# The Role of E-Health Software in Shaping Liberal Physicians’ Organizational Routines

Olivier Arsene, Claudio Vitari, Johanna Habib, Pierre Loup

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## To cite this version:

Olivier Arsene, Claudio Vitari, Johanna Habib, Pierre Loup. The Role of E-Health Software in Shaping Liberal Physicians’ Organizational Routines. 29ème conférence de l’AIM, Association Information et Management, May 2024, Montpellier, France. hal-04615533

HAL Id: hal-04615533

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Submitted on 18 Jun 2024

HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

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Distributed under a Creative Commons Attribution 4.0 International License
# The Role of E-Health Software in Shaping Liberal Physicians’ Organizational Routines

Olivier Arsene, Claudio Vitari, Johanna Habib, Pierre Loup

► To cite this version:

Olivier Arsene, Claudio Vitari, Johanna Habib, Pierre Loup. The Role of E-Health Software in Shaping Liberal Physicians’ Organizational Routines. 29ème conférence de l’AIM, Association Information et Management, May 2024, Montpellier, France. hal-04615533

HAL Id: hal-04615533

https://hal.science/hal-04615533v1

Submitted on 18 Jun 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>
<figure><img src="image_3.png" /></figure>

# The Role of E-Health Software in Shaping Liberal Physicians' Organizational Routines

Olivier Arsene, GEM / CERGAM, Aix-Marseille Université, France

Claudio Vitari, CERGAM, Aix-Marseille Université, France

Johanna Habib, CERGAM, Aix-Marseille Université, France

Pierre Loup, Université de Montpellier, France

## Abstract

Digital solutions are reshaping healthcare, affecting all aspects, from treatment and diagnosis to organizational aspects, such as scheduling appointments, consultation methods, and pre/post interactions between healthcare providers, patients, and other health partners. This study employs an exploratory, qualitative approach, comprising ten interviews with liberal physicians who use e-health software. Employing the theory of organizational routines, it investigates the adjustment of physicians' routines in response to digital health software. This approach allows an in-depth exploration of technology integration in healthcare routines, providing insights into the evolving landscape of medical practice. The research uncovers varied changes in organizational routines due to health software, showing how digital tools alter medical routines' ostensive and performative dimensions, leading to heterogeneity in practices among physicians. This research contributes to the existing body of knowledge by applying organizational routine theory in the context of digital health, highlighting the dynamic interplay between technology and medical routine.

## Keywords

E-health; organizational routines; adoption; adaptation; liberal physicians
<figure><img src="image_2.png" /></figure>

# The Role of E-Health Software in Shaping Liberal Physicians' Organizational Routines

Olivier Arsene, GEM / CERGAM, Aix-Marseille Université, France

Claudio Vitari, CERGAM, Aix-Marseille Université, France

Johanna Habib, CERGAM, Aix-Marseille Université, France

Pierre Loup, Université de Montpellier, France

## Abstract

Digital solutions are reshaping healthcare, affecting all aspects, from treatment and diagnosis to organizational aspects, such as scheduling appointments, consultation methods, and pre/post interactions between healthcare providers, patients, and other health partners. This study employs an exploratory, qualitative approach, comprising ten interviews with liberal physicians who use e-health software. Employing the theory of organizational routines, it investigates the adjustment of physicians' routines in response to digital health software. This approach allows an in-depth exploration of technology integration in healthcare routines, providing insights into the evolving landscape of medical practice. The research uncovers varied changes in organizational routines due to health software, showing how digital tools alter medical routines' ostensive and performative dimensions, leading to heterogeneity in practices among physicians. This research contributes to the existing body of knowledge by applying organizational routine theory in the context of digital health, highlighting the dynamic interplay between technology and medical routine.

## Keywords

E-health; organizational routines; adoption; adaptation; liberal physicians
<figure><img src="image_4.png" /></figure>

ΔΙΜ 2024
MONTPELLIER

# Le Rôle des Logiciels de E-Santé dans la Formation des Routines Organisationnelles des Médecins Libéraux

Olivier Arsene, GEM / CERGAM, Aix-Marseille Université, France

Claudio Vitari, CERGAM, Aix-Marseille Université, France

Johanna Habib, CERGAM, Aix-Marseille Université, France

Pierre Loup, Université de Montpellier, France

## Résumé

Les solutions numériques redéfinissent le système de santé, des traitements et des diagnostics aux aspects organisationnels tels que la planification des rendez-vous, les méthodes de consultation et les interactions entre confrères, patients et autres partenaires de santé. Cette étude adopte une approche qualitative exploratoire, comprenant 10 entretiens avec des médecins libéraux utilisant des logiciels de santé électronique. En s'appuyant sur la théorie des routines organisationnelles, elle examine l'ajustement des routines des médecins en réponse aux logiciels de santé numérique. Cette approche permet une exploration approfondie de l'intégration de la technologie dans les routines de soins de santé, offrant des aperçus sur le paysage médical en évolution. Ces recherches révèlent des changements variés dans les routines organisationnelles dues aux logiciels de santé, et montrent comment les outils numériques modifient les dimensions ostensives et performatives des routines médicales, entraînant une hétérogénéité dans les pratiques des médecins. Cette recherche contribue à la littérature existante en appliquant la théorie des routines organisationnelles dans le contexte de la médecine libérale, mettant en évidence l'interaction dynamique entre la technologie et la routine médicale.

## Mots clés

E-santé; routine organisationnelle; adoption; adaptation; médecine libérale
<figure><img src="image_3.png" /></figure>

ΔΙΜ 2024
MONTPELLIER

# Le Rôle des Logiciels de E-Santé dans la Formation des Routines Organisationnelles des Médecins Libéraux

Olivier Arsene, GEM / CERGAM, Aix-Marseille Université, France

Claudio Vitari, CERGAM, Aix-Marseille Université, France

Johanna Habib, CERGAM, Aix-Marseille Université, France

Pierre Loup, Université de Montpellier, France

## Résumé

Les solutions numériques redéfinissent le système de santé, des traitements et des diagnostics aux aspects organisationnels tels que la planification des rendez-vous, les méthodes de consultation et les interactions entre confrères, patients et autres partenaires de santé. Cette étude adopte une approche qualitative exploratoire, comprenant 10 entretiens avec des médecins libéraux utilisant des logiciels de santé électronique. En s'appuyant sur la théorie des routines organisationnelles, elle examine l'ajustement des routines des médecins en réponse aux logiciels de santé numérique. Cette approche permet une exploration approfondie de l'intégration de la technologie dans les routines de soins de santé, offrant des aperçus sur le paysage médical en évolution. Ces recherches révèlent des changements variés dans les routines organisationnelles dues aux logiciels de santé, et montrent comment les outils numériques modifient les dimensions ostensives et performatives des routines médicales, entraînant une hétérogénéité dans les pratiques des médecins. Cette recherche contribue à la littérature existante en appliquant la théorie des routines organisationnelles dans le contexte de la médecine libérale, mettant en évidence l'interaction dynamique entre la technologie et la routine médicale.

## Mots clés

E-santé; routine organisationnelle; adoption; adaptation; médecine libérale
# 1. Introduction

Digital health technologies affect how physicians organize and exercise healthcare (van Offenbeek et al., 2023) and their modes of interaction with patients (Tan et al., 2023), colleagues (Sykes & Aljafari, 2022), and administration (Yeongin Kim et al., 2022). The literature has also identified technologies potentially impacting patient behaviors (Ologeanu-Taddei et al., 2023).

The gradual introduction of health technologies has significantly accelerated over the past decade. This is in part due to the growing importance of mobile technologies and the internet in patients' daily activity, successive governmental initiatives like health security measures, the emergence of increasingly efficient solutions for appointment scheduling, consultation management, billing, and, notably, the 2020 health crisis, which forced healthcare professionals to adopt resilient practices. This central role of health technologies and their providers increasingly positions them as integral players in the healthcare pathway, on par with patients, physicians, and governmental health authorities.

Despite pressures from patients and institutions for physicians to adopt modern digital solutions to optimize their health routine — like simplified appointment scheduling, flexible consultation modalities, or digital methods for communication and prescription access—physicians might show reluctance towards such adoption and the need for interaction between health software editors and physicians (Avgerou, 2023). This adoption is rarely binary, involving a complete rejection or full embrace of digital tools, but instead presents a spectrum of possibilities. Physicians might indeed choose to implement only a few features among many, as explained by the affordance theory, to maintain control over their work routines. Such decisions represent a personal process, balancing what the tool offers or imposes, and the physician's preferred method to exercise. This nuanced approach highlights the varied degrees to which physicians integrate digital technology into their healthcare routines.

This article aims to better understand the specific organization of Liberal specialist physicians at a time when digital solutions are increasingly important in how these doctors interact with their patients. The research explores the impact of new software tools on the professional routines of doctors, specifically those tools used for patient-doctor interactions. Recently developed software features, such as online scheduling, teleconsultation, secure messaging, and document sharing, have become integral to modern medical routines. In France, key software platforms with these capabilities have been introduced in the last five years. Notable examples include "mon docteur" (2013) acquired by Doctolib (2018), allodocteur (2013), and similar features developed by other major health software companies like Axisoft.

Introducing these tools significantly shifts how doctors manage their organizational routines. The COVID-19 crisis notably accelerated their adoption, as these digital tools were crucial in maintaining healthcare services. Initially, doctors had to quickly adopt these features out of necessity. However, as the situation evolved, they started to tailor their use of these tools to suit their individual preferences and specific needs better.

Given the importance of these tools, this article will specifically focus on features like online scheduling and teleconsultation, as well as patient-doctor communication tools like secure messaging and document sharing. These features represent a significant development in the organization of medical practices and the delivery of healthcare services.

Our research question is: How do digital healthcare solutions shape the evolution of care routines in a liberal medicine context?
# 1. Introduction

Digital health technologies affect how physicians organize and exercise healthcare (van Offenbeek et al., 2023) and their modes of interaction with patients (Tan et al., 2023), colleagues (Sykes & Aljafari, 2022), and administration (Yeongin Kim et al., 2022). The literature has also identified technologies potentially impacting patient behaviors (Ologeanu-Taddei et al., 2023).

The gradual introduction of health technologies has significantly accelerated over the past decade. This is in part due to the growing importance of mobile technologies and the internet in patients' daily activity, successive governmental initiatives like health security measures, the emergence of increasingly efficient solutions for appointment scheduling, consultation management, billing, and, notably, the 2020 health crisis, which forced healthcare professionals to adopt resilient practices. This central role of health technologies and their providers increasingly positions them as integral players in the healthcare pathway, on par with patients, physicians, and governmental health authorities.

Despite pressures from patients and institutions for physicians to adopt modern digital solutions to optimize their health routine — like simplified appointment scheduling, flexible consultation modalities, or digital methods for communication and prescription access—physicians might show reluctance towards such adoption and the need for interaction between health software editors and physicians (Avgerou, 2023). This adoption is rarely binary, involving a complete rejection or full embrace of digital tools, but instead presents a spectrum of possibilities. Physicians might indeed choose to implement only a few features among many, as explained by the affordance theory, to maintain control over their work routines. Such decisions represent a personal process, balancing what the tool offers or imposes, and the physician's preferred method to exercise. This nuanced approach highlights the varied degrees to which physicians integrate digital technology into their healthcare routines.

This article aims to better understand the specific organization of Liberal specialist physicians at a time when digital solutions are increasingly important in how these doctors interact with their patients. The research explores the impact of new software tools on the professional routines of doctors, specifically those tools used for patient-doctor interactions. Recently developed software features, such as online scheduling, teleconsultation, secure messaging, and document sharing, have become integral to modern medical routines. In France, key software platforms with these capabilities have been introduced in the last five years. Notable examples include "mon docteur" (2013) acquired by Doctolib (2018), allodocteur (2013), and similar features developed by other major health software companies like Axisoft.

Introducing these tools significantly shifts how doctors manage their organizational routines. The COVID-19 crisis notably accelerated their adoption, as these digital tools were crucial in maintaining healthcare services. Initially, doctors had to quickly adopt these features out of necessity. However, as the situation evolved, they started to tailor their use of these tools to suit their individual preferences and specific needs better.

Given the importance of these tools, this article will specifically focus on features like online scheduling and teleconsultation, as well as patient-doctor communication tools like secure messaging and document sharing. These features represent a significant development in the organization of medical practices and the delivery of healthcare services.

Our research question is: How do digital healthcare solutions shape the evolution of care routines in a liberal medicine context?
## 2. Theoretical Framework

### 2.1. Organizational routines

Routines, considered essential elements in organizations, were initially envisaged as stable and repetitive (Nelson & Winter, 1982; Simon, 1991). However, the dialectic of stability and change in organizations has known new conceptualizations oriented toward analyzing the micro-dynamics of change. Among these, the theoretical approach to the dynamics of organizational routines (Pentland et al., 2012) demonstrated its strong heuristic potential to understand better how the routines evolve and how they are structured. In this approach, organizational routines are "generative systems that produce repetitive, recognizable patterns of interdependent action carried out by multiple participants" (M. S. Feldman & Pentland, 2003; Pentland & Feldman, 2005). Thus, routines represent action programs that enable us to "read" organizational events and respond to them. They result in a repetition of ways of working (Reynaud, 2001). These routines are particularly complex patterns that cannot be fully codified (Dosi et al., 1990). Routines develop within and through organizational and individual contexts (Howard-Grenville, 2005) and inherently carry with them the ability to change.

The changes then come from the participants' reflections and reactions to the different results produced by the routine. According to Feldman (2000), routines can evolve and change when 1) routine does not produce the desired effects; 2) routine produces the desired effect but creates new problems; 3) routine allows new opportunities to be created; and 4) routine leads to the collapse of ideals. Depending on the situation, the routine is "repairing" (case 1 and case 2), "extending" (case 3) or "striving" (case 4). From this perspective, routine is perceived as: "a set of possible patterns – enabled and constrained by a variety of organizational, social, physical and cognitive structures – from which organizational members enact particular performance" (Pentland & Rueter, 1994, p. 491). Viewing routines as a set of actions induces that each actor can mobilize one action as opposed to another and, consequently, introduce progressive variations in the routine (Howard-Grenville, 2005). "Any organizational routine that involves people who are capable of learning from experience, is at least partially a "live routine"" (Pentland & Feldman, 2008, p. 240).

Routines integrate two dimensions: ostensive and performative (M. Feldman, 2000). The 'ostensive' dimension refers to the representation of what the routine is, its general idea. It has a normative aspect: it defines, frames, and prescribes action (D'Adderio, 2008). This normative dimension can stem from an external regulation imposed on the individual performing the routine and from the individual's own understanding and perception of this norm. For instance, this is the case with an individual's conception of the moral and ethical obligations that bind them. The "performative" dimension corresponds to how this norm is implemented (M. Feldman, 2000). It refers to the ability of actors to interpret, modify, and, in some cases go beyond a rule or procedure entirely (D'Adderio, 2008). These are pragmatic, local, and temporary solutions to the incompleteness of norms or rules (Reynaud, 2001). Furthermore, "the actions within a routine are interdependent, individual agency is moderated or attenuated to some extent" (M. S. Feldman & Pentland, 2003, p. 105). The performative aspects are then context-dependent, and may be influenced by location, time, and people interacting within the routine. The movement between these two dimensions allows routines to evolve. "This movement between performative and ostensive provides many opportunities for people to produce variations on a routine, to select these variations, and to retain them as what it means to do this particular routine" (M. S. Feldman & Pentland, 2003). For Pentland and Feldman (2008) these two elements are self-sustaining: "Without these two aspects, the recognizable, repetitive pattern of action that caracterize organizational routines cannot be produced or reproduced" (Pentland & Feldman, 2008). "these aspects of an organizational routine may be codified or prescribed, as well as enabled and constrained, by various artifacts. Artifacts take
# 2. Theoretical Framework

## 2.1. Organizational routines

Routines, considered essential elements in organizations, were initially envisaged as stable and repetitive (Nelson & Winter, 1982; Simon, 1991). However, the dialectic of stability and change in organizations has known new conceptualizations oriented toward analyzing the micro-dynamics of change. Among these, the theoretical approach to the dynamics of organizational routines (Pentland et al., 2012) demonstrated its strong heuristic potential to understand better how the routines evolve and how they are structured. In this approach, organizational routines are "generative systems that produce repetitive, recognizable patterns of interdependent action carried out by multiple participants" (M. S. Feldman & Pentland, 2003; Pentland & Feldman, 2005). Thus, routines represent action programs that enable us to "read" organizational events and respond to them. They result in a repetition of ways of working (Reynaud, 2001). These routines are particularly complex patterns that cannot be fully codified (Dosi et al., 1990). Routines develop within and through organizational and individual contexts (Howard-Grenville, 2005) and inherently carry with them the ability to change.

The changes then come from the participants' reflections and reactions to the different results produced by the routine. According to Feldman (2000), routines can evolve and change when 1) routine does not produce the desired effects; 2) routine produces the desired effect but creates new problems; 3) routine allows new opportunities to be created; and 4) routine leads to the collapse of ideals. Depending on the situation, the routine is "repairing" (case 1 and case 2), "extending" (case 3) or "striving" (case 4). From this perspective, routine is perceived as: "a set of possible patterns – enabled and constrained by a variety of organizational, social, physical and cognitive structures – from which organizational members enact particular performance" (Pentland & Rueter, 1994, p. 491). Viewing routines as a set of actions induces that each actor can mobilize one action as opposed to another and, consequently, introduce progressive variations in the routine (Howard-Grenville, 2005). "Any organizational routine that involves people who are capable of learning from experience, is at least partially a "live routine"" (Pentland & Feldman, 2008, p. 240).

