BMJ: British EHR roll-out experience proves to be long, complex
Delivering improved healthcare through nationwide EHRs will be a long, complex and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy, according to research published online Sept. 2 in the British Medical Journal.
The research team, comprised of Aziz Sheikh, MD, a professor of primary care research and development at the University of Edinburgh in Edinburgh, Scotland, and colleagues, which included researchers from the London School of Economics and Political Science, the School of Pharmacy and the University of Nottingham, England, assessed the implementation of EHRs in five National Health Service (NHS) acute hospital and mental health trusts throughout England that have been the focus of early implementation efforts at which interim data collection and analysis were completed. They analyzed qualitative data thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data.
In 2002, the British government opted for a top-down, government-driven strategy that used standardized, commercial software applications. Interim results from the first comprehensive evaluation of the implementation of EHRs in secondary care in England reveal delays and frustration with the system, the research found.
“Hospital EHR applications are being developed and implemented far more slowly than was originally envisioned,” the authors wrote. “[T]he top-down standardized approach has needed to evolve to permit more variation and greater local choice, which hospital trusts want in order to support local activity.”
Despite the substantial delays and frustrations "there remains strong support for EHRs, including from NHS clinicians," noted the study.
According to the researchers, political and financial factors are now perceived to threaten nationwide implementation of EHRs. Interviewees identified a range of consequences of long-term, centrally negotiated contracts to deliver the NHS Care Records Service (the nationwide implementation of EHRs in England) 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,” the authors wrote. “Our data suggest support for a ‘middle-out’ approach to implementing hospital EHRs, combining government direction with increased local autonomy and for restricting detailed EHR sharing to local health communities.”
Given the planned widespread cuts to public spending and government plans to restructure the NHS in England, the authors stated they anticipate major policy revisions affecting the program. The priority, according to the authors, is to clarify the type and scale of nationwide EHRs that are now wanted and affordable.
“The English experience indicates that a ‘vision’ of introducing nationwide EHRs in the context of a broader aim to improve national healthcare can successfully kick-start an ambitious program of IT-based transformation. Realizing the vision, however, is likely to be an incremental and iterative process that unfolds over many years,” the authors concluded. "[W]hile there is no clear evidence as yet that a middle-out approach will achieve the goal of large-scale nationwide EHRs, international experience, including England's, suggests that neither a purely top-down nor bottom-up approach will likely do so."
The research team, comprised of Aziz Sheikh, MD, a professor of primary care research and development at the University of Edinburgh in Edinburgh, Scotland, and colleagues, which included researchers from the London School of Economics and Political Science, the School of Pharmacy and the University of Nottingham, England, assessed the implementation of EHRs in five National Health Service (NHS) acute hospital and mental health trusts throughout England that have been the focus of early implementation efforts at which interim data collection and analysis were completed. They analyzed qualitative data thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data.
In 2002, the British government opted for a top-down, government-driven strategy that used standardized, commercial software applications. Interim results from the first comprehensive evaluation of the implementation of EHRs in secondary care in England reveal delays and frustration with the system, the research found.
“Hospital EHR applications are being developed and implemented far more slowly than was originally envisioned,” the authors wrote. “[T]he top-down standardized approach has needed to evolve to permit more variation and greater local choice, which hospital trusts want in order to support local activity.”
Despite the substantial delays and frustrations "there remains strong support for EHRs, including from NHS clinicians," noted the study.
According to the researchers, political and financial factors are now perceived to threaten nationwide implementation of EHRs. Interviewees identified a range of consequences of long-term, centrally negotiated contracts to deliver the NHS Care Records Service (the nationwide implementation of EHRs in England) 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,” the authors wrote. “Our data suggest support for a ‘middle-out’ approach to implementing hospital EHRs, combining government direction with increased local autonomy and for restricting detailed EHR sharing to local health communities.”
Given the planned widespread cuts to public spending and government plans to restructure the NHS in England, the authors stated they anticipate major policy revisions affecting the program. The priority, according to the authors, is to clarify the type and scale of nationwide EHRs that are now wanted and affordable.
“The English experience indicates that a ‘vision’ of introducing nationwide EHRs in the context of a broader aim to improve national healthcare can successfully kick-start an ambitious program of IT-based transformation. Realizing the vision, however, is likely to be an incremental and iterative process that unfolds over many years,” the authors concluded. "[W]hile there is no clear evidence as yet that a middle-out approach will achieve the goal of large-scale nationwide EHRs, international experience, including England's, suggests that neither a purely top-down nor bottom-up approach will likely do so."