title: Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation.
abstract: 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.
authors.affiliation: eHealth Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG.
authors.forename: Ann
authors.initials: A
authors.lastname: Robertson
authors.forename: Kathrin
authors.initials: K
authors.lastname: Cresswell
authors.forename: Amirhossein
authors.initials: A
authors.lastname: Takian
authors.forename: Dimitra
authors.initials: D
authors.lastname: Petrakaki
authors.forename: Sarah
authors.initials: S
authors.lastname: Crowe
authors.forename: Tony
authors.initials: T
authors.lastname: Cornford
authors.forename: Nicholas
authors.initials: N
authors.lastname: Barber
authors.forename: Anthony
authors.initials: A
authors.lastname: Avery
authors.forename: Bernard
authors.initials: B
authors.lastname: Fernando
authors.forename: Ann
authors.initials: A
authors.lastname: Jacklin
authors.forename: Robin
authors.initials: R
authors.lastname: Prescott
authors.forename: Ela
authors.initials: E
authors.lastname: Klecun
authors.forename: James
authors.initials: J
authors.lastname: Paton
authors.forename: Valentina
authors.initials: V
authors.lastname: Lichtner
authors.forename: Casey
authors.initials: C
authors.lastname: Quinn
authors.forename: Maryam
authors.initials: M
authors.lastname: Ali
authors.forename: Zoe
authors.initials: Z
authors.lastname: Morrison
authors.forename: Yogini
authors.initials: Y
authors.lastname: Jani
authors.forename: Justin
authors.initials: J
authors.lastname: Waring
authors.forename: Kate
authors.initials: K
authors.lastname: Marsden
authors.forename: Aziz
authors.initials: A
authors.lastname: Sheikh
mesh_terms: 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
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