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Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study

BMJ 2010; 340 doi: (Published 16 June 2010) Cite this as: BMJ 2010;340:c3111
  1. Trisha Greenhalgh, director1,
  2. Katja Stramer, senior research fellow2,
  3. Tanja Bratan, research fellow2,
  4. Emma Byrne, research fellow3,
  5. Jill Russell, senior lecturer2,
  6. Henry W W Potts, lecturer3
  1. 1Healthcare Innovation and Policy Unit, Centre for Health Sciences, Barts and The London School of Medicine and Dentistry, London E1 2AD
  2. 2Division of Medical Education, University College London
  3. 3Centre for Health Informatics and Multiprofessional Education, University College London
  1. Correspondence to: T Greenhalgh p.greenhalgh{at}
  • Accepted 27 May 2010


Objective To evaluate a national programme to develop and implement centrally stored electronic summaries of patients’ medical records.

Design Mixed-method, multilevel case study.

Setting English National Health Service 2007-10. The summary care record (SCR) was introduced as part of the National Programme for Information Technology. This evaluation of the SCR considered it in the context of national policy and its frontline implementation and use in three districts.

Participants and methods Quantitative data (cumulative records created nationally plus a dataset of 416 325 encounters in participating primary care out-of-hours and walk-in centres) were analysed statistically. Qualitative data (140 interviews including policy makers, managers, clinicians, and software suppliers; 2000 pages of ethnographic field notes including observation of 214 clinical consultations; and 3000 pages of documents) were analysed thematically and interpretively.

Results Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme’s fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort.

Conclusions Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale.


  • This evaluation would not have been possible without the cooperation of a number of people and organisations. Patients and staff in the various field sites allowed us access to their work and experiences, gave freely of their time, and engaged with our desire to gain an honest, richly informed account of events. Adastra provided a large quantitative dataset and background information which allowed us to undertake an independent analysis. The evaluation benefited from the Summary Care Record Independent Evaluation (SCRIE) External Advisory Group, chaired by lay member Jenni Bowley, which served as a diverse, critical, and questioning audience for our emerging findings. Members (listed in full elsewhere14) included representatives from patient groups, academic institutions, professional organisations, and Connecting for Health. The study was part of the Connecting for Health Evaluation Programme coordinated by Richard Lilford’s team at the University of Birmingham. Academic colleagues too numerous to list provided feedback and guidance throughout the study.

  • Contributors: TG designed the study, led the development of the theoretical and methodological approach, helped with data collection, led the qualitative data analysis, drafted the paper, and is responsible for the integrity of the work. She is the guarantor. KS and TB led the qualitative data collection and helped with analysing the data and writing and revising the paper. HWWP led the quantitative data analysis and helped write and revise the paper. EB provided technical input to the study and helped write and revise the paper. JR helped develop the theoretical and methodological approach and provided expertise in evaluation methodology. Rob Stones from University of Essex provided theoretical and methodological advice. Deborah Swinglehurst assisted with data collection and analysis. Enrico Coiera, Mike Pringle, and Ole Hanseth reviewed an earlier draft of the paper and added additional insights and references.

  • Funding: The independent evaluation of the summary care record programme was funded by a research grant from the UK National Institute of Health Research (ref CFHEP002 and 007). The Medical Research Council funded a parallel research study (“healthcare electronic records in organisations,” ref 07/133) by our team in which the SCR formed one case example. The analysis presented in this paper draws on both those studies. University College London (UCL) held the research grants; the empirical work was undertaken while all authors were employed at UCL. Queen Mary University of London (QMUL) funded the salary of TG during the writing-up phase.

  • Independence from sponsors: All aspects of the study (including design; collection, analysis, and interpretation of data; writing of the report; and decision to publish) were led by the authors. Sponsors, along with other stakeholders, were given an opportunity to check drafts for accuracy, but the final decision on whether to amend drafts was made by the authors in consultation with the SCRIE External Advisory Group. The views expressed in this publication are those of the authors and not necessarily those of our employing institutions, the individual members of our advisory group, the National Institute for Health Research, Connecting for Health, or the Department of Health.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that (1) all authors have support from their respective institutions (QMUL and UCL) for the submitted work; (2) none of the authors has any relationships with any companies that might have an interest in the submitted work in the previous 3 years; (3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and (4) no authors have any non-financial interests that may be relevant to the submitted work.

  • Data sharing: No additional data available.

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