Understanding Contrasting Approaches to Nationwide Implementations of Electronic Health Record Systems: England, the USA and Australia
Open accessAbstract
As governments commit to national electronic health record (EHR) systems, there is increasing international interest in identifying effective implementation strategies. We draw on Coiera′s typology of national programmes ‐ ‘top‐down’, ‘bottom‐up’ and ‘middle‐out’ ‐ to review EHR implementation strategies in three exemplar countries: England, the USA and Australia. In comparing and contrasting three approaches, we show how different healthcare systems, national policy contexts and anticipated benefits have shaped initial strategies. We reflect on progress and likely developments in the face of continually changing circumstances. Our review shows that irrespective of the initial strategy, over time there is likely to be convergence on the negotiated, devolved middle‐out approach, which aims to balance the interests and responsibilities of local healthcare constituencies and national government to achieve national connectivity. We conclude that, accepting the current lack of empirical evidence, the flexibility offered by the middle‐out approach may make this the best initial national strategy.
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It is unlikely that organisations that are being encouraged to compete with each other will focus attention on interoperability without specific incentives of the kind promoted in the US and Canada.
“This is of particular concern as it is unlikely that organisations that are being encouraged to compete with each other will focus attention on interoperability without specific incentives of the kind that are being promoted in, for example, the US and Canada.106”
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 [106]
Section 2.2 (USA; page unavailable) describes centrally funded incentives for interoperability, and Section 3.4 says those incentives were introduced to promote nationwide interoperability. The copy does not establish that competing organisations are unlikely to prioritise interoperability without incentives, and the cited paper does not address Canadian incentives. (LLM, conf=0.86)
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Middle-out health IT programs: A scoping review of international experience
Price, C., Green, W., & Suhomlinova, O. O. (2026) · Health Policy and Technology · doi:10.1016/j.hlpt.2026.101283
- Authors
- Morrison, Z., Robertson, A., Cresswell, K., Crowe, S., & Sheikh, A.
- Affiliations
- University of Edinburgh (GB)
- University of Nottingham (GB)
- Venue
- Journal of Healthcare Engineering
- Publisher
- Wiley
- Published
- 2011-01
- Volume
- 2
- Issue
- 1
- Pages
- 25-41
- ISSN
- 2040-2295 (ISSN-L)
- 2040-2309
- OpenAlex
- W2149354967
- Cited by
- 81
- References
- 41
- Citations by year
- 2026: 4 · 2025: 2 · 2024: 4 · 2023: 5 · 2022: 2 · 2021: 4 · 2020: 1 · 2019: 6 · 2018: 7 · 2017: 5 · 2016: 2 · 2015: 11 · 2014: 6 · 2013: 15 · 2012: 6
- FWCI
- 14.38
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Journal of Healthcare Engineering (publishedVersion, cc-by)
- Edinburgh Research Explorer (University of Edinburgh) (publishedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Open Access Institutional Repository at Robert Gordon University (Robert Gordon University) (submittedVersion, cc-by)
- Funders
- Medical Research Council
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Health Professions › General Health Professions › Health Services Management and Policy
- Social Sciences › Sociology and Political Science › Information Systems Theories and Implementation
- Keywords
- electronic health records, national health information systems, top-down implementation, bottom-up implementation, middle-out approach, health policy, comparative health systems, England, Australia
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