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Cited by 41Electronic Health Records SystemsNursing Diagnosis and DocumentationHealth Policy Implementation Science

Exploring the implementation of an electronic record into a maternity unit: a qualitative study using Normalisation Process Theory

Open access
Scantlebury, Arabella, Sheard, Laura, Watt, Ian, Cairns, Paul, Wright, John, Adamson, Joy·2017·BMC Medical Informatics and Decision Making
DOI 10.1186/s12911-016-0406-0PMC PMC5219748
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Abstract

BACKGROUND: To explore the benefits, barriers and disadvantages of implementing an electronic record system (ERS). The extent that the system has become 'normalised' into routine practice was also explored. METHODS: Qualitative semi-structured interviews were conducted with 19 members of NHS staff who represented a variety of staff groups (doctors, midwives of different grades, health care assistants) and wards within a maternity unit at a NHS teaching hospital. Interviews were conducted during the first year of the phased implementation of ERS and were analysed thematically. The four mechanisms of Normalisation Process Theory (NPT) (coherence, cognitive participation, collective action and reflexive monitoring) were adapted for use within the study and provided a theoretical framework to interpret the study's findings. RESULTS: Coherence (participants' understanding of why the ERS has been implemented) was mixed - whilst those involved in ERS implementation anticipated advantages such as improved access to information; the majority were unclear why the ERS was introduced. Participants' willingness to engage with and invest time into the ERS (cognitive participation) depended on the amount of training and support they received and their willingness to change from paper to electronic records. Collective action (the extent the ERS was used) may be influenced by whether participants perceived there to be benefits associated with the system. Whilst some individuals reported benefits such as improved legibility of records, others felt benefits were yet to emerge. The parallel use of paper and the lack of integration of electronic systems within and between the trust and other healthcare organisations hindered ERS use. When appraising the ERS (reflexive monitoring) participants perceived the system to negatively impact the patient-clinician relationship, time and patient safety. CONCLUSIONS: Despite expectations that the ERS would have a number of advantages, its implementation was perceived to have a range of disadvantages and only a limited number of 'clinical benefits'. The study highlights the complexity of implementing electronic systems and the associated longevity before they can become 'embedded' into routine practice. Through the identification of barriers to the employment of electronic systems this process could be streamlined with the avoidance of any potential detriment to clinical services.

AI snapshot

Written from the paper’s full text.

TL;DR

This qualitative interview study used Normalisation Process Theory to examine implementation of an electronic record system (ERS) in a UK NHS maternity unit. Staff reported mixed understanding, limited realised clinical benefits, and perceived disadvantages including parallel paper use, integration problems, and negative impacts on time, patient-clinician interaction, and patient safety.

Key findings

  • Coherence was mixed: staff involved in implementation understood the rationale, but the majority not involved were unclear why the ERS had been introduced and felt it had been enforced without explanation.
  • Cognitive participation depended on training and support: participants reported variable training (none, a single 30 min session, or whole-day sessions), criticised timing/content, and valued the support team and “super-users,” though support was available only in weekday office hours.
  • Collective action was hindered by parallel paper and electronic records and lack of integration within and between organisations; some benefits emerged, including improved legibility, 24-h access, reliable audits, and more accurate charging to Clinical Commissioning Groups.
  • Reflexive monitoring found perceived negative impacts on the patient-clinician relationship, time, and patient safety; many still expected future benefits once the ERS was fully implemented and integrated.

Methods

  • Qualitative semi-structured interview study with 19 NHS staff (11 midwives, 7 doctors, 1 health care assistant) in a single maternity unit at an NHS teaching hospital in the North of England; 4 participants were involved in ERS implementation as support team or super-users.
  • Interviews were conducted face-to-face between April and November 2014 during the first year of phased ERS implementation, lasted 17–42 min, and were analysed thematically.
  • Normalisation Process Theory’s four mechanisms—coherence, cognitive participation, collective action, and reflexive monitoring—were adapted to inform the interview schedule and interpret findings.