Routines integrate two dimensions: ostensive and performative (M. Feldman, 2000). The 'ostensive' dimension refers to the representation of what the routine is, its general idea. It has a normative aspect: it defines, frames, and prescribes action (D'Adderio, 2008). This normative dimension can stem from an external regulation imposed on the individual performing the routine and from the individual's own understanding and perception of this norm. For instance, this is the case with an individual's conception of the moral and ethical obligations that bind them. The "performative" dimension corresponds to how this norm is implemented (M. Feldman, 2000). It refers to the ability of actors to interpret, modify, and, in some cases go beyond a rule or procedure entirely (D'Adderio, 2008). These are pragmatic, local, and temporary solutions to the incompleteness of norms or rules (Reynaud, 2001). Furthermore, "the actions within a routine are interdependent, individual agency is moderated or attenuated to some extent" (M. S. Feldman & Pentland, 2003, p. 105). The performative aspects are then context-dependent, and may be influenced by location, time, and people interacting within the routine. The movement between these two dimensions allows routines to evolve. "This movement between performative and ostensive provides many opportunities for people to produce variations on a routine, to select these variations, and to retain them as what it means to do this particular routine" (M. S. Feldman & Pentland, 2003). For Pentland and Feldman (2008) these two elements are self-sustaining: "Without these two aspects, the recognizable, repetitive pattern of action that caracterize organizational routines cannot be produced or reproduced" (Pentland & Feldman, 2008). "these aspects of an organizational routine may be codified or prescribed, as well as enabled and constrained, by various artifacts. Artifacts take
*many different forms, from written rules, procedures, and forms to the general physical setting"*
(Pentland & Feldman, 2005, p. 796)

The following figure shows the graphic representation of this conceptual framework (see Figure 1).

<figure><img src="image_5.png" /><figcaption>**Figure 1: Conceptual framework of Pentland et Feldman (2008)**</figcaption></figure>

Later studies have looked at technologies as artifacts that influence both the ostensive and performative aspects of organizational routines (P. M. Leonardi & Barley, 2008), also allowing the creation of new practices (Labatut et al., 2012). In the latter article, the distinction between routine and practice is elucidated through the examination of how technologies influence and are influenced by organizational routines, leading to the emergence of new practices. Routines are depicted as behavior patterns embedded within organizational operations, while practices encompass broader activities and are shaped by interactions between routines and technological innovations.

Here, the actor interacting with a digital artifact adapts their routines based on the features and opportunities the artifact offers. The usage of the artifact would then depend on the user's ability to identify the feature's existence and how it could improve their organizational routine. This would be followed by a post-adoption evaluation of the positive or negative impact on health practice and quality of life.

## 2.2. Organizational routines of liberal doctors

Organizational routines, initially applied within organizations where the ostensive represents the ensemble of rules and norms within the organization and the performative how individuals adapt to this environment, can also be tailored for liberal practitioners, called in France 'médecins libéraux.' It refers to medical practice within the private sector, without receiving government compensation. They establish private practices or work as freelancers, offering medical services directly to patients within their communities. While operating within the framework of the French healthcare system, liberal physicians maintain a degree of professional independence, allowing them to adapt their services to the needs and preferences of their patients while adhering to regulatory guidelines and ethical standards.

Even though liberal physicians may appear independent in their daily work, our focus was not on their individual routines but on the organizational aspects, "characterized by multiple actors and interdependent actions" (Pentland & Feldman, 2005, p. 795). Indeed, liberal physicians need to organize their schedules to align with their patients' needs and work with other health professionals like secretaries, other physicians, or health institutions.

They must also decide on the consultation's format, including its duration and location, and engage in pre- or post-consultation interactions for administrative purposes or patient follow-
*many different forms, from written rules, procedures, and forms to the general physical setting"*
(Pentland & Feldman, 2005, p. 796)

The following figure shows the graphic representation of this conceptual framework (see Figure 1).

<figure><img src="image_4.png" /><figcaption>**Figure 1: Conceptual framework of Pentland et Feldman (2008)**</figcaption></figure>

Later studies have looked at technologies as artifacts that influence both the ostensive and performative aspects of organizational routines (P. M. Leonardi & Barley, 2008), also allowing the creation of new practices (Labatut et al., 2012). In the latter article, the distinction between routine and practice is elucidated through the examination of how technologies influence and are influenced by organizational routines, leading to the emergence of new practices. Routines are depicted as behavior patterns embedded within organizational operations, while practices encompass broader activities and are shaped by interactions between routines and technological innovations.

Here, the actor interacting with a digital artifact adapts their routines based on the features and opportunities the artifact offers. The usage of the artifact would then depend on the user's ability to identify the feature's existence and how it could improve their organizational routine. This would be followed by a post-adoption evaluation of the positive or negative impact on health practice and quality of life.

## 2.2. Organizational routines of liberal doctors

Organizational routines, initially applied within organizations where the ostensive represents the ensemble of rules and norms within the organization and the performative how individuals adapt to this environment, can also be tailored for liberal practitioners, called in France 'médecins libéraux.' It refers to medical practice within the private sector, without receiving government compensation. They establish private practices or work as freelancers, offering medical services directly to patients within their communities. While operating within the framework of the French healthcare system, liberal physicians maintain a degree of professional independence, allowing them to adapt their services to the needs and preferences of their patients while adhering to regulatory guidelines and ethical standards.

Even though liberal physicians may appear independent in their daily work, our focus was not on their individual routines but on the organizational aspects, "characterized by multiple actors and interdependent actions" (Pentland & Feldman, 2005, p. 795). Indeed, liberal physicians need to organize their schedules to align with their patients' needs and work with other health professionals like secretaries, other physicians, or health institutions.

They must also decide on the consultation's format, including its duration and location, and engage in pre- or post-consultation interactions for administrative purposes or patient follow-
up. Much like in companies, this organization relies on ostensive and performative factors, interacting with artifacts.

Figure 2 illustrates this proposed adaptation of Feldman and Pentland's (2008) model in the context of independent physicians' routines.

<figure><img src="image_6.png" /><figcaption>**Figure 2: Liberal Doctors' Organizational Routines adapted from Pentland et Feldman (2008)**</figcaption></figure>

- The Ostensive aspect covers the liberal physician's practice environment, including healthcare standards, ethics, or regulations, and how they perceive it.

- The Performative aspect involves physicians adjusting their practice based on perceived Ostensive elements, personal preferences, and patient needs. These performative aspects are context-dependent and may be impacted by actors' relationships within the routine (both patients and other health professionals), location and period of practice.

- Digital tools like health software, offering features such as online scheduling and teleconsultation, interact with both Ostensive and Performative aspects. These tools evolve based on healthcare professionals' feedback and needs, influencing and being influenced by the Ostensive context, including regulatory and stakeholder behaviors.

According to the model proposed by Pentland and Feldman (2005), every evolution in one segment should systemically lead to circular adaptations in the two others.

# 3. Methodology

## 3.1. Sample and data collection

The study of how liberal physicians' routines evolve when using health software remains underexplored in the existing literature. We then conducted a qualitative exploratory study to provide deeper insights into this phenomenon. We employed semi-structured interviews with ten liberal physicians who incorporate health software in their practice for scheduling appointments, managing consultations, and interacting with patients or other health professionals. Due to the exploratory nature of this study and the limited size of the sample, only two specialties were selected: pediatricians and psychiatrists. These specialties were chosen because they serve patient populations with distinct clinical needs. For instance, a psychiatrist typically requires fewer physical examinations than a pediatrician, and a pediatrician generally sees fewer chronic cases requiring regular visits. Additionally, a general practitioner and a child psychiatrist, who both treat these patient groups, were interviewed to provide a more balanced perspective. The list of interviewed physicians and the software tools used are presented in Appendix A.
up. Much like in companies, this organization relies on ostensive and performative factors, interacting with artifacts.

Figure 2 illustrates this proposed adaptation of Feldman and Pentland's (2008) model in the context of independent physicians' routines.

<figure><img src="image_5.png" /><figcaption>Figure 2: Liberal Doctors’ Organizational Routines adapted from Pentland et Feldman (2008)</figcaption></figure>

- The Ostensive aspect covers the liberal physician's practice environment, including healthcare standards, ethics, or regulations, and how they perceive it.

- The Performative aspect involves physicians adjusting their practice based on perceived Ostensive elements, personal preferences, and patient needs. These performative aspects are context-dependent and may be impacted by actors' relationships within the routine (both patients and other health professionals), location and period of practice.

- Digital tools like health software, offering features such as online scheduling and teleconsultation, interact with both Ostensive and Performative aspects. These tools evolve based on healthcare professionals' feedback and needs, influencing and being influenced by the Ostensive context, including regulatory and stakeholder behaviors.

According to the model proposed by Pentland and Feldman (2005), every evolution in one segment should systemically lead to circular adaptations in the two others.

# 3. Methodology

## 3.1. Sample and data collection

The study of how liberal physicians' routines evolve when using health software remains underexplored in the existing literature. We then conducted a qualitative exploratory study to provide deeper insights into this phenomenon. We employed semi-structured interviews with ten liberal physicians who incorporate health software in their practice for scheduling appointments, managing consultations, and interacting with patients or other health professionals. Due to the exploratory nature of this study and the limited size of the sample, only two specialties were selected: pediatricians and psychiatrists. These specialties were chosen because they serve patient populations with distinct clinical needs. For instance, a psychiatrist typically requires fewer physical examinations than a pediatrician, and a pediatrician generally sees fewer chronic cases requiring regular visits. Additionally, a general practitioner and a child psychiatrist, who both treat these patient groups, were interviewed to provide a more balanced perspective. The list of interviewed physicians and the software tools used are presented in Appendix A.
The physicians were questioned about their utilization of health software in their daily practice, focusing on how they adopt specific technologies and features, such as digital scheduling, teleconsultations, or electronic documentation. These interviews were conducted both in-person and remotely. Due to the busy schedules of liberal physicians, the interviews were planned to last between 30 and 45 minutes. On average, the interviews lasted 45 minutes. Each interview was recorded and transcribed with the doctors' consent and then stored anonymously.

## 3.2. Analysis

In the analysis phase of the study, we employ a deductive analysis approach anchored in the theory of organizational routines. This theoretical framework provided a structured lens through which the collected data from the interviews were examined. The theory of organizational routines focuses on the repetitive patterns of behavior within organizations, which are critical to understanding how practices evolve over time (Labatut et al., 2012; Pentland & Feldman, 2005). By applying this theory, we systematically categorized and interpreted the responses of liberal physicians regarding their use of health software. This approach enabled the identification of specific patterns and variations in how these technologies influenced their daily operational routines. The deductive nature of the analysis ensured that the findings were directly linked to established theoretical constructs, thereby offering a robust and theoretically informed understanding of the dynamic interplay between technology use and routines of liberal physicians. This article focuses on three categories of digital tools used in physicians' routines, as previously discussed.

- The first category concerns physicians' appointment scheduling using online agendas.

- The second involves their choice of consultation method, focusing on teleconsultation.

- The third category relates to the evolution of doctor-patient interactions through the use of secure messaging and document-sharing tools.

To organize our results section, we systematically analyzed the three dimensions of routines, as proposed in Figure 2. The initial section will address the ostensive factors influencing the routines of liberal doctors. The second section will then describe some identified evolution of health routines and practices within this ostensive context. The final section will explore the dynamic nature of ostensive and performative aspects involving the digital artifact mediation. Since the adaptation of routines depends on a physician's ability to recognize the ostensive dimensions in which they operate and the presence or usefulness of the digital artifact's features, only dimensions explicitly identified by physicians in their interviews will be presented.

The coding was performed across two dimensions. The first dimension distinguishes between the ostensive aspects, which involve the constraints physicians perceive in performing their routines and integrating them into their care practice, and the performative aspects, which depend on their individual specificities. The second dimension categorizes the type of routine affected and the software functionalities involved. Examples of coding are presented in Appendix B. To maintain conciseness and prevent excessive use of quotations that might dilute the findings, we have chosen to provide edited quotes from their interviews that faithfully summarize their intentions (Eldh et al., 2020). Since the interviews were conducted in French, they have also been translated using generative AI, with specific instructions to faithfully represent their purpose.
The physicians were questioned about their utilization of health software in their daily practice, focusing on how they adopt specific technologies and features, such as digital scheduling, teleconsultations, or electronic documentation. These interviews were conducted both in-person and remotely. Due to the busy schedules of liberal physicians, the interviews were planned to last between 30 and 45 minutes. On average, the interviews lasted 45 minutes. Each interview was recorded and transcribed with the doctors' consent and then stored anonymously.

## 3.2. Analysis

In the analysis phase of the study, we employ a deductive analysis approach anchored in the theory of organizational routines. This theoretical framework provided a structured lens through which the collected data from the interviews were examined. The theory of organizational routines focuses on the repetitive patterns of behavior within organizations, which are critical to understanding how practices evolve over time (Labatut et al., 2012; Pentland & Feldman, 2005). By applying this theory, we systematically categorized and interpreted the responses of liberal physicians regarding their use of health software. This approach enabled the identification of specific patterns and variations in how these technologies influenced their daily operational routines. The deductive nature of the analysis ensured that the findings were directly linked to established theoretical constructs, thereby offering a robust and theoretically informed understanding of the dynamic interplay between technology use and routines of liberal physicians. This article focuses on three categories of digital tools used in physicians' routines, as previously discussed.

- The first category concerns physicians' appointment scheduling using online agendas.

- The second involves their choice of consultation method, focusing on teleconsultation.

- The third category relates to the evolution of doctor-patient interactions through the use of secure messaging and document-sharing tools.

To organize our results section, we systematically analyzed the three dimensions of routines, as proposed in Figure 2. The initial section will address the ostensive factors influencing the routines of liberal doctors. The second section will then describe some identified evolution of health routines and practices within this ostensive context. The final section will explore the dynamic nature of ostensive and performative aspects involving the digital artifact mediation. Since the adaptation of routines depends on a physician's ability to recognize the ostensive dimensions in which they operate and the presence or usefulness of the digital artifact's features, only dimensions explicitly identified by physicians in their interviews will be presented.

The coding was performed across two dimensions. The first dimension distinguishes between the ostensive aspects, which involve the constraints physicians perceive in performing their routines and integrating them into their care practice, and the performative aspects, which depend on their individual specificities. The second dimension categorizes the type of routine affected and the software functionalities involved. Examples of coding are presented in Appendix B. To maintain conciseness and prevent excessive use of quotations that might dilute the findings, we have chosen to provide edited quotes from their interviews that faithfully summarize their intentions (Eldh et al., 2020). Since the interviews were conducted in French, they have also been translated using generative AI, with specific instructions to faithfully represent their purpose.
# 4. Findings

## 4.1. Medical Routines Evolving in a Framed (Ostensive) Context

Medical routines in daily practice are grounded in a set of conditions and constraints defining the ostensive framework in which doctors operate. Physicians then adapt their routines based on their knowledge or perception of this ostensive framework.

### 4.1.1. Regulatory and Ethic Framework in the Medical Sector

Doctors face a series of guidelines impacting their routines. Ensuring the security of medical information exchanges is one of numerous priorities governed by privacy and data protection standards.

"The patient had to come each time so I can print [the file] for them because I'm not allowed to send it by email" (Dr3). "for a long time, but it's getting better lately, we used to write with a personal email. So... data security..." (Dr5). "[software editors] are also trying to secure exchanges, with everything encrypted. And to secure medical data exchanges as well" (Dr7).

Beyond regulation, many interviewed physicians reflect a genuine concern regarding data security. For example, Doctor 5 indicates, regarding the transfer of health information, "when I was asked to help with a file [sent] to my personal email address, [I preferred] to make a paper version and bring it in person." Doctor 7 confirms, "I would like to ensure that the data is indeed secure."

Simultaneously, administrative tasks, like patient record storage, follow strict rules such as "huge quantity of letters that I had to scan" (Dr1), or the "patient's medical record [...] filled in every time I see them [with] a few clinical notes, plus all the prescriptions and all the certificates" (Dr2). This "patient information is clear and updated in real-time with the Public Health Insurance" (Dr1). "The computer also allows a trace in health record of everything that happened previously" (Dr5). This administrative burden is illustrated by Doctor 10, "anyway, we lose our independence because of social security. Let's not kid ourselves." All doctors have identified the time devoted to these tasks as one of the most significant sources of time loss in therapy time. "If I don't spend so much time on administrative tasks, it affects the content of the consultation [allows] more listening with a mind less occupied by adjacent tasks" (Dr1), "the software greatly facilitates all the administrative part, bringing us closer to pure clinical work" (Dr3). Doctor 5 also raises concerns about the right to be forgotten. "What will we do with this information afterward, when [the patient] grows up, or depending on his formation choices?"

### 4.1.2. Dependence on Public Health Context

Various contextual factors influence medical routines. Pandemics, for example, led to care access limitations, changing patient consultation habits and modes. This situation encouraged long-term adoption by both patients and doctors. "It no longer scares them to make [online] appointments, or to reschedule them. Because they've gotten used to it" (Dr3). "It has become something much more natural, [compared to before] when patients weren't really used to it" (Dr10). "Before COVID, both patients and doctors were afraid of teleconsultation. We had a lot of prejudices and a lot of fears. And then, COVID dispelled all these fears. We then realized its virtuous use" (Dr5). Doctor 3 also notes a ripple effect: "Quite a few patients have adopted [teleconsultation] but not with me. [It was] for their general practitioner, gynecologist, and midwife, and they found it good."

Medical saturation, leading to appointment difficulties and medical deserts, is a challenge all surveyed physicians face, forcing them "year after year to develop new strategies" (Dr5). "Patients complain mostly about the scarcity of slots and not being able to see me often enough" (Dr2) "It's difficult for me to accept new patients, and it's the same for many of my colleagues" (Dr3) "The medical density means that we can't meet all demands" (Dr4) "In pediatrics, we are
# 4. Findings

## 4.1. Medical Routines Evolving in a Framed (Ostensive) Context

Medical routines in daily practice are grounded in a set of conditions and constraints defining the ostensive framework in which doctors operate. Physicians then adapt their routines based on their knowledge or perception of this ostensive framework.

### 4.1.1. Regulatory and Ethic Framework in the Medical Sector

Doctors face a series of guidelines impacting their routines. Ensuring the security of medical information exchanges is one of numerous priorities governed by privacy and data protection standards.

"The patient had to come each time so I can print [the file] for them because I'm not allowed to send it by email" (Dr3). "for a long time, but it's getting better lately, we used to write with a personal email. So... data security..." (Dr5). "[software editors] are also trying to secure exchanges, with everything encrypted. And to secure medical data exchanges as well" (Dr7).

Beyond regulation, many interviewed physicians reflect a genuine concern regarding data security. For example, Doctor 5 indicates, regarding the transfer of health information, "when I was asked to help with a file [sent] to my personal email address, [I preferred] to make a paper version and bring it in person." Doctor 7 confirms, "I would like to ensure that the data is indeed secure."

