Page - 197 - in Applied Interdisciplinary Theory in Health Informatics - Knowledge Base for Practitioners

focuses on how particular technologies bring particular kinds of knowledge into play and render other kinds of knowledge less visible [13]. Complexity in Domain 2, therefore, may relate to the material properties and functionality of the technology itself (especially its dependability and speed of operation); to the knowledge needed to use it (hence, to how easily staff and patients can be trained); or to the knowledge it brings into play and how much that knowledge is likely to be trusted or contested. It may also relate to the technology supply model (e.g. to what extent is the technology substitutable?) and to the intellectual property (IP) it generates (how easy is it to say who ‘owns’ the IP?). Domain 3 is the value proposition – both supply-side (value to the developer and/or healthcare system) and demand-side (value to the patient and/or insurer). Relevant to Domain 3 are various theories of value generation. Here, we describe one: transaction costs theory, which was developed to explain the governance implications of costs that constitute friction or a barrier to otherwise desirable economic or social exchange [14, 15]. The level of transaction costs on any given patient-provider interface is influenced by technology; and can be measured in terms of the number and duration of steps involved in patient pathways and clinical workflows [16, 17]. Transaction costs include search and information costs, bargaining and payment costs, or monitoring and enforcement costs. From the perspective of a consumer transaction costs are all costs incurred by the consumer that are not transferred to the seller (e.g. the time spent obtaining information on the good or service, and on prices and potential alternatives, legal fees, and the costs of establishing credibility as a buyer). From the perspective of a producer, transaction costs are all costs which the producer would not incur were they selling the good to themselves (e.g. time spent waiting while people examine the good or service, agent and advertising fees, and the costs of establishing credibility as a seller) [18]. In the software-platform revolution that began 20 years ago with the launch of eBay, and continues with Uber and Airbnb, Munger argues that “entrepreneurs have for the first time been able to specialise in selling not more stuff, but reductions in transaction costs for access to existing stuff” (page x) [19]. These platforms reduce transaction costs by providing “(1) information about identity and location [of potential transacting partners]; (2) a way of making payment that both parties can trust; and (3) a way of outsourcing trust on performance of the terms of the contract” (page 393) [19]. Often, the primary value of a technology is reduction in transaction costs; reducing frictions on the patient-provider interface – for example, patient-facing digital health innovations such as video consultations, and apps designed to support self-care in the home or help patients to locate, pay for, and rate laboratory services in their vicinity. But by reducing transaction costs, a technology may also add value by creating/maximising the capacity of a system to deliver services (on the supply side) or by creating/maximising opportunities for population access to services (on the demand side). Complexity in Domain 3 thus relates to difficulties in formulating a plausible business case for developing the technology or to verifying the assumptions about how value will be generated [20, 21]. A simple value proposition offers a clear business case for investors and evidence that patients and the health service will benefit. In a complex situation, the business case for developing the product is implausible, or rests on unverifiable assumptions, and/or the results of health technology assessment studies are unavailable or contested. In addition, a business case may be complex when it is unclear or unpredictable how the innovation will re-distribute transaction costs among stakeholders, and how this may change over time – for example, video consultations may T.GreenhalghandS.Abimbola /TheNASSSFramework–ASynthesisofMultipleTheories 197