Limitations

  • Stated: the study was conducted in a single maternity unit within one large inner-city NHS hospital and explored a single electronic system, so some barriers may reflect that specific system and context.
  • Stated: the phased implementation meant interviews captured participants at different stages, and some issues—such as dual paper/electronic use and additional time entering information twice—were direct results of that phased approach.
  • Evident from the text: findings rely on staff perceptions from 19 interviews during early implementation, with no independent observation, clinical outcome data, or longer-term follow-up to assess whether the ERS became normalised.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12911-016-0406-0

Cites

44 of 44 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 35 cited sources checked · 0 supported · 0 flagged

  • Findingreasoning

    This was considered an additional risk of the ERS because previously, unless women lost or forgot their paper records, they would have had them on their person when attending other healthcare organisations.

    “This was considered an additional risk of the ERS as previously, unless women lost or forgot their paper records, they would have had them on their person when attending other healthcare organisations.”
    Quote in the paperSubstantial claim
  • Findingown data

    Collective action (the extent the ERS was used) may be influenced by whether participants perceived there to be benefits associated with the system.

    “Collective action (the extent the ERS was used) may be influenced by whether participants perceived there to be benefits associated with the system.”
    Quote in the paperSubstantial claim
  • Findingown data

    The mix of paper and electronic media and lack of integration between departmental systems was perceived to have raised the risk that clinical information may be missed.

    “The mix of paper and electronic media and lack of integration between departmental systems was perceived to have raised the risk that clinical information may be missed.”
    Quote in the paperSubstantial claim
  • Findingown data

    Participants cited issues with staff being able to fit in training amongst busy work schedules and shift patterns.

    “however participants cited issues with staff being able to ‘fit in’ training amongst busy work schedules and shift patterns”
    Quote in the paperNot a substantial claim
  • Findingown data

    Participants cited clinical benefits largely associated with staff having access to patient records 24 hours a day and records no longer being the patients' responsibility.

    “Participants cited a number of clinical benefits, which were largely associated with staff having access to patient records 24 h a day and records no longer being the patients' responsibility.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 55
  • Classified as probably not a substantial claim. 26

  • May combine two claims.

    Findingown data

    When appraising the ERS (reflexive monitoring), participants perceived the system to negatively impact the patient-clinician relationship, time and patient safety.

    “When appraising the ERS (reflexive monitoring) participants perceived the system to negatively impact the patient-clinician relationship, time and patient safety.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The support team were responsible for rectifying data entry errors on the system made by staff, who only had the capacity to input and could not edit information within the ERS.

    “The support team were also responsible for rectifying data entry errors on the system made by staff, who only had the capacity to input, and so could not edit information within the ERS.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Participants reported that as more reliable information relating to the case mix of the maternity unit and work patterns is collected, financial benefits are occurring as the hospital is now able to charge commissioners more accurately for the care it provides.

    “Participants also reported that as more reliable information relating to the case mix of the maternity unit and work patterns is collected, financial benefits are occurring as the hospital is now able to charge commissioners (Clinical Commissioning Groups) more accurately for the care it provides”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Some participants anticipated that the ERS would remove risks associated with patients losing and forgetting paper notes, improve clinical audits and facilitate enhanced access to patient information, as staff assumed it would be integrated within and between healthcare organisations.

    “For example, some participants reported that they anticipated it would remove risks associated with patients losing and forgetting paper notes, improve clinical audits and facilitate enhanced access to patient information, as staff assumed it would be integrated within and between healthcare organisations.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A group of clinicians who received extra training and were considered super-users were available when on duty and helped clinical colleagues rectify errors made on the system.

    “A group of clinicians that received extra training on the system who were considered ‘super-users’ were available when they were on duty and helped clinical colleagues rectify errors made on the system”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The parallel use of paper and the lack of integration of electronic systems within and between the trust and other healthcare organisations hindered ERS use.

    “The parallel use of paper and the lack of integration of electronic systems within and between the trust and other healthcare organisations hindered ERS use.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The ERS was not fully implemented during the interview period, so not all aspects of care were inputted onto the ERS (e.g. anaesthetic alerts), with paper still used in these situations.

    “The ERS was not ‘fully’ implemented during the period when the interviews took place and so not all aspects of care were inputted onto the ERS e.g. anaesthetic alerts; with paper still used in these situations.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    These individuals had expected to be using an ERS within a paperless environment 7 years ago and so viewed the implementation as slow and with scepticism.

