Scholarly article on topic 'Does hype create irreversibilities? Affective circulation and market investments in digital health'

Does hype create irreversibilities? Affective circulation and market investments in digital health Academic research paper on "Social and economic geography"

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Academic research paper on topic "Does hype create irreversibilities? Affective circulation and market investments in digital health"

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Does hype create irreversibilities? Affective circulation and market investments in digital health

Marketing Theory 1-20

© The Author(s) 2017 Reprints and permission: sagepub.co.uk/journalsPermissions.nav

DOI: 10.1177/1470593117692024

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Susi Geiger

University College Dublin, Ireland

Nicole Gross

University College Dublin, Ireland

Abstract

This article draws from two conceptual lenses - the sociology of expectations and market studies -to investigate the relationship between technology hype and market investments: which promises and expectations surround hype and how they come together to shape actors' investments in an emerging market. We address this question through analysing a contemporary hype in a technology marketing context: digital healthcare. Our aim is to trace how market actors create, support and evaluate a market hype; how hype and market investments are related; and whether hype contributes to irreversibilities in shaping emerging market forms and categories. Our study indicates that hypes contribute tangibly to producing the market, not least by channelling financial, symbolic and material market investments. Furthermore, by highlighting how socio-economic, technological and policy promises become affectively loaded through circulation, we add a novel dimension to existing insights into the socio-cognitive construction of markets. We caution technology marketers, policymakers and investors against blindly following technology hype, especially when it encourages companies to engage in market investment that is unhinged from broader systems and societal, ethical or economic concerns.

Keywords

Digital health, hype cycle, market shaping, market studies, sociology of expectations Introduction

In the not-so-distant future, if you wish to see a doctor you'll either 'uber' one and your nearest on-demand healthcare provider will be at your doorstep within 15 minutes, or else you'll book a videoconference with a virtual doctor who will carry out a remote consultation with the help of

Corresponding author:

Susi Geiger, College of Business, University College Dublin, Dublin 4, Ireland. Email: susi.geiger@ucd.ie

a full 24/7 record of your vital signs. These will be captured through one or several wearable sensors and a couple of handheld 'Robodoc' medical consumer devices that clip onto your smartphone. Welcome to the brave new world of digitally enhanced healthcare! Of course, we have seen this movie many times before. A set of technologies - nano, geno, driverless cars, the Internet of Things - comes out of its early developmental closet, technology pilots signal as-of-yet hard to measure future potential, investors glimpse a gold rush of opportunities, the media and industry analysts get involved - and a new hype curve is born (Brown and Michael, 2003). Most likely, the technologies in question are first evangelized and vilified in equal measures before being absorbed into existing markets and practices in small, palatable steps that seem curiously less dramatic than the discourse that has surrounded these technologies at the beginning of their public life cycle. However, as marketing researchers, we do not have much insight into how exactly a technology hype contributes to the making and shaping of a market. Most of the models marketing researchers use to explain how markets develop are either derivatives of Rogers' (1962) diffusion of innovation curve or evolutionary models such as industry or product life cycle curves (Lambkin and Day, 1989). These models typically fail to accommodate recent insights from the market studies literature into how markets are actively and often painstakingly constructed, both in a socio-cognitive and material sense, by multiple, diverse and sometimes competing stakeholders (e.g. Araujo and Kjellberg, 2015; Cali§kan and Callon, 2010; Lawlor and Kavanagh, 2015).

Studies in the sociology of expectations have considered the development and consequences of expectations surrounding technological innovations, and in the context of marketing, an emerging literature has started to marry its arguments with the vocabulary of market studies. This research has made first inroads in investigating the role of promises in the development and shaping of markets, particularly in relation to how different networks of actors make their own visions of markets influential (Araujo et al., 2014; Geiger and Finch, 2016; Pollock and Williams, 2010). The current article follows this early trajectory to investigate the contents, voices and interests behind a particular hype and the orientation points around which market investments may be made. Specifically, we trace (1) how relevant actors create, support and evaluate a market hype; (2) how hype and market investments are related; and (3) whether hype contributes to irreversibilities in shaping emerging market forms and categories. We do so by concentrating on a technology market that has recently gone through a 'gold rush' phase, as measured by growth in venture capital (VC) investments and patent applications: digital healthcare.

We map the development of the digital health hype between 2005 and 2015, tracing the timelines and content strands of the hype, the parties involved, as well as associated technology, VC and institutional investments, and we read these as shaping what can be loosely described as the 'digital healthcare market' (though as we will see this term in itself is a disputed one). Our contributions are threefold: rather than considering the creation of new product categories as revealed in market stories (Rosa et al., 1999), we read these market stories, their circulation and promotion, as actively contributing to the construction and shaping of these markets. Furthermore, by highlighting how these stories become affectively loaded (or 'hyped') through circulation, we add a novel dimension to existing insights into the socio-cognitive construction of markets (Humphreys, 2010; Khaire and Wadhwani, 2010). Third, by revealing the circuitous trajectories and fractioning in market development, we begin to ask the critical question of 'whose futures' come to be through the circulation of market-related hype.

Conceptual background

Hype, expectations and investments

Over the past decade, the sociology of expectations has analysed the role of expectations and so-called hype cycles in technological trajectories. Borup et al. (2006) give an overview of this literature and expose its conceptual as well as analytical breadth. We focus in this article on those studies in the sociology of expectations that have specifically considered the role of hype in shaping expectations and technology trajectories (e.g. Brown, 2003; Caprotti, 2016; Ruef and Markark, 2010). According to this literature, hype happens when a new or unfamiliar technology field is heatedly discussed in public spaces, when these discussions draw investments in research and development into the area, and when these investments in turn allow the technology to develop into more concrete market trajectories. As the technology matures, social, political or cultural issues have to be taken into account, which often complicates the technology's trajectory (Brown and Michael, 2003). Because early technological promises are typically overinflated, this often leads less to a 'soft landing' or flattening of the hype curve than to a perhaps equally overblown 'valley' of disappointment, in the technology consultancy Gartner's language (Fenn and Raskino, 2008). In time, this prototypical hyberbolic curve typically levels out into a 'plateau of productivity', and the innovation becomes conventionalized.

