title: The implications of e-health system delivery strategies for integrated healthcare: lessons from England.
abstract: OBJECTIVE
  This paper explores the implications that different technical strategies for sharing patient information have for healthcare workers and, as a consequence, for the extent to which these systems provide support for integrated care.
  
  
  METHODS
  Four technical strategies were identified and the forms of coupling they made with healthcare agencies were classified. A study was conducted in England to examine the human and organizational implications of systems implemented by these four strategies. Results were used from evaluation reports of two systems delivered as part of the NPfIT (National Programme for Information Technology) and from user responses to systems delivered in two local health communities in England. In the latter study 40 clinical respondents reported the use of systems to support integrated care in six healthcare pathways.
  
  
  RESULTS
  The implementation of a detailed care record system (DCRS) in the NPfIT was problematic because it could not meet the diverse needs of all healthcare agencies and it required considerable local customization. The programme evolved to allow different systems to be delivered for each local health community. A national Summary Care Record (SCR) was implemented but many concerns were raised about wide access to confidential patient information. The two technical strategies that required looser forms of coupling and were under local control led to wide user adoption. The systems that enabled data to be transferred between local systems were successfully used to support integrated care in specific healthcare pathways. The portal approach gave many users an opportunity to view patient data held on a number of databases and this system evolved over a number of years as a result of requests from the user community.
  
  
  CONCLUSIONS
  The UK national strategy to deliver single shared database systems requires tight coupling between many users and has led to poor adoption because of the diverse needs of healthcare agencies. Sharing patient information has been more successful when local systems have been developed to serve particular healthcare pathways or when separate databases are viewable through a portal. On the basis of this evidence technical strategies that permit the local design of tight coupling are necessary if information systems are to support integrated care in healthcare pathways.
authors.affiliation: Bayswater Institute, 9 Orme Court, London W2 4RL, UK. k.d.eason@lboro.ac.uk
authors.forename: Ken
authors.initials: K
authors.lastname: Eason
authors.forename: Patrick
authors.initials: P
authors.lastname: Waterson
mesh_terms: D003299:Cooperative Behavior; D016208:Databases, Factual; D003695:Delivery of Health Care; D019033:Delivery of Health Care, Integrated / Q000379:methods* / Q000458:organization & administration*; D057286:Electronic Health Records; D006801:Humans; D007256:Information Systems; D017216:Telemedicine