board,
2010; Deloitte Australia, 2012b, 2014; Topol, 2012; McDuling, 2015).
For some, the appropriation of‘disruption’into discourses advocating
healthcare reform is yet another manifestation of‘dangerous enthusiasm’,
and indeed its originators have recognized that the theory is‘in danger of
becoming a victim of its own success’(Christensen et al., 2015: 44). For them,
the‘core concepts have been widely misunderstood...[and its key insights]
frequently misapplied’(Christensen et al., 2015: 44). It is important, therefore,
to be clear about the core argument and its application to healthcare. In our
The Digitalization of Healthcare
18

view, the theory helps to explain some of the causes of the wicked problems
facing healthcare, and goes some way towards providing useful solutions that
harness the potential of EHRs. However, it needs to be supplemented by
insights from beyond a narrow economistic view, a task that we attempt in
the following chapters.
In general, the theory of disruptive innovation seeks to explain why seem-
ingly successful businesses offering complex and expensive products which
customers like can be challenged and replaced by new market entrants with
business models that use novel technologies to offer simpler and cheaper
products and services which eventually persuade even the most loyal custom-
ers to desert incumbent providers (Christensen, 1997). As a result, incumbent
ﬁrms have to adapt their previously successful business models or face signiﬁ-
cant decline, if not extinction. The problem is that incumbent organizations are
rarely able to foresee and respond to the threat of new competitors or emerging
new markets until it is too late. The result is far-reaching sectoral change that
either sweeps away or transforms entire industries. This powerful and counter-
intuitive analysis,ﬁrst developed in the mid-1990s, has helped explain
how new business and service models enabled in particular by new digital
technologies have over time led to wholesale transformation of some industries
and in some cases the extinction of incumbentﬁrms and the emergence of new
markets (see, e.g., Christensen, 1997; Christensen and Raynor, 2003).
The idea of disruptive innovation has been applied more recently by its
originators to public services such as education and healthcare (Christensen
et al., 2009; Hwang and Christensen, 2012). Here the aim is to explain why, in
the context of novel challenges, seemingly outmoded business models have
proven difﬁcult to change. What has inhibited the disruptive innovation
needed to cure inefﬁciencies and high costs? In the case of healthcare, the
diagnosis is that many of its problems derive from the fact that hospitals and
primary care practices have been allowed to become and remain complex and
confused institutions. Hospitals in particular have high administrative over-
heads and other expenses that detract from patient care. In part these prob-
lems are caused by the persistence of a nineteenth-century business model
that supports care services and treatments which are‘expensive and complex’.
Unlike other sectors healthcare has yet to be‘transformed through improved
quality, cost, and convenience through disruptive innovation’(Christensen
et al., 2009: 419). Thus, general hospitals and independent practices, albeit
with some modiﬁcation over the years, essentially still operate as‘solution
shops’where clinical experts,‘diagnose and recommend solutions to unstruc-
tured problems’as they are‘presentedin situby patients’(Christensen et al.,
2009: 20). Doctors practise‘intuitive medicine’on a fee-for-service basis,
collecting data from tests, imaging equipment, and physical examinations of
the patient to develop diagnoses and prescribe treatments.
Digitalizing Healthcare
19

Over the years, however, a second business model has also emerged.
Accumulated evidence concerning what works in healthcare has allowed
some procedures to become standardized. Such treatments add value to health
outcomes with such certainty that, once a deﬁnitive diagnosis has been made,
the service can be charged on a feeﬁxed to the output which normally comes
with a guarantee. These so-called value-adding processes can be highly
efﬁcient when organized into specialist hospitals or clinics where the high
overheads associated with their mixing with solution-shop business models
can be reduced. Practitioners who can provide an evidence base for their
value-adding processes can in principle, therefore, disrupt the solution-shop
approach to dealing with these health conditions.
A third more emergent business model is based around the idea of facilitated
networks. This model challenges established models of care by offering a more
patient-centred approach in which providers and patients‘co-produce’
healthcare. This model is especially relevant to people with chronic condi-
tions whose treatment involves different medical specialists and behavioural
changes that require them to take more responsibility for their own health.
Compiling information on such conditions and sharing it among patients and
those engaged in their care becomes a vital part of long-term management.
Indeed, patients may be able to learn from each other, thus enhancing mutual
well-being.
According to the theory of disruptive innovation there is a place for all three
models in the future of healthcare systems but, instead of the current confused
mix, the models need to be more clearly separated and reorganized so that
they are no longer‘jumbled mixtures of multiple business models struggling
to deliver value out of chaos’(Hwang and Christensen, 2012: 1333). Expen-
sive‘solution shops’should be reserved for complex problems to be treated by
specialists, while well-understood conditions can be treated by less-qualiﬁed
practitioners according to rule-based procedures. Facilitated networks can
reduce costs further by helping patients to manage known and chronic con-
ditions themselves (Christensen et al., 2009: 131). Moreover, in this reorgan-
ized value system, no one health professional is responsible for co-ordinating
an individual’s care. Instead, electronic records provide the‘connective tissue
that draws and holds together the individual elements’of care (Christensen
et al., 2009: 131).
The fact that the digitalization of health records has been promoted for
some time but rarely been successfully implemented is, according to Christensen
and colleagues, due to the confused state of medical practice and the lack of a
coherent business model that makes their uptake worthwhile (Christensen
et al., 2009: 130–43). In particular, the beneﬁts of interoperable EHRs are
systemic in nature and from the point of view of the individual doctor‘do
not do the job better’than the paper-based and fragmented computer systems
The Digitalization of Healthcare
20

they currently use (Christensen et al., 2009: 136). Second, where EHRs have
been successfully adopted (typically in the case of the US localized implemen-
tations in privately run hospitals and clinics—see Chapter 2) proprietary sys-
tems have been developed where‘records can be accessed instantly from any
point within their systems, but generally not from points outside the system’
(Christensen et al., 2009: 136). These systems are, therefore, independent
products optimized for the internal architectures and business models of the
hospitals they serve but not compatible with, readily connected to, or easily
integrated with other hospitals outside the enterprise’s boundary, which of
course is not a concern for privately run health enterprises.
One insight to be gleaned from disruptive innovation theory for our pur-
poses is the observation that business models in healthcare can shape the
way records are understood and used. For example, in the solution-shop
model, records are clinical in nature and controlled by doctors with the
expectation that digitalization facilitates sharing among providers. In such
circumstances, disclosure to patients is largely a medical prerogative and
contingent on clinical interpretation to render information meaningful and
actionable. Similarly, in the value-added model, healthcare providers’right to
autonomous practice is constrained, but they still retain control over, and
responsibility for, medical information about patients. Again, digitalization
might be seen as vital for improving theﬂow of medical information to
enhance value-adding processes.
It is in the third business model, that facilitated by networks of interoper-
able EHRs that patients can access and possibly control, that the disruptive
and transformative potential of digitalization comes to the fore. Christensen,
Grossman, and Hwang recognize the challenges involved in establishing such
networks. Agreed technical standards need to be developed to enable systems
to communicate with each other, along with government policies to encour-
age or coerce take up. An alternative bottom-up approach might also be
possible, in which‘disruptive players...coalesce around and build their sys-
tems upon a platform’similar to social media services such as Facebook.
Over time the platform could become standardized and enable an entirely
new way to co-produce healthcare (Christensen et al., 2009: 138–9). The
theorists of disruptive innovation point to some compelling and insightful
ways in which digitalization might enable the reform of healthcare sys-
tems. However, as we will see, the challenges involved are not just ones of
ﬁnding the appropriate business models to incentivize the required innov-
ations. They also require a fundamental rethinking of established rights
and responsibilities concerning the recording, sharing, and control of
sensitive medical information. As wewill see, these rights and responsi-
bilities sit at the core of the medical division labour and the relationship
between doctors and patients.
Digitalizing Healthcare
21

Conclusion
In this chapter we have outlined some of the reasons why governments
around the world see the digitalization of healthcare and national EHRs in
particular as potential solutions to the‘wicked problems’faced by healthcare
systems. We have explored two related but contrasting propositions concern-
ing the transformation of healthcare in this way. On the one hand there are
those who see such commitment as a dangerous policy enthusiasm encour-
aged by fads and pushed by system suppliers and intermediaries eager to proﬁt
from the large public investments involved. An alternative view is provided by
proponents of the theory of disruptive innovation. They too place much faith
in the transformative potential of digital technology. However, they see such
innovation as dependent upon decisions over the mix of business models that
support the delivery of healthcare services and the degree of alignment in the
healthcare value chain. Disruption theory places much emphasis on getting
economic incentives right to persuade stakeholders to embrace new technolo-
gies and working practices. However, as we shall highlight and explore in
Chapter 3, we need to delve far deeper than this into the ways in which values
over and above those expressed in economic terms shape individual and
collective responses to digital technology in healthcare.
The Digitalization of Healthcare
22

2
The Troubled History of Implementing EHRs
In this chapter we examine the problematic experience of implementing
national EHR systems. We begin by considering the deﬁnition of an EHR by
identifying the different dimensions along which implementations can use-
fully be seen to differ. We then consider choices in relation to the different
models of consent and control available in determining access to and respon-
sibility for the content of electronic records. We then examine speciﬁc
examples of the implementation of EHR systems within selected countries
with particular reference to the extent to which they have been able to scale as
intended to the national level. The challenges and issues involved, in particu-
lar the response of key stakeholders such as clinicians and models of consent,
provide useful reference points with regard to the Australian and English
experiences which we explore in more depth in subsequent chapters.
Dimensions of EHRs and Models of Consent
It is frequently noted that the terminology around‘electronic health records’
is confusing and often the same term is used to describe different types of
record, with different purposes and contexts of use. This variety makes it
difﬁcult to compare developments across jurisdictions (Brennan, 2005;
Adler-Milstein et al., 2014). At the same time, where information is intended
to be shared across organizational and occupational boundaries at a national
scale, divergent perceptions regarding the relative strengths and weaknesses of
different models of consent come to the fore.
Deﬁning EHRs: Dimensions of Scope, Scale, and Control
Our main interest in this book is with the‘shareable’aspect of EHRs. This, it
can be suggested, involves three interrelated dimensions. Theﬁrst is the extent
to which the data in the record are intended to be shared beyond the bounded

conﬁnes of the local health enterprise at a regional or nationalscale. The
second is the extent to which thescopeof the record is intended to combine
data collectedlaterallyfrom a variety of organizations and/or clinical special-
ties andlongitudinallyby providing information about a patient’s healthcare to
a wide range of potential users over his or her lifespan. Third, there is the
extent to which the locus ofcontrolover access to and content in the record is
more or less provider- or person-centric. We express these dimensions of the
record graphically in Figure 2.1.
Deﬁned in these terms, certain kinds of EHR fall outside the scope of our
concerns, in particular electronic medical records (EMRs), which provide a
‘record of the periodic care provided mainly by one institution’for the express
use and beneﬁt of hospital doctors and GPs (Brennan, 2005: 81). Although
patients in most jurisdictions may have rights to view these records, they are
not speciﬁcally designed for this purpose (Cresswell and Sheikh, 2013) and
therefore are not intended to be shareable except between clinicians dealing
with particular episodes of care.
We therefore distinguish such EMRs from what can be termed‘shareable
EHRs’(SEHRs). As we will see, SEHRs are often implemented through the
creation of individual summary health records which are intended to allow
key information to be shared across organizational and other boundaries.
Such summary records are typically stored centrally and populated
with data periodically uploaded from hospitals, clinics, and GPs. The sum-
mary record is normally intended to contain clinical information most vital
in emergency situations and to provide an accurate and up-to-date record
of medication history, test results, and so forth. Combined with locally
Personal
control
Provider
bounded
EMR
PHR
person-
controlled
SEHR
provider-
controlled
SEHR
local
scale
regional
nation
scope cross-boundar y
Figure 2.1.Dimensions of EHRs
The Digitalization of Healthcare
24