Analysts of hype cycles argue that hype is in fact necessary for new technologies to attract enough attention, funding, interest and allies to compete against other innovations. Researchers have pointed towards three main functions which the circulation of expectations and hype fulfil: legitimation, coordination and heuristic guidance (van Lente, 2012). As coordination devices, expectations help define and articulate roles and responsibilities between actors at different levels of an ecosystem. This creates networks of 'mutually binding obligations' between innovators, investors, consumers and regulators, through which action becomes possible (Borup et al., 2006; Brown and Michael, 2003). As legitimation devices, expectations create 'protected spaces' for investment (Konrad, 2006) where research and development efforts are funded and evaluative criteria are adapted to fit the assumptions underlying the expectation. Finally, as heuristic devices, expectations channel distributed learning and knowledge in certain directions and shape socio-cognitive categories, which over time create lock-ins and diminish the space for alternative courses of collective action. Van Merkerk and Van Lente (2005) detect 'emerging irreversibilities' in these processes, pointing out that, fields that started with limitless potential futures become hardened and the scope of potentiality successively reduced. Hypes are thus necessary for technological futures to become reality. However, the corollaries of hype - the disenchantments and readjustments -may reconfigure or even halt technological trajectories. In the end, how 'successful' a hype is also depends on the infrastructural and institutional investments made during the hype cycle -expectations, much like banks, can become 'too big to fail', according to Ruef and Markard (2010).

Markets are not, they become

Conceptually, our article builds on a backdrop in market studies that sees markets as symbolic and material spaces filled through cumulative individual and collective practices, investments and network building. Guided by the technical equipment that has been put in place and by the investments, heterogeneous actors orchestrate their activities in markets and work to build both market relationships and market positions (e.g. Callon, 1998; Cali§kan and Callon, 2010; Cochoy, 2008). Market studies research has started to investigate the enrolment of actors into new market

networks and the physical investments into market infrastructures as central activities in shaping markets (e.g. Araujo and Kjellberg, 2015; Lawlor and Kavanagh, 2015). The market studies literature has also highlighted the role of ideas, models and theories in these processes (MacKenzie et al., 2007). The main argument is that theories or visions of markets do not describe markets as much as they contribute to producing them. Importantly for this current article, material and symbolic investments made now evoke images or promises of 'imagined futures' - uncertain end points of multiple actors' market shaping efforts (Beckert, 2013, 2016). Geiger and Finch (2016), for instance, demonstrate how projections of the future competitive situation in the pharmaceutical market have contributed to shaping both regulation and oversight in this market. In addition, Araujo et al. (2014) trace the current debates around the driverless car to illustrate how expectations connect actors to form powerful industrial networks and thus shape imagined markets. Esposito (2013) draws out the productive role of uncertainty in this context - it is precisely because the future is not fully knowable that expectations in markets can be generative. Thus, we can state with Kjellberg et al. (2012: 220) that 'markets are not, they become ...as a result of practical efforts by many different actors'.

Three points ought to be highlighted. First, market researchers studying the evolution of new markets have repeatedly pointed to the importance of shared stories, narratives or discourses in this process. Rosa et al. (1999) argue that stability in markets derives from shared cognitive structures which develop over time and across space, through media representations for instance. Anand and Peterson (2000) also highlight the importance of shared public representations to help reduce uncertainty in new markets. Furthermore, Khaire and Wadhwani (2010: 1282) maintain that 'category meanings shape expectations'. We would like to turn this argument on its head and propose that 'expectations shape categories'. While it is important to acknowledge that humans are often invested in market forms and categories cognitively, it is vital to emphasize that they are equally invested socially and affectively. If one contrasts the term 'expectations' with the more emotionally laden notions of 'hype' and 'disappointment', it becomes clear that affect in market creation can be shared and that 'affective circulation' (Norholm Just, 2015) may be a powerful tool for building market categories. Marketing researchers thus need to trace this affective circulation of promises alongside socio-cognitive processes.

Second, and relatedly, while the focus in the sociology of expectations typically lies on the discursive features of hype - van Lente et al. (2013: 1615) characterize hype as a 'collectively shared rhetoric about an emerging technology' - market studies research adds to this a focus on the shaping of market materialities. Araujo and Kjellberg (2015), for instance, argue that market investments can precede rather than follow market representations, thus reversing the causal relationship implied in research on product market categories. Expectations in markets are likely to drive tangible investments in the market's material equipment and infrastructures, which may create 'irreversibilities' - not just through the cognitive and affective, but also through the material framing of market trajectories.

Third, while institution building is a vital part of market creation (Humphreys, 2010; Navis and Glynn, 2010), it fails to explain how distributed actors end up engaging in relatively concerted market creation efforts. Market studies researchers need to explore why investments into certain market forms or infrastructures may be made concurrently in different places and by different, often unconnected actors. Is this convergence related purely to the identification of technological opportunity? Or is it rather a result of hype - or what Woolgar (2002) once called 'cyberbole', namely widely disseminated statements of the capacities of technologies that sweep through a

technology community, leaving little room for dissenting voices? If it is indeed the latter case, as we will argue, then an examination of 'whose voices' are being heard and listened to during a hype cycle is vital.

In sum, though technology markets may never transpire quite as expected (or perhaps feared by some), it is likely that through publicly trading promises, actors will prepare for and invest in certain markets-to-be - and in doing so will shape these future markets at every step. We thus argue that hype and market investments are intrinsically intertwined, and we will address this proposition in our empirical study presented below.

