title: Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace.
abstract: OBJECTIVE
  To evaluate the policy making process, implementation by NHS organisations, and patients' and carers' experiences of efforts to introduce an internet accessible personal electronic health record (HealthSpace) in a public sector healthcare system.
  
  
  METHODS
  Mixed method, multilevel case study.
  
  
  METHODS
  English National Health Service; the basic HealthSpace technology (available throughout England) and the advanced version (available in a few localities where this option had been introduced) were considered.
  
  
  METHODS
  National statistics on invitations sent, HealthSpace accounts created, and interviews and ethnographic observation of patients and carers. Data analysis was informed by a socio-technical approach which considered macro and micro influences on both adoption and non-adoption of innovations, and by the principles of critical discourse analysis.
  
  
  METHODS
  56 patients and carers (of whom 21 opened a basic HealthSpace account, 20 had diabetes but were not initially using HealthSpace, and 15 used advanced HealthSpace accounts to exchange messages with their general practitioner), 3000 pages of documents (policies, strategies, business plans, minutes of meetings, correspondence), observational field notes, and 160 interviews with policy makers, project managers, and clinical staff.
  
  
  RESULTS
  Between 2007 and October 2010, 172 950 people opened a basic HealthSpace account. 2913 (0.13% of those invited) opened an advanced account, compared with 5-10% of the population anticipated in the original business case. Overall, patients perceived HealthSpace as neither useful nor easy to use and its functionality aligned poorly with their expectations and self management practices. Those who used email-style messaging were positive about its benefits, but enthusiasm beyond three early adopter clinicians was low, and fewer than 100 of 30 000 patients expressed interest. Policy makers' hopes that "deploying" HealthSpace would lead to empowered patients, personalised care, lower NHS costs, better data quality, and improved health literacy were not realised over the three year evaluation period.
  
  
  CONCLUSIONS
  Unless personal electronic health records align closely with people's attitudes, self management practices, identified information needs, and the wider care package (including organisational routines and incentive structures for clinicians), the risk that they will be abandoned or not adopted at all is substantial. Conceptualising such records dynamically (as components of a socio-technical network) rather than statically (as containers for data) and employing user centred design techniques might improve their chances of adoption and use. The findings raise questions about how eHealth programmes in England are developed and approved at policy level.
authors.affiliation: Healthcare Innovation and Policy Unit, Centre for Health Sciences, Barts and the London School of Medicine and Dentistry, London E1 2AT, UK. p.greenhalgh@qmul.ac.uk
authors.forename: Trisha
authors.initials: T
authors.lastname: Greenhalgh
authors.forename: Susan
authors.initials: S
authors.lastname: Hinder
authors.forename: Katja
authors.initials: K
authors.lastname: Stramer
authors.forename: Tanja
authors.initials: T
authors.lastname: Bratan
authors.forename: Jill
authors.initials: J
authors.lastname: Russell
mesh_terms: D057286:Electronic Health Records / Q000706:statistics & numerical data*; D034742:Electronic Mail / Q000706:statistics & numerical data; D004739:England; D006291:Health Policy; D006801:Humans; D020407:Internet / Q000706:statistics & numerical data*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010358:Patient Participation / Q000706:statistics & numerical data; D012984:Software; D013222:State Medicine / Q000706:statistics & numerical data