title: Integration of a nationally procured electronic health record system into user work practices.
abstract: BACKGROUND
  Evidence suggests that many small- and medium-scale Electronic Health Record (EHR) implementations encounter problems, these often stemming from users' difficulties in accommodating the new technology into their work practices. There is the possibility that these challenges may be exacerbated in the context of the larger-scale, more standardised, implementation strategies now being pursued as part of major national modernisation initiatives. We sought to understand how England's centrally procured and delivered EHR software was integrated within the work practices of users in selected secondary and specialist care settings.
  
  
  METHODS
  We conducted a qualitative longitudinal case study-based investigation drawing on sociotechnical theory in three purposefully selected sites implementing early functionality of a nationally procured EHR system. The complete dataset comprised semi-structured interview data from a total of 66 different participants, 38.5 hours of non-participant observation of use of the software in context, accompanying researcher field notes, and hospital documents (including project initiation and lessons learnt reports). Transcribed data were analysed thematically using a combination of deductive and inductive approaches, and drawing on NVivo8 software to facilitate coding.
  
  
  RESULTS
  The nationally led "top-down" implementation and the associated focus on interoperability limited the opportunity to customise software to local needs. Lack of system usability led users to employ a range of workarounds unanticipated by management to compensate for the perceived shortcomings of the system. These had a number of knock-on effects relating to the nature of collaborative work, patterns of communication, the timeliness and availability of records (including paper) and the ability for hospital management to monitor organisational performance.
  
  
  CONCLUSIONS
  This work has highlighted the importance of addressing potentially adverse unintended consequences of workarounds associated with the introduction of EHRs. This can be achieved with customisation, which is inevitably somewhat restricted in the context of attempts to implement national solutions. The tensions and potential trade-offs between achieving large-scale interoperability and local requirements is likely to be the subject of continuous debate in England and beyond with no easy answers in sight.
authors.affiliation: eHealth Research Group, Centre for Population Health Sciences, The University of Edinburgh, Scotland, UK. Kathrin.Beyer@ed.ac.uk
authors.forename: Kathrin M
authors.initials: KM
authors.lastname: Cresswell
authors.forename: Allison
authors.initials: A
authors.lastname: Worth
authors.forename: Aziz
authors.initials: A
authors.lastname: Sheikh
mesh_terms: D019033:Delivery of Health Care, Integrated; D057286:Electronic Health Records; D004739:England; D007091:Image Processing, Computer-Assisted; D008137:Longitudinal Studies; D016347:Medical Records Systems, Computerized / Q000592:standards; D008962:Models, Theoretical; D020416:Outsourced Services; D012984:Software; D013598:Systems Theory