    “These individuals had expected to be using an ERS within a paperless environment 7 years ago and so viewed the implementation as slow and with scepticism”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Further benefits of the ERS compared with paper records included simple data entry methods, prompts for additional information during alternative care, improved communication with GPs via electronic notifications on discharge or prescription, and increased legibility and conciseness of records.

    “Further benefits of the ERS in comparison to paper records included: simple data entry methods (e.g. tick boxes), prompts for additional information during alternative care (e.g. water births), improved communication with GPs who can now receive electronic notifications when patients are discharged or prescribed medication and increased legibility and conciseness of records.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Despite an understanding among many that there were positive reasons for introducing the ERS, the historical use of paper records (and the positive view of these) made staff hesitant about the prospect of a paperless environment.

    “Despite an understanding among many that there were positive reasons for introducing the ERS, the historical use of paper records (and the positive view of these) made staff hesitant about the prospect of a paperless environment.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Participants provided examples where the ERS was beneficial to safety and quality of care, including checking visit reasons, alerting community midwives to non-attendance, mitigating risks of lost records, and emergency access.

    “Participants provided a number of examples, where this has been beneficial to the safety and quality of care provided. For instance: checking the importance or reason for visits prior to appointments; alerting community midwives in the event of patients failing to attend appointments; mitigating risks associated with patients forgetting or losing their records and accessing records in emergencies.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Participants criticised the delivery (too simplistic, dogmatic), varied content (some staff only received basics of ERS) and timing (too far in advance of or after implementation) of training.

    “However, participants criticised the delivery (too simplistic, dogmatic), varied content (some staff only received basics of ERS) and timing (too far in advance of or after implementation) of training.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The ERS could not communicate or share information with other healthcare organisations, with procedures for granting other organisations access either unknown or considered too complex.

    “Additionally, the ERS could not communicate or share information with other healthcare organisations, with the procedures for granting other organisations access either unknown or considered too complex.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The staged approach to implementing the ERS meant that the extent paper was used throughout the maternity unit varied, with some wards described as paperless whilst others were reliant on paper or both.

    “The staged approach to implementing the ERS meant that the extent that paper was used throughout the maternity unit varied, with some wards described as paperless whilst others were reliant on paper or both.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    These participants had strong expectations that the system would bring benefits and have a positive impact on practice.

    “They also had strong expectations that the system would bring benefits and have a positive impact on practice.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The majority of participants who had no involvement in ERS implementation felt they had not been informed why the system was introduced, did not have the anticipated benefits, and some clinicians felt the new system had been enforced upon them without explanation.

    “This was in contrast to those (the majority) who had no involvement in ERS implementation who felt that they had not been informed as to why the system was introduced, therefore, did not have the anticipated benefits, causing some clinicians to feel as though the new system had been enforced upon them without explanation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Participants praised the support team's assistance during early implementation, particularly for those with poor computer literacy, despite criticising their availability (weekday office hours only).

    “Despite criticising the support team’s availability (Weekday office hours only), participants praised their assistance during early implementation; particularly for those with poor computer literacy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Participants perceived there to be a reluctance to accept the ERS and the change associated with its implementation among staff within the maternity unit, which negatively impacted on their engagement with and willingness to invest their time into the ERS.

    “Participants perceived there to be a reluctance to accept the ERS and the change associated with its implementation among staff within the maternity unit, which negatively impacted on their engagement with and willingness to invest their time into the ERS.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    These participants attributed ERS implementation to the need for improved accessibility and availability of records, efficiency, research and communication with other health and care organisations.

    “These participants attributed ERS implementation to the need for improved: accessibility and availability of records, efficiency, research and communication with other health and care organisations.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Participants who had been working at the trust for a number of years were affected by the implementation of the former failed electronic record system and did not distinguish between the two systems.

    “Additionally, participants who had been working at the trust for a number of years were affected by the implementation of the former (failed) electronic record system and did not distinguish between the two systems.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Participants' willingness to engage with and invest time into the ERS (cognitive participation) depended on the amount of training and support they received and their willingness to change from paper to electronic records.

    “Participants’ willingness to engage with and invest time into the ERS (cognitive participation) depended on the amount of training and support they received and their willingness to change from paper to electronic records.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants felt that the maternity unit had already been subject to vast amounts of top-down policy change relating to increased data collection and audit requirements for maternity services.