held records over time the summary record in principle provides a longitudinal
account of all of an individual’s interactions with the healthcare system
throughout his/her life independent of single episodes of care. SEHRs differ
from EMRs in that they are intended to be shared beyond the local at a regional
and/or national scale and have a greater degree of intended mobility in space
and time, which allows the record to be shared laterally and to evolve as a
longitudinal account of an individual’s interactions with the healthcare system.
When an SEHR is intended to support information-sharing at a national
level, we will refer to it as a national EHR. A further key aspect of SEHRs is the
potential they offer for the creation of‘personal health records’(PHRs). PHRs
can be‘tethered’to SEHRs, i.e. linked to or extracted from SEHR systems
created by healthcare institutions. As we will see, tethered functionality of
this kind has featured in projects to develop national EHRs in the form of
portals and the like that provide citizens with a window into the electronic
information held about them. At the same time there is increasing interest in
‘untethered’PHRs, which are essentially consumer-controlled digital reposi-
tories of an individual’shealthdataspeciﬁcally designed to be accessed
andusedbylaypeople.PHRsofboththetetheredanduntetheredvarieties
are often promoted as a means of empowering citizens by enabling
them to control their health information. Untethered PHRs in particular
involve a shift in the locus of control over records away from clinicians and
towards citizens.
Consent Models—‘Opt in’or‘Opt out’?
The potential for shifting the locus of control over the health record high-
lights questions of rights and responsibilities in relation to such issues as
the accuracy of health information, the maintenance of the information
once recorded, and the exchange of these data in ways that are secure and
respect the privacy and other concerns of citizens. As Coiera and Clarke
observe:
the presence of an electronic environment means that more clinical workers will
be able to access patient information more often and in a greater diversity of
locations. With the broadening of access to patient information comes the risks
that such information is used for purposes not originally consented to by the
patient. (Coiera and Clarke, 2004: 130)
In the case of SEHRs these issues crystallize around the model of consent that
deﬁnes citizen rights to opt in or opt out of having an EHR. Such models also
deﬁne what, if any, choice citizens may have over the kind of information
stored on their record, who can view it, and under what circumstances. The
issue of consent becomes even more salient when the intention is to scale the
The Troubled History of Implementing EHRs
25

system beyond the immediately local situation to a regional or national level.
At this point the propensity for information about multiple episodes of care to
be shared across healthcare-enterprise boundaries over time poses particular
challenges for the development and operationalization of acceptable models
of consent. Moreover, the type of model of consent deployed involves striking
‘different balances in the trade-off between privacy, safety, and effect on
clinical work practices’(Coiera and Clarke, 2004: 131).
One view could be that no additional measures are required. That is, citizens
do not need to be given a further opportunity to express or exercise their
preferences on the grounds that privacy rules and civil liberties already exist—
for example, the legal frameworks, guidelines, and procedures that govern
informed consent in face-to-face interactions between patients and clinicians
during particular episodes of care. However, as Coiera and Clarke (2004) warn,
simply translating existing frameworks and procedures developed to govern
face-to-face human interactions can have unintended consequences and risks
in a new electronic environment. They suggest that attempting to build
existing arrangements for obtaining consent or establishing that it already
exists into a new interconnected‘electronic environment’involves some form
of automation of the process. This means that‘the parties normally associated
with that decision’will be absent and that what they term‘consent gaps’
which can be negotiated locally in face-to-face interactions might be exposed
(Coiera and Clarke, 2004: 130). This would present a problem of how to build
more precise and legally/procedurally correct routines into EHR software and
similar systems without undermining their usability through requiring
numerous‘consent actions’on the part of users, increasing clinical workloads,
and creating the potential for clinicians being refused access to information
because of rules embedded in the system (Coiera and Clarke, 2004: 130).
In an effort to address such potential problems a number of additional
consent models have been identiﬁed which seek to establish additional rights
for patients to consent to having their information shared electronically (see,
e.g., Coiera and Clarke, 2004; Goldstein and Rein, 2010). Theﬁrst of these is
anopt-outmodel which is based on the assumption that citizens by default
consent to the electronic sharing of their information but an option is pro-
vided for them to withdraw this consent if they wish. This withdrawal of
consent might involve (a) information that is already held on the electronic
record being used only for speciﬁc de-identiﬁed purposes such as public-
health reporting but not being shared between providers in identiﬁable form
for the purpose of clinical care, or (b) the citizen’s clinical information not
being recorded electronically in theﬁrst place (i.e. the information is either‘in
or out’). A second model allows citizens toopt out with exceptions. That is, they
are permitted to select the categories of health data they wish to exclude from
the record (e.g. particular conditions, medications, and so on); and/or choose
The Digitalization of Healthcare
26

which providers they are prepared to share their health information with
electronically (e.g. their own GP clinic, or hospital doctors dealing with a
particular episode of care); and/or limit the sharing of such electronic data to
speciﬁc circumstances (e.g. an emergency admission to hospital).
A third approach starts from a different default position in which citizens
have to actively provide consent if their information is to be recorded and
shared by electronic means—in other words they mustopt in. In this model
the patient’s information is either all in or all out of the EHR. However, in this
variant, once citizens opt in, they have no control over what information is
Table 2.1.Opt-in/out models of consent
Consent model Form of consent Trade-off of clinical utility versus
personal privacy
No consent No opportunity provided for
accommodation of individual
preference in sharing of personal
health data electronically on the
grounds that existing arrangements
governing face-to-face methods of
conﬁrming consent are adequate.
Danger of unintended
consequences from rigid
incorporation of legal and other
requirements within system
software to avoid‘consent gaps’
but creating multiple‘consent
actions’for clinicians and potential
barriers to clinical access, therefore
reducing system utility.
Opt out The consent of citizens to the
sharing of personal health
information electronically is
assumed but this is combined with
an additional right for patients to
opt out in full from these
arrangements.
Allows a moreﬂexible approach to
consent in system design,
maximizing clinical utility and
ensuring information required by
clinicians now and in the future in
treating patients will be available to
them.
Opt out with exceptions As above, but instead of a blanket
right citizens can select categories
of data they wish to exclude from
the record, or which providers they
will share with, or in which
circumstances.
As above, but with more
recognition of patient preferences
with regard to the privacy of
elements of their health
information.
Opt in Citizens wishing to make their
personal health information
available for sharing electronically
must actively give their consent
and, if not, deny the use of any of
their data in the system.
Provides patients with right to
protect the privacy of their health
information as they seeﬁt but
means clinicians may not have
access to the information they
might need now or in the future to
ensure high-quality and safe care.
Opt in with restrictions As above, citizens actively grant
their consent to participate but this
covers only speciﬁc categories of
data, providers, or purposes.
As above, and assumes patients are
informed enough to exercise their
rights to deny access to different
categories of data, health
professional, or for particular
healthcare episodes without
compromising the safety or quality
of care.
Source: based on Goldstein and Rein, 2010; Coiera and Clarke, 2004
The Troubled History of Implementing EHRs
27

shared, how, with whom, or for what purpose. Aﬁnal option, therefore,
provides a further degree of control to citizens by allowing them toopt in
with restrictions. Here citizens are permitted to make a predeﬁned set of their
personal health information available for sharing and are able to actively grant
their consent to participate with regard to speciﬁc categories of data or data
elements; and/or enable information toﬂow only to speciﬁc providers; and/or
allow their information to be exchanged only for speciﬁc purposes. These
broad options are summarized in Table 2.1.
As we will see in the following chapters, the relative merits ofopt-inandopt-
outmodels have been the subject of heated debate amongst policy-makers,
medical professionals, consumer groups, privacy advocates, and others. The
form and function of consent models also interact with the three dimensions
of EHRs deﬁned above. Anopt-outmodel would appear to be more conducive
to ensuring the exchange of data for the majority of the population at a
national scale and be more likely to optimize the clinical utility of the infor-
mation shared. However, this raises privacy and data security risks associated
with the centralization of information and the control of access to it. Anopt-in
system, on the other hand, trades off clinical utility against patient-privacy
concerns by providing more personal control over what data are recorded in
the system and how, when, and by whom they are accessed. However, since
patients have to opt in to the system, there is a risk that they might refuse to
do so on the basis of a limited understanding of the clinical implications of
their decision, either directly for them, or more broadly in relation to the
secondary uses of their data to improve the care of others (Coiera and Clarke,
2004: 132).
National EHR Implementation in Comparative Perspective
We now review some of the troubled experiences of implementing national
EHRs from around the world. As we will see, even in nations regarded as
leaders in e-health, building nationwide SEHRs has proven extraordinarily
difﬁcult (see, e.g., Greenhalgh et al., 2011; Stroetmann et al., 2011a; NHS
England/US Department of Health and Human Services, 2016; Wachter,
2016). In Europe, for instance, whilst the development of national EHRs has
been‘a consistent element of almost all national strategies and roadmaps’for
health policy (Stroetmann et al., 2011b: 5), progress is extremely patchy.
A survey of twenty-seven EU countries published in 2014 used a combination
of measures of technological development, appropriate organizational innov-
ation, and sociopolitical contexts to gauge progress in the implementation of
e-health strategies (Currie and Seddon, 2014). The survey results were used to
allocate countries to one of four‘eHealth proﬁles’dependent upon the degree
The Digitalization of Healthcare
28

of progress made. Those with‘frontrunner’proﬁles had well-developed and
available ICT infrastructures with e-health applications that were adopted by a
high proportion of healthcare professionals and citizens. The Netherlands,
UK, Sweden, Finland, and Denmark fell into this category. Second, there were
those with a‘follower’proﬁle—countries such as Germany, Belgium, Austria,
and France with similar infrastructures but whose take up and use of e-health
applications lagged behind the frontrunners due to sociopolitical factors
which contributed to a‘conservatism and caution in rolling out e-health ini-
tiatives’(Currie and Seddon, 2014: 790). Third were nations with a‘leapfrogger’
proﬁle, many of which were located in Central and Eastern Europe. Here ICT
infrastructures were less well developed and yet health systems exhibited a
relatively high take-up and progress in the use of e-health applications. Finally
were countries with a‘laggard’proﬁle such as Romania, Malta, and Cyprus,
which had the least-developed ICT infrastructures and adoption rates.
Similar assessments of the variability of progress have been made in other
cross-national surveys. For example, a 2012 investigation of ICT use by pri-
mary care doctors in ten developed nations discovered that‘the electronic
exchange of patient information’was‘not yet the norm in any country’
(Schoen et al., 2012: 2809). A study comparing developments in Australia,
Canada, Denmark, England, Finland, the Netherlands, and the USA also
found the type of functionality available in these nations to be quite variable.
A later survey by the WHO of e-health in Europe found that 59 per cent of
member states reported having‘a national EHR system’. However, there was a
‘wide interpretation of how EHR systems are deﬁned, structured and accessed’
(WHO, 2016: 21). Indeed, rather than collating and sharing longitudinal
records among clinicians and patients, many systems instead prioritized data
transfer between doctors, laboratories and pharmacies (WHO, 2016: 28).
A similar study of e-health developments in countries belonging to the
OECD conducted around the same time found that efforts to date have
concentrated on the provision of provider-centric records and health infor-
mation exchange. Much less work had been done to implement patient-
centric records, with England being the only country that had so far
attempted to deﬁne and measure its nationwide EHR in terms of a limited
range of patient functions, such as an ability to enter data and book appoint-
ments (Adler-Milstein et al., 2014).
With this context in mind, we now probe more deeply into the complex-
ities of implementing SEHRs at a national scale in selected larger and smaller
nations which are amongst those typically identiﬁed as leaders in e-health
developments. In all these countriesevents are still unfolding and in each
case our accounts cover the period to the end of 2015. Table 2.2 provides
a summary of each national example and a comparison with Australia
and England.
The Troubled History of Implementing EHRs
29