Simultaneously, administrative tasks, like patient record storage, follow strict rules such as "huge quantity of letters that I had to scan" (Dr1), or the "patient's medical record [...] filled in every time I see them [with] a few clinical notes, plus all the prescriptions and all the certificates" (Dr2). This "patient information is clear and updated in real-time with the Public Health Insurance" (Dr1). "The computer also allows a trace in health record of everything that happened previously" (Dr5). This administrative burden is illustrated by Doctor 10, "anyway, we lose our independence because of social security. Let's not kid ourselves." All doctors have identified the time devoted to these tasks as one of the most significant sources of time loss in therapy time. "If I don't spend so much time on administrative tasks, it affects the content of the consultation [allows] more listening with a mind less occupied by adjacent tasks" (Dr1), "the software greatly facilitates all the administrative part, bringing us closer to pure clinical work" (Dr3). Doctor 5 also raises concerns about the right to be forgotten. "What will we do with this information afterward, when [the patient] grows up, or depending on his formation choices?"

### 4.1.2. Dependence on Public Health Context

Various contextual factors influence medical routines. Pandemics, for example, led to care access limitations, changing patient consultation habits and modes. This situation encouraged long-term adoption by both patients and doctors. "It no longer scares them to make [online] appointments, or to reschedule them. Because they've gotten used to it" (Dr3). "It has become something much more natural, [compared to before] when patients weren't really used to it" (Dr10). "Before COVID, both patients and doctors were afraid of teleconsultation. We had a lot of prejudices and a lot of fears. And then, COVID dispelled all these fears. We then realized its virtuous use" (Dr5). Doctor 3 also notes a ripple effect: "Quite a few patients have adopted [teleconsultation] but not with me. [It was] for their general practitioner, gynecologist, and midwife, and they found it good."

Medical saturation, leading to appointment difficulties and medical deserts, is a challenge all surveyed physicians face, forcing them "year after year to develop new strategies" (Dr5). "Patients complain mostly about the scarcity of slots and not being able to see me often enough" (Dr2) "It's difficult for me to accept new patients, and it's the same for many of my colleagues" (Dr3) "The medical density means that we can't meet all demands" (Dr4) "In pediatrics, we are
"forced to filter a lot because we have too many demands" (Dr5) "we lack doctors, so it's very difficult to get medical appointments' (Dr6) 'I have no slots left at all' (Dr8). Doctor 10 explains, "It's the lack of general practitioners, retirements which are more frequent than installations."

Seasonality and patient geographic distance also affect care organization, requiring consultation mode adjustments. Doctor 5 confirms for seasonality: "Last winter, in December, we had three epidemics in the same month. There was RSV<fnref n="1" /> and bronchiolitis virus. We had a COVID peak, and we had the flu peak. And then, all healthcare workers were absolutely saturated."

Medical deserts also cause difficulties in finding a doctor, as indicated by Doctor 2: "Regarding medical deserts [...] I have a lot of cases of people who are in 'La Creuse' or who are at the center of France." Doctor 3 also reported "patients who haven't been able to find a [doctor], where they have settled."

#### 4.1.3. Patient Pathologies' Unpredictable Nature

The inherent uncertainty of patient health conditions leads to emergency situations and limited mobility cases. It then requires greater flexibility. "Patients are happy to be able to schedule an appointment at 3:00 in the morning" (Dr6) or "quietly in the evening or on the weekend [when the reception is closed]" (Dr7). Doctor 3 explains that "if someone feels sick on a Sunday evening and needs to see their doctor, they can't reach them at that moment. So, they have to wait until the next day". Then, as explained by Doctor 10, "If you're a parent, your child just vomited in the middle of the night at 2:00 a.m., you can make an appointment." Doctor 4 explains the therapeutic usefulness of such availability. "When parents have a sick child, they see an appointment slot for the next morning, they take it. If the child's situation deteriorates overnight, they go to the emergency room and cancel the appointment. or they wait until the next day because it wasn't worse after all. I think psychologically, it allows for a different experience of waiting."

Some emergencies may also require immediate consultation. The doctor can then "take a small teleconsultation slot to at least issue a sick leave, adjust a treatment, and defuse a situation that was becoming increasingly complicated" (Dr3), which "still allows them to have a healthcare professional on the phone or via video and define a course of action" (Dr5).

### 4.2. Performative Adaptations of Medical Organizational Routines

Considering these contextual factors, doctors adapt their routines performatively, aligning with personal and professional values.

#### 4.2.1. Simpler and More Secure Document Management

Digitizing patient records makes managing documents easier, letting them quickly fill and share digital files for prescriptions. Doctor 2 does "all the prescriptions and certificates through [the] software" to send them to patients. Patients like getting prescriptions via the app because "they can send them straight to the pharmacy and keep the document on their phone for 5 years" (Dr1). Doctor 3 points out that without the tool, "patients would have to come in each time to print their prescription or treatment adjustment because we can't send it by email."

Regarding care quality, Doctor 5 believes that "prescriptions given during teleconsultations don't affect adherence. At least, with patients, we know it works well."

This quick sharing ability also makes doctors more efficient. Doctor 1 says, "It helps me with small administrative tasks that could sometimes be problematic." Doctor 5 adds, "I think I've managed to cut down on unnecessary appointments and turn them into document sendings." Doctor 3 believes not being able to send the document "would saturate all my consultation time."

<footnote n="1">¹ Respiratory Syncytial Virus: contagious virus common cause of respiratory hospitalization in infants (Wikipedia)</footnote>
"forced to filter a lot because we have too many demands" (Dr5) "we lack doctors, so it's very difficult to get medical appointments' (Dr6) 'I have no slots left at all' (Dr8). Doctor 10 explains, "It's the lack of general practitioners, retirements which are more frequent than installations."

Seasonality and patient geographic distance also affect care organization, requiring consultation mode adjustments. Doctor 5 confirms for seasonality: "Last winter, in December, we had three epidemics in the same month. There was RSV<fnref n="1" /> and bronchiolitis virus. We had a COVID peak, and we had the flu peak. And then, all healthcare workers were absolutely saturated."

Medical deserts also cause difficulties in finding a doctor, as indicated by Doctor 2: "Regarding medical deserts [...] I have a lot of cases of people who are in 'La Creuse' or who are at the center of France." Doctor 3 also reported "patients who haven't been able to find a [doctor], where they have settled."

#### 4.1.3. Patient Pathologies' Unpredictable Nature

The inherent uncertainty of patient health conditions leads to emergency situations and limited mobility cases. It then requires greater flexibility. "Patients are happy to be able to schedule an appointment at 3:00 in the morning" (Dr6) or "quietly in the evening or on the weekend [when the reception is closed]" (Dr7). Doctor 3 explains that "if someone feels sick on a Sunday evening and needs to see their doctor, they can't reach them at that moment. So, they have to wait until the next day". Then, as explained by Doctor 10, "If you're a parent, your child just vomited in the middle of the night at 2:00 a.m., you can make an appointment." Doctor 4 explains the therapeutic usefulness of such availability. "When parents have a sick child, they see an appointment slot for the next morning, they take it. If the child's situation deteriorates overnight, they go to the emergency room and cancel the appointment. or they wait until the next day because it wasn't worse after all. I think psychologically, it allows for a different experience of waiting."

Some emergencies may also require immediate consultation. The doctor can then "take a small teleconsultation slot to at least issue a sick leave, adjust a treatment, and defuse a situation that was becoming increasingly complicated" (Dr3), which "still allows them to have a healthcare professional on the phone or via video and define a course of action" (Dr5).

### 4.2. Performative Adaptations of Medical Organizational Routines

Considering these contextual factors, doctors adapt their routines performatively, aligning with personal and professional values.

#### 4.2.1. Simpler and More Secure Document Management

Digitizing patient records makes managing documents easier, letting them quickly fill and share digital files for prescriptions. Doctor 2 does "all the prescriptions and certificates through [the] software" to send them to patients. Patients like getting prescriptions via the app because "they can send them straight to the pharmacy and keep the document on their phone for 5 years" (Dr1). Doctor 3 points out that without the tool, "patients would have to come in each time to print their prescription or treatment adjustment because we can't send it by email."

Regarding care quality, Doctor 5 believes that "prescriptions given during teleconsultations don't affect adherence. At least, with patients, we know it works well."

This quick sharing ability also makes doctors more efficient. Doctor 1 says, "It helps me with small administrative tasks that could sometimes be problematic." Doctor 5 adds, "I think I've managed to cut down on unnecessary appointments and turn them into document sendings." Doctor 3 believes not being able to send the document "would saturate all my consultation time."

<footnote n="1">¹ Respiratory Syncytial Virus: contagious virus common cause of respiratory hospitalization in infants (Wikipedia)</footnote>
"Whenever they need a document, it takes me 10 seconds, and it's done." Similarly, Doctor 4 says, "Everything is on my phone. If I forget a prescription, I resend it right away. It saves time,". Doctor 5 notes, "People get their documents very quickly, especially for simple things."

This solution also helps to share other documents like patient records. "transferring any other health documents is possible via a 'print PDF' that I download and send directly through my software." Doctor 3 also "sends a lot of documents to patients via Doctolib." (Dr10)

Digital document sending also eases transfers. "When parents ask for a sick child certificate, I say, 'I won't print it; I'll email it to you because you'll email it to your employer'" (Dr4). Integrating the software with the Digital Medical Record (DMP) makes this even easier as it "automatically sends blood test prescriptions, medication prescriptions to the patient's DMP, which they or another specialist or pharmacist can find" (Dr10). Doctor 1 says, "I'll leave something simple when I retire. I can print the file and give it to parents when they leave the region." It also implies "printing a bit less" (Dr3), which can meet ethical challenges.

However, doctors still offer paper for patients who are uncomfortable with digital or have no choice. Doctor 1 says, "Some people don't know how to set up their software to receive the prescription, so I print it for them." For these people, Doctor 5 tries "to start educating the patients [...] to make it work" because patients "aren't resistant. They just need to be more confident."

Ethical rules are, however, important, like issuing prescriptions only after consultations. Doctors 5, 7, and 8 remind us, "Some people ask for many documents, but we never see them. At some point, you must meet in person" (Dr5), "We usually do prescription renewals during a consultation" (Dr7), "Many patients ask for a prescription without a consultation, which isn't legal or ethical" (Dr8).

They may also not share all the details of a teenage patient's consultation linked to a parent's digital account. "There might be a need for some confidentiality. For example, if I see a teenager, what they tell me confidentially" (Dr1), then "we might not send it online. We can easily do a paper version" (Dr5).

### 4.2.2. More Collegial Patient Care

Shared calendars help doctors and healthcare professionals work together. Most doctors interviewed (except 1, 3, and 9) use secretaries that access and help manage their online schedules through software. The software then acts as "An interface with the secretaries" (Dr10). They "get all the new patient requests" (Dr2), which are often blocked for online appointments. The secretaries filter appointment requests and facilitate communication to avoid "picking up the phone during consultations." Instead, secretaries "put everything in a message. And I reply as soon as I can between patients" (Dr5). The same goes for Doctor 8, who "writes notes for them to pass on to patients" (Dr8).

This distribution of tasks is useful since secretaries often know the patients, which helps secretariats sort through them. "Patients don't respond the same to a practitioner as to a secretary. They censor themselves a lot with us" (Dr4). "It's good to have a local team because they know the care network resources" (Dr5).

Some doctors share calendars to better manage patient flow, like Doctor 10, who uses a shared calendar solution "linked directly to the on-call doctor's number. It relieves the emergency services, [...] the on-call doctors."

They can also, like Doctors 4 and 5, open specific time slots to colleagues who "can directly book appointments for their patients on some of my slots reserved for them" (Dr4). This better coordination is enhanced by specific messaging among doctors for cross-expertise. Doctors 1, 3, 4, 5, 6, 8, and 10 mentioned using such tools. There also are messaging solutions like Doctolib Teams. "If I need advice for a child, I send a note to a colleague specialized in their issue via
"Whenever they need a document, it takes me 10 seconds, and it's done." Similarly, Doctor 4 says, "Everything is on my phone. If I forget a prescription, I resend it right away. It saves time,". Doctor 5 notes, "People get their documents very quickly, especially for simple things."

This solution also helps to share other documents like patient records. "transferring any other health documents is possible via a 'print PDF' that I download and send directly through my software." Doctor 3 also "sends a lot of documents to patients via Doctolib." (Dr10)

Digital document sending also eases transfers. "When parents ask for a sick child certificate, I say, 'I won't print it; I'll email it to you because you'll email it to your employer'" (Dr4). Integrating the software with the Digital Medical Record (DMP) makes this even easier as it "automatically sends blood test prescriptions, medication prescriptions to the patient's DMP, which they or another specialist or pharmacist can find" (Dr10). Doctor 1 says, "I'll leave something simple when I retire. I can print the file and give it to parents when they leave the region." It also implies "printing a bit less" (Dr3), which can meet ethical challenges.

However, doctors still offer paper for patients who are uncomfortable with digital or have no choice. Doctor 1 says, "Some people don't know how to set up their software to receive the prescription, so I print it for them." For these people, Doctor 5 tries "to start educating the patients [...] to make it work" because patients "aren't resistant. They just need to be more confident."

Ethical rules are, however, important, like issuing prescriptions only after consultations. Doctors 5, 7, and 8 remind us, "Some people ask for many documents, but we never see them. At some point, you must meet in person" (Dr5), "We usually do prescription renewals during a consultation" (Dr7), "Many patients ask for a prescription without a consultation, which isn't legal or ethical" (Dr8).

They may also not share all the details of a teenage patient's consultation linked to a parent's digital account. "There might be a need for some confidentiality. For example, if I see a teenager, what they tell me confidentially" (Dr1), then "we might not send it online. We can easily do a paper version" (Dr5).

### 4.2.2. More Collegial Patient Care

Shared calendars help doctors and healthcare professionals work together. Most doctors interviewed (except 1, 3, and 9) use secretaries that access and help manage their online schedules through software. The software then acts as "An interface with the secretaries" (Dr10). They "get all the new patient requests" (Dr2), which are often blocked for online appointments. The secretaries filter appointment requests and facilitate communication to avoid "picking up the phone during consultations." Instead, secretaries "put everything in a message. And I reply as soon as I can between patients" (Dr5). The same goes for Doctor 8, who "writes notes for them to pass on to patients" (Dr8).

This distribution of tasks is useful since secretaries often know the patients, which helps secretariats sort through them. "Patients don't respond the same to a practitioner as to a secretary. They censor themselves a lot with us" (Dr4). "It's good to have a local team because they know the care network resources" (Dr5).

Some doctors share calendars to better manage patient flow, like Doctor 10, who uses a shared calendar solution "linked directly to the on-call doctor's number. It relieves the emergency services, [...] the on-call doctors."

They can also, like Doctors 4 and 5, open specific time slots to colleagues who "can directly book appointments for their patients on some of my slots reserved for them" (Dr4). This better coordination is enhanced by specific messaging among doctors for cross-expertise. Doctors 1, 3, 4, 5, 6, 8, and 10 mentioned using such tools. There also are messaging solutions like Doctolib Teams. "If I need advice for a child, I send a note to a colleague specialized in their issue via
the software" (Dr1). "It's very user friendly. It really feels like using your smartphone with WhatsApp" (Dr3). Messages can also be sent to platforms where multiple doctors can respond, like Omnidoc, where "Expert Doctors" are listed (Dr6). "the first available doctor accepts the request and responds with a suggestion of what to do" (Dr5). This tool "goes beyond doctors. You can also have Osteopaths, social workers, physiotherapists, nurses, etc." (Dr10).

#### 4.2.3. Easier Access to Healthcare Professionals

Doctors have taken steps to make care more accessible and raise the visibility of their services. This visibility can relate to the doctor's specialization. Doctors 2 and 4 use this by highlighting "icons showing 'I'm familiar with ASD and ADHD'" (Dr2). Same for Doctor 4 who "listed on my homepage with keywords: ADHD, ASD, learning disorders". It's also possible to "display pop-ups at each booking step" (Dr2), which helps patients choose the right specialist and avoids misunderstandings or bad faith: "There are some things they must click on beforehand. If they haven't read it, it's their fault. And if they have read it and still come when they should not, well, it's their fault too." (Dr10). This also indicates the doctor's availability. "They can see my workload by looking at my availability." (Dr3). This can ease tensions: "Now people book their appointments, and when they see there aren't any, they can't assume the secretary is refusing to give them one, [as they used to say before]" (Dr1).

Increased accessibility also comes from better communication about last-minute openings for urgent needs. To accommodate emergencies, some doctors open slots at the last minute, like Doctor 1: "When I arrive in the morning, I often add 4 to 5 emergency appointments for the day" and Doctor 2: "I can offer very specific appointments very quickly, even 2 to 3 days in advance". There can also be last-minute cancellations. "What's handy are the appointment reminders and the fact that patients can book in the gaps, so I almost never have gaps in my schedule" (Dr2). Thanks to an alert system, "a canceled appointment can immediately be offered to another family on a waiting list" (Dr5). It "allows for a quicker appointment when there was sometimes a 3-week wait. Thus, their appointment can be on the same day" (Dr3).

Doctor 2 says that "this can have a public health benefit by allowing more people to visit a doctor easily."

#### 4.2.4. Enhanced Patient-Doctor Interaction

Interactions with patients are easier using dedicated messaging tools. Doctor 2 says their online booking tool "communicates really well with the patient from the start. Even before making the appointment, you've already sent lots of information." It's also not always possible to respond immediately to a request. "As a lot of things don't necessarily require a physical meeting, being able to tell them: 'OK, I've taken note, send me a message tomorrow morning, and I'll call you back to set up an appointment.' shows we're there, not instantly available at the snap of a finger, but we're there" (Dr4). Doctor 7 says, "It speeds up exchanges and ease the medical interaction between patients and doctors."