    “Secondly, participants felt that the maternity unit had already been subject to vast amounts of ‘top-down’ policy change (from local and wider NHS initiatives) relating to increased data collection and audit requirements for maternity services.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Amongst those with responsibility for facilitating implementation and assisting colleagues with ERS, coherence was strong, coinciding with the official perspective of the institution as enabling the organisation to move towards a paperless environment.

    “Amongst those with responsibility for facilitating implementation and assisting colleagues with ERS, coherence was strong - coinciding with the official perspective of the institution as enabling the organisation to move towards a paperless environment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Coherence (participants' understanding of why the ERS has been implemented) was mixed: those involved in ERS implementation anticipated advantages such as improved access to information, while the majority were unclear why the ERS was introduced.

    “Coherence (participants’ understanding of why the ERS has been implemented) was mixed – whilst those involved in ERS implementation anticipated advantages such as improved access to information; the majority were unclear why the ERS was introduced.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Although some participants reported that they were yet to see clinical benefits from the ERS, others felt that benefits had started to emerge.

    “Although some participants reported that they were yet to see clinical benefits from the ERS, others felt that benefits had started to emerge.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Some individuals reported benefits such as improved legibility of records, while others felt benefits were yet to emerge.

    “Whilst some individuals reported benefits such as improved legibility of records, others felt benefits were yet to emerge.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    A number of participants reported expectations that the ERS, once fully implemented, will enable all patient information to be stored in one place, which is predicted to be of benefit in emergency situations as the ERS will alert staff to allergies and risk factors.

    “A number of participants reported expectations that the ERS, once fully implemented, will enable all patient information to be stored in one place; something which is predicted to be of benefit in emergency situations as the ERS will alert staff to allergies and risk factors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Reasons for this included perceptions that some staff still see the paper record as the primary record, greater detail being entered into paper notes than on the ERS, staff not being aware and/or checking both sets of notes, and insufficient time to document in both records.

    “A variety of reasons for this were provided including: perceptions that some staff still see the paper record as the primary record, greater detail being entered into paper notes than on the ERS, staff not being aware and/or checking both sets of notes and insufficient time to document in both records”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Findingown data

    Participants raised concerns that important information may be being missed or not documented adequately in either record system.

    “Participants also raised concerns that important information may be being missed or not documented adequately in either record system.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing). May combine two claims.

    Findingown data

    Additional anticipated benefits included improvements to patient flow, research, audit, performance and planning, record security and accuracy, and fewer missing records.

    “Additional anticipated benefits included improvements to: patient flow, research, audit, performance and planning, record security and accuracy and fewer missing records”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    The phased approach to implementing the system meant that interviews were conducted with participants who were experiencing different stages of implementation, with some of the issues identified a direct result of the phased implementation and the subsequent dual use of paper and electronic records.

    “The phased-approach to implementing the system meant that interviews were conducted with participants who were experiencing different stages of implementation, with some of the issues identified a direct result of the phased implementation and the subsequent dual use of paper and electronic records.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Any potential detrimental impact of the ERS and interaction with patients was also perceived to have consequences for patient safety.

    “Any potential detrimental impact of the ERS and interaction with patients was also perceived to have consequences for patient safety”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Of those that reported a negative impact, a proportion felt that they are now spending as much time with patients as they did when using the paper records and suggested that the detrimental impact on their interactions may be constrained to early implementation.

    “However, of those that reported a negative impact, a proportion felt that they are now spending as much time with patients as they did when using the paper records and suggested that the detrimental impact on their interactions may be constrained to early implementation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Once the ERS is integrated within and across healthcare organisations, participants expected quicker referral times as they will no longer have to wait for letters.

    “Once the ERS is integrated within and across healthcare organisations, participants also expected quicker referral times as they will no longer have to wait for letters.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A minority of participants anticipated that the ERS would negatively affect their interaction with patients, but they made a concerted effort and had successfully avoided this.

    “A minority of participants anticipated that although they expected the ERS to negatively affect their interaction with patients, ‘they made a concerted effort’ and had successfully avoided this.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participants described how, because they had to physically turn away from the patient and concentrate more when using the computer, they felt they were not giving patients enough attention.

