Lessons learned from England's national electronic health record implementation: implications for the international community

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.