Methodology

Industry context

Our study focuses on an industry that has attracted significant investments and attention over the last number of years. Digital healthcare falls into the wider category of the Internet of Things, which is an umbrella term for a number of interlinked markets currently developing around the computing power, interoperability and data flows of everyday objects (Weinberg et al., 2015). Spanning business-to-business and consumer markets, digital health is a strong growth industry in terms of the number of active companies and the amount of VC funding it has received over the past years. Indeed, both numbers have grown more than fourfold over the 5-year period 20102015: Over 400 companies were funded in 2015 (up from 118 in 2010), through over US$5 billion in VC funding (up from US$880 million in 2010) in the United States alone (www.cbinsights.com; www.RockHealth.com). During the same time period, Apple, IBM, Google, Philips, Salesforce and several other large technology multinationals all announced strategic investments in healthcare. The years 2014 and 2015 also saw a wave of digital health initial public offerings - Fitbit's raising of US$733 million being the most prominent among them - and mergers and acquisitions, such as the apparel company Under Armour's acquisition of the weight loss app MyFitnessPal.

Current pressures on many national healthcare systems are a central catalyst to this scurry of activities. Global healthcare systems are under immense pressure to deliver significant cost-efficiencies and radically improve the scope and quality of the delivery of care at the same time (Frow et al., 2016). To address these issues, new models of healthcare are sketched where all stakeholders in a health system (patients, carers, insurance companies and governments) are seamlessly connected through digital or mobile health technologies (Davidson et al., 2015).

Data collection and analysis

Similar to previous studies investigating the creation of market categories or forms over time (Araujo and Kjellberg, 2015; Khaire and Wadhwani, 2010; Rosa et al., 1999), we studied our empirical phenomenon - the digital health hype - by tracing and analysing secondary material: press releases, newspaper reports, government publications, publicly available market statistics and online sources, such as blogs and curated content. We also performed a Google Trends and Google patent search for these years, using the following search words: connected health, electronic health (e-health), digital health, mobile health (m-health), digital medicine, telemedicine, telecare and wearable technology in health. We focused our study on one geography (Ireland) and a 10-year period (2005-2015) but also considered global developments in our inquiry. While we acknowledge the limitations of relying on secondary data only, we see publicly available documents as places where expectations and promises from diverse communities are brought to each

Table 1. Text corpus.

Type Texts Article hits Years examined

Focal - mainstream media Irish Independent 27 2005-2015

Irish Times 51 2005-2015

Irish Examiner 16 2005-2015

Sunday Business Post 29 2005-2015

Sunday Independent 8 2005-2015

Contextual - online blogs, magazines and interviews Topic m-health 19 2014-2015

Topic e-health 103 2014-2015

Topic connected health 204 2014-2015

Policy documents, directives and legislation Ireland 5 2008-2015

EU 2 2015

Total 464

EU: European Union.

other's attention, juxtaposed and contested (Weingart et al., 2000). We do not, however, conflate these public and media representations of the technology hype for the 'real thing', that is we are alert to the voices behind these representations and their potential agendas, including the media's own attention economies. In addition, though we do not directly draw on this experience for this particular article, both authors were part of a government-funded research centre for connected health between 2013 and 2016, which provided vital background knowledge of the industry and its evolution.

Our data analysis focused on identifying changes in the tenor related to the digital health hype, what voices were visible behind the hype, what promises were circulated, and to whom these promises were made. In parallel, we traced technological, financial and regulatory investments through publicly available statistics, technology press releases and government documents. As Table 1 illustrates, our main body of data during this stage covered all mainstream newspapers as well as policy documents in our focal geographic area (the Republic of Ireland), which we searched for through several databases by utilizing the same search words as used for our Google Trends analysis. This exercise yielded 138 relevant documents, which became the main corpus of our analysis. For the final 2 years of our 10-year timeframe (2014-2015), which our initial analysis revealed to be the zenith of the digital health hype, we broadened this data collection to popular global internet sources in order to capture the larger socio-economic discourses in this market. As Marres and Moates (2015) have forcefully argued, the significance of the web as a contemporary data collection site directs attention to the interactions among a variety of actors - including civil society, the media, science, government and industry - in the articulation of public issues. Internet materials for this timeframe were researched via an online platform called Flipboard. This tool allows for the collection and storage of items of interest by a curator, and we selected the most prolific curators for each of our main search terms (m-health, e-health, connected health), effectively utilizing them as expert filters to tap into the vast universe of internet material. All 464 texts of interest (see Table 1) were stored electronically and mapped according to source, keyword and context, including a short description of its content.

We first coded the 464 texts of interest inductively, asking which promises, expectations or disappointments emerged from the texts. Based on this open coding process, we developed a list of semantic markers, which helped to identify broader commonalities between the three different types of texts, and then recoded the entire text base. We subsequently aggregated data to trace the chronological

2007: Launch of Apple iPhone and Appstore

2011: Quantified self movement takes off

maps mobile health into 'through of disillusionment' category

2014: Gartner

2015: Ireland lauches Healthy Ireland initiative and refocusses

2005: HSE Framework on

Ehealth Transformation

2010: EU sets digital agenda 2020 set

ehealth strategy

Promises of Promises of

collaborative prevention of

medicine, illness and

improved care enhanced care

Promises of self- and remote management

Promises of patient empowerment, tech innovation and new realities

medicine, improved care

Rekindled promises of collaborative

and cost

savings

and cost savings

Figure 1. Timeline.

Source: Authors own.

development of the field from 2005 to 2015 (Figure 1). This timeline permitted us to identify changes in the technology hype alongside institutional and symbolic investments made in this market.