These tools "provide a certain interactivity which, sometimes, can really reassure and streamline the journey because we're not blocking a consultation with something that doesn't require one" (Dr4). A short teleconsultation can indeed streamline certain tasks. According to Doctor 7, "If I didn't do teleconsultation, I'd need to see patients in the office. People would have to travel to get the results, and clearly, it's not the same commitment for me." Doctor 5 adds, "There are teleconsultations that are just for administrative documents, so indeed, we don't need to examine." Doctor 8 also uses a "teleconsultation module for consultations, sending documents, and payments." Doctor 10 has "patients who now prefer teleconsultations over coming to the office for something like a renewal of orthopedic insoles or things like that where I don't need to see them in person." "It's a complement, not a downgrade, because there are
the software" (Dr1). "It's very user friendly. It really feels like using your smartphone with WhatsApp" (Dr3). Messages can also be sent to platforms where multiple doctors can respond, like Omnidoc, where "Expert Doctors" are listed (Dr6). "the first available doctor accepts the request and responds with a suggestion of what to do" (Dr5). This tool "goes beyond doctors. You can also have Osteopaths, social workers, physiotherapists, nurses, etc." (Dr10).

#### 4.2.3. Easier Access to Healthcare Professionals

Doctors have taken steps to make care more accessible and raise the visibility of their services. This visibility can relate to the doctor's specialization. Doctors 2 and 4 use this by highlighting "icons showing 'I'm familiar with ASD and ADHD'" (Dr2). Same for Doctor 4 who "listed on my homepage with keywords: ADHD, ASD, learning disorders". It's also possible to "display pop-ups at each booking step" (Dr2), which helps patients choose the right specialist and avoids misunderstandings or bad faith: "There are some things they must click on beforehand. If they haven't read it, it's their fault. And if they have read it and still come when they should not, well, it's their fault too." (Dr10). This also indicates the doctor's availability. "They can see my workload by looking at my availability." (Dr3). This can ease tensions: "Now people book their appointments, and when they see there aren't any, they can't assume the secretary is refusing to give them one, [as they used to say before]" (Dr1).

Increased accessibility also comes from better communication about last-minute openings for urgent needs. To accommodate emergencies, some doctors open slots at the last minute, like Doctor 1: "When I arrive in the morning, I often add 4 to 5 emergency appointments for the day" and Doctor 2: "I can offer very specific appointments very quickly, even 2 to 3 days in advance". There can also be last-minute cancellations. "What's handy are the appointment reminders and the fact that patients can book in the gaps, so I almost never have gaps in my schedule" (Dr2). Thanks to an alert system, "a canceled appointment can immediately be offered to another family on a waiting list" (Dr5). It "allows for a quicker appointment when there was sometimes a 3-week wait. Thus, their appointment can be on the same day" (Dr3).

Doctor 2 says that "this can have a public health benefit by allowing more people to visit a doctor easily."

#### 4.2.4. Enhanced Patient-Doctor Interaction

Interactions with patients are easier using dedicated messaging tools. Doctor 2 says their online booking tool "communicates really well with the patient from the start. Even before making the appointment, you've already sent lots of information." It's also not always possible to respond immediately to a request. "As a lot of things don't necessarily require a physical meeting, being able to tell them: 'OK, I've taken note, send me a message tomorrow morning, and I'll call you back to set up an appointment.' shows we're there, not instantly available at the snap of a finger, but we're there" (Dr4). Doctor 7 says, "It speeds up exchanges and ease the medical interaction between patients and doctors."

These tools "provide a certain interactivity which, sometimes, can really reassure and streamline the journey because we're not blocking a consultation with something that doesn't require one" (Dr4). A short teleconsultation can indeed streamline certain tasks. According to Doctor 7, "If I didn't do teleconsultation, I'd need to see patients in the office. People would have to travel to get the results, and clearly, it's not the same commitment for me." Doctor 5 adds, "There are teleconsultations that are just for administrative documents, so indeed, we don't need to examine." Doctor 8 also uses a "teleconsultation module for consultations, sending documents, and payments." Doctor 10 has "patients who now prefer teleconsultations over coming to the office for something like a renewal of orthopedic insoles or things like that where I don't need to see them in person." "It's a complement, not a downgrade, because there are
many things, especially in administrative or treatment adjustments [that do not require face-to-face consultation]" (Dr4).

Finally, treatment follow-up or adjustment can also be done remotely. "These tools for Adjusting care are very handy because I don't necessarily need to examine the patient to hear that 'they've made progress in speech therapy, and we might do occupational therapy to get them on a computer'" (Dr4). "I sometimes offer it for treatment follow-ups where I know it won't take much time, and I don't want to make patients travel a long way just for 15-20 minutes" (Dr8).

### 4.2.5. Flexibility avoiding lack of healthcare

To tackle mobility issues and unexpected events, doctors have become more flexible, tailoring the format and length of consultations as needed.

This timesaving can come from adjusting the consultation length, as Doctor 2 does with "mini appointments that don't clog up my schedule and let me see many people per week while maintaining care quality." Doctor 4 also notes that "being able to offer very short slots for emergencies can help ease things a bit." Regular mini-emergency appointments are also possible. "I have slots that open up, shorter 10-minute ones that open up 16 hours ahead. I have 12 of these a day" (Dr10).

As mentioned earlier, time optimization can also result from better administrative task management, thus dedicating more actual time to patients. As Doctor 3 puts it, "The idea of saving time isn't to do more things, but to have better quality time since I don't shorten my consultations [...] We still keep time to discuss other things, because before, sometimes, consultations were just medical-administrative."

Flexibility can also come through teleconsultations for patients unable to be present in person. This could be due to medical deserts or patients relocating. "I have many people in La Creuse or central France, either because they were in Grenoble and then moved, or because, through blogs, social media, it's known that a certain psychiatrist is knowledgeable about autism spectrum disorders, so they contact me for that" (Dr2). Similarly, Doctor 3 has "currently, a few patients who couldn't find psychiatrists where they've moved to. There are always such situations. Rather than stopping the follow-up, they chose to maintain a connection with [me]." For Doctor 5, "patients moving and needing to keep in touch happens. For instance, while people are looking for a doctor in a new region, I can continue with teleconsultations because I know the child well. So, it's true we're glad to be able to help people while they find a solution." These follow-ups also include students moving for their studies or people living in remote areas. "The vast majority of people are those I've seen in person, and then we started a follow-up, for example, for a student who went abroad. I also have quite a few people in the mountains, you know? Like a ski patroller living [there]. They are often seasonal workers who move a lot. I have quite a few of them. People who are 3 months here, 3 months there. in summer, they go to do their season by the sea, and we keep up the follow-up. Finally, all these people who are more nomadic or live in [remote areas], I mostly see them through video consultation" (Dr2). Doctor 10 has "had cases of patients, particularly student patients who've moved. For example, a patient who went to Strasbourg called for a suspected kidney stone. So [I] tried to manage with the local emergency services to send a doctor on call." This doctor has "even had a patient in Australia." Holiday periods are, as a matter of fact, also leading to these situations. As Doctor 5 says, "during the summer, I do a lot more teleconsultations because people aren't at home. So, I do teleconsultations with people during their holidays. I also do them sometimes with people abroad. Always for my patients, not for new patients. but it's a huge service to them. Because rather than ending up in an emergency room in some country, not knowing the local language. I see their child; I can see if it's serious or not. And often, we manage with their medication kit, nine times out of ten. So, it avoids a complicated healthcare journey."
many things, especially in administrative or treatment adjustments [that do not require face-to-face consultation]" (Dr4).

Finally, treatment follow-up or adjustment can also be done remotely. "These tools for Adjusting care are very handy because I don't necessarily need to examine the patient to hear that 'they've made progress in speech therapy, and we might do occupational therapy to get them on a computer'" (Dr4). "I sometimes offer it for treatment follow-ups where I know it won't take much time, and I don't want to make patients travel a long way just for 15-20 minutes" (Dr8).

### 4.2.5. Flexibility avoiding lack of healthcare

To tackle mobility issues and unexpected events, doctors have become more flexible, tailoring the format and length of consultations as needed.

This timesaving can come from adjusting the consultation length, as Doctor 2 does with "mini appointments that don't clog up my schedule and let me see many people per week while maintaining care quality." Doctor 4 also notes that "being able to offer very short slots for emergencies can help ease things a bit." Regular mini-emergency appointments are also possible. "I have slots that open up, shorter 10-minute ones that open up 16 hours ahead. I have 12 of these a day" (Dr10).

As mentioned earlier, time optimization can also result from better administrative task management, thus dedicating more actual time to patients. As Doctor 3 puts it, "The idea of saving time isn't to do more things, but to have better quality time since I don't shorten my consultations [...] We still keep time to discuss other things, because before, sometimes, consultations were just medical-administrative."

Flexibility can also come through teleconsultations for patients unable to be present in person. This could be due to medical deserts or patients relocating. "I have many people in La Creuse or central France, either because they were in Grenoble and then moved, or because, through blogs, social media, it's known that a certain psychiatrist is knowledgeable about autism spectrum disorders, so they contact me for that" (Dr2). Similarly, Doctor 3 has "currently, a few patients who couldn't find psychiatrists where they've moved to. There are always such situations. Rather than stopping the follow-up, they chose to maintain a connection with [me]." For Doctor 5, "patients moving and needing to keep in touch happens. For instance, while people are looking for a doctor in a new region, I can continue with teleconsultations because I know the child well. So, it's true we're glad to be able to help people while they find a solution." These follow-ups also include students moving for their studies or people living in remote areas. "The vast majority of people are those I've seen in person, and then we started a follow-up, for example, for a student who went abroad. I also have quite a few people in the mountains, you know? Like a ski patroller living [there]. They are often seasonal workers who move a lot. I have quite a few of them. People who are 3 months here, 3 months there. in summer, they go to do their season by the sea, and we keep up the follow-up. Finally, all these people who are more nomadic or live in [remote areas], I mostly see them through video consultation" (Dr2). Doctor 10 has "had cases of patients, particularly student patients who've moved. For example, a patient who went to Strasbourg called for a suspected kidney stone. So [I] tried to manage with the local emergency services to send a doctor on call." This doctor has "even had a patient in Australia." Holiday periods are, as a matter of fact, also leading to these situations. As Doctor 5 says, "during the summer, I do a lot more teleconsultations because people aren't at home. So, I do teleconsultations with people during their holidays. I also do them sometimes with people abroad. Always for my patients, not for new patients. but it's a huge service to them. Because rather than ending up in an emergency room in some country, not knowing the local language. I see their child; I can see if it's serious or not. And often, we manage with their medication kit, nine times out of ten. So, it avoids a complicated healthcare journey."
Patients' pathologies can also cause them to be remote. Doctors 2 and 3 mention that some patients, such as those with autism or agoraphobia, can still be seen if they can't leave their homes. "I know that if I don't accept for them teleconsultation, they'll never see a psychiatrist. So, it's better to keep a thin, maybe more artificial connection than if it were in an office, but at least keep a connection" (Dr2). "When it's a symptom like agoraphobia, we know these are complicated symptoms to stabilize. Just telling people to go outside doesn't always work well, and teleconsultation can indeed help maintain a connection. I feel it has defused more situations because people tended not to leave their homes at all, not come to appointments, and end up not getting treated." (Dr3)

Lastly, some situations might lead to switching an in-person consultation to a last-minute remote one. Patients doing so "tends to annoy me. at the same time, I still see them in consultation. So, it's quite handy". "I had a patient who was late and stuck in traffic. He was going to arrive, I think, 10 minutes before the appointment ended. And we thought, 'Well, we can do a teleconsultation.' This flexibility was useful. In this case, it's a downgrade. But I'd say a satisfactory downgrade" (Dr9).

This flexibility can be constrained by the context, like for Doctor 6, who only used this solution during the confinement period to continue following patients but rejected this solution otherwise.

### 4.2.6. Increased Doctor Availability

Using tools that streamline time-consuming or unrelated treatment tasks naturally lightens the workload and increases available consultation slots. Each doctor reported gaining availability thanks to digital tools. For example, Doctor 4 notes, "saving 5 minutes per consultation on the number of clicks, page loads, and the overall fluidity of the product." "Customizing and setting everything up has saved me an hour a day" (Dr5).

Motivated by personal needs like family life, these adaptations allow doctors with family responsibilities to continue offering consultations.

Women often highlighted the importance of teleconsultation for their family life, as shown by the following testimonials. "Whether I'm at my office or home, I can be very responsive and present without it intruding on my personal life. It allows me to do what I want, where I want. Thanks to full web access, I can take care of my children and I remain highly available to check a file when I have a patient on the phone" (Dr4). "Having online access, as a woman, is crucial. Being a doctor means constantly juggling our professional and family lives. I've always worked from home to some extent, which allowed me to come home earlier or be there for my children" (Dr5). "Teleconsultation is truly simple on Doctolib, and as women, we clearly need it, now more than ever" (Dr7).

Doctor 5 considers that, in general, "for [younger doctors], online software is a given. Having to go back to the office to turn on the computer and check a file is no longer viable". This leads to a routine that resembles telework: "when I'm not at my clinic, I can do video consultations" (Dr1), "Tuesday afternoons I'm at home doing teleconsultations. It's also very comfortable for me to be at home, relaxed. You see, I'm in remote work mode" (Dr9).

Some doctors who haven't yet tried it are also interested in this possibility. "I've never dared to do it yet. Apparently, it's quite straightforward. I haven't had the chance to do it yet. I'm not ruling it out. I might do it in the future" (Dr10).

Some doctors, like Doctor 3, also see an opportunity to regain lost patient proximity. "We're returning to what we knew at a certain time when the doctor was in the village, and patients went to see them when they were not feeling well. Due to societal evolution, the doctors can no longer be those people because it would mean we'd have no family life, right? But we are still in a way present at all times" (Dr3).
Patients' pathologies can also cause them to be remote. Doctors 2 and 3 mention that some patients, such as those with autism or agoraphobia, can still be seen if they can't leave their homes. "I know that if I don't accept for them teleconsultation, they'll never see a psychiatrist. So, it's better to keep a thin, maybe more artificial connection than if it were in an office, but at least keep a connection" (Dr2). "When it's a symptom like agoraphobia, we know these are complicated symptoms to stabilize. Just telling people to go outside doesn't always work well, and teleconsultation can indeed help maintain a connection. I feel it has defused more situations because people tended not to leave their homes at all, not come to appointments, and end up not getting treated." (Dr3)

Lastly, some situations might lead to switching an in-person consultation to a last-minute remote one. Patients doing so "tends to annoy me. at the same time, I still see them in consultation. So, it's quite handy". "I had a patient who was late and stuck in traffic. He was going to arrive, I think, 10 minutes before the appointment ended. And we thought, 'Well, we can do a teleconsultation.' This flexibility was useful. In this case, it's a downgrade. But I'd say a satisfactory downgrade" (Dr9).

This flexibility can be constrained by the context, like for Doctor 6, who only used this solution during the confinement period to continue following patients but rejected this solution otherwise.

### 4.2.6. Increased Doctor Availability

Using tools that streamline time-consuming or unrelated treatment tasks naturally lightens the workload and increases available consultation slots. Each doctor reported gaining availability thanks to digital tools. For example, Doctor 4 notes, "saving 5 minutes per consultation on the number of clicks, page loads, and the overall fluidity of the product." "Customizing and setting everything up has saved me an hour a day" (Dr5).

Motivated by personal needs like family life, these adaptations allow doctors with family responsibilities to continue offering consultations.

Women often highlighted the importance of teleconsultation for their family life, as shown by the following testimonials. "Whether I'm at my office or home, I can be very responsive and present without it intruding on my personal life. It allows me to do what I want, where I want. Thanks to full web access, I can take care of my children and I remain highly available to check a file when I have a patient on the phone" (Dr4). "Having online access, as a woman, is crucial. Being a doctor means constantly juggling our professional and family lives. I've always worked from home to some extent, which allowed me to come home earlier or be there for my children" (Dr5). "Teleconsultation is truly simple on Doctolib, and as women, we clearly need it, now more than ever" (Dr7).

Doctor 5 considers that, in general, "for [younger doctors], online software is a given. Having to go back to the office to turn on the computer and check a file is no longer viable". This leads to a routine that resembles telework: "when I'm not at my clinic, I can do video consultations" (Dr1), "Tuesday afternoons I'm at home doing teleconsultations. It's also very comfortable for me to be at home, relaxed. You see, I'm in remote work mode" (Dr9).

Some doctors who haven't yet tried it are also interested in this possibility. "I've never dared to do it yet. Apparently, it's quite straightforward. I haven't had the chance to do it yet. I'm not ruling it out. I might do it in the future" (Dr10).

Some doctors, like Doctor 3, also see an opportunity to regain lost patient proximity. "We're returning to what we knew at a certain time when the doctor was in the village, and patients went to see them when they were not feeling well. Due to societal evolution, the doctors can no longer be those people because it would mean we'd have no family life, right? But we are still in a way present at all times" (Dr3).
## 4.3. A Performative-Ostensive Feedback Loop Shaping Health Routines

While performative adaptations of medical practices are beneficial in many ways, the dynamic nature of routines also led to evolutions toward its ostensive aspects, introducing new constraints such as new regulations or changing patient expectations and behaviors.

### 1. Regulation tightening the reins for some digital solutions

The rapid adoption of teleconsultation following the COVID-19 crisis led to a significant increase in its use, especially in fields not requiring much physical clinical examination. Doctor 2 points out that psychiatry "isn't like cardiology or neurology. We don't need to examine our patients in the same way. So, it's bound to evolve a lot." "Currently, the regulation states we must limit the number of teleconsultations, setting a cap at 20% of all consultations" (Dr3). "Right now, we're in discussions with Social Security, which, at the end of 2022, sent us letters threatening severe penalties if we exceeded the 20% teleconsultation threshold across all patients. They wanted to forbid us from exceeding 20% teleconsultation, using arguments that aren't really valid in psychiatry. And now, unions are standing up to argue that teleconsultation makes sense in psychiatry" (Dr2). This is supported by Doctor 3, who notes that for distant patients discussed earlier, "if we had to stop teleconsultation or say 'Well, we only do 20%', it would mean stopping care, which wouldn't be good from a public health perspective."

#### 4.3.1. Technology as a Catalyst of preexisting patient behaviors...

Integrating these tools, leading to more flexibility and availability has also shifted patient expectations and behaviors. Such contextual evolution may then impact the performative dimension of the physicians' routine. Some doctors, like 3 and 4, report not being much affected by this. However, many physicians have noticed an evolution towards a consumerist approach to healthcare, with an attitude of "I come when I want, as often as I want" (Dr2). Thus, Doctor 3 talks about a "Click & Drive" behavior, and Doctor 9 about "Click & collect". Some attempts at explanation have emerged:

- **Too easy with online tools:** "The ease of making appointments can lead to impulsivity" (Dr3), "Cancelling an appointment through a secretary is harder on a human level than just clicking on a 'cancel' button" (Dr5).