    “Participants also described how because they had to physically turn away from the patient and concentrate more when using the computer, they felt they were not giving patients enough attention.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Some staff perceived the ERS to increase the potential for inputting errors, particularly following system upgrades or when new members of staff not used to the ERS joined the wards, which also contributed to their unwillingness to use the system.

    “In addition, some staff perceived the ERS to increase the potential for inputting errors, particularly following system upgrades or when new members of staff (e.g. junior doctors) that were not used to the ERS joined the wards; which also contributed to their unwillingness to use the system”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Whilst some participants who had been using the ERS for longer explained that the ERS was becoming quicker to use, many felt that the trust were underestimating the added time pressures associated with the ERS.

    “Whilst some participants who had been using the ERS for longer did explain that the ERS was becoming quicker to use, many felt that the trust were underestimating the added time pressures associated with the ERS”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    This study also highlighted that some individuals were hesitant about the prospect of working within a paperless environment, with some individuals preferring to use paper for certain tasks.

    “Our study also highlighted that some individuals were hesitant about the prospect of working within a paperless environment, with some individuals preferring to use paper for certain tasks.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The findings suggest participants had some positive experiences of, or awareness of colleagues realising benefits from, using the ERS since implementation, and this would be expected to positively influence their continuing engagement with (cognitive participation) and use of the ERS (collective action).

    “These findings suggest that participants had some positive experiences of, or awareness of colleagues having realised benefits from using the ERS since its implementation, and this in turn would be expected to positively influence their continuing engagement with (cognitive participation) and use of the ERS (collective action)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Record keeping in maternity care differs to other specialties as women are responsible for their paper records, with their care documented on the paper record at each visit to community or hospital-based healthcare.

    “This particular setting was selected as record keeping in maternity care differs to other specialties as women are responsible for their paper records, with their care documented on the paper record at each visit to community or hospital-based healthcare [9].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Hawley G, Janamian T, Jackson C, SA W. In a maternity shared-care environment, what do we know about the paper hand-held and electronic health record: a systematic literature review. BMC Pregnancy Childbirth. 2014;14(1):1. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The study highlights the complexity of implementing electronic systems and the associated longevity before they can become 'embedded' into routine practice.

    “The study highlights the complexity of implementing electronic systems and the associated longevity before they can become ‘embedded’ into routine practice.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    A reflexive approach was taken to data collection and analysis.

    “A reflexive approach was taken to data collection and analysis.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Empirical evidence that explores the benefits, barriers and disadvantages of implementing electronic records has recently been summarised in a systematic review of 22 studies, which identified technical issues alongside financial and time constraints as the most frequently reported barriers associated with electronic record implementation.

    “Empirical evidence that explores the benefits, barriers and disadvantages of implementing electronic records has recently been summarised in a systematic review [8] of 22 studies, which identified technical issues alongside financial and time constraints as the most frequently reported barriers associated with electronic record implementation.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] Boonstra A, Broekhuis M. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions. BMC Health Serv Res. 2010;10(1):231. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Despite expectations that the ERS would have a number of advantages, its implementation was perceived to have a range of disadvantages and only a limited number of 'clinical benefits'.

    “Despite expectations that the ERS would have a number of advantages, its implementation was perceived to have a range of disadvantages and only a limited number of ‘clinical benefits’.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    A recent systematic review noted that clinicians working within the GP-maternity shared care environment had positive perceptions of the paper record; however the response to electronic records was more mixed.

    “A recent systematic review noted that clinicians working within the GP-maternity shared care environment had positive perceptions of the paper record; however the response to electronic records was more mixed [9].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Hawley G, Janamian T, Jackson C, SA W. In a maternity shared-care environment, what do we know about the paper hand-held and electronic health record: a systematic literature review. BMC Pregnancy Childbirth. 2014;14(1):1. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    The study site, a large inner-city NHS hospital maternity unit, was considered representative of other UK NHS trusts.

    “The study provides an in-depth exploration of an electronic record implementation at a large inner-city NHS hospital and so was considered representative of other UK trusts.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Participants were sampled until a range of specialities and professions within the maternity unit were represented and no new themes emerged.

    “Participants were sampled until a range of specialities and professions within the maternity unit were represented and no new themes emerged.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    None of the research team were involved in the ERS implementation or worked in the maternity unit, and the research team may therefore be considered neutral relating to prior expectations.

