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Lessons Learned from England’s National Electronic
Health Record Implementation:
Implications for the International Community
Kathrin M. Cresswell
eHealth Research Group
Centre for Population Health Sciences
The University of Edinburgh
0044 131 650 9241
Kathrin.Beyer@ed.ac.uk
Ann Robertson
eHealth Research Group
Centre for Population Health Sciences
The University of Edinburgh
0044 131 650 9459
A.R.R.Robertson@ed.ac.uk
Aziz Sheikh
eHealth Research Group
Centre for Population Health Sciences
The University of Edinburgh
0044 131 650 4151
Aziz.Sheikh@ed.ac.uk
ABSTRACT
Background: National electronic health record (EHR) programs
are increasingly being pursued across the world with the aim of
improving the safety, quality and efficiency of healthcare. Despite
significant international investments, and particularly in the light
of reported “failures”, there is surprisingly little evidence on the
specific and potentially transferable factors associated with the
planning and execution of large-scale EHR implementations.
England embarked on a National Program in 2002, characterized
by “top-down”, central procurement of a few, standardized EHR
systems. Objectives: To evaluate the national implementation and
adoption of EHRs in English hospitals and derive lessons for this
and other national EHR programs. Design: We conducted a
qualitative case study-based longitudinal evaluation drawing on
sociotechnical principles. Setting: Data were collected from 12
“early adopter” hospitals across England. Data sources: Our
dataset consisted of 431 semi-structured interviews; 590 hours of
observations; 334 sets of notes from observations, researcher field
notes and notes from conferences; 809 hospital documents; and 58
national and regional documents. Results: A range of factors
emerged as important. These included software characteristics and
user involvement in shaping technology; realistic timelines,
balancing the national EHR vision and stakeholder expectations;
relationship building and communication; balancing national
progress with allowing local accommodation; and maintaining
central direction whilst permitting degrees of local autonomy.
Conclusions: It is not possible to be prescriptive for achieving
“successful” national EHR implementations. Nonetheless, we
identify dimensions likely to be of greater significance than
others, in a range of national contexts. We argue that design,
based on users’ requirements, and accommodation of the
technology in the healthcare setting need to occur on a small-scale
first before building out to satisfy organizational, local health
economy and national needs, and that this needs time. Our results
will we hope offer evidence to inform national strategies for
large-scale and expensive EHR ventures.
Categories and Subject Descriptors
D.2.11 Computer Systems Organization [General]: Systems
Application Architecture
General Terms
standardization
Keywords
Electronic health records; national implementation; sociotechnical
evaluation
1. INTRODUCTION
In pursuing more efficient and safer healthcare to larger
populations with increasingly complex conditions, there is now
growing international interest in the potential of information
technology (IT) (1;2). Costly and multifaceted electronic health
record systems (EHRs) have been central to these efforts (3-7).
These consist of longitudinal patient records that can be shared
across care settings and associated clinical and management
functionalities. However, to date many implementations of such
systems and associated benefits have been achieved on relatively
small scales. Here, systems have been extensively customized to
local contexts. Challenges even in these smaller scale
implementations have in the main related to difficulties of
systems embedding with clinical and organizational workflows
(2;8;9). In contrast to these smaller implementations, larger scale
national ventures pose appreciably more challenges. But they also
offer the potential for significant benefits, particularly in relation
to secondary uses and larger scale data sharing. National EHR
implementations are therefore internationally pursued. However,
no nationally interoperable system or agreed-upon “best”
approach to realizing benefits exists as yet. Strategies for national
EHR implementations vary from connecting local systems in
individual care settings to implementing nationally procured
solutions (1;2;10). Nationally procured solutions are often
designed with interoperability considerations from their inception.
England has attempted this by procuring commercial EHR
systems nationally and implementing these centrally in individual
care settings (11-14). As there is limited evidence with regard to
any large scale implementation approaches, it is vital that other
countries learn from these experiences. This will help to ensure
that the chances of realizing benefits are maximized. In the
present paper, we focus on key lessons from the English
experience of implementing nationally procured EHRs in
hospitals. In doing so, we draw on our work evaluating the
introduction of these systems in selected care settings.