- **A shift in mindsets:** "People are now used to immediate responses. That is, if there's no reply within 24 hours, there's irritation." (Dr5), "There's a bit of a Click & Collect culture. It's 'I cancel, it's not a big deal'." (Dr9),

- **Health as a consumer good:** "I feel like a McDonald's employee. You see, with patients coming in with lists. And several say, 'Anyway, you're here to do what I say, and that's it.' I had a case with a patient doing teleconsultations, not just with me, and was asking for repeated sick leaves." (Dr10)

This consumerist evolution can also manifest as disengagement in the care journey. "Making and canceling appointments is so simple that... I find patient commitment isn't always optimal. You have patients who can cancel their appointment the evening before for the next day" (Dr2). "Maybe [patients] take [the consultation] a bit more lightly" (Dr8). "This conflict between flexibility and too much flexibility, even disengagement, tends to annoy me. For example, when I have a patient who at the last minute says, 'Ah, I've got a cold' or 'I didn't wake up.' What annoys me the most is 'I woke up late. And I'm still groggy. Can we do a teleconsultation?'" (Dr9). "There are times - But then, is it due to the tool? Or is it due to the patient? - I'm thinking of the same situation where the patient has trouble... She woke up late, and she's doing the teleconsultation from her bed, lying down" (Dr10)

In addition, a problem that can aggravate caregiver saturation is overbooking. "I've seen several times, 10 appointments, even 2 a week." (Dr2). "Some [patients] would take two different slots
4.3. A Performative-Ostensive Feedback Loop Shaping Health Routines

While performative adaptations of medical practices are beneficial in many ways, the dynamic
nature of routines also led to evolutions toward its ostensive aspects, introducing new
constraints such as new regulations or changing patient expectations and behaviors.

1. **Regulation tightening the reins for some digital solutions**

The rapid adoption of teleconsultation following the COVID-19 crisis led to a significant increase in its use, especially in fields not requiring much physical clinical examination. Doctor 2 points out that psychiatry "isn't like cardiology or neurology. We don't need to examine our patients in the same way. So, it's bound to evolve a lot." "Currently, the regulation states we must limit the number of teleconsultations, setting a cap at 20% of all consultations" (Dr3). "Right now, we're in discussions with Social Security, which, at the end of 2022, sent us letters threatening severe penalties if we exceeded the 20% teleconsultation threshold across all patients. They wanted to forbid us from exceeding 20% teleconsultation, using arguments that aren't really valid in psychiatry. And now, unions are standing up to argue that teleconsultation makes sense in psychiatry" (Dr2). This is supported by Doctor 3, who notes that for distant patients discussed earlier, "if we had to stop teleconsultation or say 'Well, we only do 20%', it would mean stopping care, which wouldn't be good from a public health perspective."

4.3.1. **Technology as a Catalyst of preexisting patient behaviors...**

Integrating these tools, leading to more flexibility and availability has also shifted patient expectations and behaviors. Such contextual evolution may then impact the performative dimension of the physicians' routine. Some doctors, like 3 and 4, report not being much affected by this. However, many physicians have noticed an evolution towards a consumerist approach to healthcare, with an attitude of "I come when I want, as often as I want" (Dr2). Thus, Doctor 3 talks about a "Click & Drive" behavior, and Doctor 9 about "Click & collect". Some attempts at explanation have emerged:

- **Too easy with online tools:** "The ease of making appointments can lead to impulsivity" (Dr3), "Cancelling an appointment through a secretary is harder on a human level than just clicking on a 'cancel' button" (Dr5).

- **A shift in mindsets:** "People are now used to immediate responses. That is, if there's no reply within 24 hours, there's irritation." (Dr5), "There's a bit of a Click & Collect culture. It's 'I cancel, it's not a big deal'." (Dr9),

- **Health as a consumer good:** "I feel like a McDonald's employee. You see, with patients coming in with lists. And several say, 'Anyway, you're here to do what I say, and that's it.' I had a case with a patient doing teleconsultations, not just with me, and was asking for repeated sick leaves." (Dr10)

This consumerist evolution can also manifest as disengagement in the care journey. "Making and canceling appointments is so simple that... I find patient commitment isn't always optimal. You have patients who can cancel their appointment the evening before for the next day" (Dr2). "Maybe [patients] take [the consultation] a bit more lightly" (Dr8). "This conflict between flexibility and too much flexibility, even disengagement, tends to annoy me. For example, when I have a patient who at the last minute says, 'Ah, I've got a cold' or 'I didn't wake up.' What annoys me the most is 'I woke up late. And I'm still groggy. Can we do a teleconsultation?'" (Dr9). "There are times - But then, is it due to the tool? Or is it due to the patient? - I'm thinking of the same situation where the patient has trouble... She woke up late, and she's doing the teleconsultation from her bed, lying down" (Dr10)

In addition, a problem that can aggravate caregiver saturation is overbooking. "I've seen several
times, 10 appointments, even 2 a week." (Dr2). "Some [patients] would take two different slots
to have a choice of times" (Dr5); doctor 10 also typically mentions "the 'just in case'
appointment booking. Patients who make appointments on Friday evening for Monday thinking,
'I'm a bit sick, so I'll just book an appointment,' and cancel the consultation 3 hours before,
which sometimes can't be filled by another patient."

To address these evolutions, physicians make specific adjustments in their use of digital tools
and establish new organizational rules.

4.3.2. ... prompting doctors to establish internal rules.

As suggested in the previous section, these behaviors occasionally lead to performative
reactions. Specific rules were set to limit online first appointments, teleconsultation conditions,
and punctuality to effectively manage new behaviors.

Doctors 3, 5, 9, and 10 don't accept online bookings from new patients due to schedule saturation. All require either a call or an email (Dr3) or contacting the secretary (Dr5, Dr9, Dr10). Although not explicitly stated in interviews, this rule is unanimously shared by other interviewed doctors. Teleconsultation also has many instructions. For example, the first appointment must be in person unless in exceptional cases. Doctor 2 explains that "the quality of the connection is better when initiated in real life [...] it's mainly about establishing trust because you have intuition, contact, warmth, the empathetic aspect, right from the start." "I chose not to take new patients via video. I see all new patients in person" (Dr3). "I don't take new patients via teleconsultation. Because you need to know the patient. I need to physically know the patient to do a good job." (Dr4), "A rural patient we've never seen in person can't have a teleconsultation. Because it's our responsibility to diagnose correctly, you really need to have established a trustful in-person relationship" (Dr5). Exceptions were, of course, made during COVID, as reported by Doctors 2 and 3.

Patients' rules of conduct are also established. Doctor 5 illustrates this: "When people make teleconsultation appointments, there is indeed a small paragraph explaining that in certain situations, teleconsultation is not suitable." "We have to remind them that no, a consultation isn't while walking in the street. You need to sit down, be calm, quiet. And without anyone else nearby" (Dr8). "It's up to me to say 'No! we don't do teleconsultation when lying in bed.'"

The importance of occasional face-to-face consultations is also emphasized. "We still try to meet in person occasionally because seeing each other is important. We always have the option to block video appointments and encourage in-person meetings, but it becomes a tug of war." (Dr3), "It makes more sense to have someone physically present. It's makeshift by definition, so it can't be qualitative in the long run." (Dr4), "This is an occasional help for a patient. It's not a follow-up. There are people who ask for a lot of documents, but we never see them. At some point, you have to meet in person." (Dr5), "Once every 6 months I see them at the office, once every 6 months I don't mind doing a teleconsultation. Not all the time, but once out of 2, I can do it." (Dr10)

Non-compliance with rules can lead to sanctions. For example, Doctor 2 blocks patients who
overbook "when I've only allowed 2".

Penalties for sudden and unnotified cancellations often include being blacklisted, as Doctors 1, 2, 4, and 10 indicate they do. However, Doctor 10 notes the limitations of these measures, with patients creating multiple accounts to make new appointments.

4.3.3. Limitations in Using Certain Features or rejection.

Faced with challenges from new technologies, some doctors have chosen to limit or revert their
use of teleconsultation, as shown by Doctor 6, who stopped using teleconsultation after Covid-
19's confinement; doctor 2, facing cognitive overload, or Doctor 7 and 9, who had difficulties
in booking and setting appointments.
to have a choice of times" (Dr5); doctor 10 also typically mentions "the 'just in case'
appointment booking. Patients who make appointments on Friday evening for Monday thinking,
'I'm a bit sick, so I'll just book an appointment,' and cancel the consultation 3 hours before,
which sometimes can't be filled by another patient."

To address these evolutions, physicians make specific adjustments in their use of digital tools
and establish new organizational rules.

4.3.2. ... prompting doctors to establish internal rules.

As suggested in the previous section, these behaviors occasionally lead to performative
reactions. Specific rules were set to limit online first appointments, teleconsultation conditions,
and punctuality to effectively manage new behaviors.

Doctors 3, 5, 9, and 10 don't accept online bookings from new patients due to schedule saturation. All require either a call or an email (Dr3) or contacting the secretary (Dr5, Dr9, Dr10). Although not explicitly stated in interviews, this rule is unanimously shared by other interviewed doctors. Teleconsultation also has many instructions. For example, the first appointment must be in person unless in exceptional cases. Doctor 2 explains that "the quality of the connection is better when initiated in real life [...] it's mainly about establishing trust because you have intuition, contact, warmth, the empathetic aspect, right from the start." "I chose not to take new patients via video. I see all new patients in person" (Dr3). "I don't take new patients via teleconsultation. Because you need to know the patient. I need to physically know the patient to do a good job." (Dr4), "A rural patient we've never seen in person can't have a teleconsultation. Because it's our responsibility to diagnose correctly, you really need to have established a trustful in-person relationship" (Dr5). Exceptions were, of course, made during COVID, as reported by Doctors 2 and 3.

Patients' rules of conduct are also established. Doctor 5 illustrates this: "When people make teleconsultation appointments, there is indeed a small paragraph explaining that in certain situations, teleconsultation is not suitable." "We have to remind them that no, a consultation isn't while walking in the street. You need to sit down, be calm, quiet. And without anyone else nearby" (Dr8). "It's up to me to say 'No! we don't do teleconsultation when lying in bed.'"

The importance of occasional face-to-face consultations is also emphasized. "We still try to meet in person occasionally because seeing each other is important. We always have the option to block video appointments and encourage in-person meetings, but it becomes a tug of war." (Dr3), "It makes more sense to have someone physically present. It's makeshift by definition, so it can't be qualitative in the long run." (Dr4), "This is an occasional help for a patient. It's not a follow-up. There are people who ask for a lot of documents, but we never see them. At some point, you have to meet in person." (Dr5), "Once every 6 months I see them at the office, once every 6 months I don't mind doing a teleconsultation. Not all the time, but once out of 2, I can do it." (Dr10)

Non-compliance with rules can lead to sanctions. For example, Doctor 2 blocks patients who
overbook "when I've only allowed 2".

Penalties for sudden and unnotified cancellations often include being blacklisted, as Doctors 1, 2, 4, and 10 indicate they do. However, Doctor 10 notes the limitations of these measures, with patients creating multiple accounts to make new appointments.

4.3.3. Limitations in Using Certain Features or rejection.

Faced with challenges from new technologies, some doctors have chosen to limit or revert their
use of teleconsultation, as shown by Doctor 6, who stopped using teleconsultation after Covid-
19's confinement; doctor 2, facing cognitive overload, or Doctor 7 and 9, who had difficulties
in booking and setting appointments.
4.4. A digital artifact positioned at the crossroads, nurturing interactive dynamic of health routines.

The development of digital tools in healthcare is positioned at the interface between performative adaptations and ostensive requirements. At the same time, it balances doctors' expectations to ensure their loyalty, considering the contextual constraints in healthcare, while offering tools that will impact each of these two facets. It then constantly adjusts to the moving nature of health routines.

**4.4.1. Developments in Response to Physicians' Practice Needs**

The pressing need to meet doctors' specific requirements has pushed health platform providers to adopt a co-development approach. Doctors 4 and 5 have been involved in initial surveys by one of these software companies. "This software was built with doctors during its design phase, and they've continued to run working groups to evolve it based on doctors' needs." (Dr5). "I attended the very first meeting at their headquarters. They gathered practitioners from all specialties and organized a brainstorming session with their teams, asking us what good software looked like. The basics, like the homepage and what we expected from such software. They really started from scratch, and I was quite involved in these meetings. After that, I was one of the pioneers." (Dr4). This collaborative approach enables the customization and adaptation of tools based on direct user feedback. Most doctors report being regularly contacted by their software editor for feedback on their needs. "They are very responsive to satisfaction levels." (Dr5) "We regularly get short surveys by email, and you can tell the improvements are made thoughtfully. There's a partnership, after all, with appointment scheduling software, directly with medical software." (Dr10)

Over time, the software has evolved to meet their expectations increasingly. "In the beginning, we knew there were things that needed improvement. For example, initially, there were no weight or height charts, etc. They improved things step by step, and continue to improve." (Dr1). "They expanded very quickly and effectively for a new product. I was a beta tester for the initial version, which was far from perfect, but they made rapid progress" (Dr4). "Initially, there was a pioneer dynamic: we reported a need, and a few weeks later, the feature was added. It was wonderful. I saw real progress; every time we reported a difficulty or a need, it was immediately addressed. That was their strength in the beginning." (Dr5)

One software publisher, Doctolib, also established an online community of doctors to gather these needs and challenges. "They later set up a community to share ideas and difficulties." (Dr5), where they "can raise questions on a kind of doctors' forum." (Dr8)

While some doctors note a slowdown in responsiveness, they observe regular and useful updates to address their issues. "They don't listen to suggestions as much anymore. In the beginning, during the software's co-development and even at the very start, all feedback was considered. We talked about the software and suggested something, and a few weeks later, we saw it in the update. And that's much less true now; I've been using it since 2020, and it's been very difficult for the past 6 or 8 months. I think there are still many things to improve in the software. They shouldn't [rest on their laurels]." (Dr4) "Now, the pace [of innovations] is a bit slower, but in the first year, the progress was rapid." (Dr5) "Every month, they send an email to announce what they've implemented new." (Dr3) "[I see their willingness to improve and listen to practitioners]. At least, they are constantly evolving. And there are updates every day, sometimes several times a day." (Dr7)

This collaboration between technology developers and healthcare professionals ensures that the solutions implemented are technically viable and seamlessly integrated into medical workflows.

**4.4.2. Within an Ostensive Regulatory Framework**
## 4.4. A digital artifact positioned at the crossroads, nurturing interactive dynamic of health routines.

The development of digital tools in healthcare is positioned at the interface between performative adaptations and ostensive requirements. At the same time, it balances doctors' expectations to ensure their loyalty, considering the contextual constraints in healthcare, while offering tools that will impact each of these two facets. It then constantly adjusts to the moving nature of health routines.

### 4.4.1. Developments in Response to Physicians' Practice Needs

The pressing need to meet doctors' specific requirements has pushed health platform providers to adopt a co-development approach. Doctors 4 and 5 have been involved in initial surveys by one of these software companies. "This software was built with doctors during its design phase, and they've continued to run working groups to evolve it based on doctors' needs." (Dr5). "I attended the very first meeting at their headquarters. They gathered practitioners from all specialties and organized a brainstorming session with their teams, asking us what good software looked like. The basics, like the homepage and what we expected from such software. They really started from scratch, and I was quite involved in these meetings. After that, I was one of the pioneers." (Dr4). This collaborative approach enables the customization and adaptation of tools based on direct user feedback. Most doctors report being regularly contacted by their software editor for feedback on their needs. "They are very responsive to satisfaction levels." (Dr5) "We regularly get short surveys by email, and you can tell the improvements are made thoughtfully. There's a partnership, after all, with appointment scheduling software, directly with medical software." (Dr10)

Over time, the software has evolved to meet their expectations increasingly. "In the beginning, we knew there were things that needed improvement. For example, initially, there were no weight or height charts, etc. They improved things step by step, and continue to improve." (Dr1). "They expanded very quickly and effectively for a new product. I was a beta tester for the initial version, which was far from perfect, but they made rapid progress" (Dr4). "Initially, there was a pioneer dynamic: we reported a need, and a few weeks later, the feature was added. It was wonderful. I saw real progress; every time we reported a difficulty or a need, it was immediately addressed. That was their strength in the beginning." (Dr5)

One software publisher, Doctolib, also established an online community of doctors to gather these needs and challenges. "They later set up a community to share ideas and difficulties." (Dr5), where they "can raise questions on a kind of doctors' forum." (Dr8)

While some doctors note a slowdown in responsiveness, they observe regular and useful updates to address their issues. "They don't listen to suggestions as much anymore. In the beginning, during the software's co-development and even at the very start, all feedback was considered. We talked about the software and suggested something, and a few weeks later, we saw it in the update. And that's much less true now; I've been using it since 2020, and it's been very difficult for the past 6 or 8 months. I think there are still many things to improve in the software. They shouldn't [rest on their laurels]." (Dr4) "Now, the pace [of innovations] is a bit slower, but in the first year, the progress was rapid." (Dr5) "Every month, they send an email to announce what they've implemented new." (Dr3) "[I see their willingness to improve and listen to practitioners]. At least, they are constantly evolving. And there are updates every day, sometimes several times a day." (Dr7)

This collaboration between technology developers and healthcare professionals ensures that the solutions implemented are technically viable and seamlessly integrated into medical workflows.

### 4.4.2. Within an Ostensive Regulatory Framework
To be a certified health platform in France, a health software must meet several regulatory standards. As Doctor 1 reminds us, "data is shared. It's part of the 'Ségur de la santé'. There are certain requirements concerning the software you use. It must be able to tell you, for example, the proportion of your patients that had a visual examination, an auditory examination, or autism screening. It can display how many asthmatic children I requested functional respiratory explorations, etc. That's what the CPAM requires within the framework of OPTAM, I think. It's part of the software specifications that the publisher must comply with" (Dr1). These regulations have evolved over time, such as compatibility with the DMP imposed by Ségur 2. "My medical software was upgraded to Ségur 2. So, I'm directly connected to the DMP. Now, in addition to printing the prescription, I send it directly to the patient's DMP so there's a record of everything I do." (Dr10). Doctor 2 has the "impression that [software publishers] are trying to follow what the government and general health policies want closely, and to pool, coordinate, and ultimately connect everyone." Sometimes poorly explained, these changes can lead to misunderstandings, as Doctor 5 testified: "with the Ségur healthcare plan, we didn't quite understand the IT side of things. We had the impression of an acceleration without fully understanding the ins and outs."

