title: Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals.
abstract: OBJECTIVE
  To evaluate the implementation and adoption of the NHS detailed care records service in "early adopter" hospitals in England.
  
  
  METHODS
  Theoretically informed, longitudinal qualitative evaluation based on case studies.
  
  
  METHODS
  12 "early adopter" NHS acute hospitals and specialist care settings studied over two and a half years.
  
  
  METHODS
  Data were collected through in depth interviews, observations, and relevant documents relating directly to case study sites and to wider national developments that were perceived to impact on the implementation strategy. Data were thematically analysed, initially within and then across cases. The dataset consisted of 431 semistructured interviews with key stakeholders, including hospital staff, developers, and governmental stakeholders; 590 hours of observations of strategic meetings and use of the software in context; 334 sets of notes from observations, researchers' field notes, and notes from national conferences; 809 NHS documents; and 58 regional and national documents.
  
  
  RESULTS
  Implementation has proceeded more slowly, with a narrower scope and substantially less clinical functionality than was originally planned. The national strategy had considerable local consequences (summarised under five key themes), and wider national developments impacted heavily on implementation and adoption. More specifically, delays related to unrealistic expectations about the capabilities of systems; the time needed to build, configure, and customise the software; the work needed to ensure that systems were supporting provision of care; and the needs of end users for training and support. Other factors hampering progress included the changing milieu of NHS policy and priorities; repeatedly renegotiated national contracts; different stages of development of diverse NHS care records service systems; and a complex communication process between different stakeholders, along with contractual arrangements that largely excluded NHS providers. There was early evidence that deploying systems resulted in important learning within and between organisations and the development of relevant competencies within NHS hospitals.
  
  
  CONCLUSIONS
  Implementation of the NHS Care Records Service in "early adopter" sites proved time consuming and challenging, with as yet limited discernible benefits for clinicians and no clear advantages for patients. Although our results might not be directly transferable to later adopting sites because the functionalities we evaluated were new and untried in the English context, they shed light on the processes involved in implementing major new systems. The move to increased local decision making that we advocated based on our interim analysis has been pursued and welcomed by the NHS, but it is important that policymakers do not lose sight of the overall goal of an integrated interoperable solution.
authors: eHealth Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9DX, UK. aziz.sheikh@ed.ac.uk
authors: Aziz
authors: A
authors: Sheikh
authors: Tony
authors: T
authors: Cornford
authors: Nicholas
authors: N
authors: Barber
authors: Anthony
authors: A
authors: Avery
authors: Amirhossein
authors: A
authors: Takian
authors: Valentina
authors: V
authors: Lichtner
authors: Dimitra
authors: D
authors: Petrakaki
authors: Sarah
authors: S
authors: Crowe
authors: Kate
authors: K
authors: Marsden
authors: Ann
authors: A
authors: Robertson
authors: Zoe
authors: Z
authors: Morrison
authors: Ela
authors: E
authors: Klecun
authors: Robin
authors: R
authors: Prescott
authors: Casey
authors: C
authors: Quinn
authors: Yogini
authors: Y
authors: Jani
authors: Maryam
authors: M
authors: Ficociello
authors: Katerina
authors: K
authors: Voutsina
authors: James
authors: J
authors: Paton
authors: Bernard
authors: B
authors: Fernando
authors: Ann
authors: A
authors: Jacklin
authors: Kathrin
authors: K
authors: Cresswell
mesh_terms: D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D003191:Comprehensive Health Care / Q000379:methods* / Q000706:statistics & numerical data; D003284:Contract Services; D057286:Electronic Health Records / Q000458:organization & administration*; D004739:England; D006078:Government Programs / Q000706:statistics & numerical data*; D006284:Health Plan Implementation / Q000458:organization & administration / Q000706:statistics & numerical data*; D006291:Health Policy; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D019982:Organizational Case Studies; D009936:Organizational Innovation; D015397:Program Evaluation; D011446:Prospective Studies; D036301:Qualitative Research; D012984:Software; D013222:State Medicine / Q000458:organization & administration* / Q000706:statistics & numerical data; D018581:Technology Transfer; D013997:Time Factors