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2. METHODS
We conducted a qualitative, longitudinal, real-time evaluation of
the introduction of national EHRs into English hospitals drawing
on sociotechnical principles that emphasize the mutually shaping
relationship between social and technical factors (15;16). Data
were collected from September 2008 until February 2011. Our
detailed methods are reported elsewhere (17), but we give a brief
overview below.
We purposefully sampled 12 hospitals across England being
amongst the first to implement nationally procured EHR software
systems. We conceptualized these as case study sites in order to
gain an insight into local processes and consequences of systems
introduction (18-20). We used these insights to draw transferable
lessons for other contexts (i.e. settings yet to implement EHR
systems). In the light of the limited number of implementations
taking place at the time of our data collection, we had to be
somewhat opportunistic, but where possible sampled sites of
varying demographics, software solutions and geographical
locations (see Box 1) (21).
Box 1. Summary of case study sites
Eight acute, three mental health, and one community setting
Six teaching sites and six non-teaching sites
Five more autonomous sites
Three different software systems across sites
Locally, initial contacts were made with the Head of IT, who
acted as the first point of contact for snowball sampling other
local stakeholders including healthcare professionals who were
not part of the implementation team (doctors, nurses, allied
healthcare professionals), implementation team members,
managers and administrative staff (22;23). Each interviewee was
asked to recommend other potential interviewees and differing
viewpoints were actively sought. In order to gain an insight into
wider national processes surrounding the EHR introduction, we
also opportunistically sampled other stakeholders not directly
connected to case study sites but involved in the national
implementation strategy. These were approached through
recommendations from interviewees and through personal
contacts. They included software developers, national
implementers, independent sector representatives and
governmental stakeholders.
Our main method of data collection consisted of semi-structured
audio-taped interviews reflecting the explorative nature of our
research. The focus of these discussions was to investigate
stakeholders’ concerns and experiences in relation to using and
implementing national EHR systems. Where possible, interviews
were conducted at two time points, with an approximately six
month gap in between, in order to capture changes over time (e.g.
whether a certain amount of embedding of the software had
occurred and/or attitudes had changed). In doing so, we actively
attempted to explore varying perspectives of a range of
stakeholders. Interviews were complemented by observations of
local strategic implementation meetings and use of the software in
the respective care settings. This allowed exploring of informal
processes and “real world” (as opposed to reported) issues and
how these were tackled locally (e.g. how users would react to a
slow-loading screen and what consequences this had for the
running of clinics). Researchers also collected local documents
(including project initiation and lessons learned reports) and
national documents (including governmental reports and reviews
of progress relating to the national EHR systems) in order to keep
abreast of formally planned changes and actual developments on
the ground. We assigned lead researchers who collected and
analyzed data in individual case study sites in order to allow
immersion in local contexts and gain an in-depth insight into local
contingencies. During data collection, emerging findings
informed subsequent research activities, which helped to refine
and test emerging hypotheses (24;25). This involved feeding back
emerging findings to local implementation team members as the
study progressed. Data collection continued until no new major
themes emerged i.e. the point at which researchers felt they had
gained sufficient insights into the complexities of each case
during the time they were in the field. Data analysis was informed
by sociotechnical principles, paying careful attention to how
social and technical dimensions evolved over time. It was
facilitated by regular analysis workshops amongst the wider team
to discuss emerging findings and explore new potential avenues
for investigation (15;16). We combined deductive thematic
analysis (based on a substantive review of the empirical literature)
with inductive thematic analysis to allow new themes to emerge
from the data (15;26;27). After analyzing each case study
separately, and integrating individual data sources within cases,
we aggregated findings across cases and integrated these with
findings obtained from the wider national environment (i.e.
interviews with stakeholders outside the immediate hospital
environment, and national documents).
3. RESULTS
We collected data through 431 semi-structured interviews. In
addition, we obtained 334 sets of notes from 590 hours of
observations, researcher field notes and notes from conferences.
These were complemented by 809 hospital documents and 58
national and regional documents. Overall we found that
accommodation and technological design needed to occur on a
local/organizational level first before satisfying organizational,
local health economy and national needs. In doing so, we have
identified five overarching themes, which we will discuss in the
paragraphs below.