Our findings trace how the digital health market was shaped through a sequence of promises made by a variety of actors on the one hand and tangible market investments on the other (see Figure 1). The next three subsections summarize our findings of these processes. First, we begin by examining the period of 2005-2010, which was characterized by a problematization of traditional healthcare delivery, coupled with visions of a promised land of digitally enhanced health provision. The stories circulated in the media during this time laid the foundations for the emergence of a new market space, enabled by emergent technology developments, some private capital influx and government attention. In the second section, we discuss the promises that underpinned a veritable technology and capital investment explosion between 2011 and 2014. In our third phase, from 2015 onwards, more critical emergent voices around the new technologies; some highly publicized commercial failures resulted in tangible changes in market investment practices and in a critical reconsideration of the fundamental promises underpinning digital healthcare.

The promised land of digital healthcare: 2005-2010

Early signs of an emergent market in digital healthcare date back to the first implementations of electronic medical records and telemonitoring in the 1990s. Yet, only about a decade ago has technology started to more fundamentally influence how stakeholders think about healthcare delivery. Early media reports saw connected health, e-health, digital health, m-health, digital medicine and telemedicine as essentially the 'same thing' in the sense that they describe technology-enabled healthcare delivery. The public discourse around digital health in Ireland from

Findings

Interest over time Go gle Trends

• mhealth • eheafth • telehealth • telecare • wearable technology

Average 1 Jan 2004 1 Sep 2015

Worldwide. 2004 - present.

Figure 2. Google Trends for selected market categories. Data source: Google Trends (www.google.com/trends).

2005 to 2007 evolved around how technology could relieve an overburdened healthcare provider. Emergent technologies, including sensors, video links and data sharing points, promised to connect healthcare providers over a distance and permit them to collaborate - 'allowing physicians and other medical experts to view vital diagnostic and other information in real time, regardless of their location' (Irish Independent, 5 November 2005). Such technology-led promises of better connection, remote care and prevention soon nurtured an early enthusiasm for these emergent technologies, which swept over to the country's political leadership. The 'promised land' of technology-enhanced healthcare delivery became imprinted in a 15-year Health Service Executive framework programme on eHealth Transformation in Ireland (Department of Health, 2006). As Figure 2 indicates, the technical exigencies and possibilities of telemedicine were the best known and offered an important early anchor point to build healthcare providers' expectations around the emerging categories of e-health or digital health (Irish Independent, 1 April 2005). However, because experiences with telemedicine technologies had already been made, these early promises were moderated by some healthcare providers who observed that 'teleconferencing has failed to grasp complex procedural and legal complexities when it comes to deciding on treatments' (Irish Examiner, 18 May 2005). Thus, at the very beginning of the emergent digital health hype stood a clear caution from healthcare providers that in order to be workable, digital health projects needed a regulatory and legislative 'framework' (ibid.) and a measure of sensitivity to existing healthcare practices.

The launch of the first iPhone in 2007 presented a watershed moment for the development of m-health technologies. 'Mobiles can help to save lives' became the new mantra for technology developers in this space (Irish Times, 7 October 2005). The years 2008 and 2009 brought the first generation of health-related apps as well as first glimpses of augmented reality in healthcare (Sunday Business Post, 19 September 2009). However, despite these more consumer-focused forays, the main promise of technology-enabled healthcare was still centred on relieving the healthcare provider by enabling remote care for problematic care segments, and the press painted a bright and not too-distant future where elderly patients could 'monitor their chronic conditions and get medical advice without having to leave their homes' (Irish Times, 24 November 2009).

During this time frame, technology development accelerated, and numerous devices to diagnose and monitor chronic conditions were announced in the press (e.g. Sunday Business Post, 4 January 2009). Increasing levels of investment in these technologies were partly fuelled by socio-economic promises that they would 'improve quality of care, reduce re-admission and significantly ease the burden of an ageing population on the healthcare system' (Irish Times, 18 May 2010). At an institutional level, actors rallied around these promises of collaborative medicine, improved care and remote management. The European Union (EU) Commission's Digital Agenda 2020, for instance, promoted e-health records, smartphone use, medical robotics and assisted/ambient living. Indeed, in unveiling this agenda, the EU's Directorate General for Competition Commissioner, Neelie Kroes, enthusiastically presented the potential of e-health as being 'most amazing and life changing' (Irish Independent, 5 November 2010). At a local level, Irish government-backed experimentation around market network formation aimed to bring heterogeneous commercial actors together. Early examples included the national trial ofa 24-hour emergency response for the elderly as well as new industry collaborations, for instance, around a technology for falls prevention in the elderly (Irish Independent, 5 July 2007). Thus, promises of strong public actor support at both EU and national levels fuelled the first big wave of healthcare technology and early market network development in Ireland (Irish Times, 27 May 2011).

Riding the tech wave: 2011-2014

Envisioned by policymakers and healthcare providers as a tool to deliver socio-economic relief to an overburdened healthcare system, by 2011, the emerging digital healthcare market had seen a great deal of technology development. However, it mostly lacked large-scale testing and adoption of these technologies by patients, carers or healthcare providers. Government and technology providers started to focus their efforts on such implementation issues (Irish Independent, 22 October 2012). Government agencies investigated how the scaling of the digital health sector could be supported more strongly at a national level and started to invest money specifically into market building exercises (Budget Speech, 2013). The stakes were perceived as significant: one government representative called it nothing less than a wholesale transition from 'industrial' to 'information age healthcare' (Sunday Business Post, 6 October 2013). Market players from very different industry sectors all showed an interest in unlocking this 'multibillion' market opportunity, and previously unconnected commercial actors were announcing collaborations almost at a daily rate (Sunday Independent, 2 December 2012). Equally frequently, further tech innovations were announced in the press, including apps to tackle obesity (Sunday Business Post, 28 March 2012), remote monitoring systems for dementia care (Wicklow People, 29 August 2012) and platforms to treat mental health (Irish Times, 6 December 2012).

