"We are doing it together, don't worry" - A qualitative study on the implementation of electronic medical records in German hospitals.

Background: The ongoing implementation of electronic medical records (EMRs) in German hospitals is currently slow. Implementation science widely acknowledges the barriers and facilitators to implementation. Thus, specific preconditions are necessary to address the former and to support an effective EMR implementation. However, a lack of knowledge exists about these necessary preconditions in Germany. This study aims to gain insight into key stakeholders' experiences with implementing EMR systems in German hospitals to identify preconditions for embedding EMRs in this social context.

Methods: Expert interviews were conducted with members of hospital-wide implementation teams concerning EMR implementation. The interviewees belonged to the nursing, IT, medical, and pharmaceutical professions and worked in hospitals with different contextual characteristics. The interview guideline was based on the practical Consolidated Framework for Implementation, which supports the systematic assessment of potential barriers and facilitators to identify implementation strategies and necessary adaptations. Data was collected between May 2021 and September 2022, and the interviews were analyzed using qualitative content analysis.

Results: Thirteen interviews were conducted with employees from eleven hospitals. Five critical preconditions emerged for EMR implementation based on our analysis: 1) adaptation, where the clinical context and EMRs are aligned; 2) stakeholder co-production, where all relevant stakeholders (e. g., professional groups, departments, and hierarchical levels) are involved in planning, implementing, and evaluating; 3) end-user participation, where end-users are involved in the implementation through close support and training; 4) integration into daily routines, where EMRs are integrated into daily work, including work processes that initially require additional effort but are necessary to experience the relative advantages; and 5) the continuous Plan-Do-Check-Act cycle, where the EMR implementation process is continuously reviewed and adjusted. In addition, activities to enact these preconditions were derived based on the interview data.

Discussion: Our findings indicate that overall contextual adaptation is required. The five preconditions include essential activities to facilitate the integration of the EMR into daily routines. Participation, communication, and support are fundamental, as described in the international literature. Failure to comply with these preconditions can lead to challenges during implementation, such as end-user resistance.

Conclusion: Considering social and technical aspects is paramount in implementing EMRs, which may also apply to future digital innovations' change management processes.