This regulatory compliance ensures digital tools offer operational efficiency and adhere to legal and ethical standards essential for medical practice.

#### 4.4.3. Adapting Flexibility to Patient Behaviors...

In addition to physicians' performative adaptation, the software was adapted to consider new patient behavior and needs. "I believe they conducted studies showing a 90% reduction in unattended appointments" (Dr5). The software editors then introduced features such as appointment reminders, the ability to blacklist, and asking for explanations to curb cancellation behavior.

"They have a system that reminds them of the appointment the day before, by email and SMS. They can't ignore that they have an appointment with me." (Dr2) "When setting up the appointment, they receive a message 7 days before, and by email and on their mobile phone, then 48 hours before. So, to forget an appointment, you almost have to do it on purpose."

They also offered physicians some flexibility in configuration to limit the negative impact of such behavior, like the possibility of overbooking, as explained by Doctor 10. "I saw that you can add extra slots. That is, unfortunately, I happened to have up to 7 or 8 patients per day who didn't show up. So, I arranged for every hour to see 5 patients instead of 4. Actually, with this software, there's a trick that allows you to overbook your slots."

Digital solutions aim to enhance patient engagement and improve the care experience by recognizing and incorporating these behaviors into tool development. However, Doctor 10 reminds us that "patients always find a way to circumvent and take advantage of the tool" (Dr10).

#### 4.4.4. ...And Reactivity facing public health challenges.

Tools quickly adapted to meet urgent health challenges, such as the COVID-19 pandemic. "We saw a surge in teleconsultation with the lockdown, that's for sure. A real explosion during the lockdown. And Doctolib, in this case, was very responsive." (Dr10) This demanded effective tools for remote healthcare and visibility. "During the COVID period, they offered the possibility to use the teleconsultation option, which my other health software didn't have" (Dr3). This need for responsiveness is because malfunctions can lead to rejection. Doctor 6, who forcefully experienced the use of teleconsultation during the pandemic, used a free solution "a bit complicated and with many clicks, so a waste of time. Furthermore, an aspect that bothers me is the poor quality." Doctor 9 also notes that "while the digital tool is very good, it's still
To be a certified health platform in France, a health software must meet several regulatory standards. As Doctor 1 reminds us, "data is shared. It's part of the 'Ségur de la santé'. There are certain requirements concerning the software you use. It must be able to tell you, for example, the proportion of your patients that had a visual examination, an auditory examination, or autism screening. It can display how many asthmatic children I requested functional respiratory explorations, etc. That's what the CPAM requires within the framework of OPTAM, I think. It's part of the software specifications that the publisher must comply with" (Dr1). These regulations have evolved over time, such as compatibility with the DMP imposed by Ségur 2. "My medical software was upgraded to Ségur 2. So, I'm directly connected to the DMP. Now, in addition to printing the prescription, I send it directly to the patient's DMP so there's a record of everything I do." (Dr10). Doctor 2 has the "impression that [software publishers] are trying to follow what the government and general health policies want closely, and to pool, coordinate, and ultimately connect everyone." Sometimes poorly explained, these changes can lead to misunderstandings, as Doctor 5 testified: "with the Ségur healthcare plan, we didn't quite understand the IT side of things. We had the impression of an acceleration without fully understanding the ins and outs."

This regulatory compliance ensures digital tools offer operational efficiency and adhere to legal and ethical standards essential for medical practice.

#### 4.4.3. Adapting Flexibility to Patient Behaviors...

In addition to physicians' performative adaptation, the software was adapted to consider new patient behavior and needs. "I believe they conducted studies showing a 90% reduction in unattended appointments" (Dr5). The software editors then introduced features such as appointment reminders, the ability to blacklist, and asking for explanations to curb cancellation behavior.

"They have a system that reminds them of the appointment the day before, by email and SMS. They can't ignore that they have an appointment with me." (Dr2) "When setting up the appointment, they receive a message 7 days before, and by email and on their mobile phone, then 48 hours before. So, to forget an appointment, you almost have to do it on purpose."

They also offered physicians some flexibility in configuration to limit the negative impact of such behavior, like the possibility of overbooking, as explained by Doctor 10. "I saw that you can add extra slots. That is, unfortunately, I happened to have up to 7 or 8 patients per day who didn't show up. So, I arranged for every hour to see 5 patients instead of 4. Actually, with this software, there's a trick that allows you to overbook your slots."

Digital solutions aim to enhance patient engagement and improve the care experience by recognizing and incorporating these behaviors into tool development. However, Doctor 10 reminds us that "patients always find a way to circumvent and take advantage of the tool" (Dr10).

#### 4.4.4. ...And Reactivity facing public health challenges.

Tools quickly adapted to meet urgent health challenges, such as the COVID-19 pandemic. "We saw a surge in teleconsultation with the lockdown, that's for sure. A real explosion during the lockdown. And Doctolib, in this case, was very responsive." (Dr10) This demanded effective tools for remote healthcare and visibility. "During the COVID period, they offered the possibility to use the teleconsultation option, which my other health software didn't have" (Dr3). This need for responsiveness is because malfunctions can lead to rejection. Doctor 6, who forcefully experienced the use of teleconsultation during the pandemic, used a free solution "a bit complicated and with many clicks, so a waste of time. Furthermore, an aspect that bothers me is the poor quality." Doctor 9 also notes that "while the digital tool is very good, it's still
imperfect. Regularly, there are small lags or connection problems, or the image is not very good quality. So, we lose a lot compared to someone before us".

# 5. Discussion

## 5.1. Systemic and Evolving Nature of Health Routines

These changes in routines, as the model proposed by Feldman and Pentland (2003) shows, occur through a dialogue between what practitioners perceive as imposed in their many routines (ostensive) and how they decide to adjust the routine considering it (performative). These decisions may provoke ostensive reactions, such as new regulation of the cap on the percentage of teleconsultations or an increased perception of ethical matters such as the need for secure message exchanges. The context in which physicians exercise also affects their performative reaction. For instance, limited healthcare personnel availability in France or the digital divide may lead to reduce the use of online appointment features. These responses lead to adjustment loops, influenced by their impact on the practitioner, both in professional matters and personal, such as quality of life.

Feldman and Pentland (2008) and Labatut et al. (2012) suggest that technological artifacts impact both ostensive and performative dimensions. For example, the emergence of new tools such as health software and their features may impact patient or colleague actions and behaviors, inducting performative adjustment from the physicians. The health software is developed within a framework that considers regulatory changes (Ségur de la santé in France) and healthcare professionals' needs, with initial co-development strategies or ongoing interactions via calls or forums. Once patients adopt these tools, their behavior is positively or negatively affected. It may be their expectation for digital solutions for appointment bookings, consultations, or document transmission, such as prescriptions, remotely. These software and functionalities may also influence physicians' organizational capabilities regarding consultation flexibility, offered services, or co-expertise access.

The systemic nature between the artifact, the ostensive, and the practices makes medical routines dynamic. Each dimension can evolve spontaneously. For example, the rapid evolution of these tools, like the innovation pace claimed by France's leading health software, Doctolib. According to its leader in November 2023, "In the next twelve months, we will release more innovations than in the past ten years, including a messaging system, a cooperation tool among caregivers, an online patient registration tool, intelligent assistants for healthcare professionals, prevention tools, and the possibility to pay online." (Stanislas, 2023) This desire for regular innovation is illustrated by the recent integration of a feature that two of the interviewed physicians, doctors 4 and 5, regretted not having in early 2023. However, this was implemented a few months later, as Doctor 8 indicated allowing both parents to link their child to both accounts to receive documents and appointments. The interview with Doctolib's CEO also mentioned implementing artificial intelligence solutions, as Doctor 10 wished to help him in his everyday medical routine. Contextual elements like patient behaviors, healthcare partner behaviors, medical deserts, regulations, and the nature of pathologies can also evolve.

Due to the inertia in considering these evolutions and the fact that adaptation isn't immediate, some inertia in routine evolution can be expected. These delays, such as adapting tools to changes in performative and ostensive segments, can cause friction or frustration, potentially leading to disengagement in using these tools, as seen with Doctors 2 and 6. This can also give various actors time to anticipate routine changes to better support them.

## 5.2. Affordance et adoption

These software solutions fit well within the conceptual framework proposed by the theoretical model of Feldman and Pentland (2003), having a normalizing effect on certain care practices,
imperfect. Regularly, there are small lags or connection problems, or the image is not very good quality. So, we lose a lot compared to someone before us".

# 5. Discussion

## 5.1. Systemic and Evolving Nature of Health Routines

These changes in routines, as the model proposed by Feldman and Pentland (2003) shows, occur through a dialogue between what practitioners perceive as imposed in their many routines (ostensive) and how they decide to adjust the routine considering it (performative). These decisions may provoke ostensive reactions, such as new regulation of the cap on the percentage of teleconsultations or an increased perception of ethical matters such as the need for secure message exchanges. The context in which physicians exercise also affects their performative reaction. For instance, limited healthcare personnel availability in France or the digital divide may lead to reduce the use of online appointment features. These responses lead to adjustment loops, influenced by their impact on the practitioner, both in professional matters and personal, such as quality of life.

Feldman and Pentland (2008) and Labatut et al. (2012) suggest that technological artifacts impact both ostensive and performative dimensions. For example, the emergence of new tools such as health software and their features may impact patient or colleague actions and behaviors, inducting performative adjustment from the physicians. The health software is developed within a framework that considers regulatory changes (Ségur de la santé in France) and healthcare professionals' needs, with initial co-development strategies or ongoing interactions via calls or forums. Once patients adopt these tools, their behavior is positively or negatively affected. It may be their expectation for digital solutions for appointment bookings, consultations, or document transmission, such as prescriptions, remotely. These software and functionalities may also influence physicians' organizational capabilities regarding consultation flexibility, offered services, or co-expertise access.

The systemic nature between the artifact, the ostensive, and the practices makes medical routines dynamic. Each dimension can evolve spontaneously. For example, the rapid evolution of these tools, like the innovation pace claimed by France's leading health software, Doctolib. According to its leader in November 2023, "In the next twelve months, we will release more innovations than in the past ten years, including a messaging system, a cooperation tool among caregivers, an online patient registration tool, intelligent assistants for healthcare professionals, prevention tools, and the possibility to pay online." (Stanislas, 2023) This desire for regular innovation is illustrated by the recent integration of a feature that two of the interviewed physicians, doctors 4 and 5, regretted not having in early 2023. However, this was implemented a few months later, as Doctor 8 indicated allowing both parents to link their child to both accounts to receive documents and appointments. The interview with Doctolib's CEO also mentioned implementing artificial intelligence solutions, as Doctor 10 wished to help him in his everyday medical routine. Contextual elements like patient behaviors, healthcare partner behaviors, medical deserts, regulations, and the nature of pathologies can also evolve.

Due to the inertia in considering these evolutions and the fact that adaptation isn't immediate, some inertia in routine evolution can be expected. These delays, such as adapting tools to changes in performative and ostensive segments, can cause friction or frustration, potentially leading to disengagement in using these tools, as seen with Doctors 2 and 6. This can also give various actors time to anticipate routine changes to better support them.

## 5.2. Affordance et adoption

These software solutions fit well within the conceptual framework proposed by the theoretical model of Feldman and Pentland (2003), having a normalizing effect on certain care practices,
providing more autonomy for the patient and efficiency for the doctor, utilized in contexts such as the challenge of accessing healthcare professionals. However, there is an interesting difference from the model. If these tools become firmly embedded in routines, with real effects on health routines, patient expectations and behaviors in the general population, or regulation to impose administrative constraints, it remains possible for these doctors not to use these tools or certain of their functionalities. A physician is not obligated to use an online booking platform, to use it alone or with a secretary, nor to use teleconsultation solutions. The performative aspect here is not just in adapting the routine using the software but also in rejecting these tools or some of their functionalities. This presents an interesting parallel with the theory of affordances, where the technological artifact offers functionalities that may not necessarily be usable or perceived as useful, where the affordance presented by the tool is therefore not actualized (Anderson & Robey, 2017; Bernhard et al., 2013). Thapa and Sein (2018) emphasized the significance of the interaction between artifacts, user intentions, and socio-cultural contexts. This connection is also found in the theory of affordances when conceptualized as relational. Authors, such as Leonardi (2011, p. 163), already linked organizational routines to affordances, showing how "people draw on the infrastructure created out of past imbrications (routines or technologies) to construct perceptions of affordances". Similarly, Hazra and Priyo (2022) have proposed connections between affordances and other forms of routines (Routine Activity Theory).

An example of a non-usable affordance would be teleconsultation for practitioners whose practice involves physical contact with the patient requiring a face-to-face consultation. On the other hand, some practitioners may consider the use of the tool to have deleterious effects on the practice of care, such as Doctor 6, who prefers direct contact with patients to not miss out on information, or Doctor 7, who does not want to resort to autonomous patient appointment booking to avoid misdirections. Following previous work in affordance actualization in Digital Health (Islind et al., 2019; Thapa & Sein, 2018), this theory could help better understand the perception and actualization of affordance proposed by the digital artifact in a specific ostensive context. In a trial-error processual aspect, the liberal doctors may also have perceived at a time some features as very useful in their practice and quality of life and going back after experiencing unexpected border effects as explained by Docteur 9 for video consultation. These results are coherent with the same observations in adjacent contexts such as telework with companies initially prone to develop such practice, then going back after experiencing negative border effects on interpersonal interaction, social isolation, or loss of productivity or control over collaborators (Athanasiadou & Georgios, 2021)

The conducted interviews revealed specifics that could lead to the perception of affordance and the desire to actualize it. Doctor specialization can lead to different clinical needs for remote consultation tools, as seen in psychiatry, or to patient profiles unsuitable for these tools. Interviews touched on aspects like language barriers, with Doctors 1 and 7 noting, "Some patients, often non-French-speaking immigrants, need their family's or social services' assistance to make appointments." (Dr1) "Language and computer tool difficulties mainly occur with foreign patients, though most adapt well to using Doctolib." (Dr7). Generational divides also play a role, as Doctors 2 and 3 state, "Patients over 60 tend to make appointments traditionally, while the 18-40 age group prefers [online booking]." (Dr2) "There's a preference for traditional appointment-making methods among some of my older patients who don't use the internet." (Dr3)

The doctor's profile and affinity for digital technologies also may affect how they adopt tools. The interviews showed various adoption routines among doctors due to the gradual introduction of digital health management solutions. Historical literature has long noted that adoption rates match adopter profiles (Rogers, 2003) or perceived usefulness or ease of use related to tool complexity or past computing experiences (Venkatesh et al., 2003). The interviews highlighted
providing more autonomy for the patient and efficiency for the doctor, utilized in contexts such as the challenge of accessing healthcare professionals. However, there is an interesting difference from the model. If these tools become firmly embedded in routines, with real effects on health routines, patient expectations and behaviors in the general population, or regulation to impose administrative constraints, it remains possible for these doctors not to use these tools or certain of their functionalities. A physician is not obligated to use an online booking platform, to use it alone or with a secretary, nor to use teleconsultation solutions. The performative aspect here is not just in adapting the routine using the software but also in rejecting these tools or some of their functionalities. This presents an interesting parallel with the theory of affordances, where the technological artifact offers functionalities that may not necessarily be usable or perceived as useful, where the affordance presented by the tool is therefore not actualized (Anderson & Robey, 2017; Bernhard et al., 2013). Thapa and Sein (2018) emphasized the significance of the interaction between artifacts, user intentions, and socio-cultural contexts. This connection is also found in the theory of affordances when conceptualized as relational. Authors, such as Leonardi (2011, p. 163), already linked organizational routines to affordances, showing how "people draw on the infrastructure created out of past imbrications (routines or technologies) to construct perceptions of affordances". Similarly, Hazra and Priyo (2022) have proposed connections between affordances and other forms of routines (Routine Activity Theory).

An example of a non-usable affordance would be teleconsultation for practitioners whose practice involves physical contact with the patient requiring a face-to-face consultation. On the other hand, some practitioners may consider the use of the tool to have deleterious effects on the practice of care, such as Doctor 6, who prefers direct contact with patients to not miss out on information, or Doctor 7, who does not want to resort to autonomous patient appointment booking to avoid misdirections. Following previous work in affordance actualization in Digital Health (Islind et al., 2019; Thapa & Sein, 2018), this theory could help better understand the perception and actualization of affordance proposed by the digital artifact in a specific ostensive context. In a trial-error processual aspect, the liberal doctors may also have perceived at a time some features as very useful in their practice and quality of life and going back after experiencing unexpected border effects as explained by Docteur 9 for video consultation. These results are coherent with the same observations in adjacent contexts such as telework with companies initially prone to develop such practice, then going back after experiencing negative border effects on interpersonal interaction, social isolation, or loss of productivity or control over collaborators (Athanasiadou & Georgios, 2021).

The conducted interviews revealed specifics that could lead to the perception of affordance and the desire to actualize it. Doctor specialization can lead to different clinical needs for remote consultation tools, as seen in psychiatry, or to patient profiles unsuitable for these tools. Interviews touched on aspects like language barriers, with Doctors 1 and 7 noting, "Some patients, often non-French-speaking immigrants, need their family's or social services' assistance to make appointments." (Dr1) "Language and computer tool difficulties mainly occur with foreign patients, though most adapt well to using Doctolib." (Dr7). Generational divides also play a role, as Doctors 2 and 3 state, "Patients over 60 tend to make appointments traditionally, while the 18-40 age group prefers [online booking]." (Dr2) "There's a preference for traditional appointment-making methods among some of my older patients who don't use the internet." (Dr3)

The doctor's profile and affinity for digital technologies also may affect how they adopt tools. The interviews showed various adoption routines among doctors due to the gradual introduction of digital health management solutions. Historical literature has long noted that adoption rates match adopter profiles (Rogers, 2003) or perceived usefulness or ease of use related to tool complexity or past computing experiences (Venkatesh et al., 2003). The interviews highlighted
profiles of doctors with a strong appetite for technology who want to test the latest solutions, such as Doctors 1 and 10, which suggests they are innovators according to Rogers' theory.