The mindful cyborg

The year 2012 saw the emergence of technology-enabled self-care and wellness management as a distinct consumer-focused market category in the public media. Soaring levels of smartphone adoption and developments in adjacent technology areas such as cloud computing and data analytics stoked public and commercial interest in consumer empowerment, wellness and self-care. Interest in these concepts partly emanated from grassroots consumer movements such as the quantified-self movement, which came to broad public attention around this time. Furthermore, they were also fuelled by the previous period's turn to mobile-based technologies, which now started to mature. Figure 2, which maps international Google Trends, illustrates the significant rise

Patents Intl. 2005-2015

1200 1000 800 600 400 200 0

2005 2006 2007 2008 Connected health Telecare •

ehealth «

Implantable sensor •

2009 2010 2011 ™ Digital health — Mhealth -

^ Wearable device « ^ Wearable technology

2012 2013 2014 2015 Telehealth Mobile health Wearable sensor

Figure 3. International patents filed 2005-2015. Data source: Google Patents search.

of interest in wearable technology as well as a clear fall in references to telemedicine, perhaps indicating a slow convergence of market actors on a core category (Rosa et al., 1999).

Figures 3 and 4 illustrate a peak in patent creation in 2012/2013 for healthcare technologies internationally (Figure 3) and in Europe (Figure 4), with a clear trend toward consumer sensor technology. Phone apps, bloodstream sensors, biostamps, robotic pills, electronic tattoos and wearable sensors were all hailed as breakthroughs to a new reality in which ubiquitous mobile technology would empower the patient to self-manage their health (Irish Independent, 31 May 2013; Irish Times, 11 September 2013; Sunday Business Post, 18 November 2013).

However, some commentators felt that the emerging consumer-centric technologies had become ever more disconnected from medical healthcare practices (Irish Independent, 31 May 2013). Furthermore, the boundaries between medical and wellness devices remained unclear, and regulatory and legal frameworks to guide technology development and market creation were still lacking (Irish Times, 29 January 2014). Thus, while early government investment had aimed at nurturing an industry that promised to alleviate the state's crushing health cost burden, those investments had arguably not been equalled by efforts to provide a solid institutional backdrop for the industry. In the United States, the US Food and Drug Administration (FDA) now started to define some guidelines around when a device, sensor or app ought to be registered and approved as a medical device (MobileHealthNews, 16 January 2013). This move had repercussions on the development of the global market: The United States was seen as a crucial market for digital health technology providers, and the quick rewards of consumer-facing technology rather than onerous FDA approvals for clinical applications proved a strong investment lure for start-up companies and

Patents Europe 2005-2015

50 40 30 20 10 0

2007 2008 ' Connected health

Telecare

1 ehealth

' Implantable sensor

2009 2010 2011 2012 Digital health

— Mhealth

Wearable device

Wearable technology

2013 2014 2015 Telehealth

Mobile health

Wearable sensor

Figure 4. European patents filed 2005-2015.

Data source: Google Patents search.

venture capitalists alike. In fact, with investment more than doubling between 2012 and 2013 and rapidly increasing in deal size (www.cbinsights.com), VCs now prominently embraced digital health and further stimulated a technology race around consumer wellness. This action transformed the market landscape, according to one report, into a 'tech-utopia' of empowered consumer-patients (Sunday Business Post, 2 March 2014).

The justification for significant financial investments in this market category was cemented by a myriad of ever more optimistic market size and growth predictions by industry analysts, marketing agencies and consultants, which were often widely circulated across the technology media world. For instance, the wearables market was predicted to grow from 20 million in 2013 to 160 million units shipped annually in just 2 years (Business Insider UK, 7 January 2015), and the m-health device market was forecast to grow eightfold from US$5.1 billion in 2013 to US$41.8 billion in 2023 (mHealth Watch, 7 July 2014).

Trough of disillusionment?

Until early 2014, the public discourse was dominated by seemingly unbridled tech optimism, as expressed through constant upward revisions of market predictions, daily investment announcements and ubiquitous press releases on the latest technology launches. The latter featured a gamut ranging from so-called 'moonshot' technologies such as the Google-Novartis collaboration on a glucose measuring contact lens, through emerging platforms like the Apple HealthKit, to increasingly intense competition around wearable technology and consumer apps (NY Times, 27 April 2014). In short, the wealth of consumer health technology now permitted willing consumers to turn themselves into 'mindful cyborgs' (Irish Times, 18 September 2014). At the same time, and perhaps somewhat surprisingly, patent filing started to drop (Figures 3 and 4) and concerns related to the new market started to multiply from healthcare providers, statutory regulators and

consumers themselves. These included concerns about the security of personal information and sensitive data (Sunday Business Post, 25 May 2014), data breaches and cyberattacks (Sunday Business Post, 25 May 2014; Healthcare IT News, 12 December 2014), low levels of interoperability (Healthcare IT News, 11 December 2014) and an absence of meaningful information generated by devices and sensors (Healthcare IT News, 22 August 2014). Digital health was criticized for failing to give real benefits to healthcare providers (The Atlantic, April 2014), creating a mindless sea of data (Information Week, 4 January 2014) and lacking clinical evidence of effectiveness (PatientView, 23 November 2014). Furthermore, social concerns started to be voiced more loudly, for example, that digital technology was driving actors in the healthcare system further apart rather than connecting them (Healthcare IT News, 30 October 2014), ignoring or stigmatizing certain social groups (Yahoo News, 8 May 2014), creating loneliness in vulnerable groups like the elderly (The Guardian Newspaper, 28 May 2014) and contributing to a rise in so-called cyberchondriacs among the 'worried well' (Medical Daily, 7 May 2014). Some providers had recalls (Mobilhealth News, 9 October 2014), and high-profile market players such as Nike and most prominently Google decided to abandon parts of their wearable technology efforts (Recode, 18 April 2014). If proof of the mounting scepticism was needed, industry analyst Gartner, 'promissory organization' par excellence (Pollock and Williams, 2010, 2016), saw mobile health monitoring falling headfirst into the 'trough of disillusionment' in their 2014 emergent technology hype cycle (www.gartner.com). Thus, by the end of 2014, it had become evident that technological innovation alone was not going to deliver the wholesale healthcare revolution that had originally been promised (CIO, 25 November 2014), and that market investment in this space was in fact a long game, to be played on a socio-economic as well as a technological pitch.

