title: Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems.
abstract: BACKGROUND
  A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments' healthcare reform strategies. The resulting politically-initiated large-scale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money.
  
  
  METHODS
  Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England's National Health Service's Care Records Service (NHS CRS).
  
  
  CONCLUSIONS
  We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations → intervention → changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions.
  
  
  CONCLUSIONS
  New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.
authors.affiliation: Division of Health Studies, School of Health Sciences & Social Care, Brunel University, Uxbridge UB8 3PH, UK. amir.takian@brunel.ac.uk
authors.forename: Amirhossein
authors.initials: A
authors.lastname: Takian
authors.forename: Dimitra
authors.initials: D
authors.lastname: Petrakaki
authors.forename: Tony
authors.initials: T
authors.lastname: Cornford
authors.forename: Aziz
authors.initials: A
authors.lastname: Sheikh
authors.forename: Nicholas
authors.initials: N
authors.lastname: Barber
mesh_terms: D057191:Capacity Building; D003195:Computer Communication Networks / Q000458:organization & administration; D019033:Delivery of Health Care, Integrated; D004059:Diffusion of Innovation; D057286:Electronic Health Records / Q000331:legislation & jurisprudence; D004739:England; D006284:Health Plan Implementation; D006291:Health Policy; D006801:Humans; D007373:Interinstitutional Relations; D017146:Models, Organizational; D009313:National Health Programs; D015397:Program Evaluation / Q000379:methods*; D012922:Social Change