Table 2.2.
National EHR project comparisons in selected nations
Country/project Provider- or patient-centric
system
Consent model Problems and issues Outcomes
USA (pop. 325 million)
Provider-centric with scope focused on individual clinics and hospitals (EMR) rather than creation of national information-sharing network.
Based on local legal frameworks and regulatory practices, no national model.
Financial incentives not delivering expected results, clinician opposition to pace of change, and expectations concerning patient engagement with the record.
Successful outcomes largely con
ﬁ
ned to exemplars in
integrated insurer/provider healthcare enterprises. These models do not readily scale beyond the enterprise. An
‘
EHR
for all Americans
’
has not yet
been delivered.
Federal incentive scheme to encourage meaningful use of EHRs by GPs, hospitals, and other health providers. Germany (pop. 80 million)
Smart-card-based system which gives citizens degrees of control over access to and content of the record in consultation with clinicians.
Akin to opt-in with exceptions as citizens must carry a smart card but can exercise control over what and who accesses information through this.
Ongoing clinician concern over the security of patient data; technical dif
ﬁ
culties in
developing appropriate smart-card technology and infrastructure.
Roll-out of new cards began in 2011 and since 2015 they offer the only legal proof of entitlement. New laws passed in 2015 to provide incentives and eventual penalties to drive upload of data by doctors. National SEHRs still in the future.
E-health smart card coupled with strategy to develop national SEHR. Netherlands (pop.17 million)
Provider-centric SEHR system to draw and exchange data from existing regional systems through national switchpoint. Intention to scale to national level.
Originally information exchange to be on a need-to-know basis with patient consent (de facto opt-in). Attempts to improve take-up by imposing opt-out system have so far failed to win approval in legislative process.
Doctors reluctant to
ﬁ
nance
roll-out of national EHR and share patient data because of privacy concerns. Dislike of top-down national approach in context of successful regional systems for exchanging data.
Signi
ﬁ
cant progress in sharing of
electronic health data at regional level. However, problematic progress towards national EHR system has meant initiative now scaled back.
National Information and Communication Institute for Healthcare tasked with developing national EHR to enable exchange of patient data. Denmark (pop. 5.6 million)
Provider-centric with regional scope. Citizen and provider access via portal.
Opt-out model. Consent to collect and exchange information for purposes of care is assumed unless patients object.
Bottom-up approach has led to fragmentation and some problems with interoperability when attempting to aggregate data.
High levels of interorganizational sharing of health information at regional level but top-down attempts to integrate data through a national EHR have been problematic.
Two failed and an ongoing attempt at national EHR in context of bottom-up development of regional health data exchange infrastructure.

New Zealand (pop. 4.6 million)
Provider-centric with regional scope.
Opt-out. View that distributed approach
lacks national co-ordination and is confusing in terms of procurement criteria but top- down centralized approaches also rejected in preference for ‘
middle-out
’
approach.
New Zealand healthcare system has made more progress than most towards integrated care models but has not developed a nation-scale EHR amidst concerns that a more distributed rather than centralized approach is more appropriate.
Focus on development of infrastructure for sharing clinical information with distributed approach to EHRs. Australia (pop. 24 million)
Patient-centric national SEHR system running in parallel with providers
’
EMRs and
information exchanges.
Initially opt-in but plans to move to opt-out in the light of slow citizen take-up and clinician concerns over value.
Opposition from doctors to system which
‘
demedicalized
’
the record and privacy group concerns over state control over citizen information.
Aspirations to transform healthcare by shifting the locus of control from doctors have been thwarted by implementation problems, opposition, and lack of citizen interest.
First attempt to build national SEHR system abandoned. Second attempt in progress. England (pop. 54 million)
Top-down procurement of systems intended to replace all existing systems based around a national summary care record.
Initially opt-in assumed but limited rights to opt out eventually granted.
Opposition from clinicians and within NHS, plus strong resistance from privacy groups.
National e-health infrastructure abandoned, although some elements were implemented. SCR roll-out much delayed and currently taking place.
Attempt to build national e-health infrastructure abandoned in favour of more localized solutions.

United States: Problems of Incentivizing‘Meaningful Use’by Clinicians
In 2009 President-elect Barack Obama recommitted the USA to a goal (previ-
ously set by President George Bush) that withinﬁve years‘every American’
would have an‘electronic health record’, thereby saving‘billions of dollars
and thousands of jobs’and‘reducing the deadly but preventable medical
errors that pervade our health-care system’(Obama, 2009). This required an
investment of US$29 billion over ten years to support the‘meaningful use’of
EHRs as a core component of the national recovery plan developed in
response to the 2008 globalﬁnancial crisis (Blumenthal, 2011). The invest-
ment and associated objectives were enshrined in the HITECH (Health Infor-
mation Technology for Economic and Clinical Health) Act of 2009. The act
was crafted within a context of a highly disjointed and privatized healthcare
sector described by one observer as a‘cottage industry’marked by‘fragmen-
tation at the national, state, community, and practice levels’, with no national
policy frameworks or mechanisms for guiding or organizing the sector as a
whole (Shih et al., 2008: ix). As a result, unlike in most other countries, there is
no policy mechanism through which a single format or architecture for a
national EHR could be developed centrally and supported for use by providers
and citizens across the nation (Morrison et al., 2011).
Instead, the main national policy instruments available to policy-makers are
legal andﬁnancial incentives to encourage the take up of EHRs by healthcare
providers. However, one review of progress prior to the HITECH Act found
that existing incentives provided‘little motivation to share information across
institutions’(Diamond and Shirky, 2008: 384). Indeed, the much-vaunted
exemplars of EHR development and use found in the literature (see, e.g.,
Chen et al., 2009) tend to be located within the boundaries of closed or inte-
grated systems of care, such as those administered by the Veterans Health
Administration or private corporations such as the Mayo Clinic and Kaiser
Permanente, some of which provide both health insurance and care. In such
situations, it is easier and advantageous to‘have most of the data in one place’
(McGee, 2007: 3).
To stimulate the take-up of SEHRs outside and across these closed systems,
the HITECH Act set out new incentives to healthcare providers who could
demonstrate‘meaningful use’of certiﬁed EHRs through speciﬁc functions
such as improved data capture and processing, smoother service delivery,
and eventually better health outcomes (Blumenthal, 2011). The program
was designed to deliver incentives in stages, with the criteria used to deﬁne
‘meaningful use’becoming more demanding over time. After 2015, healthcare
providers would also be penalized for not using EHRs (Blumenthal, 2009).
There is some evidence that these incentives stimulated uptake. For
example, the Commonwealth Fund found that the proportion of primary
The Digitalization of Healthcare
32

care physicians who reported using EHRs rose from 46 per cent in 2009 to
69 per cent in 2012. By 2012, however, only 31 per cent were able to elec-
tronically exchange patient summaries and test results with doctors outside
their practice. This capacity was mostly conﬁned to large practices and those
working in integrated healthcare systems (Schoen et al., 2012). There was also
a sharp increase in the number of hospitals using an EHR (most likely an
EMR). From a low base of about 10 per cent before the HITECH Act, by 2014
more than half of the hospitals in the US were reported to have at least a‘basic’
system in operation. However, many had only a limited capacity to share data
with other organizations (Adler-Milstein et al., 2014).
As the incentive scheme developed, concerns about the HITECH process also
emerged. For example, in 2013 a group of US senators published a white paper in
which they called for a‘reboot’of the strategies used to stimulate the adoption of
EHRs (Thune et al., 2013). They noted that despite the stated focus on‘data
capture and sharing’,therewasno‘clear path’towards interoperability. Instead,
there was a‘misplaced focus on use of technology within silos’which did little to
enhance the co-ordination of care (Thune et al., 2013: 11). The senators also
criticized what they saw as an‘aggressive, one-size-ﬁts-all implementation
schedule’that failed to acknowledge the different priorities and capabilities of
diverse organizations across the healthcare sector (Thune et al., 2013: 12).
Other stakeholders also mounted‘an outburst of opposition’to the pro-
gramme as they found the more demanding criteria required to demonstrate
meaningful use over time too difﬁcult to fulﬁl (Terry, 2014).
As a result of these and other criticisms, the ambitious timescales
announced at the beginning of the HITECH programme were revised. The
requirement that‘at least 10 percent of patients view, download, and transmit
their health information and send a secure electronic message to their
provider’, which had caused particular anxiety, was lowered to 5 per cent of
patients (McCartney, 2013). However, doubts remained. A survey of almost
2,000 physicians found that 55 per cent planned to forgo compliance with
new meaningful use criteria in 2015 that required them to show that they are
making EHRs available to their patients (Irving, 2015). Because of these and
other problems, which include the practice by some vendors of blocking
communications with their competitors’systems, the implementation of the
new meaningful use criteria has at the time of writing been delayed to 2016.
However, it seems that such measures will not address the crux of the prob-
lem. New research has claimed that the ‘continuing fragmentation of
U.S. healthcare ensures that incomplete clinical data in primary site EHRs is
a widespread problem’, suggesting that policy-makers needed to focus
more‘on the quality and utility of health information and ways these can
be improved, instead of simply tallying up EHR purchases and supposed
capabilities’(Madden et al., 2016).
The Troubled History of Implementing EHRs
33