    “None of the research team were involved in the ERS implementation or worked in the maternity unit. The research team may therefore be considered to be in a neutral position relating to any prior expectations to the study or the ERS' implementation.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    A purposive sampling frame was used to ensure that interviewees represented a variety of staff groups, grades and wards.

    “This was taken into account in the sampling strategy - a purposive sampling frame was used to ensure that interviewees represented a variety of staff groups, grades and wards as it was anticipated that staff would have different usage and experience of the ERS depending on their roles and responsibilities.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    AS conducted the analysis alongside regular discussions with JA and LS in order to scrutinise the robustness of the theme development and mapping the themes onto the concepts of NPT.

    “AS conducted the analysis alongside regular discussions with JA and LS in order to scrutinise the robustness of the theme development and mapping the themes onto the concepts of NPT.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Paper records have been widely used in maternity care since the co-operation card was introduced in the UK in 1956, which made paper records a successful and integral tool for maternity shared care.

    “Paper records have been widely used in maternity care since the co-operation card was introduced in the UK in 1956, which made paper records a successful and integral tool for maternity shared care [10].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] Hamilton S. Obstetric record card for use in general practice. Practitioner. 1956;176(1051):79–81.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Although there is international pressure for hospitals to implement electronic records, based on the belief that these systems will transform the quality and safety of healthcare, there is little empirical evidence to support this.

    “Although there is international pressure for hospitals to implement electronic records, based on the belief that these systems will transform the quality and safety of healthcare [1, 2], there is little empirical evidence to support this.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [1] Catwell L, Sheikh A. Evaluating eHealth interventions: the need for continuous systemic evaluation. PLoS Med. 2009;6(8):e1000126. source

      Not checked in the free run.

    • cites [2] Department of Health. Personalised health and care 2020. 2014. Available online from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/384650/NIB_Report.pdf .

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The heterogeneity of electronic record implementation (different hospitals, approaches, systems) means Randomised Controlled Trials in this area are difficult.

    “However, the heterogeneity of electronic record implementation (different hospitals, approaches, systems) means Randomised Controlled Trials in this area are difficult.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    This study has added to a body of mainly US literature, which has identified potential disadvantages of electronic systems.

    “The study has added to a body of mainly US literature, which has identified potential disadvantages of electronic systems.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    This study expands on the limited UK evidence and adds to international evidence surrounding electronic records by using NPT as a framework to identify the benefits, barriers and disadvantages of implementing an ERS during the early stages of implementation.

    “The study expands on the limited UK evidence and adds to international evidence surrounding electronic records, by using NPT as a framework to identify the benefits, barriers and disadvantages of implementing an ERS during the early stages of implementation.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Existing literature on the benefits of electronic records is largely U.S. or primary care based and reports potential rather than actual benefits, with a large proportion of this evidence reporting the potential for electronic records to improve patient safety.

    “Existing literature on the benefits of electronic records is largely U.S or primary care based [18–34] and reports ‘potential’ rather than actual benefits; with a large proportion of this evidence reporting the potential for electronic records to improve patient safety [19, 21, 23, 27–30].”
    Quote in the paperSubstantial claim0 of 10 sources checked
    • cites [18] Eden KB, et al. Examining the value of electronic health records on labor and delivery. Am J Obstet Gynecol. 2008;199(3):307. e1-307. e9.

      Not checked in the free run.

    • cites [19] Øvretveit J, et al. Improving quality through effective implementation of information technology in healthcare. Int J Qual Health Care. 2007;19(5):259–66. source

      Not checked in the free run.

    • cites [20] Menon S, et al. Electronic health record–related safety concerns: a cross‐sectional survey. Journal Healthc Risk Manag. 2014;34(1):14–26. source

      Not checked in the free run.

    • cites [21] Evans S, Stemple C. Electronic health records and the value of health IT. J Manag Care Pharm. 2008;14(6):16–18.

      Not checked in the free run.

    • cites [22] Lee J, Kuo Y-F, Goodwin JS. The effect of electronic medical record adoption on outcomes in US hospitals. BMC Health Serv Res. 2013;13(1):1. source

      Not checked in the free run.

    • cites [23] Likourezos A, et al. Physician and nurse satisfaction with an electronic medical record system. Journal Emerg Med. 2004;27(4):419–24. source

      Not checked in the free run.