The voyage continues: 2015 onwards

Despite critical voices becoming louder and VC investment and patent growth softening between 2014 and 2015, the hype did not seem to die down just yet. A renewed surge of promises around back-to-back connectivity saw technology launches running the full gamut of what some commentators started to call 'the Medical Internet of Things' (Mobcon, 2 April 2015). Amid this continuing innovation push and despite warning signs from the financial markets that the digital health hype had climaxed (Fastcompany, 3 February 2016), growth estimates of previous years were revised upwards yet again. Predictions anticipated the value of the mobile health market to rise to nearly US$50 billion in just 5 years (Benefits Pro, 2 September 2015) at a compound annual growth rate of 48% between 2013 and 2020 (Healthcare Dive, 3 September 2015).

Although consumers and healthcare providers now started to garner some practical benefits from the new market category, commentators remained sceptical as to whether digital healthcare's original promises of collaborative medicine, improved care and cost savings were being fulfilled. Rather than redefining the healthcare space as initially modelled on an existing market category, which emphasized connectivity (telemedicine), VC and technology investment strategies seemed to have tipped the market towards consumerization and empowerment. Furthermore, even the consumer market exhibited clear growing pains in comparison to earlier rhetoric, especially when seen against the canvas of the socio-cultural practices into which products had inserted themselves. This was evident in reports of consumers being concerned about the security of connected devices and remote fitness tracking tools (mHealth Intelligence, 2 September 2015), in high abandonment rates in wearables usage and in observations that the technologies were used almost exclusively by the wrong people - namely 'the young, rich, healthy and connected' (Medcity News, 4 November

2015). A review of the over 160,000 healthcare apps demonstrated that many have an insignificant user-base as well as an uneven socio-geographic reach (Mobile Health Economics, 2015) and that a mere 36 apps accounted for half of all downloads. Importantly, and corroborating our reading of a hype cycle skewed toward consumer technology, only 160 apps or 0.1% had FDA approval, thus considered 'medical grade' rather than consumer apps (MedcityNews, 17 September 2015). Despite the original promises to build fully networked healthcare ecosystems, technology platforms were also criticized for their lack of interoperability and compatibility (MobileHealth News, 15 March 2015). Even self-proclaimed 'Health Knowledge Engine' Google admitted that they could not guarantee that medical information is up to date, take liability for errors and ensure that patients could have fair input (33 Charts, 11 February 2015).Thus, concern mounted that digital health had yet to illustrate true tangible value to consumers and clinical evidence to healthcare practitioners (mHealth News, 21 August 2015). This concern was bluntly summarized by the American Medical Association's CEO in his 2016 Annual Meeting address when he described e-health as 'digital snake oil', sending shock waves through an industry that had persistently played up its role in modern healthcare. Of course, this statement may partly betray its own agenda, coming as it were from a profession that had traded on its expertise since human memory and that may now fear the democratization of this expertise. In any case, it demonstrates that digital healthcare companies had so far failed to gain broad support of their most important stakeholders - physicians.

With that, market actors market actors were once again reminded of the fact that alongside technology investments, in order truly to empower patients, the whole healthcare ecosystem needed to change - including an update of payment models (Jdsupra Business Advisor, 1 September 2015), the creation of interoperability among systems and devices (Medicity, 17 September 2015), and changes in attitude by healthcare providers (NY Times, 16 April 2015). In order to provide digital health initiatives with a sounder institutional scaffolding, Irish government actors started to revitalize the category's original promises of collaborative medicine via social initiatives like the Healthy Ireland initiative and practical implementation programmes around long-dormant e-health strategies (Department of Health, 2015). Thus, with a flavour of éternel retour, by late 2015, systemic change became yet again the central focus of government actors and healthcare providers alike. Whereas patents and private capital investments may have peaked and the 'dumb money' exited the market (Medcity News, 3 November 2015; 29 October 2015; FastCompany, 3 February 2016), this is perhaps a glimpse of an emerging long-term market reality, underpinned by investments in socioeconomic and institutional reform and enabled rather than singlehandedly driven by the promises of technological innovation. After a full 10 years, the prize question remains whether or not 'Digital health [is] finally about to turn all that hype into results' (Fortune, 11 May 2016).

Discussion

Market trajectories

This study sought to examine (1) how actors create, support and evaluate a market hype, (2) how hype relates to market investments, and (3) whether hype contributes to irreversibilities in emerging markets. Previous research in the sociology of expectations has identified legitimation, coordination and heuristic guidance as important functions of hype (van Lente, 2012). Our findings corroborate these insights and add vital understandings to the role hype plays with regard to market investments and market shaping. As we demonstrate in this article, in markets located on a hype cycle, a lot of market building happens in a rapidly changing context and under prolonged periods

of radical uncertainty. In such a context, managers are tasked to pin down and predict many moving parts - in our case, political players and venture capitalists' interest, changes in attitudes and behaviours of patients and healthcare professionals, institutional and regulatory changes, and the maturing of associated technologies (for instance, cloud storage and data analytics). We contend that in this sea of change, circulating socio-economic, technological and policy promises provide important orientation for market investments to occur from multiple distributed parties.