3.1 Software characteristics and user
involvement in shaping technology
Our results indicated that the most important pre-requisite for
implementing complex EHRs was the existence of software that
was usable, or could be ‘made usable’, and modified over time to
suit the evolving needs of a variety of user groups. In case studies
where software design reflected user needs or was customized to
do so over time, users were more motivated and early benefits
were more likely to be realized. Conversely, where system design
was felt to be inadequate, this often resulted in increased
workloads for users, who often spent a long time browsing the
system to find information they needed due to slow loading of
screens. In some cases there were also perceived adverse
consequences for organizational functioning as clinical users
stated that administrative tasks increased, whilst clinical time was
compromised. Therefore, in some instances, patient throughput
was reduced.
Lack of system usability was overall particularly evident in
systems that had been untested and not previously implemented
(of which there was one out of three), whilst systems that had
routinely been implemented in other contexts were often more
usable. The only way to achieve system usability seemed to be by
consulting users and incorporating their suggestions into system
design. This was often done through designated representatives
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who fed back user concerns to the implementation team. Sites
where this was achieved often consisted of small-scale
implementations but tended to have more motivated users, whilst
sites where users did not feel listened to tended to have
increasingly stressed and frustrated users.“But I’ve had a lot of
frustrations with it and continue to have. I don’t really feel, cause
we’ve handed information through the system to the [name of
system] representative [each team has one of these to feed back
problems], I don’t really feel any changes have been made really,
I don’t know no, there was a slight change to the template.”
(Interview, Healthcare Professional)
3.2 Realistic timelines, expectations and
balancing the national EHR vision
Across softwares and settings, we further found that stakeholders
often stated that the ambitious implementation timelines
hampered progress, with expectations far exceeding what was
realistically achievable. The ambitious vision of nationally shared
detailed EHRs over time changed to many stakeholders believing
that it was more realistic to only share certain demographic
information: “What would have been ideal is the shared care
record vision which was one system like [name of system] … until
six to nine months ago I still believed that we could deliver that.
[…] I think the only way of doing that now is an expanded
summary care record or something like that…” (Interview,
Manager) For example, users were often disappointed with the
observed benefits of using national software that in many cases
was perceived to slow down individual work practices. This was
more pronounced with some software packages than others, but
particularly so when users could not conceptualize the exact
functionality (as some systems were still in development and
could not be demonstrated). There was therefore uncertainty as to
what benefits could be expected in the future and it was difficult
to plan implementation activities. This was exacerbated by, in
some instances, users reporting to have been presented with a
system that looked different than the one they had seen in
practice.
3.3 Relationship building at all levels
We also found that aligning the interests of diverse stakeholder
groups was important throughout the national implementation.
Relevant stakeholders did not only include those within the
immediate hospital environment but also those outside the case
study sites, such as developers, who incorporated suggested
software changes. However, across settings we found that local
relationship building between suppliers and users was often
inhibited by centrally managed contracts resulting in delays in
incorporating locally requested software changes due to complex
bureaucratic processes. “Strange, very strange, and in some ways
I think that’s what drives some of the frustration probably from
both parties sitting at the far end is, you know, if we can’t engage
with the customer how do we know we’re delivering something
that’s going to be beneficial and vice versa, you know, if they’ve
got to go through seven loops to get something fixed and then you
get a question coming back, why do you want that, because
you’ve not got that direct communication the frustration
increases.” (Interview, Developer) Nationally negotiated
contracts largely excluded individual hospitals. Therefore,
implementation team members had limited power for making the
systems usable in each environment due to national arrangements.
Those that delivered the software were often more concerned with
receiving monetary rewards as opposed to high quality
implementations locally: “…this kind of slightly difficult
contractual relationship where unless you throw it over the wall
in the right format it’s not our problem… Yes and I actually know
its not because your company is only going to make money if
this…system is credible for the rest of the NHS [National Health
Service] and it doesn’t look credible while you’re being very
careful about whether you’re in it with us or not you know, you
need to be over on our side of the fence, its needs to worry you as
much as it worries us about getting this right and that has been
quite a difficult...” (Interview, Manager) Other stakeholders of
relevance included associated commercial and governmental
bodies as well as IT professionals and healthcare workers
themselves. These different groups were often not used to
working together. Consequently, communication was often
complicated with many stakeholders feeling that other parties
were “speaking an entirely different language” to themselves.
