Table 3 Example of a case study investigating the introduction of the electronic health records[5]

Context: Healthcare systems globally are moving from paper-based record systems to electronic health record systems. In 2002, the NHS in England embarked on the most ambitious and expensive IT-based transformation in healthcare in history seeking to introduce electronic health records into all hospitals in England by 2010.

Objectives: To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide formative feedback for local and national rollout of the NHS Care Records Service.

Study design: A mixed methods, longitudinal, multi-site, socio-technical collective case study.

The cases: Five NHS acute hospital and mental health Trusts that have been the focus of early implementation efforts.

Data collection: Semi-structured interviews, documentary data and field notes, observations and quantitative data.

Analysis: Qualitative data were analysed thematically using a socio-technical coding matrix, combined with additional themes that emerged from the data.

Key findings:

   1. Hospital electronic health record systems have developed and been implemented far more slowly than was originally envisioned.

   2. The top-down, government-led standardised approach needed to evolve to admit more variation and greater local choice for hospitals in order to support local service delivery.

   3. A range of adverse consequences were associated with the centrally negotiated contracts, which excluded the hospitals in question.

   4. The unrealistic, politically driven, timeline (implementation over 10 years) was found to be a major source of frustration for developers, implementers and healthcare managers and professionals alike.

Main limitations: We were unable to access details of the contracts between government departments and the Local Service Providers responsible for delivering and implementing the software systems. This, in turn, made it difficult to develop a holistic understanding of some key issues impacting on the overall slow roll-out of the NHS Care Record Service. Early adopters may also have differed in important ways from NHS hospitals that planned to join the National Programme for Information Technology and implement the NHS Care Records Service at a later point in time.