Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals

Aziz Sheikh*, Tony Cornford, Nicholas Barber, Anthony Avery, Amirhossein Takian, Valentina Lichtner, Dimitra Petrakaki, Sarah Crowe, Kate Marsden, Ann Robertson, Zoe Morrison, Ela Klecun, Robin Prescott, Casey Quinn, Yogini Jani, Maryam Ficociello, Katerina Voutsina, James Paton, Bernard Fernando, Ann JacklinKathrin Cresswell

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

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Objectives: To evaluate the implementation and adoption of the NHS detailed care records service in "early adopter" hospitals in England. Design: Theoretically informed, longitudinal qualitative evaluation based on case studies. Setting: 12 "early adopter" NHS acute hospitals and specialist care settings studied over two and a half years. Data sources: Data were collected through in depth interviews, observations, and relevant documents relating directly to case study sites and to wider national developments that were perceived to impact on the implementation strategy. Data were thematically analysed, initially within and then across cases. The dataset consisted of 431 semistructured interviews with key stakeholders, including hospital staff, developers, and governmental stakeholders; 590 hours of observations of strategic meetings and use of the software in context; 334 sets of notes from observations, researchers' field notes, and notes from national conferences; 809 NHS documents; and 58 regional and national documents. Results: Implementation has proceeded more slowly, with a narrower scope and substantially less clinical functionality than was originally planned. The national strategy had considerable local consequences (summarised under five key themes), and wider national developments impacted heavily on implementation and adoption. More specifically, delays related to unrealistic expectations about the capabilities of systems; the time needed to build, configure, and customise the software; the work needed to ensure that systems were supporting provision of care; and the needs of end users for training and support. Other factors hampering progress included the changing milieu of NHS policy and priorities; repeatedly renegotiated national contracts; different stages of development of diverse NHS care records service systems; and a complex communication process between different stakeholders, along with contractual arrangements that largely excluded NHS providers. There was early evidence that deploying systems resulted in important learning within and between organisations and the development of relevant competencies within NHS hospitals. Conclusions: Implementation of the NHS Care Records Service in "early adopter" sites proved time consuming and challenging, with as yet limited discernible benefits for clinicians and no clear advantages for patients. Although our results might not be directly transferable to later adopting sites because the functionalities we evaluated were new and untried in the English context, they shed light on the processes involved in implementing major new systems. The move to increased local decision making that we advocated based on our interim analysis has been pursued and welcomed by the NHS, but it is important that policymakers do not lose sight of the overall goal of an integrated interoperable solution.

Original languageEnglish
Article numberd6054
Number of pages14
Issue number7829
Publication statusPublished - 17 Oct 2011

Bibliographical note

We are grateful to the participating hospitals for supporting this work and to all interviewees who kindly gave their time. Throughout the process of undertaking this work we have had helpful support from colleagues at the NHS Connecting for Health Evaluation Programme led by Richard Lilford and supported by Lee Priest, Nathalie Maillard, and Jo Foster. Lee Priest also represented the funders on our independent project steering committee, which was chaired by David Bates. Other members of this committee included Martin Buxton, Antony Chuter, Ian Cowles, and Kathy Mason. We also acknowledge the support of the National Institute for Health Research, through the Comprehensive Clinical Research Network.

Funding: This report is independent research commissioned by the NHS Connecting for Health Evaluation Programme. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NHS Connecting for Health Evaluation Programme, or the Department of Health.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and


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