This was particularly apparent when healthcare professionals
attempted to communicate their needs to managers and system
developers. Again, this was slightly less pronounced in small-
scale implementation settings, where designated members of the
implementation team had established good personal relationships
with software users.
3.4 Balancing national progress with allowing
local accommodation
We further observed a tension between the need to show
implementation progress locally and an incremental
implementation approach to allow for local accommodation of the
technological change to occur. The best way of helping to
accommodate the changes brought about with a new EHR was
characterized by an incremental implementation approach by
most organizational stakeholders, although replacing patient
administration functionality was by nature somewhat larger-scale.
Pressure to show progress too quickly, on the other hand, seemed
to result in unintended consequences at individual and
organizational levels, such as the need to adopt workarounds and
resulting knock-on effects. These included for example entering
data into the system at a later point whilst taking notes on paper
during the clinical encounter because the system was viewed as
too time-consuming and clinical responsibilities took priority. As
a result, the computer system was not as up-to-date as paper
records. We found this to be the case across softwares and
settings:“…it’s very frustrating when if you’re in a clinic with
time pressures, you’ve got a patient sat there, you need to be
getting on to treat them, you know, you might have another few in
the clinic waiting… So what we’re doing you see there is writing
it all down and going into [the computer system] when we have
time later.” (Interview, Healthcare Professional)
3.5 Central guidance and local autonomy
Despite the need for new EHR systems to satisfy user and
organizational needs, our results have also pointed to the
importance of considering standards for larger scale
interoperability. However, these concerns seemed to be secondary
to most organizational stakeholders as local accommodation
needed to occur first. Conversely, a primary focus on
interoperability was felt to compromise local usability as the
design of the software in many cases lacked tailoring to local
needs. Nevertheless, most also acknowledged that a certain
amount of political guidance and setting of standards was
important for a national implementation in order to guide
organizations, whilst imposing national systems was felt to be
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unlikely to work: “… the framework and the technology…still
needs applications and modifications to meet localized
requirements… so there’s still a need for services deployment
management and also certification of specific tools that would be
used by various organizations.” (Interview, Independent Sector)
Most participants, irrespective of setting and software
functionality, also argued that a central authority overseeing
implementation should focus on connecting local and natural
groupings of healthcare organizations first in order to bring local
benefits, before considering larger scale interoperability and data
sharing.
4. DISCUSSION
Our findings echo many of the factors associated with EHR
implementation and adoption in the literature (28-38), but provide
unique insights into the worldwide first attempt to implement
nationally procured software. The results therefore build on the
existing literature by illustrating that a central management model
and a primary focus on national integration can undermine the
best efforts to make a system usable and fit a particular
environment. This was apparent by systems lacking
customizability and therefore not fulfilling the needs of individual
users as well as organizations. As a result, the centralized
implementation model has, over time, increasingly allowed more
local input in system choice (39;40). We have therefore argued
that accommodation and technological design needs to occur on a
local/organizational level first and begin with the user. Only when
local factors are attended to will a system be able to satisfy
organizational (e.g. management and small-scale information
sharing), local health economy (e.g. local information sharing)
and national needs (e.g. interoperability and secondary uses).
However, in large-scale national ventures there is a danger that an
initial focus on interoperability may cloud this essential
consideration of user involvement in shaping technological
developments. A word of caution is however needed at this stage
as there were clearly reasons for nationally procuring EHR
solutions, particularly in relation to cost savings through large-
scale contracting and anticipated benefits associated with
interoperability of standardized systems (41). The main danger
then is that if efforts are too localized, there may be no coherent
approach to implementation, resulting in potentially compromised
interoperability. Arguably, a balance needs to be struck between
both standardization and localized developments and there appear
to be trade-offs resulting from a too concentrated focus on either.
