Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation.
OBJECTIVE
To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service.


METHODS
A mixed methods, longitudinal, multisite, socio-technical case study.


METHODS
Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete. Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data. Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the top-down, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a "middle-out" approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities.


CONCLUSIONS
Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations' perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.
Robertson
Ann
A
eHealth Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG.
Cresswell
Kathrin
K
Takian
Amirhossein
A
Petrakaki
Dimitra
D
Crowe
Sarah
S
Cornford
Tony
T
Barber
Nicholas
N
Avery
Anthony
A
Fernando
Bernard
B
Jacklin
Ann
A
Prescott
Robin
R
Klecun
Ela
E
Paton
James
J
Lichtner
Valentina
V
Quinn
Casey
C
Ali
Maryam
M
Morrison
Zoe
Z
Jani
Yogini
Y
Waring
Justin
J
Marsden
Kate
K
Sheikh
Aziz
A
D003284:Contract Services; D057286:Electronic Health Records / Q000458:organization & administration* / Q000592:standards / Q000639:trends; D004739:England; D006751:Hospital Information Systems / Q000458:organization & administration / Q000592:standards / Q000639:trends; D006801:Humans; D033181:Information Dissemination; D011446:Prospective Studies; D013222:State Medicine
Healthc Q. 2007;10(2):107-16
17491575
Lancet. 2006 Sep 9;368(9539):901-2
16962865
Lancet. 2001 Aug 11;358(9280):483-8
11513933
BMJ. 2007 Jun 30;334(7608):1360
17510104
N Engl J Med. 2009 Apr 9;360(15):1477-9
19321856
Ann Intern Med. 2006 May 16;144(10):742-52
16702590
Inform Prim Care. 2009;17(1):1-4
19490767
PLoS Med. 2011 Jan 18;8(1):e1000387
21267058
BMJ. 2008 Oct 23;337:a1786
18948344
Inform Prim Care. 2009;17(3):153-60
20074427
J Am Med Inform Assoc. 2009 May-Jun;16(3):271-3
19407078
N Engl J Med. 2010 Mar 25;362(12):1066-9
20335582
PLoS Med. 2009 Aug;6(8):e1000126
19688038
BMJ. 2004 May 15;328(7449):1197-9
15142933
N Engl J Med. 2009 Apr 16;360(16):1628-38
19321858
BMJ. 2010 Jun 16;340:c3111
20554687