Germany: Smart Cards and the’Easy Exchange’of Health Information
Germany’s attempt to introduce a nationwide e-health infrastructure provides
another example of the multifaceted challenges that arise in a large, federally
structured country with a highly complex health system (Stroetmann et al.,
2010: 41). Within this context the role of the German Federal Ministry of
Health is largely conﬁned to setting the legal frameworks within which
healthcare is funded and delivered. Germany’s e-health strategy has taken
advantage of the fact that since 1995 citizens have used smart cards to access
universal health insurance. In 2003 the laws governing health insurance were
amended to allow the administrative details embedded in these cards to be
supplemented over time with additional healthcare information. As aﬁrst
step, extra insurance and emergency health data would be added and the
card modiﬁed to enable electronic prescribing (Jähn et al., 2005; Stroetmann
et al., 2010). There were also plans to store more comprehensive health rec-
ords on central servers connected to a network that would enable sharing.
Updated electronic cards would be provided in 2006. The collection, storage,
and sharing of information in and through this network would only occur
with citizens’consent, with access controlled by users through their smart
cards in consultation with their healthcare providers (Stafford, 2008; Hoerbst
et al., 2011). The project involved providing new electronic health insurance
cards for around 70 million citizens, as well as technical equipment for several
hundred thousand healthcare providers to read and process the data. As such,
it was regarded as‘one of the largest IT-projects’to be undertaken worldwide
(Hoerbst et al., 2011: 83).
However, pilot studies showed that much work would be needed to make the
new cards and accompanying infrastructure acceptable to stakeholders. Because
of poor interoperability and the need for high security standards, storing infor-
mation on the card and obtaining patient details from them took longer than
equivalent paper-based processes. Electronic prescribing and accessing data in
emergency situations were also cumbersome (Stroetmann, 2010: 27). Moreover,
although health insurers supported the new cards as more reliable than the
older ones, which were often fraudulently used, doctors were vigorously
opposed to their introduction. They felt that the security of private medical
information held on centralized servers could not be guaranteed, and citizens’
records might be vulnerable to commercial exploitation (Stafford, 2008). Citi-
zens who were surveyed also expressed concerns about security and privacy,
even though an overwhelming majority was in favour of the card’s develop-
ment (Hoerbst et al., 2011).
Following the federal election of 2009, the new government reviewed plans
for the electronic health card, whose implementation was by then three years
behind schedule. After a hiatus, the government decided that implementation
The Digitalization of Healthcare
34

should go ahead. By then, the system had cost€1.7 billion. Under the
relaunched plan, the new cards would carry much the same basic identity
and entitlement data as the older smart cards but would also feature, as a
measure intended to combat fraud, a photograph of the holder. In addition,
other security features were embedded in the cards, which were also designed
to accommodate future developments that would, with the holder’s consent,
enable a greater range of health information to be accessed through or stored
on the card (Clarke et al., 2013).
Roll-out of the cards commenced in 2011 and healthcare insurers were
required to provide new cards to all their members within two years (Federal
Ministry of Health, 2013). Since the beginning of 2015, the card is the only
accepted‘proof of entitlement’for medical and dental care (Federal Ministry
of Health, 2015). In mid-2015, in an attempt to expedite progress, a new law
set out requirements and deadlines for the further development of the cards
and the infrastructures to support them. This included incentives to doctors to
upload data and new penalties operative from 2018 if they do not do so.
Reports suggest that doctors’staunch opposition to such changes seem to
have‘softened slightly’, although they are still concerned about the security
of their patients’information (Stafford, 2015). Moreover, despite recent
progress, it appears that some aspects of the infrastructure required to support
the new plans are lagging in development (Federal Ministry of Health, 2013,
2015) and that the‘controlled, secure common access to patient data by all
involved in the care of a speciﬁc person’may still be some way off (Stroetmann
et al., 2010: 41).
The Netherlands: Problems Scaling Regional Networks into a National EHR
The Netherlands is noted for the considerable progress it has made in the
development of regional infrastructures for the electronic sharing of health
data such that‘e-Health has to a large extent been integrated in the regular
process of healthcare delivery’(Flim, 2010: 31).
However, Dutch attempts to scale these efforts to the national level appear
to have been less successful. Discussions about implementing a national EHR
began in the mid-1990s and culminated in the formation in 2002 of the
National Information and Communication Institute for Healthcare. This
organization—a‘national competence centre’for e-health—was intended
to develop components that would allow data to be‘pulled’from doctors’
records and exchanged through a national‘switchpoint’akin to a‘trafﬁc
control tower which regulates the exchange of patient data between health-
care providers’(Flim, 2010: 26). Information would only be exchanged on a
need-to-know basis with the consent of patients. The roll-out of this system
was to have been completed by 2004. However, doctors were reluctant to
The Troubled History of Implementing EHRs
35

Exploring the Variety of Random
Documents with Different Content

dominant factor attaching itself to a wild species in recent times. None of the cases are
satisfactorily recorded or analysed as yet, but the evidence is clear that doubledayaria is a
dominant to its type, and in several other dark varieties, though the pigment deposited is
not black, the records show that the increased amount of the pigment almost certainly is
due to a positive factor. Of this, Hemerophila abruptaria is a good example.
[24]
There are
some irregularities in the results, but taken together they leave little doubt that the dark
brown variety is a dominant and the light, yellowish brown a recessive.
A curious parallel to the rise of the melanic moths in England is provided by the case of
the Honey-creepers or Sugar-birds, in certain West Indian islands.
[25]
These birds of the
genus Coereba (Certhiola) range from Southern Mexico to the Northern parts of South
America and through the whole chain of the West Indian islands and Bahamas except
Cuba. There are numerous local forms, and many of the islands have types peculiar to
themselves, as is usual in such cases. Some of the types or species range through several
islands, but according to Austin Clark
[26]
no island has more than one of them. Cory
[27]
reckoned twelve such species within the Antillean region. They are small birds about the
size of a nuthatch with a general colouring of black, yellow, and white. From the island of
St. Vincent the Smithsonian Institution received in the late seventies of last century several
completely black specimens in addition to two of the usual type of colouring. The black
were described by W. N. Lawrence as atrata, and those marked with the usual yellow and
white were called saccharina. The collector (Mr. F. A. Ober) reported that the black form
was common, and that the saccharina form was rarer. Lawrence remarks, "Had there been
only a single example (of the black form) I should have considered it as probably a case of
abnormal colouring, but it seems to be a representative form of the genus in this island."
[28]
There is of course no doubt of the correctness of the view taken by Austin Clark that
"atrata" is a black variety. The black bird is in every respect, other than colour, identical
with saccharina, and it is even possible to detect a greenish colour in the areas which
would normally be yellow, showing plainly enough the yellow pigment obscured by the
black.
We have next the interesting fact that like our melanic moths the dark form is replacing
the "type." At the time of Ober's visit the type was already in a minority, but now it is
nearly or perhaps actually extinct, though the black form is one of the commonest birds on
the island. Austin Clark found no specimen when he collected there in 1903-4, though
formerly it was not uncommon in the vicinity of Kingston and in the immediate windward
district of St. Vincent.
The Grenadines are geographically just south of St. Vincent, though separated by a
deep channel. In these islands no black forms have yet been taken, but Grenada, the next
island to the south, has both normals and blacks. There are trifling differences of size
between the Grenada birds and those from St. Vincent, the Grenada specimens being
slightly smaller and for this reason they have received distinct names, the form marked
with yellow and white being called Godmani (Cory) and the black, Wellsi (Cory), but this
merely introduces a useless complication. There is evidence that in Grenada, as in St.
Vincent, the black is gradually ousting the original type, but the process has not gone so
far as in St. Vincent. Austin Clark very properly compares this case of the Sugar-birds with
that of Papilio turnus, which as is well-known, has a black female in the southern parts of

its distribution, in addition to a female of the yellow type, but in the Northern States the
black female does not occur.
During the present year P. R. Lowe, who lately studied Coerebas on a large scale in the
West Indies, has published an important paper on the subject.
[29]
He calls attention to the
fact that Cory recently found a black form of Coereba on Los Roques Islands, and he
himself discovered another on the Testigos Islands. Both localities are on the coast of
Venezuela, far from St. Vincent and Grenada. The whole problem is thus further
complicated by the fact that the black varieties have, as we are almost driven to admit,
arisen independently in remote places. Improbable as this conclusion may be, it is still
more difficult to regard all the black forms as derived from one source. For first, they
present definite small differences from each other; and secondly we have to remember a
consideration of greater importance, that the very fact that each island has its own type
must be accepted as proving that the localities are effectively isolated from each other, and
that migration must be a very rare event.
The rarity of such illustrative cases is, I believe, more apparent than real. It is probably
due to the extreme reluctance of systematists to admit that such things can be, and of
course to the almost complete absence of knowledge as to the genetic behaviour of wild
animals and plants. Only in such examples as this of the Coereba, where colour constitutes
the sole difference, or that of the moths which have been minutely studied by many
collectors, does the significance of the facts appear. The arrangement of catalogues and
collections is such that much practical difficulty of a quite unnecessary kind is introduced.
For example, in this very case of Coereba, I find the British Museum has a fine series from
Grenada including 3 normals and 11 black, and also 16 blacks from St. Vincent. If the black
specimens from Grenada were put with the normals which are almost certainly nothing but
a recessive form of the same bird, the variation would strike the eye on even a superficial
glance at the drawer. But following the notions so naively expressed in the passage quoted
above from W. N. Lawrence, the blacks from Grenada are put apart together with the other
blacks from St. Vincent, though two of them were shot on the same date as one of the
normals.

CHAPTER VII
Local Differentiation . Continued
Overlapping Forms
The facts of the distribution of local forms on the whole are consistent with the view
that these forms come into existence by the sporadic appearance of varieties in a
population, rather than by transformation of the population as a whole. Of such
sporadically occurring varieties there are examples in great abundance, though by the
nature of the case it can be but rarely that we are able to produce evidence of a previous
type being actually superseded by the variety. When the two forms are found co-existing in
the same area they are usually recorded as one species if intergrades are observed, and as
two species if the intergrades are absent. On the other hand when two forms are found
occupying separate areas, when, that is, the process of replacement is completed in one of
the areas, then forthwith each is named separately either as species or subspecies.
Successive observations carried out through considerable periods of time would be
necessary to establish beyond question that the history proceeds in one way rather than
another. Such continuity of observation has for the most part never been attempted. The
kind of information wanted has indeed only been lately recognized, and really critical
collecting is a thing of only the last few decades. The methods of the older collectors, who
aimed at bringing together a few typical specimens of all distinct forms, are of little service
in this class of inquiry, which is better promoted by the indiscriminate collection of large
numbers of common forms from many localities. When this has been done on a
comprehensive scale we shall be in a position to form much more confident judgments as
to the general theory of evolution.
Some little work of the kind has however been done and the results are already of
great value. Seeing that the differentiation of local forms is only made possible by isolation,
it necessarily happens that the collector finds one form in one locality and another in a
distinct locality, and there is no evidence as to the behaviour which the two representative
species might exhibit if they came into touch with each other. In the most familiar
examples of such distinction each inhabits an island, completely occupying it to the
exclusion of any other similar form. It can only be when the two representative species
occupy parts of a continental area connected with each other by regions habitable for the
organism in question, that there is a chance of seeing the two forms in contact. Often also,
even where this condition is satisfied, the habits, social organisation, or some other special
cause may act as a barrier which prevents the distinguishable forms from ever coming into
such complete contact as to interbreed or to behave as a genetically continuous race.
When genetic continuity is ensured by a constant diffusion of the population over the
whole area which they inhabit there will manifestly be no formation of local races. The
practical uniformity, for example, of so many species of birds which inhabit widely
extended ranges of Western Europe is doubtless maintained by such constant diffusion.
When, as in the case of the Falcons, many localities have peculiar forms, the fact may be

taken as conclusive evidence that there is little or no diffusion; and when we find in such a
species as the Goldfinch that in spite of migratory fluctuations there are nevertheless
geographical races fairly well differentiated, it may similarly be inferred that these
fluctuations habitually move up and down on paths which do not intermingle. There are
however a few examples of animals, not given to much irregular wandering, which occupy
a wide and continuous range of diversified country and are differentiated as local races in
two or more districts, though the distinct races meet in intervening areas. Of these the
most notorious illustration which has been investigated with any thoroughness is that of
the species of Colaptes (Woodpeckers) known in the United States as Flickers. The study of
the variations of these forms, made by J. A. Allen
[1]
is an admirable piece of work, with
which every student of variation and evolutionary problems should make himself familiar.
The two forms with which we are most concerned are known as C. auratus and C. cafer,
and are very strikingly different in appearance. In size, proportions, general pattern of
colouration, habits, and notes, the two are alike, but they differ in the following seven
respects as stated by Allen.
Auratus Cafer