In answer to our first two research questions, we have shown that the first periods of the digital health hype revolved around the notion of connectivity, amid health systems aching for modernization and battling with access and cost issues. Many of the media reports circulated during this time were clearly aspirational and agenda setting in tone. The grand initial promises of collaborative medicine, improved care and cost savings thus provided important legitimacy and an impetus for technological and market investment - a first prominent orientation point, so to speak, in building maps and infrastructure in the emerging digital healthcare market. As coordination device, early promises of seamless connectivity also sketched 'mutually binding obligations', to speak with van Lente (2012), around collaboration needs between commercial actors from different industries. This was vital: in order to make this particular market happen, previously disconnected actors - technology start-ups, pharmaceutical multinationals, healthcare providers and insurers - had to join forces. However, in the absence of concrete institutional guidance for these collaborations for instance in clarifying data security or interoperability standards, the shaping of the new market space soon became the purview of those who were literally most invested in this space - technology firms and venture capitalists.

On this basis, the second period of the hype turned into a technology peak converging around consumer and wellness solutions. 'Wearable health tech' emerged in the public domain as by far the most talked-about market category - providing the second market shaping heuristic and orientation point. The associated notion of consumer empowerment offered further legitimacy for public officials and capitalists alike to engage in this emerging space. Almost daily growth forecasts delivered additional heuristic guidance in the form of financial promises around a seemingly bottomless and rapidly adopting consumer market, which fuelled ever-increasing financial interests and added to the general exuberance.1 Regarding the market's representational practices, these heuristics were also discernible in the declining use of the term 'connected health' in favour of the more neutral and perhaps more individualistically connoted'm-' or 'e-' health monikers (Figure 2).2

It was only in the third phase of 'disillusionment', to speak in hype cycle language, that regulatory, social and systemic promises came to the fore again. In this period of renewed realism, stakeholders' debates returned to consider proof of value, interoperability and return on investment - circling back to the very promises that heralded the beginning of the digital health hype. The difference is that at this stage, the VCs' and technology providers' vision of a technological future in healthcare, centred on individualized mobile technology, had become heavily underwritten by technological and financial investments and highly legitimized. It remains to be seen exactly what kind of institutional work it will take to reorient these investments to those earlier promises of connectivity across the entire medical realm. Thus, in answer to our third research question, of whether market hypes create irreversibilities in market trajectories, we conclude that hypes may not necessarily lead to points of no return in markets. However, like oil tankers, once a market's course has been set through circulating promises, associated legitimating, coordination and heuristic practices and ensuing market investments, it may be slow and rather onerous to change.

Theoretical contributions

Recent market studies have highlighted that a market develops through and around complex configurations of agencies and actors who have distinct and often divergent goals as well as uneven abilities to influence market investments (e.g. Araujo and Kjellberg, 2015; Cali§kan and Callon, 2010; Lawlor and Kavanagh, 2015). Inline with these findings, we point out that a technology may be widely talked about but cannot simply be 'talked into' a really existing market without tangible market investments. Meshing the focus on market shaping offered by market studies with that on the circulation of ideas in the sociology of expectations, we trace such market investments in the form of government initiatives and capital influx alongside technology hype. Our data indicates that hype cycles' legitimating, coordinating and heuristic functions, as crystallized in the sociology of expectations, not only drive technology trajectories but also motivate the development of market infrastructures, networks and policies. It is important to emphasize that these processes are never disinterested; based on our study, we suggest that those shouting loudest may not always succeed at shaping the market to their wishes and visions. However, the heavy and emotionally charged circulation of certain promises ahead of others through public reports, media and social networks does influence and perhaps even skew investment flows and collective imaginations of the emerging category. In the public sphere, promises often appear delinked from individual agendas and actors and portrayed as something of a 'Zeitgeist' phenomenon. Importantly, this does not mean that these promises are authorless, nor that they are unanimous or uncontested - the scepticism of healthcare provider voices emerging in some of the media reports we analysed speaks loudly to this. This raises essential questions about the role of technology journalists in bringing a future market into being, to add to similar research on the roles and responsibilities of consultants (Pollock and Williams, 2016) and forecasters (Beckert, 2016).

Our focus on hype also adds to research in marketing and market studies (e.g. Cali§kan and Callon, 2010) by highlighting the affective and relational nature of the circulated promises. The market shaping effects of such 'emotions that bind the collective', as Ahmed (2004) may say, have arguably been neglected in previous accounts of market category creation (e.g. Humphreys, 2010; Khaire and Whadwani, 2010). Ahmed rightly observes that 'emotions do things' (2004: 119) - they shape what she calls 'affective economies'. Where she focuses on the economies of hate, we emphasize the constitution of a market through feverish anticipation, expectation and hope. In the case of digital health, market actors, investors and government representatives quite literally appear to have been swept away by the affective circulation of promises of a 'new and improved' connected world in healthcare. In our case, this has likely contributed not only to some rather hasty public policy commitments, but also to many a 'unicorn' valuation in this field, many of which were not justified by firm performance or revenues.3 Of course, though the fanfare may be loud and the hype heated, building a 'really existing' market involves the slow and often laborious integration of new technologies into existing infrastructures, exchange and user practices, which is a gradual process that happens mostly away from media searchlights and grand future visions. We agree with Brown and Michael (2003) that overheating may be necessary for this market work to get underway, but we are also giving concrete shape to their notion of 'overshoots', when market actors find themselves literally and figuratively overinvested in a market-to-be.

We summarize our arguments in Figure 5, which captures and conceptualizes these dynamics. Socio-economic, technological and policy promises gain momentum and prominence through affective colouring and repeated circulation - creating a 'hype'. This affective circulation has important legitimating, coordinating and heuristic functions, which in turn help motivate and direct

Figure 5. A framework of market hype-investment cycles.

market investments. The more a 'really existing market' appears to emerge, the more hyping occurs in the first instance, as market actors can now build their promises on value projections, policy commitments, technology showcases and other no-longer-purely fictional expectations. Also, those who invest in an emerging market are of course interested in adding to the exuberance around it - as the old saying goes, a rising tide lifts all boats. But eventually, these market investments also provide important test cases and reality checks, which may counterbalance at least some of the affective overshoots of the early days in a market's evolution and which may, in the end, also contribute to dampening down the hype. We indicate these dynamics in our Figure 5 through the backwards arrows from 'market investments' to 'affective circulation'.

