Implementation of electronic health records in England likely to be a long, complex and iterative process

Research: Implementation and adoption of nationwide electronic health records in secondary care in England: Qualitative analysis of interim results from a prospective national evaluation

Interim results from the first comprehensive evaluation of the implementation of electronic health records in secondary care in England have found delays and frustration with the system, according to research published on bmj.com today.

The authors, led by Professor Aziz Sheikh from The University of Edinburgh (and which included researchers from The London School of Economics and Political Science, The School of Pharmacy and The University of Nottingham), say experiences from the first-wave implementation site "indicate that delivering improved healthcare through nationwide electronic health records is likely to be a long, complex and iterative process."

Professor Sheikh and his team assessed the implementation of electronic records in five NHS acute hospital and mental health trusts throughout England. Their evaluation consisted of undertaking interviews, making observations and reviewing key documents.

The evaluation reveals that hospital electronic health records are being developed and implemented far more slowly than was originally hoped. The authors believe this is because "the top-down standardised approach has needed to evolve to permit greater flexibility and local choice in electronic health records systems and their delivery."

Despite the substantial delays and frustrations "there remains strong support for electronic health records, including from NHS clinicians", says the study.

Electronic health records are being introduced in Europe, North America, Australasia, the Middle East and elsewhere. Globally there have been varying approaches to developing electronic care records systems.

In 2002 the government in England opted for a top-down, government-driven strategy that used standardised, commercial software applications. In contrast, Australia and the USA have chosen more devolved strategies.

The nationwide implementation of electronic health records in England, known as the NHS Care Records Service, is the cornerstone of the -12.7bn National Programme for IT.

Given the planned widespread cuts to public spending and government plans to restructure the NHS in England, the authors anticipate major policy revisions affecting the National Programme. The priority, according to the authors, is to clarify the type and scale of nationwide electronic health records that are now wanted and affordable.

The authors argue that the English experience shows that having a 'vision' of nationwide electronic health records can be successful in kick-starting such an ambitious programme, but realising this vision is likely to be a process that evolves over many years, perhaps even decades.

They conclude that "while there is no clear evidence as yet that a middle-out approach will achieve the goal of large scale nationwide electronic health records, international experience, including England's, suggests that neither a purely top-down nor bottom-up approach will likely do so."