    • cites [24] Pollak VE, Lorch JA. Effect of electronic patient record use on mortality in End Stage Renal Disease, a model chronic disease: retrospective analysis of 9 years of prospectively collected data. BMC Med Inform Decis Mak. 2007;7(1):1. source

      Not checked in the free run.

    • cites [25] Silow-Carroll S, Edwards JN, Rodin D. Using electronic health records to improve quality and efficiency: the experiences of leading hospitals. Issue Brief (Commonw Fund). 2012;17:1–40.

      Not checked in the free run.

    • cites [26] Thakkar M, Davis DC. Risks, barriers, and benefits of EHR systems: a comparative study based on size of hospital. Perspect Health Inf Manag. 2006;3(5):1–19.

      Not checked in the free run.

    • cites [27] Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff. 2005;24(5):1103–17. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    A number of the issues reported in this study were a result of the phased approach to implementing the ERS, which provides some evidence of negative consequences associated with implementing electronic records using a phased approach.

    “A number of the issues reported in this study were a result of the phased approach to implementing the ERS. This provides some evidence of negative consequences associated with implementing electronic records using a phased approach.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The extent of normalisation reported here was largely a result of human (e.g. computer literacy), organisational and contextual factors (e.g. the previous failed implementation of an ERS) and the phased approach to implementation, which resulted in the parallel use of paper and slow implementation of the ERS throughout the maternity unit.

    “The extent of ‘normalisation’ reported here, was largely a result of human (e.g. computer literacy), organisational and contextual factors (e.g. the previous failed implementation of an ERS) and the phased approach to implementation; which resulted in the parallel use of paper and slow implementation of the ERS throughout the maternity unit.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Given the pressure on hospitals to implement electronic records globally, it is anticipated that some of the benefits, barriers and disadvantages are transferable and will provide useful insights to other healthcare organisations implementing similar systems.

    “Given the pressure on hospitals to implement electronic records globally, it is anticipated that some of the benefits, barriers and disadvantages are transferable and will provide useful insights to other healthcare organisations implementing similar systems.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    In light of the limited benefits and various barriers and disadvantages experienced since the ERS was implemented, it may be that as well as being a requirement to undertake their job, staff continue to use the system as they expect benefits to emerge in the future.

    “In light of the limited benefits and various barriers and disadvantages experienced since the ERS was implemented, it may be that as well as being a requirement to undertake their job, staff continue to use the system as they expect benefits to emerge in the future.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    In this study, whilst a range of different barriers to implementation were reported, a large proportion of these were a result of the phased approach to implementation and the parallel use of paper within the maternity unit.

    “For example, in our study whilst a range of different barriers to implementation were reported, a large proportion of these were a result of the phased approach to implementation and the parallel use of paper within the maternity unit.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    This study explored the implementation of a single electronic system, with a number of the barriers and disadvantages being the result of design and implementation issues of that specific system.

    “The study also explored the implementation of a single electronic system, with a number of the barriers and disadvantages being the result of design and implementation issues of that specific system.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    This is consistent with findings from this study, as even individuals that were yet to see any actual benefits of the ERS believed that the ERS would lead to benefits in the future (e.g. through alerting to allergies and risk factors in emergencies).

    “This is consistent with findings from our study, as even individuals that were yet to see any actual benefits of the ERS believed that the ERS would lead to benefits in the future (e.g. through alerting to allergies and risk factors in emergencies).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    This is the first study to qualitatively explore clinicians' perceptions and experiences of a maternity system's implementation into an NHS trust.

    “This is the first study to qualitatively explore clinicians’ perceptions and experiences of a maternity system’s implementation into an NHS trust.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A recent systematic review of systematic reviews that explored factors influencing the implementation of e-health concluded that issues around e-health implementation are both multi-level and complex, as no single factor was identified as a key barrier or facilitator.

    “This is consistent with a recent systematic review of systematic reviews that explored factors influencing the implementation of e-health [17]. The review concluded that issues around e-health implementation are both multi-level and complex, as no single factor was identified as a key barrier or facilitator [17].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Ross J, Stevenson F, Lau R, Murray E. Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update). Implement Sci. 2016;11(1):146. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In support of this study's findings, health professionals largely accepted the electronic record and felt it increased the reliability and legibility of information, but they found it time consuming and reported issues with accessing computers.