Others, without an obvious passion for technology, quickly saw its usefulness, suggesting they are early adopters, like doctors 3, 4, and 5.

Some doctors used technology at an early majority level, with material use without specific commitment, like doctors 7, 8, or 9.

We also found some doctors who appreciated computers less, like doctors 6 and 2, who would only use it when truly useful, suggesting a late majority profile.

Finally, there are the laggard profiles that reject technology. Although not the target of this survey, none were interviewed, but the interviewees mentioned several colleagues fitting this profile. Notably, there is not necessarily a relationship with the practitioner's age.

Finally, an essential dimension related to philosophy, such as the importance of family life or personal ethical approaches to practicing medicine, is also notable.

"What this computerization allowed me from the start, and made me want to optimize and participate in, is that I picked up my children every day at 4:30 pm. I was always connected, but it allowed me to live that life." (Dr4) "Access was online. And that, as a woman, I'd say, is crucial. As a woman, being a doctor means we're constantly juggling our professional and family lives. I've always worked from home to some extent, allowing me to come home earlier or be there for my children." (Dr5) "What saves my life is that it allows me to practice the way I like. I'm from the intermediate generation, between the one that's coming now and the one beginning in the 80's, for example. Having the intense activity he could have was out of the question. It just wasn't compatible with the life I wanted to lead." (Dr4)

In conclusion, the artifact's role in the physician's health routines diverges somewhat from that of digital artifacts in other organizational routines. The significant position of the solutions they provide within a complex framework involving multiple actors in a highly innovative health sector makes them more of a distinct actor in the evolution of medical routines. Therefore, software editors occupy a role that can be likened to a health partner, as seen in the discourse of some interviewed physicians, affecting the quality of care and the quality of life of the various actors who adopt them, as well as public health in the environment where they are implemented. This increasingly prominent position will need to be analyzed more deeply than it has been previously, particularly in its systemic dimension with the other aspects of the medical routine presented in this article. The specific position of health software at the interface between the ostensive and performative dimensions of medical routines is particularly interesting. For example, it would be valuable for Health software editors to understand how they can position themselves to balance situations deemed difficult by other healthcare actors regarding the ostensive rules that may be imposed on them.

## 6. Theoretical Contribution of the Study

This study aims to apply Organizational Routine Theory to a specific population: liberal doctors dealing with explicit and implicit organizational rules. Initially focused on how routines are reproduced and adapted within a group, Organizational Routine Theory is built on three key pillars: ostensive aspects (such as plans, rules, and procedures), performative aspects (including actions, practices, and behaviors), and the artifacts that support these routines. Traditionally, this theory has been used in environments where routines are shared and collectively followed within structured organizations. However, this research extends its application to the specific field of liberal physicians. Although the practice of liberal medicine might seem to involve individual routines, closer examination reveals a more intricate and interconnected reality. This study considers the interactions with various key players in the healthcare journey (colleagues, institutions, regulation, patients) and technological artifacts (like health software), where the
profiles of doctors with a strong appetite for technology who want to test the latest solutions,
such as Doctors 1 and 10, which suggests they are innovators according to Rogers' theory.

Others, without an obvious passion for technology, quickly saw its usefulness, suggesting they
are early adopters, like doctors 3, 4, and 5.

Some doctors used technology at an early majority level, with material use without specific commitment, like doctors 7, 8, or 9.

We also found some doctors who appreciated computers less, like doctors 6 and 2, who would
only use it when truly useful, suggesting a late majority profile.

Finally, there are the laggard profiles that reject technology. Although not the target of this
survey, none were interviewed, but the interviewees mentioned several colleagues fitting this
profile. Notably, there is not necessarily a relationship with the practitioner's age.

Finally, an essential dimension related to philosophy, such as the importance of family life or
personal ethical approaches to practicing medicine, is also notable.

"What this computerization allowed me from the start, and made me want to optimize and participate in, is that I picked up my children every day at 4:30 pm. I was always connected, but it allowed me to live that life." (Dr4) "Access was online. And that, as a woman, I'd say, is crucial. As a woman, being a doctor means we're constantly juggling our professional and family lives. I've always worked from home to some extent, allowing me to come home earlier or be there for my children." (Dr5) "What saves my life is that it allows me to practice the way I like. I'm from the intermediate generation, between the one that's coming now and the one beginning in the 80's, for example. Having the intense activity he could have was out of the question. It just wasn't compatible with the life I wanted to lead." (Dr4)

In conclusion, the artifact's role in the physician's health routines diverges somewhat from that
of digital artifacts in other organizational routines. The significant position of the solutions they
provide within a complex framework involving multiple actors in a highly innovative health
sector makes them more of a distinct actor in the evolution of medical routines. Therefore,
software editors occupy a role that can be likened to a health partner, as seen in the discourse
of some interviewed physicians, affecting the quality of care and the quality of life of the various
actors who adopt them, as well as public health in the environment where they are implemented.
This increasingly prominent position will need to be analyzed more deeply than it has been
previously, particularly in its systemic dimension with the other aspects of the medical routine
presented in this article. The specific position of health software at the interface between the
ostensive and performative dimensions of medical routines is particularly interesting. For
example, it would be valuable for Health software editors to understand how they can position
themselves to balance situations deemed difficult by other healthcare actors regarding the
ostensive rules that may be imposed on them.

**6. Theoretical Contribution of the Study**

This study aims to apply Organizational Routine Theory to a specific population: liberal doctors dealing with explicit and implicit organizational rules. Initially focused on how routines are reproduced and adapted within a group, Organizational Routine Theory is built on three key pillars: ostensive aspects (such as plans, rules, and procedures), performative aspects (including actions, practices, and behaviors), and the artifacts that support these routines. Traditionally, this theory has been used in environments where routines are shared and collectively followed within structured organizations. However, this research extends its application to the specific field of liberal physicians. Although the practice of liberal medicine might seem to involve individual routines, closer examination reveals a more intricate and interconnected reality. This study considers the interactions with various key players in the healthcare journey (colleagues, institutions, regulation, patients) and technological artifacts (like health software), where the
routines of liberal physicians are not isolated but deeply embedded in a network of interdependencies and mutual influences. Using Organizational Routine Theory to understand routines in healthcare, this study underscores the role of technological artifacts and professional interactions and specificities in shaping and evolving routines. Initially, we clarified Organizational Routine Theory, focusing on the important concepts of ostensive (the ideal or typical pattern of a routine) and performative (the actual enactment of a routine) aspects and the impact of digital artifacts on these. We then examined how rules, ethics, and digital environments may influence their routines despite the physician's independence from institutional guidelines like those in hospitals or clinics. Our research encompasses various elements such as medical fields, patient backgrounds, medical methods, and ethics to understand how these factors shape routines. This new application of the theory offers fresh insights into the diversity of medical practices and the growing integration of digital tools in these routines.

## 7. Implications for Practitioners and Policymakers

Explaining the complex and evolving nature of healthcare routines and the impact of digital tools on them is helpful for public health regulators. A deeper understanding of the challenges faced by liberal doctors can lead to more effective regulations. Without this insight, regulations might not fully utilize these tools to improve healthcare aspects like reducing appointment waiting times or managing chronic diseases.

This article is also valuable for health software editors as it offers a framework showing how health software impacts the work of liberal doctors. It guides the creation of software features and products that align with the ways doctors adopt new routines. The study shows the specific needs and challenges faced by independent doctors. It highlights the importance of considering formal rules and actual medical practices in software design, leading to more effective and user-friendly products. It also emphasizes the need for software editors to be aware of the importance of their positioning as a health actor in health practice and the well-being of doctors.

another dimension raised by this research and the testimonies of certain doctors is the need for tailored software solutions. Indeed, a common issue among many doctors is dissatisfaction with paying for software features they do not use. By understanding the diverse ways in which doctors adopt routines, developers can create more flexible and customizable software. This approach meets the varied needs of the medical community, enhancing overall satisfaction.

In conclusion, this research provides theoretical insights and practical guidance for health software developers and public health policymakers. It aims to bridge the gap between theory and practice, facilitating the development of improved digital health solutions that benefit public health and patient care.

## 8. Limitations

This study has several limitations. The first is the small number of liberal doctors interviewed, mainly due to their busy schedules and the shortage of physicians in France. Since only the aspect of the organizational routine explicitly expressed by interviewed physicians was used, the limited number does not fully capture the wide picture of liberal organizational routines. Expanding this research to include more physicians with diverse backgrounds, like digital literacy, length of practice, or specialty, would help better understand the dynamics leading to specific routine adoption.

A second limitation is the use of qualitative analysis methods. While this approach enabled exploratory analysis and helped validate the use of organizational routines theory to understand organizational dynamics, it lacks the ability to generalize findings. Adding quantitative analysis
routines of liberal physicians are not isolated but deeply embedded in a network of interdependencies and mutual influences. Using Organizational Routine Theory to understand routines in healthcare, this study underscores the role of technological artifacts and professional interactions and specificities in shaping and evolving routines. Initially, we clarified Organizational Routine Theory, focusing on the important concepts of ostensive (the ideal or typical pattern of a routine) and performative (the actual enactment of a routine) aspects and the impact of digital artifacts on these. We then examined how rules, ethics, and digital environments may influence their routines despite the physician's independence from institutional guidelines like those in hospitals or clinics. Our research encompasses various elements such as medical fields, patient backgrounds, medical methods, and ethics to understand how these factors shape routines. This new application of the theory offers fresh insights into the diversity of medical practices and the growing integration of digital tools in these routines.

## 7. Implications for Practitioners and Policymakers

Explaining the complex and evolving nature of healthcare routines and the impact of digital tools on them is helpful for public health regulators. A deeper understanding of the challenges faced by liberal doctors can lead to more effective regulations. Without this insight, regulations might not fully utilize these tools to improve healthcare aspects like reducing appointment waiting times or managing chronic diseases.

This article is also valuable for health software editors as it offers a framework showing how health software impacts the work of liberal doctors. It guides the creation of software features and products that align with the ways doctors adopt new routines. The study shows the specific needs and challenges faced by independent doctors. It highlights the importance of considering formal rules and actual medical practices in software design, leading to more effective and user-friendly products. It also emphasizes the need for software editors to be aware of the importance of their positioning as a health actor in health practice and the well-being of doctors.

another dimension raised by this research and the testimonies of certain doctors is the need for tailored software solutions. Indeed, a common issue among many doctors is dissatisfaction with paying for software features they do not use. By understanding the diverse ways in which doctors adopt routines, developers can create more flexible and customizable software. This approach meets the varied needs of the medical community, enhancing overall satisfaction.

In conclusion, this research provides theoretical insights and practical guidance for health software developers and public health policymakers. It aims to bridge the gap between theory and practice, facilitating the development of improved digital health solutions that benefit public health and patient care.

## 8. Limitations

This study has several limitations. The first is the small number of liberal doctors interviewed, mainly due to their busy schedules and the shortage of physicians in France. Since only the aspect of the organizational routine explicitly expressed by interviewed physicians was used, the limited number does not fully capture the wide picture of liberal organizational routines. Expanding this research to include more physicians with diverse backgrounds, like digital literacy, length of practice, or specialty, would help better understand the dynamics leading to specific routine adoption.

A second limitation is the use of qualitative analysis methods. While this approach enabled exploratory analysis and helped validate the use of organizational routines theory to understand organizational dynamics, it lacks the ability to generalize findings. Adding quantitative analysis
with a larger group of physicians could identify patterns and specifics for different healthcare professions.

A third limitation is the recent large-scale adoption of certain technologies. The dynamic nature of routines, shaped by a trial-and-error process, may require more time for physicians to establish their preferred practices. A longitudinal study of these evolving practices would be valuable.

## References

Anderson, C., & Robey, D. (2017). Affordance potency: Explaining the actualization of technology affordances. *Information and Organization, 27*(2), 100-115.
https://doi.org/10.1016/j.infoandorg.2017.03.002

Athanasiadou, C., & Georgios, T. (2021). Telework: Systematic Literature Review and Future Research Agenda. *Heliyon, 7*, e08165. https://doi.org/10.1016/j.heliyon.2021.e08165

Avgerou, C. (2023). Digital development: Stories of hope from health and social development. *Information Systems Journal, 33*(4), 986-987. Complementary Index.
https://doi.org/10.1111/isj.12432

Bernhard, E., Recker, J., & Burton-Jones, A. (2013). *Understanding the Actualization of Affordances: A Study in the Process Modeling Context*. 5.

D'Adderio, L. (2008). The Performativity of Routines: Theorising the Influence of Artefacts and Distributed Agencies on Routines Dynamics. *Research Policy, 37*, 769-789.
https://doi.org/10.2139/ssrn.1309622

Dosi, G., Teece, D., & Winter, S. (1990). Les frontières des entreprises: Vers une théorie de la cohérence de la grande entreprise. *Revue d'Économie Industrielle, 51*, 238-254.
https://doi.org/10.3406/rei.1990.1315

Eldh, A., Arestedt, L., & Berterö, C. (2020). Quotations in Qualitative Studies: Reflections on Constituents, Custom, and Purpose. *The International Journal of Qualitative Methods, 19*. https://doi.org/10.1177/1609406920969268

Feldman, M. (2000). Organizational Routines as a Source of Continuous Change. *Organization Science - ORGAN SCI, 11*, 611-629. https://doi.org/10.1287/orsc.11.6.611.12529

Feldman, M. S., & Pentland, B. T. (2003). Reconceptualizing Organizational Routines as a Source of Flexibility and Change. *Administrative Science Quarterly, 48*(1), 94-118.
https://doi.org/10.2307/3556620

Hazra, U., & Priyo, A. K. K. (2022). Unethical practices in online classes during COVID-19 pandemic: An analysis of affordances using routine activity theory. *Journal of Information, Communication & Ethics in Society, 20*(4), 546-567.
https://doi.org/10.1108/JICES-10-2021-0102

Howard-Grenville, J. (2005). The Persistence of Flexible Organizational Routines: The Role of Agency and Organizational Context. *Organization Science, 16*, 618-636.
https://doi.org/10.1287/orsc.1050.0150

Islind, A. S., Snis, U. L., Lindroth, T., Lundin, J., Cerna, K., & Steineck, G. (2019). The Virtual Clinic: Two-sided Affordances in Consultation Practice. *Computer Supported Cooperative Work (CSCW), 28*(3), 435-468. https://doi.org/10.1007/s10606-019-09350-3

Labatut, J., Aggeri, F., & Girard, N. (2012). Discipline and Change: How Technologies and Organizational Routines Interact in New Practice Creation. *Organization Studies, 33*(1), 39-69. https://doi.org/10.1177/0170840611430589
with a larger group of physicians could identify patterns and specifics for different healthcare professions.

A third limitation is the recent large-scale adoption of certain technologies. The dynamic nature of routines, shaped by a trial-and-error process, may require more time for physicians to establish their preferred practices. A longitudinal study of these evolving practices would be valuable.

## References

Anderson, C., & Robey, D. (2017). Affordance potency: Explaining the actualization of technology affordances. *Information and Organization, 27*(2), 100-115.
https://doi.org/10.1016/j.infoandorg.2017.03.002

Athanasiadou, C., & Georgios, T. (2021). Telework: Systematic Literature Review and Future Research Agenda. *Heliyon, 7*, e08165. https://doi.org/10.1016/j.heliyon.2021.e08165

Avgerou, C. (2023). Digital development: Stories of hope from health and social development. *Information Systems Journal, 33*(4), 986-987. Complementary Index.
https://doi.org/10.1111/isj.12432

Bernhard, E., Recker, J., & Burton-Jones, A. (2013). *Understanding the Actualization of Affordances: A Study in the Process Modeling Context*. 5.

D'Adderio, L. (2008). The Performativity of Routines: Theorising the Influence of Artefacts and Distributed Agencies on Routines Dynamics. *Research Policy, 37*, 769-789.
https://doi.org/10.2139/ssrn.1309622

Dosi, G., Teece, D., & Winter, S. (1990). Les frontières des entreprises: Vers une théorie de la cohérence de la grande entreprise. *Revue d'Économie Industrielle, 51*, 238-254.
https://doi.org/10.3406/rei.1990.1315

Eldh, A., Arestedt, L., & Berterö, C. (2020). Quotations in Qualitative Studies: Reflections on Constituents, Custom, and Purpose. *The International Journal of Qualitative Methods, 19*. https://doi.org/10.1177/1609406920969268

Feldman, M. (2000). Organizational Routines as a Source of Continuous Change. *Organization Science - ORGAN SCI, 11*, 611-629. https://doi.org/10.1287/orsc.11.6.611.12529

Feldman, M. S., & Pentland, B. T. (2003). Reconceptualizing Organizational Routines as a Source of Flexibility and Change. *Administrative Science Quarterly, 48*(1), 94-118.
https://doi.org/10.2307/3556620

Hazra, U., & Priyo, A. K. K. (2022). Unethical practices in online classes during COVID-19 pandemic: An analysis of affordances using routine activity theory. *Journal of Information, Communication & Ethics in Society, 20*(4), 546-567.
https://doi.org/10.1108/JICES-10-2021-0102

Howard-Grenville, J. (2005). The Persistence of Flexible Organizational Routines: The Role of Agency and Organizational Context. *Organization Science, 16*, 618-636.
https://doi.org/10.1287/orsc.1050.0150

Islind, A. S., Snis, U. L., Lindroth, T., Lundin, J., Cerna, K., & Steineck, G. (2019). The Virtual Clinic: Two-sided Affordances in Consultation Practice. *Computer Supported Cooperative Work (CSCW), 28*(3), 435-468. https://doi.org/10.1007/s10606-019-09350-3

Labatut, J., Aggeri, F., & Girard, N. (2012). Discipline and Change: How Technologies and Organizational Routines Interact in New Practice Creation. *Organization Studies, 33*(1), 39-69. https://doi.org/10.1177/0170840611430589
Leonardi, P. (2011). When Flexible Routines Meet Flexible Technologies: Affordance, Constraint, and the Imbrication of Human and Material Agencies. *MIS Quarterly*, 35(1), Article 1. https://doi.org/10.2307/23043493

Leonardi, P. M., & Barley, S. R. (2008). Materiality and change : Challenges to building better theory about technology and organizing. *Information and Organization*, 18(3), 159-176. https://doi.org/10.1016/j.infoandorg.2008.03.001

Nelson, R. R., & Winter, S. G. (1982). *An Evolutionary Theory of Economic Change*. Belknap Press: An Imprint of Harvard University Press.