For example, despite nationally led strategies resulting in a likely
optimization of technical integration and interoperability, there is
a danger that these systems are not accepted and used by end-
users as local motivations for use may be neglected. Conversely,
if the emphasis is solely on building systems arising from local
need, these are likely to be used, but major issues may arise when
attempting to integrate systems on a larger scale. In the light of
our findings, and the need to build on user informed system
design, the second extreme scenario would, however, be
preferable, as integration of systems appears secondary and local
benefits may still be realized even if national systems integration
is initially not achieved. Despite these important insights, our
case-study based design may mean limited transferability of
findings to other settings, but this was not our aim. We have
instead focused on drawing transferable lessons for international
efforts of implementing large-scale EHR systems (summarized in
Box 2). Many of these are in line with the existing literature (28-
38).
Box 2. Summary of lessons learned from the English venture
The initial focus should be on making the software
usable. This should be informed by users.
Expectations need to be realistic. Benefits may take a
long time to realize, and systems may initially slow
down work practices and impact adversely on
organizational functioning.
Implementing EHRs in an ongoing process and needs to
be expected to continue in line with changing local and
national needs as well as political landscapes.
Efforts should ideally begin with the user, before
moving on to more general organizational and national
requirements. A balance between customization and
standardization is vital.
Aligning efforts of various stakeholder groups is
necessary for an integrated approach to the vision.
Appropriate time and resources need to be allocated
nationally to allow the process of local accommodation
to occur. Centrally negotiated contracts may inhibit
these desired developments.
It is also important to note that we are reporting on the early
stages of implementation and adoption only and can therefore not
claim transferability of findings for the later stages of the English
venture.
5. CONCLUSIONS
We have summarized the lessons learned from the English
attempt to implement national-scale centrally procured EHR
systems and outlined lessons that can be learned from these
experiences to inform other international ventures. In doing so,
we have argued that initial efforts should focus on designing
technology that is fit for local use and satisfies user and
organizational needs. Important, but secondary to these
developments should be large-scale interoperability. We hope that
the lessons drawn from our work and summarized in Box 2 will
inform future efforts and help to ensure that large-scale EHR
implementations proceed as smoothly as possible with the highest
chances of fulfilling the promise of improving the safety and
quality of care.
6. ACKNOWLEDGMENTS
We are very grateful to the participating hospitals for supporting this work
and to all interviewees who kindly gave their time. We also acknowledge the
work by our colleagues in the evaluation team. KC was supported by an MRC
studentship. We have had helpful support from colleagues at the NHS
Connecting for Health Evaluation Programme and our Independent Project
Steering Committee. We acknowledge the support of the National Institute
for Health Research, through the Comprehensive Clinical Research Network.
We are also grateful to the helpful feedback of the five expert reviewers.
7. REFERENCES
(1) Catwell L, Sheikh A. Information technology system users
must be allowed to decide on the future direction of major
national IT initiatives. Inform Prim Care 2009; 17(1):1-4.
(2) Protti D. Comparison of information technology in general
practice in 10 countries. Healthcare Quarterly 2007;
10(2):107-115.
(3) Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth
E et al. Systematic review: impact of health information
technology on quality, efficiency, and costs of medical care.
Ann Intern Med 2006; 144:742-752.
688
(4) Cresswell K, Sheikh A. The NHS Care Record Service:
recommendations from the literature on successful
implementation and adoption. Inform Prim Care 2009;
17(3):153-160.
(5) Friedman C, Abbas U. Is medical informatics a mature
science? A review of measurement practice in outcome
studies of clinical systems. Int J Med Inform 2003; 69(2-
3):261-272.
(6) Greenhalgh T, Potts H, Wong G, Bark P, Swinglehurst D.
Tensions and paradoxes in electronic patient record
research: a systematic literature review using the meta-
narrative method. Milbank Q 2009; 87(4):729-788.
(7) Black A, Car J, Pagliari C, Anandan C, Cresswell K. The
Impact of eHealth on the quality and safety of health care: a
systematic overview. PLoS Med 2011; 8(1).
(8) Shekelle P, Goldzweig C. Costs and benefits of health
information technology: an updated systematic review.
2009. London, RAND Corporation.
(9) Lorenzi N, Novak L, Weiss J, Gadd C, Unertl K. Crossing
the implementation chasm: a proposal for bold action. J Am
Med Inform Assoc 2008; 15(3):290-296.
(10) Coiera E. Building a National Health IT system from the
middle out. J Am Med Inform Assoc 2009; 16(3):271-273.
