title: Integrating commercial ambulatory electronic health records with hospital systems: An evolutionary process.
abstract: OBJECTIVE
  The increase in electronic health record implementation in all treatment venues has led to greater demands for integration within and across practice settings with different work cultures. We study the evolution of coordination processes when integrating ambulatory-specific electronic health records with hospital systems.
  
  
  METHODS
  Longitudinal qualitative study using semi-structured interviews and archival documentation throughout a 5-year implementation and integration of obstetrical ambulatory and hospital records with a goal of achieving a perinatal continuum of care.
  
  
  RESULTS
  As users implement and integrate electronic health records, there is an evolution in their focus from technology acceptance to structural adaptation to coordination. The users' perspective on standardization evolves from initial concern about the unintended consequences of standardization to recognition of its importance and then finally to more active acceptance. The system itself cannot drive all reengineering; the organization must impose specific work process changes and as the user's perspective evolves, more individually adapted and aligned change will occur. Computer integration alone does not result in coordination; users must value integrated information and incorporate this information within their workflows.
  
  
  CONCLUSIONS
  Users initially view electronic health records as a documentation tool, but over time they come to recognize the benefits of the system for clinical information retrieval, and finally, for care coordination after the integrated information provided through electronic health records becomes more complete, accessible and adapted to meet user needs. As this occurs, coordination mechanisms move beyond pooled standardization through sequential plans coordinated by the organization to reciprocal mutual adjustments for clinical decision making by individuals. Trust in the information source, not software interoperability, is critical for information sharing.
  
  
  CONCLUSIONS
  Organizations implementing commercial electronic health records cannot simply assume that reciprocal coordination will immediately occur. It takes time for users to adjust, and enculturate coordination goals, during which time there are adaptive structurations that require organizational response, and changes in mechanisms for achieving coordination.
authors.affiliation: Lehigh University Department of Management, Bethlehem, PA 18015, United States. Electronic address: sas6@lehigh.edu.
authors.forename: Susan A
authors.initials: SA
authors.lastname: Sherer
authors.affiliation: Lehigh University Department of Economics, Bethlehem, PA 18015, United States.
authors.forename: Chad D
authors.initials: CD
authors.lastname: Meyerhoefer
authors.affiliation: Lehigh Valley Health Network, Allentown, PA 18105, United States.
authors.forename: Michael
authors.initials: M
authors.lastname: Sheinberg
authors.affiliation: Lehigh Valley Health Network, Allentown, PA 18105, United States.
authors.forename: Donald
authors.initials: D
authors.lastname: Levick
mesh_terms: D000553:Ambulatory Care; D019033:Delivery of Health Care, Integrated; D057286:Electronic Health Records / Q000458:organization & administration*; D006801:Humans; D033181:Information Dissemination; D016247:Information Storage and Retrieval; D008137:Longitudinal Studies; D016347:Medical Records Systems, Computerized / Q000592:standards*; D008962:Models, Theoretical; D017149:Private Sector; D036301:Qualitative Research; D012984:Software
keywords: Care coordination; Clinical information retrieval; Electronic health records