Ologeanu-Taddei, R., Guthrie, C., & Blegind Jensen, T. (2023). Digital transformation of professional healthcare practices: Fitness seeking across a rugged value landscape. *European Journal of Information Systems*, 32, 1-18. https://doi.org/10.1080/0960085X.2023.2165978

Pentland, B., & Feldman, M. (2005). Organizational Routines as a Unit of Analysis. *Industrial and Corporate Change*, 14, 793-815. https://doi.org/10.1093/icc/dth070

Pentland, B., & Feldman, M. (2008). Designing Routines: On the Folly of Designing Artifacts, while Hoping for Patterns of Action. *Information and Organization*, 18, 235-250. https://doi.org/10.1016/j.infoandorg.2008.08.001

Pentland, B., Feldman, M., Becker, M., & Liu, P. (2012). Dynamics of Organizational Routines: A Generative Model. *Journal of Management Studies*, 49. https://doi.org/10.1111/j.1467-6486.2012.01064.x

Pentland, B., & Rueter, H. (1994). Organizational Routines as Grammars of Action. *Administrative Science Quarterly*, 39, 484. https://doi.org/10.2307/2393300

Reynaud, B. (2001). « Suivre des règles » dans les organisations. *Revue d'Économie Industrielle*, 97, 53-68. https://doi.org/10.3406/rei.2001.1799

Rogers, E. M. (2003). *Diffusion of Innovations, 5th Edition* (5th edition). Free Press.

Simon, H. A. (1991). Bounded Rationality and Organizational Learning. *Organization Science*, 2(1), 125-134. https://doi.org/10.1287/orsc.2.1.125

Stanislas, N.-C. (2023, novembre 18). *Messagerie soignants-patients, paiement, design... : Le patron de Doctolib dévoile ce qui va changer* [Ouest-France]. https://www.ouest-france.fr/sante/messagerie-soignants-patients-paiement-design-le-patron-de-doctolib-devoile-ce-qui-va-changer-0cba26a0-83fe-11ee-9b65-2282e6d4bdd9

Sykes, T. A., & Aljafari, R. (2022). We Are All in This Together, or Are We? Job Strain and Coping in the Context of an E-Healthcare System Implementation. *Journal of Management Information Systems*, 39(4), 1215-1247. Business Source Complete. https://doi.org/10.1080/07421222.2022.2127450

Tan, H., Zhang, X., & Yang, Y. (2023). Satisfaction or gratitude? Exploring the disparate effects of physicians' knowledge sharing on patients' service evaluation in online medical consultations. *Information Systems Journal*, 1. Business Source Complete. https://doi.org/10.1111/isj.12440

Thapa, D., & Sein, M. K. (2018). Trajectory of Affordances: Insights from a case of telemedicine in Nepal. *Information Systems Journal*, 28(5), 796-817. https://doi.org/10.1111/isj.12160

van Offenbeek, M. A. G., Vos, J. F. J., & Boonstra, A. (2023). Understanding variation in subunit adoption of electronic health records: Facilitating and constraining configurations of critical dependencies. *European Journal of Information Systems*, 1-23. Business Source Complete. https://doi.org/10.1080/0960085x.2023.2225786
Leonardi, P. (2011). When Flexible Routines Meet Flexible Technologies: Affordance, Constraint, and the Imbrication of Human and Material Agencies. *MIS Quarterly*, 35(1), Article 1. https://doi.org/10.2307/23043493

Leonardi, P. M., & Barley, S. R. (2008). Materiality and change : Challenges to building better theory about technology and organizing. *Information and Organization*, 18(3), 159-176. https://doi.org/10.1016/j.infoandorg.2008.03.001

Nelson, R. R., & Winter, S. G. (1982). *An Evolutionary Theory of Economic Change*. Belknap Press: An Imprint of Harvard University Press.

Ologeanu-Taddei, R., Guthrie, C., & Blegind Jensen, T. (2023). Digital transformation of professional healthcare practices: Fitness seeking across a rugged value landscape. *European Journal of Information Systems*, 32, 1-18. https://doi.org/10.1080/0960085X.2023.2165978

Pentland, B., & Feldman, M. (2005). Organizational Routines as a Unit of Analysis. *Industrial and Corporate Change*, 14, 793-815. https://doi.org/10.1093/icc/dth070

Pentland, B., & Feldman, M. (2008). Designing Routines: On the Folly of Designing Artifacts, while Hoping for Patterns of Action. *Information and Organization*, 18, 235-250. https://doi.org/10.1016/j.infoandorg.2008.08.001

Pentland, B., Feldman, M., Becker, M., & Liu, P. (2012). Dynamics of Organizational Routines: A Generative Model. *Journal of Management Studies*, 49. https://doi.org/10.1111/j.1467-6486.2012.01064.x

Pentland, B., & Rueter, H. (1994). Organizational Routines as Grammars of Action. *Administrative Science Quarterly*, 39, 484. https://doi.org/10.2307/2393300

Reynaud, B. (2001). « Suivre des règles » dans les organisations. *Revue d'Économie Industrielle*, 97, 53-68. https://doi.org/10.3406/rei.2001.1799

Rogers, E. M. (2003). *Diffusion of Innovations, 5th Edition* (5th edition). Free Press.

Simon, H. A. (1991). Bounded Rationality and Organizational Learning. *Organization Science*, 2(1), 125-134. https://doi.org/10.1287/orsc.2.1.125

Stanislas, N.-C. (2023, novembre 18). *Messagerie soignants-patients, paiement, design... : Le patron de Doctolib dévoile ce qui va changer* [Ouest-France]. https://www.ouest-france.fr/sante/messagerie-soignants-patients-paiement-design-le-patron-de-doctolib-devoile-ce-qui-va-changer-0cba26a0-83fe-11ee-9b65-2282e6d4bdd9

Sykes, T. A., & Aljafari, R. (2022). We Are All in This Together, or Are We? Job Strain and Coping in the Context of an E-Healthcare System Implementation. *Journal of Management Information Systems*, 39(4), 1215-1247. Business Source Complete. https://doi.org/10.1080/07421222.2022.2127450

Tan, H., Zhang, X., & Yang, Y. (2023). Satisfaction or gratitude? Exploring the disparate effects of physicians' knowledge sharing on patients' service evaluation in online medical consultations. *Information Systems Journal*, 1. Business Source Complete. https://doi.org/10.1111/isj.12440

Thapa, D., & Sein, M. K. (2018). Trajectory of Affordances: Insights from a case of telemedicine in Nepal. *Information Systems Journal*, 28(5), 796-817. https://doi.org/10.1111/isj.12160

van Offenbeek, M. A. G., Vos, J. F. J., & Boonstra, A. (2023). Understanding variation in subunit adoption of electronic health records: Facilitating and constraining configurations of critical dependencies. *European Journal of Information Systems*, 1-23. Business Source Complete. https://doi.org/10.1080/0960085x.2023.2225786
Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User Acceptance of Information Technology: Toward a Unified View. *MIS Quarterly*, 27(3), 425-478.
https://doi.org/10/gc8zn2

Yeongin Kim, Ayvaci, M. U. S., Raghunathan, S., & Ayer, T. (2022). When It Creates Legal Vulnerability: Not Just Overutilization but Underprovisioning of Health Care Could Be a Consequence. *MIS Quarterly*, 46(3), 1483-1515. Supplemental Index.

# Appendix

## Appendix A. List of interviews

<table><thead><tr><td></td><td>Speciality</td><td>Liberal since</td><td>Gender</td><td>Adopter</td></tr></thead><tbody><tr><td>Doctor 1</td><td>pediatrician</td><td>1984</td><td>Male</td><td>Innovator</td></tr><tr><td>Doctor 2</td><td>Psychiatrist</td><td>2017</td><td>Female</td><td>Late Majority</td></tr><tr><td>Doctor 3</td><td>Psychiatrist</td><td>2016</td><td>Male</td><td>Early Addopter</td></tr><tr><td>Doctor 4</td><td>pediatrician</td><td>2006</td><td>Female</td><td>Early Addopter</td></tr><tr><td>Doctor 5</td><td>pediatrician</td><td>1999</td><td>Female</td><td>Early Addopter</td></tr><tr><td>Doctor 6</td><td>pediatrician</td><td>2007</td><td>Male</td><td>Late Majority</td></tr><tr><td>Doctor 7</td><td>pediatrician</td><td>2019</td><td>Female</td><td>Early Majority</td></tr><tr><td>Doctor 8</td><td>Pedo-Psychiatrist</td><td>2016</td><td>Female</td><td>Early Majority</td></tr><tr><td>Doctor 9</td><td>Psychiatrist</td><td>2018</td><td>Male</td><td>Early Majority</td></tr><tr><td>Doctor 10</td><td>Generalist</td><td>2020</td><td>Male</td><td>Innovator</td></tr></tbody></table>

## Appendix B. examples of coding

<table><thead><tr><td>Quotes</td><td>Routine dimension</td><td>Routine impacted</td></tr></thead><tbody><tr><td>We're in talks with Social Security, who [...] sent us letters threatening us with the worst punishments if we exceed the 20% threshold for teleconsultations.</td><td>ostensive</td><td>consultation</td></tr><tr><td>I think they're also trying to secure exchanges, because everything is encrypted [...] which allowed us to eliminate our office email box.</td><td>ostensive</td><td>doc management</td></tr><tr><td>Patients complain that there aren't enough appointments and that I can't see them often enough, but it has nothing to do with the schedule. It's just that we don't have enough psychiatrists in France.</td><td>ostensive</td><td>Appointment</td></tr><tr><td>I almost adjust from one day to the next. Because, with the online scheduling setup, when I see certain patients, I know communication is rapid.</td><td>performative</td><td>Appointment</td></tr><tr><td>If I need a clinical examination with consultations, I reschedule fairly quickly. [after a teleconsultation that requires an examination]</td><td>performative</td><td>consultation</td></tr><tr><td>Whether I'm at my office or at home, I can be very reactive and very present without it encroaching on my personal life.</td><td>performative</td><td>consultation</td></tr></tbody></table>
Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User Acceptance of Information Technology: Toward a Unified View. *MIS Quarterly*, 27(3), 425-478.
https://doi.org/10/gc8zn2

Yeongin Kim, Ayvaci, M. U. S., Raghunathan, S., & Ayer, T. (2022). When It Creates Legal Vulnerability: Not Just Overutilization but Underprovisioning of Health Care Could Be a Consequence. *MIS Quarterly*, 46(3), 1483-1515. Supplemental Index.

# Appendix

## Appendix A. List of interviews

<table><thead><tr><td></td><td>Speciality</td><td>Liberal since</td><td>Gender</td><td>Adopter</td></tr></thead><tbody><tr><td>Doctor 1</td><td>pediatrician</td><td>1984</td><td>Male</td><td>Innovator</td></tr><tr><td>Doctor 2</td><td>Psychiatrist</td><td>2017</td><td>Female</td><td>Late Majority</td></tr><tr><td>Doctor 3</td><td>Psychiatrist</td><td>2016</td><td>Male</td><td>Early Addopter</td></tr><tr><td>Doctor 4</td><td>pediatrician</td><td>2006</td><td>Female</td><td>Early Addopter</td></tr><tr><td>Doctor 5</td><td>pediatrician</td><td>1999</td><td>Female</td><td>Early Addopter</td></tr><tr><td>Doctor 6</td><td>pediatrician</td><td>2007</td><td>Male</td><td>Late Majority</td></tr><tr><td>Doctor 7</td><td>pediatrician</td><td>2019</td><td>Female</td><td>Early Majority</td></tr><tr><td>Doctor 8</td><td>Pedo-Psychiatrist</td><td>2016</td><td>Female</td><td>Early Majority</td></tr><tr><td>Doctor 9</td><td>Psychiatrist</td><td>2018</td><td>Male</td><td>Early Majority</td></tr><tr><td>Doctor 10</td><td>Generalist</td><td>2020</td><td>Male</td><td>Innovator</td></tr></tbody></table>

## Appendix B. examples of coding

<table><thead><tr><td>Quotes</td><td>Routine dimension</td><td>Routine impacted</td></tr></thead><tbody><tr><td>We're in talks with Social Security, who [...] sent us letters threatening us with the worst punishments if we exceed the 20% threshold for teleconsultations.</td><td>ostensive</td><td>consultation</td></tr><tr><td>I think they're also trying to secure exchanges, because everything is encrypted [...] which allowed us to eliminate our office email box.</td><td>ostensive</td><td>doc management</td></tr><tr><td>Patients complain that there aren't enough appointments and that I can't see them often enough, but it has nothing to do with the schedule. It's just that we don't have enough psychiatrists in France.</td><td>ostensive</td><td>Appointment</td></tr><tr><td>I almost adjust from one day to the next. Because, with the online scheduling setup, when I see certain patients, I know communication is rapid.</td><td>performative</td><td>Appointment</td></tr><tr><td>If I need a clinical examination with consultations, I reschedule fairly quickly. [after a teleconsultation that requires an examination]</td><td>performative</td><td>consultation</td></tr><tr><td>Whether I'm at my office or at home, I can be very reactive and very present without it encroaching on my personal life.</td><td>performative</td><td>consultation</td></tr></tbody></table>
<table><tr><td>I also have paper files. I'm at the crossroads, half modern and half traditional.</td><td>performative</td><td>doc management</td></tr></table>

## Appendix C. Software adoption by physician

<table><thead><tr><th></th><th>consultation software</th><th>online agenda</th><th>teleconsultation</th><th>tele expertise</th></tr></thead><tbody><tr><td>Doctor 1</td><td>1995 (axisanté) then doctolib (2017)</td><td>2017 Mon Docteur - then Doctolib (2017)</td><td>Doctolib (2020)</td><td>NA</td></tr><tr><td>Doctor 2</td><td>2017 (axisanté) then doctolib (2023)</td><td>2017 Mon Docteur - then Doctolib (2017)</td><td>Doctolib (2020)</td><td>NA</td></tr><tr><td>Doctor 3</td><td>2016 (VEDA) then doctolib (2019)</td><td>Doctolib (2019)</td><td>Doctolib (2020)</td><td>Teams (2020)</td></tr><tr><td>Doctor 4</td><td>2006 (axisanté) then doctolib (X)</td><td>2017 Mon Docteur - then Doctolib (2017)</td><td>Doctolib (2020)</td><td>Teams (2020)</td></tr><tr><td>Doctor 5</td><td>1999 (medistory) then axisanté (2002) and doctolib (2021)</td><td>Doctolib (2018)</td><td>Doctolib (2020)</td><td>Omnidoc (2020)</td></tr><tr><td>Doctor 6</td><td>axisanté (2007)</td><td>Doctolib (2021)</td><td>NA</td><td>Omnidoc (2020)</td></tr><tr><td>Doctor 7</td><td>axisanté (2019)</td><td>Doctolib (2020)</td><td>Care (2020) then Doctolib</td><td>Omnidoc (2020)</td></tr><tr><td>Doctor 8</td><td>Word (2016) MediStory (2018) Doctolib (2021)</td><td>Doctolib (2020)</td><td>Doctolib (2020)</td><td>MonSISSRA (2020) puis Doctolib</td></tr><tr><td>Doctor 9</td><td>Docteur Santé (2018) + Pdf</td><td>Doctolib (2018) + Excel</td><td>Doctolib (2020)</td><td>MonSISSRA (2020) then Doctolib</td></tr><tr><td>Doctor 10</td><td>Docteur Santé (2020)</td><td>Doctolib (2020)</td><td>Doctolib (2020)</td><td>Idomed (2020) et Omnidoc (2020)</td></tr></tbody></table>
<table><tr><td>I also have paper files. I'm at the crossroads, half modern and half traditional.</td><td>performative</td><td>doc management</td></tr></table>

Appendix C. Software adoption by physician

<table><thead><tr><th></th><th>consultation software</th><th>online agenda</th><th>teleconsultation</th><th>tele expertise</th></tr></thead><tbody><tr><td>Doctor 1</td><td>1995 (axisanté) then doctolib (2017)</td><td>2017 Mon Docteur - then Doctolib (2017)</td><td>Doctolib (2020)</td><td>NA</td></tr><tr><td>Doctor 2</td><td>2017 (axisanté) then doctolib (2023)</td><td>2017 Mon Docteur - then Doctolib (2017)</td><td>Doctolib (2020)</td><td>NA</td></tr><tr><td>Doctor 3</td><td>2016 (VEDA) then doctolib (2019)</td><td>Doctolib (2019)</td><td>Doctolib (2020)</td><td>Teams (2020)</td></tr><tr><td>Doctor 4</td><td>2006 (axisanté) then doctolib (X)</td><td>2017 Mon Docteur - then Doctolib (2017)</td><td>Doctolib (2020)</td><td>Teams (2020)</td></tr><tr><td>Doctor 5</td><td>1999 (medistory) then axisanté (2002) and doctolib (2021)</td><td>Doctolib (2018)</td><td>Doctolib (2020)</td><td>Omnidoc (2020)</td></tr><tr><td>Doctor 6</td><td>axisanté (2007)</td><td>Doctolib (2021)</td><td>NA</td><td>Omnidoc (2020)</td></tr><tr><td>Doctor 7</td><td>axisanté (2019)</td><td>Doctolib (2020)</td><td>Care (2020) then Doctolib</td><td>Omnidoc (2020)</td></tr><tr><td>Doctor 8</td><td>Word (2016) MediStory (2018) Doctolib (2021)</td><td>Doctolib (2020)</td><td>Doctolib (2020)</td><td>MonSISSRA (2020) puis Doctolib</td></tr><tr><td>Doctor 9</td><td>Docteur Santé (2018) + Pdf</td><td>Doctolib (2018) + Excel</td><td>Doctolib (2020)</td><td>MonSISSRA (2020) then Doctolib</td></tr><tr><td>Doctor 10</td><td>Docteur Santé (2020)</td><td>Doctolib (2020)</td><td>Doctolib (2020)</td><td>Idomed (2020) et Omnidoc (2020)</td></tr></tbody></table>