(11) Brennan S. The biggest computer programme in the world
ever! How's it going? JITE 2007; 22:201-211.
(12) Greenhalgh T, Stramer K, Bratan T, Byrne E, Russell J,
Hinder S et al. The devil's in the detail: final report of the
independent evaluation of the Summary Care Record and
Health Space programmes. 2010. University College
London.
(13) Hendy J, Fulop N, Reeves B, Hutchings A, Collin S.
Implementing the NHS information technology programme:
qualitative study of progress in acute trusts. BMJ 2007;
334(7608):1360.
(14) Public Accounts Committee. The National Programme for
IT in the NHS: progress since 2006. 2009.
(15) Cornford T, Doukidis G, Forster D. Experience with a
structure, process and outcome framework for evaluating
and information system. Omega 1994; 22(5):491-504.
(16) Cresswell K, Worth A, Sheikh A. Actor-Network Theory
and its role in understanding the implementation of
information technology developments in healthcare. BMC
Med Inf Dec Mak 2010; 10(1):67.
(17) Cresswell K, Ali M, Avery A, Barber N, Cornford T, Crowe
S et al. The long and winding road…an independent
evaluation of the implementation and adoption of the NHS
Care Records Service in secondary care in England.
http://www.haps.bham.ac.uk/publichealth/cfhep/005.shtml.
2011.
(18) George A, Bennett A. Case studies and theory development
in the social sciences. London, England: MIT Press
Cambridge, 2005.
(19) Stake R. The art of case study research. London: Sage,
1995.
(20) Yin R. Case study research, design and methods. London:
Sage, 2009.
(21) Patton M. Qualitative research & evaluation methods.
London: Sage, 2002.
(22) Silverman D. Doing qualitative research, a practical
handbook. London: Sage, 2000.
(23) Peters T, Waterman R. In search of excellence: lessons from
America's best run companies. New York: Harper and Row,
1982.
(24) Becker H. Sociological work. London: Allen Lane, 1971.
(25) Miles M, Huberman A. Qualitative data analysis. London:
Sage, 1984.
(26) Corbin J, Strauss A. Strategies for qualitative data analysis.
CA: Sage, 2008.
(27) Mays N, Pope C. Quality in qualitative health research.
London: BMJ Publication Group, 1999.
(28) Berg M. Implementing information systems in health care
organizations: myths and challenges. Int J Med Inform
2001; 64:143-156.
(29) Beynon-Davies P, Lloyd-Williams P. When health
information systems fail. Top Health Inf Manage 1999;
19(4):66-79.
(30) Bingi P, Sharma M, Godla JK. Critical issues affecting an
ERP implementation. ISM 2001; 16(3):7-14.
(31) Brender J, Ammenwerth E, Nykänen P, Talmon J. Factors
influencing success and failure of health informatics
systems - a pilot Delphi study. Methods Inf Med 2006;
45(1):125-136.
(32) Glaser J. More on management's role in IT project failure.
Healthc Financ Manage 2005; 59:82-89.
(33) Goldfinch S. Pessimism, computer failure, and information
systems development in the public sector. Pub Adm Rev
2007; 67:917-929.
(34) Heeks R. Health information systems: Failure, success and
improvisation. Int J Med Inf 2006; 75:125-137.
(35) McManus J, Wood-Harper T. Understanding the sources of
information systems project failure. Manag Serv 2007;38-
43.
(36) Pare G, Sicotte C, Jaana M, Girouard D. Prioritizing the risk
factors influencing the success of clinical information
system projects. A Delphi study in Canada. Meth Inf Med
2008; 47(3):251-259.
(37) Wears R, Cook R, Perry S. Automation, interaction,
complexity, and failure: A case study. Reliability
Engineering & System Safety 2006; 91.
(38) Wing L. Investigating success factors in enterprise
application integration: a case-driven analysis. EJIS 2005;
14(2):175-187.
(39) Department of Health. Equity and excellence: Liberating
the NHS. 2010.
(40) Cabinet Office. Government ICT Strategy.
http://www.cabinetoffice.gov.uk/content/government-ict-
strategy. 2011.
(41) Craig D. Plundering the Public Sector. London: Constable,
200
689
