Research

Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation

BMJ 2010; 341 doi: 10.1136/bmj.c4564 (Published 2 September 2010)
Cite this as: BMJ 2010;341:c4564
  1. Ann Robertson1,
  2. Kathrin Cresswell1,
  3. Amirhossein Takian2,
  4. Dimitra Petrakaki3,
  5. Sarah Crowe4,
  6. Tony Cornford3,
  7. Nicholas Barber2,
  8. Anthony Avery4,
  9. Bernard Fernando1,
  10. Ann Jacklin5,
  11. Robin Prescott1,
  12. Ela Klecun3,
  13. James Paton6,
  14. Valentina Lichtner3,
  15. Casey Quinn4,
  16. Maryam Ali3,
  17. Zoe Morrison1,
  18. Yogini Jani2,
  19. Justin Waring4,
  20. Kate Marsden4,
  21. Aziz Sheikh1
  1. 1eHealth Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG
  2. 2Department of Practice and Policy, School of Pharmacy, University of London, London
  3. 3Department of Management, London School of Economics and Political Science, London
  4. 4Division of Primary Care, University of Nottingham, Nottingham
  5. 5Imperial College Healthcare NHS Trust, London
  6. 6Burton Hospitals NHS Foundation Trust, Burton upon Trent
  1. Correspondence to: A Sheikh, professor of primary care research and development, aziz.sheikh{at}ed.ac.uk
  • Accepted 5 August 2010

Abstract

Objectives To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service.

Design A mixed methods, longitudinal, multisite, socio-technical case study.

Setting Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete.

Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data.

Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the top-down, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a “middle-out” approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities.

Conclusions Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations’ perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.

Footnotes

  • We thank the participating trusts for supporting this work and all interviewees who kindly gave of their time. We are grateful to the Independent Project Steering Committee overseeing this evaluation (chaired by Professor David Bates and including Professor Martin Buxton, Antony Chuter, Lee Priest, and Kathy Mason). We also thank the independent NHS Connecting for Health Evaluation Programme (CFHEP), led by Professor Richard Lilford and supported by Jo Foster and Lee Priest from the University of Birmingham. We thank Professors Denis Protti, Trish Greenhalgh, and David Bates for constructive comments on an earlier draft of this manuscript.

  • Contributors: AS conceived this study and—with KC, BF, RP, AA, AJ, TC, EK, JP, and NB—secured the funding for this work. They, together with CQ and JW, are the grant holders for this project. AS is the overall principal investigator, with AA, TC, and NB leading research from their respective centres. KC, AT, DP, SC, VL, MA, ZM, YJ, KM, and AR are the researchers working on this evaluation. AR and AS led the writing of this manuscript, with co-authors commenting on drafts of the paper. AR and AS are guarantors for the study.

  • Funding: This report is independent research commissioned by the National Institute for Health Research. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health.

  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.orge/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) all authors have support in the form of a grant from the NHS CFHEP for the submitted work; (2) no author has a relationship with any company that might have an interest in the submitted work in the previous three years; (3) no author’s spouse, partner, or children have financial relationships that may be relevant to the submitted work; and (4) no author has non-financial interests that may be relevant to the submitted work.

  • Data sharing: Additional supporting data drawn from the five, interim case studies reported here are available on request from the corresponding author (aziz.sheikh@ed.ac.uk).

  • Accepted 5 August 2010

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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