1.  Quills yellow. 1.  Quills red.
2.  Male with a black malar stripe. 2.  Male with a red malar stripe.
3.  Adult female with no malar stripe.3.
Adult female with usually a brown malar
stripe.
4.  A scarlet nuchal crescent in both sexes.4.  No nuchal crescent in either sex.
5.  Throat and fore neck brown. 5.  Throat and fore neck grey.
6.  Whole top of head and hind neck grey.6.  Whole top of neck and hind neck brown.
7.
General plumage with an olivaceous
cast.
7.  General plumage with a rufescent cast.
These differences are illustrated in the accompanying coloured plate, which has been most
kindly prepared for me under the instructions of Dr. F. M. Chapman of the American
Museum of Natural History. Before going further it is worth considering the nature of these
differences a little more closely. All but the last are large differences which no one would
overlook even in a hasty glance at the birds. If the only distinction lay in the colour of the
quills we might feel fairly sure that auratus was a recessive form of cafer, and so probably
it is in this respect. Similarly the black malar stripe of auratus is in all probability recessive
to the red malar stripe of cafer and I imagine the pigments concerned are comparable with
those in the Gouldian Finch (Poephila gouldiae) of Australia. Both sexes in that species may
have the head black, red, or, less often, yellow, and though it is not any longer in question
that birds may breed in either plumage, I believe that the young are always black-headed
and I imagine that those which become red-headed possess a dominant factor absent from
the permanently black-headed birds.
[2]
Yellow as a recessive form of a red is certainly very
common, but red and black as variants of the same pigment are less usual. In the Gouldian
Finch we seem to have a case where a pigment can assume all three forms. It would be
interesting to know whether the red of the malar stripes in Colaptes is a pigment of the
same nature as the red of the quills. Both in Colaptes and in Poephila gouldiae I have seen
specimens intermediate between the black and the red, and the appearance of the part

affected was exactly alike in the two cases, red feathers coming up among the black ones,
and many feathers containing both red and black pigments mixed together.
The development of the scarlet nuchal crescent in auratus and the absence of this
conspicuous mark in cafer constitute from the physiological point of view the most
remarkable pair of differences. When the red crescent is not formed, the feathers which
would bear it are exactly like the rest, and no special pigment is visible in them which one
can regard as ready to be modified into red. If the crescent is due to a factor it must
therefore be supposed that this factor has the power of modifying the pigment of the neck
in one special place alone. Dr. W. D. Miller called my attention to the fact that a similar
variation occurs in another American woodpecker, the Sapsucker, Sphyropicus varius.
[3]
I do not suggest that such variations are without parallel: indeed in P. gouldiae the
factor which turns the black of the head into scarlet affects one special region of the black
only, being sharply distinct from the unmodified black of the throat. These regions of the
head are however often the seat of special colours in birds.
[4]
So also may be instanced
the variety of the Common Guillemot (Uria troile) which has a white line round the eyes
and at the sides of the head where the normal has no such mark; but this line is formed in
a very special place, the groove joining the eye to the ear, whereas the feathers of the
nuchal crescent are not ostensibly distinguished from those adjacent.
[5]
The transposition of the brown and the grey on the back and front of the neck also
constitutes a very remarkable difference. If either grey or brown depends on a factor then
it must be supposed that auratus has one of these factors and cafer the other.
From these several considerations it is quite clear that if auratus and cafer are
modifications of the same type produced by presence or absence of factors, several
independent elements must be concerned, and to unravel their inter-relations would be
most difficult even if it were possible to breed the types under observation, which is of
course quite beyond present possibilities.
The distribution of the two is as follows. On the east side of the Continent C. auratus,
relatively pure, occupies the whole of Canada and the States from the North to Galveston.
Westward it extends across the whole continent in the more northern region to Alaska, but
in its pure form it only reaches down the Pacific coast to about the northern border of
British Columbia. Its southern and western limit is thus roughly a line drawn from north of
Vancouver, southeast to North Dakota and then south to Galveston. C. cafer in the
comparatively pure form inhabits Mexico, Arizona, California (except Lower California and
the opposite coast), central and western Nevada, Utah, Oregon, and is bounded on the
east by a line drawn from the Pacific south of Washington, south and eastward through
Colorado to the mouth of the Rio Grande or the Gulf of Mexico. Between the two lines thus
roughly defined is a band of country about 1,200-1,300 miles long and 300-400 miles
wide, which contains some normal birds of each type, but chiefly birds exhibiting the
characters of both, mixed together in various and irregular ways. Even in the areas
occupied by the pure forms occasional birds are recorded with more or less indication of
characteristics of the other form, but within the area in which the two forms are
conterminous, the mixed birds are in the majority. The condition of these birds of mixed
character is described by Allen as follows:

"As has been long known—indeed, as shown by Baird in 1858—the
'intermediates' or 'hybrids' present ever-varying combinations of the
characters of the two birds, from individuals of C. auratus presenting only
the slightest traces of the characters of C. cafer, or, conversely—
individuals of C. cafer presenting only the slightest traces of the
characters of C. auratus—to birds in which the characters of the two are
about equally blended. Thus we may have C. auratus with merely a few
red feathers in the black malar stripe, or with the quills merely slightly
flushed with orange, or C. cafer with either merely a few black feathers in
the red malar stripe, or a few red feathers at the sides of the nape, or an
incipient, barely traceable scarlet nuchal crescent. Where the blending of
the characters is more strongly marked, the quills may be orange-yellow
or orange-red, or of any shade between yellow and red, with the other
features of the two birds about equally blended. But such examples are
exceptional, an unsymmetrical blending being the rule, the two sides of
the same bird being often unlike. The quills of the tail, for example, may
be part red and part yellow, the number of yellow or red feathers varying
in different individuals, and very often in the opposite sides of the tail in
the same bird. The same irregularity occurs also, but apparently less
frequently, in the quills of the wings. In such cases the quills may be
mostly yellow with a few red or orange quills intermixed, or red with a
similar mixture of yellow. A bird may have the general colouration of true
cafer combined with a well-developed nuchal crescent, or nearly pure
auratus with the red malar stripes of a cafer. Sometimes the body
plumage is that of C. auratus with the head nearly as in pure cafer, or
exactly the reverse may occur. Or we may have the general plumage as in
cafer with the throat and crown as in auratus, and the malar stripe either
red or black, or mixed red and black, and so on in almost endless
variations, it being rare to find, even in birds of the same nest, two
individuals alike in all their features of colouration. Usually the first trace
of cafer seen in auratus manifests itself as a mixture of red in the black
malar stripe, either as a few red feathers, or as a tipping of the black
feathers with red, or with merely the basal portion of the feathers red.
Sometimes, however, there is a mixture of orange or reddish quills, while
the malar stripe remains normal. In C. cafer the traces of auratus are
usually shown by a tendency to an incipient nuchal crescent, represented
often by merely a few red-tipped feathers on the sides of the nape; at
other times by a slight mixture of black in the red malar stripe."
Such a state of things accords very imperfectly with expectations under any received
theory of Evolution. As in some of the instances discussed in the first chapter we have here
two fairly definite forms, nearly allied, which on any evolutionary hypothesis must have
been evolved either the one from the other, or both from a third form at a time not very
remote from the present, as time must be measured in evolution. Yet though intermediates
exist in some quantity, no one can for a moment suggest that they are that definite
intermediate from which auratus and cafer descend in common. One cannot imagine that
the immediate ancestor of these birds was a mosaic, made up of asymmetrical patches of

each sort: but that is what many of the intermediates are. It is not much easier to suppose
the ancestor to have been a nondescript, with a compromise between the developed
characters of each, with quills buff, malar stripes neither black nor red, with a trace of
nuchal crescent, and so on. Such Frankenstein-monsters have played, a considerable part
in the imaginations of evolutionary philosophers, but if it were true that there was once a
population of these monsters capable of successful existence, surely they should now be
found as a population occupying the neutral zone between the two modern forms. Yet,
though much remains to be done in clearing up the facts, one thing is certain, namely that
the neutral zone has not a definite and normally intermediate population, but on the
contrary it is peopled by fragments of the two definite types and miscellaneous mongrels
between them.
On the other hand, one cannot readily suppose that either form was the parent of the
other. The process must have involved both addition and loss of factors, for whatever
hypothesis be adopted, such changes must be supposed to have occurred. A careful
statistical tabulation of the way in which the characters are distributed in the population of
the mixed zone would be of great value, and till that has been done there is little that can
be said with certainty as to the genetics of these characters. In the collection of Dr. Bishop
of New Haven I was very kindly allowed to examine a sample, all taken at random, near
together, in Saskatchewan. There were females 4 adult, 2 young; males 4 adult and 5
young. This number, though of course insufficient, is enough to give some guide as to the
degree of definiteness which the characters generally show in their variations. Of the 15
birds, 8 had simply yellow quills; 2 had red; 1 was almost red but had one yellow tail-quill;
3 were intermediate and 1 was buff. As regards the malar patch, which can only be
determined properly in the adult males, 1 was red, 1 was approximately red, 2
intermediate. As to nuchal crescent 4 females had none, 2 females very slight; 7 males had
it, 1 had only a slight crescent, and 1 had none. In point of quills therefore 10 were
definite out of 15; in point of crescent, 11 were definite out of 15; and in point of malar
patch 1 only was definite out of 4. The last is a feature directly dependent on age and so
counts for less, but as regards the other two features there is some indication that the
factors show definiteness in their behaviour. It must be remembered that we have no
knowledge what the heterozygous form may be, and in the case of red and yellow it is
probably a reddish buff. The patch-works are no doubt to be compared with other well-
known pied forms, and in these we must suppose the active factor broken up, which it
probably can be very easily. The asymmetry, which Allen notices as so marked a feature, in
the distribution of the red and yellow quills of the tail especially, recalls that of the black
markings in the pied Canaries. As is well known to students of variations some pigment-
factors in some animals are apparently uncontrolled by symmetry, while in other specific
cases symmetry is the rule. On the other hand the blackness or redness of the malar
patches is, I think, as a rule nearly symmetrical. It should be mentioned that two of Dr.
Bishop's young birds belonged to the same nest, one a female with red quills, the other a
male with yellow. Both are without crescent.
As to the question whether certain combinations of characters occur with special
frequency, the evidence is insufficient to give a definite answer. Among all the birds I have
seen in America or in England I have not yet found one having the malar patches black
without any nuchal crescent. Of Dr. Bishop's 8 adults not one, however, showed the
combination of the three chief features normal for auratus or for cafer.