    “Additionally, and in support of our study’s findings, whilst health professionals largely accepted the electronic record and felt it increased the reliability and legibility of information they found it time consuming and reported issues with accessing computers [9].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Hawley G, Janamian T, Jackson C, SA W. In a maternity shared-care environment, what do we know about the paper hand-held and electronic health record: a systematic literature review. BMC Pregnancy Childbirth. 2014;14(1):1. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A systematic review of paper and electronic health records within a maternity shared-care environment reported that whilst women and healthcare professionals generally spoke positively about paper records, they held mixed opinions towards electronic maternity records.

    “This is consistent with a systematic review of paper and electronic health records within a maternity shared-care environment that reported that whilst women and healthcare professionals generally spoke positively about paper records, they held mixed opinions towards electronic maternity records [9].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Hawley G, Janamian T, Jackson C, SA W. In a maternity shared-care environment, what do we know about the paper hand-held and electronic health record: a systematic literature review. BMC Pregnancy Childbirth. 2014;14(1):1. source

      Not checked in the free run.

68 of 68

  • The authors state this as an assumption.

    The four mechanisms of Normalisation Process Theory are a useful way of identifying factors affecting the ERS’ implementation and for determining the extent that the system has been embedded into routine practice.

    “The four main mechanisms of NPT were considered a useful way of identifying factors affecting the ERS’ implementation and for determining the extent that the system has been embedded into routine practice.”
1 of 1

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Using Normalization Process Theory, AI will become embedded in society both individually and collectively and ultimately will be a necessity in the daily routine of a physician.

    “Using the Normalization Process Theory, we perceive that AI will become embedded in society both individually and collectively and ultimately will be a necessity in the daily routine of a physician. 53”

    From Educating Future Physicians in Artificial Intelligence (AI): An Integrative Review and Proposed Changes (2021) · cites this paper as [53]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Quoted participant ID is absent from the participant table

    Minor

    The quotation identifies the specialist senior midwife as 051602, but Table 1 lists 051610 instead. The paper says each participant was assigned a unique ID, and 051602 does not appear among the 19 listed participants.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. Digital Health Intelligencece. Hunt annouces £4.2 billion for NHS IT. 2016. Available online from: http://www.digitalhealth.net/news/47167/hunt-announces-%C2%A34.2-billion-for-nhs-it .
  2. Appleby J, Galea A, Murray M. The NHS productivity challenge experience from the front line. King’s fund. 2014. Available online from: https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/the-nhs-productivity-challenge-kingsfund-may14.pdf .
  3. Evans S, Stemple C. Electronic health records and the value of health IT. J Manag Care Pharm. 2008;14(6):16–18.

Cited by

Sorted by citations

Related

Authors
Scantlebury, A., Sheard, L., Watt, I., Cairns, P., Wright, J., & Adamson, J.
Affiliations
  • University of York (GB)
  • Bradford Royal Infirmary (GB)
  • Newcastle University (GB)
Corresponding author
Scantlebury, Arabella
ORCID
Venue
BMC Medical Informatics and Decision Making
Publisher
Springer Science and Business Media LLC
Published
2017-01-07
Volume
17
Issue
1
Pages
4-4
ISSN
1472-6947 (ISSN-L)
DOI
10.1186/s12911-016-0406-0
PMC
PMC5219748
OpenAlex
W2569741158
Semantic Scholar
faba15f16860fc102ee6f1aeefa3e462b42b1dfd
Cited by
41
References
44
Citations by year
2026: 1 · 2025: 5 · 2024: 8 · 2023: 1 · 2022: 2 · 2021: 10 · 2020: 6 · 2019: 3 · 2018: 5
FWCI
5.25
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • BMC Medical Informatics and Decision Making (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
  • Newcastle University ePrints (Newcastle Univesity) (cc-by)
Funders
University of York and Bradford Institute for Health Research
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Keywords
electronic health records, maternity ward, implementation barriers, Normalisation Process Theory, clinical information systems, print-to-digital transition, staff training and support, patient-clinician relationship, patient safety, clinical workflow
MeSH terms
Attitude of Health Personnel, Hospitals, Maternity, Humans, Midwifery, Physicians, Qualitative Research, Electronic Health Records

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-07.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-07.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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