Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation
Open accessAbstract
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.
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Emerging qualitative findings were fed back to participating hospitals, NHS Connecting for Health, and funders through formative feedback sessions, and the discussions informed subsequent data collection and final analysis.
“Throughout the study, emerging qualitative findings were fed back to individual participating hospitals, NHS Connecting for Health, and our funders through formative feedback sessions.12 The discussions that ensued informed subsequent data collection and were taken into account in the final analysis.”
From Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in early adopter hospitals (2011) · cites this paper as [12]
The Methods > Data analysis passage says emerging findings were shared with participating trusts for feedback. It does not say they were fed back to NHS Connecting for Health or funders through formative feedback sessions. Methods > Data collection says emerging themes shaped subsequent data collection, but the copy does not establish that the feedback discussions informed data collection or final analysis. Page numbers are not available in our copy. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThere was a substantive move away from the initial top-down implementation model to an increase in local involvement in decision making, particularly in London and the Southern areas.
“There was in particular a substantive move away from the initial “top-down” implementation model to an increase in local involvement in decision making, particularly in London and the Southern areas.12”
From Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in early adopter hospitals (2011) · cites this paper as [12]
The Discussion (Considering these findings in an international context; page unavailable) describes a partial migration from a top-down to a middle-out approach. The Discussion (Policy implications; page unavailable) also says some trusts gained greater influence over system choice, design, delivery, and configuration. The paper does not establish that this shift was particularly pronounced in London and the Southern areas, and “substantive” is stronger than its description of a partial migration. (LLM, conf=0.84)
Experimental — accuracy not yet measuredPolicymakers have already started to shift the focus to more local efforts to procure and implement electronic health records, reinforced by changes in the coalition government's outlook, planned NHS changes, and the current economic climate.
“Policymakers have already started to shift the focus to more local efforts to procure and implement electronic health records, these being reinforced by the changes in outlook of the coalition government, the planned changes to the NHS in England (such as a drive to increasing the autonomy of hospitals from the control of central government), and the current economic climate.12 18 85”
From Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in early adopter hospitals (2011) · cites this paper as [12]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredThe 'top down' nature of the national programme has, despite ensuring necessary high level leadership and support, contributed to a lack of organisational and user involvement in decision making.
“The “top down” nature of the national programme has, despite ensuring necessary high level leadership and support,12 contributed to a lack of organisational and user involvement in decision making.”
From Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in early adopter hospitals (2011) · cites this paper as [12]
The citation is attached to the claim that the top-down programme ensured necessary high-level leadership and support. The Discussion describes the approach as centrally directed, but its Policy implications section says consistent Department of Health leadership could help alleviate difficulties; it does not establish that the programme ensured such leadership and support. The subsequent claim about limited local involvement is not the part directly cited here. (LLM, conf=0.78)
Experimental — accuracy not yet measuredIn accordance with existing literature, evidence of actual benefits reported in this study was limited to a number of clinically orientated benefits surrounding improved information availability, accessibility and legibility.
“In accordance with existing literature, evidence of actual benefits reported in our study were limited to a number of ‘clinically orientated’ benefits surrounding improved information availability, accessibility and legibility [19, 23, 31–34].”
From Exploring the implementation of an electronic record into a maternity unit: a qualitative study using Normalisation Process Theory (2017) · cites this paper as [32]
NHS Connecting for Health's difficulties with the implementation of EHRs into hospitals in England is a prime example of the challenges that can ensue if socio-technical factors are given insufficient attention.
“NHS Connecting for Health's difficulties with the implementation of EHRs into hospitals in England is a prime example of the challenges that can ensue if such socio-technical factors are given insufficient attention [148].”
From The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview (2011) · cites this paper as [148]
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- Authors
- Robertson, A., Cresswell, K., Takian, A., Petrakaki, D., Crowe, S., Cornford, T., Barber, N., Avery, A., Fernando, B., Jacklin, A., Prescott, R., Klecun, E., Paton, J., Lichtner, V., Quinn, C., Ali, M., Morrison, Z., Jani, Y., Waring, J., Marsden, K., & Sheikh, A.
- Affiliations
- University of Edinburgh (GB)
- University of London (GB)
- University of Nottingham (GB)
- Imperial College Healthcare NHS Trust (GB)
- Burton Hospitals NHS Foundation Trust (GB)
- Corresponding author
- Sheikh, A.
- ORCID
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2010-09-01
- Volume
- 341
- Issue
- sep01 3
- Pages
- c4564-c4564
- ISSN
- 0007-1447 (ISSN-L)
- 0959-8138
- 1468-5833
- PMC
- PMC2933355
- OpenAlex
- W2122314483
- Cited by
- 230
- References
- 31
- Citations by year
- 2026: 5 · 2025: 10 · 2024: 4 · 2023: 7 · 2022: 6 · 2021: 5 · 2020: 8 · 2019: 15 · 2018: 14 · 2017: 18 · 2016: 15 · 2015: 19 · 2014: 22 · 2013: 32 · 2012: 23
- FWCI
- 48.86
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by-nc
- Locations
- BMJ (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion)
- London School of Economics and Political Science Research Online (London School of Economics and Political Science) (acceptedVersion)
- Durham Research Online (Durham University) (acceptedVersion)
- Durham Research Online (Durham University) (submittedVersion, cc-by)
- London School of Economics and Political Science Research Online (London School of Economics and Political Science) (submittedVersion)
- Sussex Research Online (University of Sussex) (submittedVersion)
- Aberdeen University Research Archive (Aberdeen University) (submittedVersion, cc-by-nc)
- Brunel University Research Archive (BURA) (Brunel University London) (submittedVersion, cc-by-nc)
- Research Publications (Maastricht University) (submittedVersion, cc-by-nc)
- UCL Discovery (University College London) (submittedVersion)
- Figshare (submittedVersion)
- Edinburgh Research Explorer (University of Edinburgh) (submittedVersion, other-oa)
- Open Access Institutional Repository at Robert Gordon University (Robert Gordon University) (submittedVersion, cc-by)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Funders
- National Institute for Health and Care Research
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Social Sciences › Sociology and Political Science › Information Systems Theories and Implementation
- Health Sciences › Health Professions › General Health Professions › Health Services Management and Policy
- Keywords
- electronic health records, secondary care, hospital information systems, implementation, technology adoption, middle-out approach, local autonomy, health data sharing, health communities, stakeholder communication, NHS trusts, mental health services, socio-technical systems
- MeSH terms
- Contract Services, England, Hospital Information Systems, Humans, Prospective Studies, State Medicine, Information Dissemination, Electronic Health Records
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