Besides the two forms that we have hitherto considered, several other local types exist,
and these throw some further light on the problem. Of these the most important in this
connexion is chrysoides, which inhabits the whole of southern California and the mainland
opposite. This remarkable form is as Allen says, very different from auratus except that it
has the quills yellow like auratus, not red like cafer. So that we find here in the extreme
west of the whole distribution a type agreeing in one of its chief features with the eastern
type. Between this and cafer intergrades have, according to Allen, not been found. The
relations of this chrysoides are, Allen thinks, rather with mexicanoides, a southern, smaller
race with colours more intense, which inhabits Guatemala, but however that may be, it
must be regarded as a cafer which has lost its red quills. The island of Guadeloupe off
Lower California has an island form. Beyond the other side of the continent there is also an
island form of auratus, inhabiting Cuba, so that clearly the yellow quills can extend into the
tropics.
The above account is in many respects incomplete, but it suffices to give an outline of
the chief facts. The whole problem is complicated by the undoubted effects of an uncertain
amount of migration, and in many, perhaps all, districts, the winter population differs from
the summer population of the same localities. The existence of these seasonal ebbs and
flows is now well known to ornithologists, and most of the bird species of temperate
regions are subject to them.
Difficult as it may be to conceive the actual process of origin of the two types auratus
and cafer, it is I think still harder to suggest any possible circumstance which can have
determined their development as distinct races, or which can maintain that distinctness
when created. Some will no doubt be disposed to appeal once more to our ignorance and
suggest that if we only knew more we should see that the yellow quills, the black
"moustache" and the red crescent, specially qualify auratus for the north and eastern
region, and the red quills, red "moustache" and absence of crescent fit cafer to the
conditions of its homes. Each can judge for himself, but my own view is that this is a vain
delusion, and that to cherish it merely blunts the receptivity of the mind, which if
unoccupied with such fancies would be more ready to perceive the truth when at last it
shall appear. Think of the range of conditions prevailing in the country occupied by auratus
—a triangle with its apex in Florida and its base the whole Arctic region of North America.
Is it seriously suggested that there is some element common to the "conditions" of such an
area which demands a nuchal crescent in the Flickers, though the birds of the cafer area,
almost equally varied, can dispense with the same character? Curiously enough, the
geographical variation of Sphyropicus varius, another though a very different
Woodpecker
[6]
shows that conversely the nuchal crescent can be dispensed with in the
Eastern form though it is assumed by the Western.
[7]
Allen points out the interesting additional fact that superposed upon each of the two
distinct forms, auratus and cafer, are many geographical variations which can very
naturally be regarded as climatic. Each decreases in size from the North southward, as so
many species do.
[8]
They become paler in the arid plains, and show the ordinary phases
which are seen in other birds having the same distribution. Such differences we may well
suppose to be determined directly or indirectly, by environment, and we may anticipate
with fuller knowledge it will be possible to distinguish variations of this nature as in the

broad sense environmental, from the larger differences separating the two main types of
Colaptes, which I surmise are altogether independent of such influences.
It is generally supposed that phenomena like those now so well established in the case
of Colaptes are very exceptional, and as has already been stated a number of
circumstances must combine in order that they may be produced. I suspect however that
the examples are more numerous than is commonly thought. In all likelihood the three
forms Sphyropicus varius, nuchalis and ruber are in a very similar condition though the
details have not, so far as I know, been worked out. A complex example which is closely
parallel to the case of Colaptes was described by F. M. Chapman
[9]
at the same date as
Allen's work. This is the case of Quiscalus, the Grackles, which in the North American
Continent have three fairly distinct forms which Chapman speaks of as Q. aeneus, Q.
quiscula, and Q. quiscula aglaeus. The birds are all, so far as pigment is concerned, dark
blackish brown, but the head and mantle have superposed a metallic sheen of
interference-colours which in the various forms take different tints, bluish green, bronze
green, or bronze purple. The details are complicated and difficult to appreciate without
actual specimens, but the two common types are sufficiently distinct. The birds inhabit the
whole area east of the Rockies, quiscula aglaeus occupying Florida and the Southern States
southwest of a band of country about a hundred miles broad extending roughly from
Connecticut to the mouth of the Mississippi; and aeneus taking the area north and west of
this band. In discussing this case Chapman expresses the same view as Allen does in the
Colaptes case, that there are two distinct populations, substantially fixed, and that the
band of country in which they meet each other has a mongrel population, with no
consistent type, but showing miscellaneous combinations of the character of the two chief
types.
The warblers of the genus Helminthophila provide another illustration which has points
of special interest. The two chief species are H. pinus, which has a yellow mantle and
lower parts, white bars on the wings, a black patch behind the eyes and a broad black
mark on the throat; and H. chrysoptera with dark grey mantle and pale whitish grey lower
parts, yellow bars on the wings, and grey marks on cheeks and throat where pinus has
black. These two birds are exceeding distinct, and in addition their songs are quite unlike.
H. pinus ranges through the eastern United States up to Connecticut and Iowa. H.
chrysoptera is a northern form extending down to Connecticut and New Jersey. Both are
migrants.
In these two States, where the two types overlap, certain forms have been repeatedly
found which have been described as two distinct species, Lawrencei and leucobronchialis.
Dr. L. B. Bishop and Mr. Brewster showed me two long series of Helminthophila containing
various intergrades between the four named kinds, and details regarding these may be
found in Chapman's North American Warblers and in Dr. Bishop's paper in Auk, 1905, XXII.
Though the characters evidently break up to some extent, the series can be represented as
due to recombinations of definite factors more easily than the others which I have
described. The differentiating characters are:
Pinus Chrysoptera

1.  Mantle and lower parts yellow (Y
1
).  1.  Mantle and lower parts grey (y
1
).
2.  Wing-bars white (y
2
). 2.  Wing-bars yellow (Y
2
).
3.  Cheek and throat not black (b). 3.  Cheek and throat black (B).
The grey pigment of the mantle is common to both, but is masked by the yellow in
pinus, the net result being an olive-green.
[10]
I am much indebted to Dr. F. M. Chapman for the loan of the coloured plate in which
these distinctions are shown. It first appeared in his book, North American Warblers.
We cannot tell whether yellow or not-yellow is due to the presence of a factor, but we
may suppose that one or other gives the special colour to the parts. The black of character
3 is no doubt a dominant. Thus pinus becomes Y
1
y
2
b and chrysoptera in y
1
Y
2
B. The
Lawrencei which has the underparts yellow, wing-bars white, and black patches is Y
1
y
2
B
and leucobronchialis which has mantle and underparts not-yellow, wing-bars yellow and no
black patches is y
1
Y
2
b. This representation, it should be clearly understood, is tentative
and approximate only. The characters are not really sharp, for there is much grading; but
allowing for the effects of heterozygosis and for some actual breaking-up of factors I
believe it gives a fairly correct view of the case. In particular we can see how it meets the
difficulty which Chapman felt in accepting leucobronchialis as in any sense derived from
pinus which has a yellow breast, and chrysoptera which has a black throat, seeing that
leucobronchialis has neither. We now recognize at once that this form could be produced
by ordinary re-combination of the absence of Y
1
with the absence of B.
I note also with great interest that the modern observers agree that the so-called
hybrids may have the song either of the one species, or of the other, or a song
intermediate between the two. It may also be added that these two types have several
times been seen, in the breeding season, paired with each other or with one of the other
combinations.
Fig. 1.  Helminthophila pinus, male.
Fig. 2.  Helminthophila pinus, female.
Fig. 3.  "Lawrence's Warbler," male; one of the integrading forms.
Fig. 4.  "Brewster's Warbler," male; another of the integrading forms.
Fig. 5.  Helminthophila chrysoptera, male.
Fig. 6.  Helminthophila chrysoptera, female.

Allen
[11]
has described another excellent American example, the Tits of the group
Baeolophus bicolor-atricristatus. The form bicolor belongs to the eastern States and ranges
from the Atlantic coast to the Great Plains, and atricristatus, of east Mexico, extends from
Vera Cruz to central Texas. In southern and central Texas the breeding ranges adjoin, and
in this country various intermediates occur. The chief types differ in two main points.

B. bicolor B. atricristatus

Forehead varies from deep black Forehead white to buffish white.
to dull black, suffused with rusty brown.
Crown and crest grey, Crown and crest black, abruptly
slightly darker than the back. contrasting with the back.
The intergrades between the two have, as usual, received specific names. A detailed
description is given by Allen, from which it appears that the gradation is very complete. In
one case a series of 16 adults were all intermediates. It is not stated whether the collector
took these at random, but from the local lists it is clear that the types are found not far
away from the place where the intergrades were shot.
Another very striking case is that of the Tanagers, of the genus Rhamphocoelus. In this
group there are several local forms which are related to each other in remarkable ways.
The forms known as passerinii and icteronotus exhibit the clearest phenomena of
intergradation. The species passerinii has a brilliant scarlet and black male, and it inhabits
Honduras and Nicaragua. Proceeding southwards along the isthmus we find next
costaricensis which has a male like that of passerinii (but a female with more orange than
the olive-grey female of passerinii). Next we come to Panama which is occupied by
icteronotus, sharply distinguished from passerinii by the fact that the scarlet is replaced by
lemon-yellow. This same icteronotus occurs again as a pure type in Ecuador and many
other parts of South America; but Colombia, between Panama and Ecuador, contains
scarlets like passerinii, yellows like icteronotus, and various intergrades of several shades
of orange. The passerinii males from Nicaragua are indistinguishable from those of
Colombia, and the icteronotus of Ecuador are the same as those in Panama. The orange
intergrades, doubtless heterozygous forms, though collected at the same locality (Medellin
in Colombia) as several pure yellows and pure scarlets, are in the British Museum series
sorted out as a separate species under the name chrysonotus! Complications are
introduced by the relations of these forms to another named type, flammigerus, but we
may for our purpose leave that out of consideration, and say that the order of geographical
sequence from Honduras to Ecuador is (1) scarlet, (2) yellow, (3) mixture of types, scarlet,
yellow, orange, (4)yellow.
Similar examples exist in the birds of the old world, but I do not know of any that have
been studied so fully as those of America. The best known is that of the two Rollers,
Coracias indicus which spreads from Asia Minor through Persia, Baluchistan, the Indian
Peninsula and Ceylon, and affinis which ranges from Nepal, through Assam, Tenasserim
and the Indo-Chinese countries. The two types are very different and may be distinguished
as follows:
C. indicus C. affinis

Mantle drab brown-chestnut. Dark olive-green.
Breast chestnut. Dull purple brown.
Throat purplish, streaked with white. Purple, streaked with blue.
Upper tail-coverts indigo. Turquoise.
The wings are the same in both. In the provinces of Nepal, Sikhim, and Darjiling the
two species coexist, with the result that intergrades have been frequently recorded. The
line of intergradation extends to the coast, and birds showing various combinations of the
two types from the Calcutta district exist in collections.
[12]
The case is interesting inasmuch
as like that of Quiscalus it shows a series of combinations of various metallic colours. Some
of these are probably evoked by the development of pigment behind striations or other
interferences already existing, but in the present state of knowledge it would be quite
impossible to suggest what the actual factors producing these appearances may be.
There are, naturally, many other cases among birds which are suspected of being in
reality comparable, but in most of them the evidence is still inadequate. Among
Lepidoptera also there are a few of these; perhaps the most striking is that of Basilarchia
"proserpina."
[13]
The genus is well known to European collectors under the name
Limenitis, of which we in England have one species, L. sibylla, the "White Admiral." A
species very like sibylla in general appearance is common in the northern parts of the
United States, ranging through Canada and Northern New England, but rarely south of
Boston. This species has the conspicuous white bands across both wings like our sibylla.
There is also a more Southern type known as astyanax, which is very different in its
appearance, being without the white bands and having a broad irroration of blue scales on
the posterior border of the hind wings. The two are so distinct that one would not be
tempted to suspect any very close relation between them. In its distribution astyanax is
described by Field as replacing arthemis south of latitude 42°. About Boston it is much
more common than arthemis.
The two forms encroach but little on each other's territory, but where they do coexist, a
third form, known as proserpina, is found which is almost intermediate, with the white
bands much reduced. There is now no doubt that this proserpina is a heterozygous form,
resulting from a combination of the characters of arthemis and astyanax. Field succeeded
in rearing a brood of 16 from a proserpina mother caught wild which laid 31 eggs, and of
these, nine (five males, four females) resembled the mother, being proserpina, and seven
(four males, three females) were arthemis. There can be no question therefore that the
mother had been fertilised by a male arthemis and that no-white-band is a factor partially
dominant over the white band. Another point of interest which Field observed was that the
proserpina female refused to lay on birch, poplar or willow, but accepted wild cherry
(Prunus serotina) a species on which astyanax can live, though that tree is not known to
be eaten by arthemis. Incidentally also the observations show that sterility cannot be
supposed to be the bar which maintains the distinctness of arthemis and astyanax.
In this connection Papilio oregonia and bairdii should be mentioned.
[14]
P. oregonia is
one of the numerous forms like machaon, but rather paler. It is a northern insect,