Practical contributions

Our investigation holds important lessons for market actors and policymakers alike. First, rather than blindly riding the wave of technology hypes, we extoll technology marketers to seek out the concerns of all of the market's stakeholders - especially those critical voices that are all too often side-lined once a hype sweeps over a technology community. In our case, these were the voices that indicated the real pain points digital health technology may be able to address, beyond the merits of hyper-individualized consumer devices or 'gadgetism'. Companies that have listened to these voices now seem most adapted to the broader socio-economic agendas that are currently revitalized. While such reality checks may not always be aligned with early investor requirements, they may lead to a more sustainable innovation strategy in the longer term. Second, while many marketing managers are familiar with notions of take-off or tipping points within product life cycles, our study indicates that in this age of hyper-mediation, market environments and expectations are prepared often long before products actually reach the market - expectations may thus precede market categories. Marketers may wish to consider the extent to which they can use the hype during market emergence to their own advantages.

In contrast, rather than fuelling the hype under the banner of procyclical policies such as 'establishing technology leadership', as arguably happened in our case, policymakers may consider the adoption of 'countercyclical' hype policies.4 In our case, investment and attention were arguably drawn in those directions that held the greatest opportunities for relatively large-scale user adoption and quick return on investments. There is a strong argument to be made that an emergent industry that is already coveted by private capital may not require much additional

government aid to flourish. Instead, government agencies should look to those parts of a market on a hype curve that are being underserviced by venture capitalists and offer other investment routes to those market actors that develop technologies which may not be 'trending'. They should also ensure that the technology hype is accompanied by carefully thought out institutional market investment, thus ensuring the greatest possible inclusion of market stakeholders. More generally, we would argue that hype cycles require both acute awareness and very careful handling by policymakers to prevent, detect and counterbalance their overshoots.

Future research

Overall, our study highlights that market hypes do more than just contributing to shaping product categories at a socio-cognitive level. In particular we emphasize the strong affective valence of hypes and its effect on market (over)investments. We would encourage future research to expand on our exploratory findings and further investigate the dynamics of this affective circulation, especially the roles and responsibilities of specific promissory actors in it - prominently those of technology journalists and venture capitalists. More generally, we would argue that the role of shared emotion requires more prominence in market studies - while the literature's emphasis on material investments has been important, we would encourage future research to focus on how collective affect contributes to market shaping and market investment (see also Norholm Just, 2015). Finally, a more detailed investigation of how government policy measures can counteract technology market overshoots would also be extremely valuable, going some way of rethinking innovation policy in an information age that seems all too eager to jump on any 'cyberbole' (Woolgar, 2002) bandwagon coming along.

Author's note

Previous versions of this article have been presented at the 4th Interdisciplinary Market Studies Workshop, the Academy of Market Science Conference in Orlando/Florida, the Society for the Social Studies of Science (4S) Conference, Denver/Colorado, and at seminars at the Paul Merage Business School, University of California, Irvine and the University of Hawai'i at Manoa Shidler College of Business.

Acknowledgements

The authors would like to thank participants at the 4th Interdisciplinary Market Studies Workshop, the Academy of Marketing Science Conference in Orlando/Florida, the Society for the Social Studies of Science (4S) Conference, Denver/Colorado, and at seminars at the Paul Merage Business School, University of California, Irvine and the University of Hawai'i at Manoa Shidler College of Business for their constructive feedback and suggestions, in particular, Prof. Alladi Venkatesh and Prof. Elizabeth Davidson. The authors would also like to thank Dr Liz McFall and Prof. Katy Mason for their comments on a draft version of this article, Prof. Luis Araujo for his always excellent editorial guidance and our three anonymous reviewers for their highly useful comments and suggestions. All remaining errors are of course our own.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/

or publication of this article: Parts of this research have been funded by the University College

Dublin Seed Fund no. 1155. Susi Geiger benefitted from funding from the European Union's

Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant

agreement no. 654732 while writing this article.

1. The number of 'zombie start-ups' in this market bears witness to just how coveted by capital many technology entrepreneurs in this market were during this particular period (Accenture, 2015).

2. It is noteworthy that even 10 years later, there remains a representational fragmentation over how to label this market. In the United States, event organizers and consultants respectively claim labels such as 'Health 2.0' or 'digital health'. In Europe, the moniker e-health seems to have taken hold at least in government circles.

3. Unicorn valuations are those where start-ups are valued at over US$1 billion, often on the basis of future potential rather than actual sales. The tragic tale of former digital health media darling Theranos, a company valued at over US$9 billion in 2014 and currently under investigation by two US Federal agencies for unfounded claims over its technology (Wall Street Journal, 27 April 2016), is a warning sign for many overenthusiastic venture capitalists and journalists eager to jump on the next hype bandwagon.

4. This idea of a countercyclical hype policy was suggested to us by one of our reviewers, to whom we are very grateful.

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Susi Geiger is a professor of Marketing & Market Studies at University College Dublin, Ireland. Her research focuses on marketing and sales in highly complex markets where value has to be created across a broad ecosystem. In recent times, this research has centred on the healthcare system, including research and collaborations with pharmaceutical and digital health companies. She is the author of many highly cited academic articles, for instance in Research Policy, Entrepreneurship Theory and Practice, Industrial Marketing Management, Journal of Business Research, and many others, and has coauthored and edited two books.

Nicole Gross lectures marketing at University College Dublin and Dublin City University. She has an international research network and is an active member of various research groups including the European Group for Organization Studies, Academy of Management, Industrial Marketing and Purchasing Group and Business Model Community. Her research interests include high-tech marketing especially in healthcare markets, entrepreneurship, practice research, business models and market innovation.