La construction sociale et l’hybridation des logiques marchandes et du système de santé dans l’émergence, le succès et la pérennité des entreprises de technologies innovantes en santé

With the advent of micro-computing in the 1980s, the Internet in the 1990s and the completion of the sequencing of the human genome at the turn of the 21st century, the number of companies developing health technologies has exploded. Nonetheless, hospital practice and day-to-day interactions with health professionals working in different sectors of the Quebec health system and other Canadian provinces reflect a large difference between the number of technologies appearing in conferences and blogs, and those adopted and used in the field. But while the evaluation of technologies and the study of the diffusion of innovations led to an important scientific literature, few studies have so far explored the emergence of innovative health technology companies taking into account the point of view of all the actors involved. It is this lack of knowledge that our study wishes to fill, by asking how an emerging health technology company can be socially constructed by initiating certain competitive actions and why these actions may differ according to the type of company, demands and pressures from economic and healthcare system actors. The research objectives are therefore to define how innovative health technology companies establish themselves by using the effect of their competitive actions while giving them meaning, determining the influence of the type of business and the patterns of social construction activities on competitive actions, sensemaking activities and responses to the pressures of institutional actors, and finally identify the strategies used by entrepreneurs to address the institution that is the health system. In order to answer the questions raised by field observations, this research was organized in three successive parts, exploring three different points of view. The first is that of an external observer to health technology start-ups. The second part is that of the actors around these companies and the third is that of the entrepreneurs themselves. The first part consists of a multiple case study using explanation-building analysis strategy. The study was based on the analysis of press releases (n = 664) and general media articles (n = 627). The sample includes five Canadian companies listed on the Toronto Stock Exchange in the form of four startups that made an initial bid from 2000 to 2003 and a well-established firm. Of these, three were in the health sector, one in the e-commerce sector, while the well-established company was a health electronic infrastructure solutions company. Overall, during the emergence of the company, marketing and symbolic actions, coupled with the use of opinion leaders and high-profile people, were significantly more pronounced with the health-based startups when compared to the firm who was not in the health sector. In the early months of emergence, as communications and signals increased, health-based startups were the only firms to use cognitive and pragmatic legitimacy, relying on cognition rather than personal interest or moral judgment of the actors. In addition, we observed differences in the use of marketing and symbolic actions and also in the use of opinion leaders. This suggests a differential influence of the social construction model and firm type on the level and mix of market actions and sensegiving activities between health and non-health technology companies. The second and third components consist of two sets of semi-structured interviews, where a thematic analysis was used to identify and report themes while organizing and describing the data set thoroughly. For the second part, the sample for semi-structured interviews includes 10 medical specialists, 4 health professionals involved in health technology acquisition, 3 health technology assessment units’ members, and 3 investors in health technologies. We have determined that the acquisition and diffusion of health technologies are increasingly regulated and must respond to increasing pressures from a large number of actors who, conversely, see their agency power diminish. We also found that the pressures to institutionalize practices, as well as the decoupling of the objectives of the health system from those of other actors, are addressed by “political” strategies; the power of key influencers such as investors and medical specialists, as well as mistrust of marketing actions are addressed with “associative” strategies; the pressures arising from the growing need for evidence-based evidence are addressed through “normative” strategies. Finally, the fragmentation of a public health system and the heterogeneity of local procurement processes are approached with “identity” strategies. The third part focuses on how entrepreneurs seize opportunities, create their entrepreneurial organization, and give it legitimacy, and examined the triggers, constraints and pressures involved in this process. The sample for the interviews consisted of 20 entrepreneurs and strategic partners involved in the development and commercialization of health technologies. At each stage, we identified a predominant institutional process, whether it be the decoupling, the influence of the organizational field or the search for legitimation. We found that each stage of the start-up was triggered by situations where the entrepreneur faced barriers and constraints in the form of a misalignment of boundaries, poor performance of competing technologies, and of resource asymmetry. Our findings can help healthcare professionals, decision-makers and evaluators understand the process of adoption and diffusion of health technologies and contribute to the development of procurement procedures through targeted policies and revised processes. For investors, our study allows them to identify the barriers that pace the speed at which new technologies are making their way into clinical practice and the health care system. The results can also provide a framework for developing baseline data to evaluate current and future investments. A better understanding of the differences in health technology startups compared to other startups could help entrepreneurs prioritize competitive actions and better understand perceived intentions and real health needs during the social emergence of the company. For the healthcare system, the results can be used to develop and enrich procurement and evaluation policies and guidelines that will improve access to safe, effective and high quality medical technologies.

Keyphrases: Entrepreneurship, Innovation in health, Legitimacy, Reputation-building, Isomorphism, Neo-institutional theory, Competitive actions, Institutional pressures, Social construction, Health technologies