inhabiting British Colombia east of the Cascade Range, and reaching to Colorado. P. bairdii
is a much darker butterfly, representing the asterias group of the genus Papilio. Like
asterias it has the abdomen spotted at the sides, not banded as in the machaon group. It
belongs to Arizona and Utah extending into Colorado. From Colorado the form brucei is
described, more or less intermediate, like bairdii but with the abdomen banded as in
oregonia. W. H. Edwards records the results of rearing the offspring of the bairdii-like and
of the oregonia-like mothers. Each was found able to have offspring of both kinds, that is
to say, bairdii females gave both forms, and oregonia females gave both forms. It is not
possible to say which is dominant, since the fathers were unknown. On general grounds
one may expect that the bairdii form will be found to dominate, but this is quite doubtful.
From this particular discussion I omit reference to those examples in which the
permanently established types are obviously associated with special conditions of life.
Where considerable climatic differences exist between localities, or when we pass from
South to North, or from the plains into Alpine levels we often find that in correspondence
with the change of climate there is a change in the characteristics of a species common to
both. When I say "species" in such a connection I am obviously using the term in the
inclusive sense. Some would prefer to say that in the two sets of conditions two
representative species exist. Whichever expression be preferred it is plain that such
examples present another phase of the problem we have been just considering, and in
them also we have an opportunity of observing the consequences of the overlap of two
closely related types, but there are advantages in considering them separately. In the
examples hitherto given, with the possible exception of the Papilios,
[15]
the two fixed types
severally range over so extensive a region that it may fairly be supposed that in the
different parts they are subject to considerable diversities of climate. There is no
outstanding difference that we know distinguishing the habitats of the two forms; but in
comparing Alpine with Lowland forms, or essentially northern with essentially southern
forms we do know an external circumstance, temperature, that may reasonably be
supposed to have an influence, direct or indirect, on the population.

CHAPTER VIII
LOCALLY DIFFERENTIATED FORMS. Continued.
Climatic Varieties
In this chapter we will examine certain cases which illustrate phenomena comparable
with those just considered, though as I have already indicated, they form to some extent a
special group. The outstanding fact that emerges prominently from the study of the local
forms is that when two definite types, nearly allied, and capable of interbreeding with
production of fertile offspring, meet together in the region where their distributions
overlap, though intergrades are habitually found, there is no normally or uniformly
intermediate population occupying the area of intergradation. Such phenomena as these
must, I think, be admitted to have great weight in any attempt to construct a theory of
evolution. True we must hesitate in asserting their positive significance, but I see no
escape from the conclusion that they throw grave doubt on conventional views. Again and
again the same question presents itself. If A and B lately emerged from a common form
why is that common form so utterly lost that it does not even maintain itself in the region
of overlapping? Almost equally difficult is it, in the cases which I have numerated, to apply
concrete suggestions based on any factorial scheme. We may see that in Heliconius erato
the type with the red mark on the hind wing probably contains a dominant factor, and that
where the red mark is absent the metallic colours are exposed; and that similarly the green
metallic colour may have another factor which distinguishes it from the blue. In this way
we can fairly easily represent the various types of erato on a factorial system as the result
of the various possible combinations of two pairs of factors. But there we stop, and we are
quite unable to suggest any reason why one area should have the red and the green type
while another should have the blue also. So again with Colaptes or the Warblers. By
application of a factorial system, admittedly in a somewhat lax fashion, the genetic
interrelations of the types can be represented; but how it comes about that each type
maintains a high degree of integrity in its own region we can only imagine. Each has in
actual fact a stability which the intermediate forms have not, but we cannot yet analyse
the nature of that stability. Mendelian conceptions show us how by segregation the
integrity of the factors can be in some degree maintained, but not why certain
combinations of factors should be exceptionally stable. All that is left us to fall back on is
the old unsatisfying suggestions that some combinations may have greater viability than
others, that there may be a tendency for like to mate with like, and so forth.
These difficulties acquire more than ordinary force in those cases in which the two fixed
types inhabit regions differing in some respect so obvious and definite that we are
compelled to regard each type as climatic and as specially adapted to the conditions. When
for example an animal has a distinct type never met with except in Arctic or Alpine
conditions, and another type proper to the plains and temperate regions, what are the
characteristics of the population of intermediate latitudes or at intermediate levels? Some
of the examples discussed in the last chapter may be instances of this very nature, but

even if they are not, others are forthcoming which certainly are. The evidence of these
cases leads to the suspicion that with further knowledge they will be found to consist of
two classes, some in which the observer as he passes from the one climate to the other
will find the intermediate area actually occupied by a population of intermediate character,
and others in which, though we may presume the maintenance of intermediate conditions
in the transitional area, there is no definite transitional population. This interrupted or
discontinuous distribution seems, so far as I have means of judging, to be by far the more
common of the two. I do not doubt that by sufficient search individuals representing every
or almost every transitional form can be found, but it is apparently rare that populations
corresponding to these several grades can be seen. The question has in few if any cases
been studied with precision sufficient to provide a positive answer; but I suspect that real
and complete continuity, in the sense thus defined, will only be found where the character
of the local populations depends directly on the conditions of life, and shows an immediate
response to changes in them apart from that postponed response which we suppose to be
achieved by selection. Obviously the character must be one, like size for instance, capable
of sensibly complete gradation.
The only example I have met with of the phenomenon of anything like a complete
intergradation between local types really distinct in kind is that provided by the butterfly
Pararge egeria. It is well known to entomologists that this insect exists in two very
different types, a northern one, the "Speckled Wood" of England, in which the spots are a
pale whitish yellow, and a southern type having the full fulvous colour that we know as
characteristic of megaera, the "Gatekeeper." It appears that Linnaeus gave the name
egeria to the southern type,
[1]
and our own is now called egerides. Broadly speaking, so
far as Great Britain, France, and the Spanish Peninsula are concerned, the tawny-coloured
egeria occupies Spain and western France up to the latitude of Poitiers and the pale yellow
egerides extends from Scotland, where it has a scanty distribution, through southern
England, where in suitable localities it is common, and the north of France to Paris.
[2]
The
two types when placed side by side are strikingly different from each other, and are an
excellent illustration of what is meant by climatic variation. The insect is not a great
traveller and probably scarcely ever wanders far from its home. It should therefore be
possible by collecting from north to south to find out how the transition is effected,
whether suddenly or gradually. This at various times I have endeavoured to do, but I am
still without exact information as to the population in certain critical areas. In addition to
the information derived from specimens which I have collected or seen in the collections of
others there is a good account of the general distribution in Europe given by the Speyers,
[3]
who evidently paid more attention to the subject than most lepidopterists have done,
and many more recent records. In particular Oberthür
[4]
has published many details as to
the distribution in western France and I am especially indebted to Mr. H. Rowland-Brown
for a long series of notes as to the distribution in France generally, and to Mr. H. E. Page
and Dr. T. A. Chapman, Mr. Oberthür Prof. Arrigoni degli Oddi, Mr. H. Williams and other
correspondents, for showing me forms from many localities. The butterfly is attached for
the most part to woods of deciduous trees and to country abounding in tall hedges or
rough scrub. It is not usually to be found in highly cultivated districts or in very dry
regions. Hence there is necessarily some want of continuity in the distribution at the
present time and I should think a mile or two of arable land without big hedges would
constitute a barrier hardly ever passed. The larva feeds on several coarse grasses,

especially Dactylis glomerata. Barrett mentions also Triticum repens. In this country the
winter is usually passed in the larval stage, but I have found that in captivity, at least,
there is much irregularity. The larvæ feed whenever the weather is not very cold and may
pupate, but if sharp cold comes on when they are pupating or nearly full-grown they often
get killed unless protected.
Some writers speak of a difference between the early and later broods, but I have
never noticed this, and I do not think that the general tone of the yellow is affected by the
seasons (see Tutt, Ent. Rec., IX, 1897, p. 37).
[5]
Beginning at the south of Spain the thoroughly fulvous type egeria is common at
Gibraltar in the Cork woods, at Granada, and doubtless generally. Lederer is said to have
found only this type in Spain (Speyer), and though I have no precise information as to
other places in the Peninsula north of Jaen I feel tolerably sure that there is no change
from south to north.
[6]
Immediately north of the Pyrenees we still meet egeria exclusively,
and up to Poitiers at least there is no noticeable change. But somewhere between Poitiers
and the bottom of the Loire valley at Tours, the genuine southern type comes to an end,
and the whole population begins at the Loire to be of an intermediate type, easy to
distinguish both from egeria and from egerides. As to the exact condition of the species in
the fifty miles separating St. Savin on the Vienne from places on the Loire I have no
adequate information. I have only one small sample from there, but it does contain insects
both of the southern and intermediate types taken on the same day, in a wood near
Preuilly. Oberthür also states that at Nantes the true southern form exists in company with
the northern. From this I infer that the southern form extends up the coast further than it
does inland, but I imagine the representative spoken of as northern would be of usual
Brittany or intermediate type.
The Vienne river joins the Loire, so the true southern type reaches over into the basin
of the Loire. From the Loire (Tours, Corméry) north to Calvados (Balleroy) only the
intermediate is found, so far as I know, and the same type extends over Brittany.
[7]
In
general, however, the woods near Paris have the thoroughly northern type egerides, but at
St. Germain-en-Laye and at Etampes (Oberthür) the population approaches the
intermediate type.
On the whole the intermediate type is certainly less homogeneous than either of the
extremes, and females with the two central spots either paler or more fulvous than the rest
are not uncommon, but I have never taken one on the Loire or in Brittany which I should
class with either of the extreme types.
Before speaking of the distribution in other parts of France and in Europe generally I
will briefly state the results of my breeding experiments. The work was done many years
ago before we had the Mendelian clue, and it is greatly to be hoped that some one will find
opportunities of repeating it. Crossing the English and the thoroughly southern type the
families produced agree entirely with the intermediates of Brittany and the Loire.
Reciprocals are alike. Of F
2
I only succeeded in raising very few and of those that I had
(about 30) nearly all were intermediate in character, though perhaps rather less uniform
than F
1
. One family alone, containing only 4 specimens, had one egerides, and three
fulvous intermediates. As the case stands alone I hesitate whether or not to suppose it due
to some mistake. Moreover from F
1
crossed back with the respective parental types I had

