Designers’ wayfinding in standardization paradoxes in acute care

The success of digital health information exchange (HIE) technologies depends on standardization. These HIE standards evolve out of an everchanging installed base such as other standards, technologies and work practices. Based on information infrastructure research, we conceptualize the design process of standards as a paradoxical endeavor in which standards need to be simultaneously: stable and evolvable; transformable and continuable; universal and locally adaptable. We were interested in how designers cultivate these inherent standardization paradoxes during their design efforts. We argue that we need to incorporate a wayfinding approach to decenter the designers and conceptualize them as an active part of their environment shaping new changes within their phronetic awareness. In our longitudinal case study, we traced back multiple published versions of a HIE standard for the Dutch acute care to uncover how stakeholders became aware of their changing installed base. Designers’ wayfinding strategies illuminate how they became aware of changes in the installed base, and at the same time showed how their interventions rendered certain standardization paradoxes salient again. We highlight how designers either ignored, engaged, or even changed the installed base that explained why and when (novel) cultivation strategies were developed and employed. Cultivation strategies as ways to rebalance standardization paradoxes in turn reshaped the evolving installed base, creating new possibilities for future changes. Moreover, our analysis illustrated how cultivation strategies could enable a ‘both/and’ thinking rather than the current ‘either/or’ thinking that plagues both the ‘top-down’ and ‘bottom-up’ approaches when dealing with standardization paradoxes.