Intended for healthcare professionals

Information In Practice

Kaiser Permanente's experience of implementing an electronic medical record: a qualitative study

BMJ 2005; 331 doi: (Published 01 December 2005) Cite this as: BMJ 2005;331:1313
  1. J Tim Scott (jts1{at}, senior lecturer1,
  2. Thomas G Rundall, professor2,
  3. Thomas M Vogt, director3,
  4. John Hsu, physician scientist4
  1. 1School of Management, University of St Andrews, St Andrews KY16 9SS
  2. 2School of Public Health, University of California, Berkeley, CA 94720, USA
  3. 3Kaiser Permanente Centre for Health Research, Hawaii, HI 96817, USA
  4. 4Kaiser Permanente Division of Research, Oakland, California, CA 94612, USA
  1. Correspondence to: J T Scott
  • Accepted 20 September 2005


Objective To examine users' attitudes to implementation of an electronic medical record system in Kaiser Permanente Hawaii.

Design Qualitative study based on semistructured interviews.

Setting Four primary healthcare teams in four clinics, and four specialty departments in one hospital, on Oahu, Hawaii. Shortly before the interviews, Kaiser Permanente stopped implementation of the initial system in favour of a competing one.

Participants Twenty six senior clinicians, managers, and project team members.

Results Seven key findings emerged: users perceived the decision to adopt the electronic medical record system as flawed; software design problems increased resistance; the system reduced doctors' productivity, especially during initial implementation, which fuelled resistance; the system required clarification of clinical roles and responsibilities, which was traumatic for some individuals; a cooperative culture created trade-offs at varying points in the implementation; no single leadership style was optimal—a participatory, consensus-building style may lead to more effective adoption decisions, whereas decisive leadership could help resolve barriers and resistance during implementation; the process fostered a counter climate of conflict, which was resolved by withdrawal of the initial system.

Conclusions Implementation involved several critical components, including perceptions of the system selection, early testing, adaptation of the system to the larger organisation, and adaptation of the organisation to the new electronic environment. Throughout, organisational factors such as leadership, culture, and professional ideals played complex roles, each facilitating and hindering implementation at various points. A transient climate of conflict was associated with adoption of the system.


  • Embedded Image The interview prompt sheet used in the study appears on

  • Embedded Image This is the abridged version of an article that was first posted on on 3 November 2005:

  • Contributors See

  • Funding The Commonwealth Fund of New York supported Tim Scott through a Harkness Fellowship. The Garfield Foundation provided funding for the data collection.

  • Competing interests TMV and JH work for Kaiser Permanente, the organisation implementing the system under study.

  • Ethical approval The Kaiser Permanente Hawaii Institutional Review Board gave ethical approval.

  • Accepted 20 September 2005
View Full Text