fairly long series, especially from F
1
× the southern type, and looking at these families I
cannot see any clear evidence of segregation. On the contrary, I think that though there
are slight irregularities, they would, taken as a whole, be classed as coming between the
intermediate type and the extreme form used as the second parent. This at least is true
when the second parent was of the southern type.
On this evidence I have regarded the case as one in which there is no good evidence of
segregation and as conforming most nearly with the conventional view of gradual
transition in response to climatic influences. Such influence must however be indirect; for I
reared five generations of the northern type in England, and these, though they included
several abnormal-looking specimens in the last generation and then died out, did not show
any noticeable change from the fulvous colour of the wild type. Merrifield
[8]
also found that
heat applied to pupae of the northern type produced no approach to the southern type.
Looking at the facts now in the light of more experience it seems to me just possible
that the case may be one in which, as in Nilson-Ehle's Wheats, the dominant differs from
the recessive in having two pairs of factors with similar effects. The fulvous type for
example may have two or more elements in separate pairs which together produce the full
effect, and the intermediate may have one of these. If this were so, some segregation
should of course eventually be observable, but the proportion of the various fulvous and
fulvous-intermediate individuals would be large, and the reappearance of actual
representatives of the northern type might be rare. I admit that this is a somewhat
strained interpretation of the facts, and as yet it is not entitled to serious consideration.
Nevertheless I am led to form some such expectation partly from the great difficulty in the
way of any other, partly from the evidence of the small mixed sample found at Preuilly and
partly from the statements given by Oberthür. There are moreover other features in the
general distribution of the species which make it improbable that the dependence on
climate can after all be so close. Published lists are unfortunately of little use in deciding
which form occurs at a particular place, because, since the name Meone has ceased to be
used for the southern form, there is no complete unanimity among authors as to the
application of the names egeria and egerides, and unless more particulars are given, either
name may be used for either form. Besides this, difficulty arises from the fact that the
intermediate type is not generally distinguished at all, and English collectors finding it, may
easily record it as the southern type. From Staudinger's note on the distribution, I gather
that he, on the contrary, reckoned the intermediate with the northern type, as do the
Speyers also. The late Mr. J. W. Tutt was careful to distinguish the three forms and has left
several useful records. Easy therefore as it might seem to be to make out the distribution
of such a familiar insect in its various modifications, there are serious practical difficulties,
and until long series are brought together with this special object in view many obscurities
will remain.
With only the series from England, the west of France, and Spain before one it would
be easy to regard the successive series of tones as a fair measure of climate; the brighter
the colour, the hotter might one expect the locality to be. Such rough correspondence is
often to be observed in butterflies and birds. It becomes impossible to take these simple
views in the light of more complete knowledge. Beginning with France the fulvous egeria
occupies the lower valley of the Rhone, probably from well above Lyon, though I have no
exact information respecting the country above Avignon. According to Speyer it also takes

the department of Lozère. The same authority says that Puy-de-Dôme has "egeria,"
meaning perhaps the intermediate form, with the fulvous form much less commonly. Next
comes the curious fact that though the Lower Rhone (Avignon, Tarascon, Nîmes) has the
true fulvous form, Hyères, Cannes, Grasse, Nice, Digne, and Alassio have the intermediate.
Savoy has the intermediate (Chambéry) and even egerides perhaps, though in the same
latitude on the west of France there is nothing but the fulvous type. At Chalseul and
Besançon (Doubs) the ordinary northern type is found. Switzerland generally, I believe, has
the northern type, but Staudinger gives egeria for Valais and the intermediate occurs in
Vaud.
[9]
The south side of the Alps has probably colonies of the pale egerides, and of
intermediates. Orta, with a very hot summer, has the English type (Tutt, Ent. Rec., XII,
1900, p. 328). Locarno has the intermediate (ibid., XV, 1903, p. 321). North Italy in general
and western Piedmont have the intermediate; but further south egeria begins, at what
region I do not know. Speyer gives on his own authority the remarkable statement that at
Florence both extremes occur, but chiefly intermediates between the two. Mr. R. Verity
however kindly informs me that in his experience this is not so, and that neither the real
southern type nor the northern occur there. Sardinia, Sicily, Crete all have the southern
type. Greece probably has various types. Staudinger (Hor. Ross., VII, 1870, p. 78) says
intermediates resembling Nice types common everywhere, but from "Greece" the British
Museum has a series that would pass for English specimens; and the same type occurs
near Constantinople. The island of Corfu has a pale intermediate, distinct from egerides
but approaching it. In Roumania all three forms are recorded from various places: egeria in
the Dobrutscha; not quite typical (presumably an intermediate) at Bukharest; intermediate
in various mountainous localities as well as in Macedonia and Dalmatia; but egerides in
Azuga at about 3,000 feet.
[10]
Hungary has the true egerides also. (Cf. Caradja, Deut. Ent.
Zt., IX, p. 58.) Mathew records the same from Gallipoli (E. M. M., 1881, p. 95). Staudinger
does not distinguish the intermediates from the northern, but he gives "egerides" for
Armenia and Fergana (Central Asia). As against the mere proximity of a great mountain
chain being the influence which keeps the Riviera population intermediate may be
mentioned the fact that the northern foothills of the Pyrenees have the pure southern type,
and the climate of Cambo must surely be far cooler than that of Nice. The exact locality of
the Greek specimens is not given, but there can be no part of Greece which is not much
hotter in summer than Brittany, or Calvados, which have the intermediate, not the English
type.
In face of these facts it can scarcely be maintained that average temperature is the
efficient cause of the particular tone of colour which the butterfly shows in a given region.
Nevertheless it is clear that climate counts for much in determining the distribution. It is
noticeable that though the pale egerides can be established in a warm climate we never
find egeria in cold climates, and even the intermediate is not found in places that have a
hard winter. I suspect that the distribution of the broods through the year and the
condition of the animal at the onset of hard frost are features which really determine
whether a strain can live in a particular place or not. Though the truth of the suggestion
cannot be tested by experiments in captivity, which at once introduce disturbances, I
incline to the idea that egeria has not got the right periodicity for northern climates. If it
could arrange its life so that the population consisted either of young larvae, or perhaps of
thoroughly formed pupae
[11]
at the onset of winter, it might, for any obvious reason to the
contrary, be able to live in England. It is irregularly "polyvoltine," as the silk-worm breeders

say, and as soon as a little warmth encourages it, a new generation starts into being,
which if the frost comes at an untimely moment, is immediately destroyed. Many species
are continually throwing off individuals which feed up fast
[12]
and emerge at once if the
temperature permits, and I imagine a species of Satyrid wholly or largely represented by
such individuals could scarcely survive in a country which had a hard winter. For such a
climate some definite periodicity in the appearance of the broods may well be
indispensable. But assuming that egeria is cut off from cold climates for such a reason,
there is nothing yet to connect these habits with the fulvous colour, and until breeding can
be carried out on a satisfactory scale there is no more to be said.
From time to time records appear of individual specimens more or less fulvous being
caught in southern England, especially in the New Forest.
[13]
It would be interesting to
know what offspring such individuals might produce. From the evidence now given some
notion both of the strength and the weakness of the case considered as one of continuous
climatic variation can be formed. I know no other equally satisfactory. Whether or not
definite mixture of the intermediates with either of the extremes will be proved to occur,
the case differs materially from those considered in the last chapter in the fact that at all
events there is no general overlapping of forms. In a species so little given to wandering,
overlapping could indeed scarcely be expected to occur. It is this circumstance which
makes the species preeminently suitable as a subject for the study of climatic influences,
and I trust that entomologists with the right opportunities may be disposed to explore the
facts further.
Just as many species, like egeria, have varieties which can be regarded as adapted to
northern and southern regions, so there are also several which have lowland and Alpine
forms quite distinct from each other. Every such case presents an example of the problem
we have been considering. As the collector passes from the plains to the Alpine region,
how will he find the transition from one form to the other effected? Does the lowland form
give place to the Alpine form suddenly, with a region in which the two are mixed, or will he
find a zone inhabited by an intermediate population? I have spent a good deal of time
examining the facts in the case of Pieris napi and its Alpine female variety bryoniae, and
though there are many complications which still have to be cleared up, no doubt is possible
as to the main lines of the answer. If in any valley in the Alps inhabited by both napi and
bryoniae the collector catches every specimen he can, beginning at the bottom and
working up to 7,000 feet, he will at first get nothing but napi. At about 2,500 feet, he may
catch an occasional bryoniae flying with the napi. After 3,000 feet napi usually ceases, and
only bryoniae are found. As an exception a colony of napi may be met with at much
greater heights. I once found them in numbers at about 6,000 feet.
[14]
Not only were they
free from any trace of modification in the direction of bryoniae, but they were of the
thoroughly southern type of napi, being a late brood of that large and very pale kind
(meridionalis) almost destitute both of dark veining above and of green veining below,
which are common on the shores of Lago Maggiore and in other hot southern localities.
Not far off at the same level were typical bryoniae in fair abundance. Occasionally an
intermediate may be met with. I have taken a few, for example, at Macugnaga and at
Fobello. These, however, in my experience are rarities in the Alps. Fleck
[15]
gives notes on
the distribution in Roumania which shows the same state of things. The lowland form is

not transformed though found at great heights, and at Azuga (nearly 3,000 feet) bryoniae
occurs with only occasional "flavescens," viz., intermediates of the second brood.
If this were all the evidence we should be satisfied that the lowland and Alpine types
keep practically distinct, overlapping occasionally, but rarely interbreeding. The problem
would remain, how is the distinctness of the two types maintained in the region of
overlapping? Nowadays, I suppose, we should incline to answer this question by reference
to segregation, and perhaps by an appeal to selective mating. The suggestion that
segregation does take place is certainly true to some extent. There are, however,
difficulties in the way, and the whole subject is one of great complexity. My own
experiments were made in pre-Mendelian times and were not arranged with the simplicity
which we now know to be essential. The results are neither extensive enough nor clear
enough to settle the many collateral questions which have to be considered, and the work
ought to be done again. Nevertheless, some notes of the observations may have a
suggestive value.
When I began, I did not sufficiently appreciate that the "napi" group, omitting the
North American forms, and the Asiatic representatives, has at least three chief types in
western Europe. The differences we have to deal with are manifested by the females only,
so in this account particulars as to the males are omitted for the most part. These are (1)
our own British napi; (2) the form found in the south, from the Loire downwards, and in
the Italian Alps, which I think may be spoken of as meridionalis; (3) bryoniae, which is a
form clearly recognizable in the female only, and is found only in the arctic regions and in
the Alps above 2,500 feet. The first two have several broods, two, three, or more,
according to opportunity, and the first brood is different from the later ones. In napi the
markings on the upper surface are a dark grey but in meridionalis they are a pale silvery
grey and much less extensive. In the later broods of napi there is much less general
irroration of the veins, and the spots stand out as more defined and blacker. These
differences vary greatly in degree of emphasis. In meridionalis the later broods are entirely
different from the first. Instead of having silvery markings they have the ground colour
quite white, with the spots large and a full black. On the under side of the hind wings the
usual green veins are almost absent, and I have seen individuals which could scarcely be
distinguished from rapae. To these later broods the term napaeae is sometimes applied,
but I here use meridionalis for the southern race in general as applicable to all broods.
The female bryoniae is totally unlike the others. The ground colour is a full yellow, and
each nervure is thickly irrorated with a brown pigment often spreading so far as to hide the
ground almost entirely in the fore-wings. The males corresponding with these females are
not certainly distinguishable from those of our own napi. Both sexes have the green
veining of the underside of the hind wing fully developed, rather more than is usual in the
lowland races, but this is not really diagnostic of the variety. The first serious difficulty
arises in regard to the second brood of bryoniae. It is stated that there is only one brood,
[16]
but I feel fairly sure that a second brood is sometimes produced, and that the females
with a yellow ground and diminished irroration of the veins, not very uncommon in the
Italian Alps in July to August, are generally representatives of it. Such insects would of
course be classed with bryoniae in collections.
My experiments began with eggs of true bryoniae females caught at about 2,500 feet
early in July. These emerged in August-September as intermediates with yellow ground

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