Adoption, non-adoption, and abandonment of a personal electronic health record: case study of HealthSpace
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5814 (Published 17 November 2010) Cite this as: BMJ 2010;341:c5814
- Trisha Greenhalgh, director1,
- Susan Hinder, freelance researcher2,
- Katja Stramer, senior research fellow3,
- Tanja Bratan, research fellow3,
- Jill Russell, senior lecturer3
- 1Healthcare Innovation and Policy Unit, Centre for Health Sciences, Barts and the London School of Medicine and Dentistry, London E1 2AT, UK
- 2RAFT Research and Consulting, Downham, Clitheroe BB7 4BN, UK
- 3Division of Medical Education, University College London
- Correspondence to: T Greenhalgh p.greenhalgh{at}qmul.ac.uk
- Accepted 2 September 2010
Abstract
Objective To evaluate the policy making process, implementation by NHS organisations, and patients’ and carers’ experiences of efforts to introduce an internet accessible personal electronic health record (HealthSpace) in a public sector healthcare system.
Design Mixed method, multilevel case study.
Setting English National Health Service; the basic HealthSpace technology (available throughout England) and the advanced version (available in a few localities where this option had been introduced) were considered.
Main outcome measures National statistics on invitations sent, HealthSpace accounts created, and interviews and ethnographic observation of patients and carers. Data analysis was informed by a socio-technical approach which considered macro and micro influences on both adoption and non-adoption of innovations, and by the principles of critical discourse analysis.
Participants 56 patients and carers (of whom 21 opened a basic HealthSpace account, 20 had diabetes but were not initially using HealthSpace, and 15 used advanced HealthSpace accounts to exchange messages with their general practitioner), 3000 pages of documents (policies, strategies, business plans, minutes of meetings, correspondence), observational field notes, and 160 interviews with policy makers, project managers, and clinical staff.
Results Between 2007 and October 2010, 172 950 people opened a basic HealthSpace account. 2913 (0.13% of those invited) opened an advanced account, compared with 5-10% of the population anticipated in the original business case. Overall, patients perceived HealthSpace as neither useful nor easy to use and its functionality aligned poorly with their expectations and self management practices. Those who used email-style messaging were positive about its benefits, but enthusiasm beyond three early adopter clinicians was low, and fewer than 100 of 30 000 patients expressed interest. Policy makers’ hopes that “deploying” HealthSpace would lead to empowered patients, personalised care, lower NHS costs, better data quality, and improved health literacy were not realised over the three year evaluation period.
Conclusion Unless personal electronic health records align closely with people’s attitudes, self management practices, identified information needs, and the wider care package (including organisational routines and incentive structures for clinicians), the risk that they will be abandoned or not adopted at all is substantial. Conceptualising such records dynamically (as components of a socio-technical network) rather than statically (as containers for data) and employing user centred design techniques might improve their chances of adoption and use. The findings raise questions about how eHealth programmes in England are developed and approved at policy level.
Footnotes
This evaluation would not have been possible without the cooperation of several 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. 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 in our detailed report25) 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. We thank four BMJ reviewers (Hamish Fraser, Peter Singleton, Enrico Coiera, and Erwin Klein Woolthuis) who made detailed comments on an earlier draft of the paper and added additional insights and references.
Contributors: TG designed the study, led the development of the theoretical and methodological approach, helped with data collection, led the data analysis, drafted the paper, and is responsible for the integrity of the work. She is the guarantor. KS and TB led the data collection. SH did the fieldwork for the ethnographic study of 20 people with diabetes. JR helped develop the theoretical and methodological approach and provided expertise in evaluation methodology. All authors helped with analysing data and writing and revising the paper. 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, or the Department of Health.
Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) All authors have support from their employing organisations for the submitted work; (2) No authors have had relationships with organisations 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) Authors have no non-financial interests that may be relevant to the submitted work.
Ethical approval: This study was approved by Thames Valley multicentre research ethics committee in January 2007 (06/MRE12/81 and subsequent amendments) and North West 8 multicentre research ethics committee in September 2009 (09/H1013/36 and subsequent amendments).
Data sharing: No additional data available.
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