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Introducing a nationally shared electronic patient record:Case study comparison of Scotland, England, Wales andNorthern Ireland

Trisha Greenhalgha,∗, Libby Morrisb,c, Jeremy C. Wyattd,Gwyn Thomase, Katey Gunningf

a Global Health, Policy and Innovation Unit, Barts and the London School of Medicine and Dentistry, Abernethy Building, 2 Newark St.,London E1 2AT, United Kingdomb Hermitage Medical Practices, Edinburgh EH10 4RP, United Kingdomc Clinical Advisor for e-Health Scottish Government, United Kingdomd Leadership Chair in eHealth Research, Leeds Institute of Health Sciences, University of Leeds, United Kingdome Chief Information Officer for Wales and Director of Informatics Health and Social Care, Welsh Government, United Kingdomf Performance Management & Service Improvement Directorate, Northern Ireland Health and Social Care Board, United Kingdom

a r t i c l e i n f o

Article history:

Received 19 January 2012

Received in revised form

19 November 2012

Accepted 17 January 2013

Keywords:

Electronic patient record

Change management

Human factors

Case study

Health information exchange

a b s t r a c t

Aim: To compare the experience of the four UK countries in introducing nationally accessible

electronic summaries of patients’ key medical details, intended for use in emergency and

unscheduled care episodes, and generate transferable lessons for other countries.

Method: Secondary analysis of data collected previously on all four schemes; cross-case

comparison using a framework derived from diffusion of innovations theory.

Main findings: Whilst all four programmes shared a similar vision, they differed widely in

their strategy, budget, implementation plan, approach to clinical and public engagement and

approach to evaluation and learning. They also differed, for various reasons, in stakeholder

alignments, the nature and extent of resistance to the programme and the rate at which

records were created. A nationally shared, widely accessible electronic record has powerful

symbolic meaning; it may or may not be perceived as improving the quality and safety of

care or (alternatively) as threatening patient confidentiality or the traditional role of the

doctor or nurse. ‘Hard’ project management oriented to achieving specific milestones and

deadlines sometimes appeared counterproductive when it cut across the ‘softer’ aspects of

the programmes.

Conclusion: When designing and implementing complex technologies with pervasive impli-

cations, policymakers must consider not only technical issues but also the personal, social

and organisational aspects of the programme. A judicious blend of ‘hard’ and ‘soft’ man-

agement appears key to managing such programmes.

© 2013 Elsevier Ireland Ltd. All rights reserved.

∗ Corresponding author. Tel.: +44 20 7882 7325; fax: +44 20 83431348.E-mail address: p.greenhalgh@qmul.ac.uk (T. Greenhalgh).

1386-5056/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ijmedinf.2013.01.002

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1. Background

Most citizens, and clinicians, are positive about the idea of asecure summary of key medical details, accessible from wher-ever the patient seeks care [1–3]. Many European countries,and others such as Australia, USA and Canada, are currentlyseeking to establish such a summary [4–6]. The potential ben-efits of a nationally-accessible electronic record (known inthe USA as health information exchange), assuming sucha system to be fully secure, perfectly accurate and univer-sally accessible, are often assumed to be self-evident [7].Despite this, attempts to implement nationally shared sum-mary records have often met with troubled fortunes. TheUnited Kingdom is a unitary state containing four separatecountries: England, Scotland, Wales and Northern Ireland.Between 2004 and 2008, each of these countries started tointroduce their own national, centrally stored electronic sum-mary record. There was much in common between thesefour schemes (for example, all were based on an extractfrom the record held by the patient’s National Health Service(NHS) general practitioner and accessible by authorised staffvia a secure connection). But there were also significantdifferences between them. Of particular note is the differ-ence in population of the four countries, which ranged from51 million in England to 1.8 million in Northern Ireland(see Box 1 ).

All authors of this paper were involved in at least oneof the four individual programmes (English programme –TG and JW; Scottish – LM and JW; Welsh programme – GH;Northern Irish – KG and LM); various papers have beenpublished on these individual programmes [2,8–10,29]. Thispaper reports the results of a reflective reanalysis and cross-case comparison of the data collected for each individualprogramme. We summarise key differences and reflect onlessons learnt across the four schemes with a view to inform-ing implementation of these and related developments inother countries. Because of differences in the level of (andbudget for) research on these programmes in each of thefour countries, the findings presented here are a mix offormal research findings, routinely collected data and ourown reflections as people who were closely involved inimplementing the programmes; they should be interpretedaccordingly.

In this paper we first describe features of each of thefour programmes. Regrettably but inevitably, the differentcontexts and priorities of the different programmes led todifferent types and levels of data being available on eachof them, so whilst we have made every effort to comparelike with like, this has not been possible in all aspects ofthe programmes. Second, we describe a methodology forthe cross-case comparison of these programmes. Third, wepresent the findings of this analysis under the headings ofscoping and set-up; system design; ‘hard’ and ‘soft’ aspectsof implementation; approach to data quality; and approach toevaluation, monitoring and learning. Finally, we conclude thatmany important lessons have been learned from this exer-cise and recommend that those embarking on comparableprogrammes should take time to study the lessons reportedhere.

Box 1: Implementation challenges for programmesintroducing a shared electronic summary record

1. Scoping and set-up:a. Naming and framing the programmeb. Defining the stake holdersc. Defining the scope and purpose of the shared

recordd. Assigning leadership roles and domains of respon-

sibilitye. Setting strategic direction

2. Designing the system:a. Deciding who will do what (including who will

set the standards, build the technology, undertaketesting, etc.)

b. Defining the use case(s) and core clinical content– including what the record will be used for, whatdata it will contain, where it will be available, andwho may access it under what circumstances

c. Designing the underlying record architecture (e.g.coding structure) including security features andaccess controls

d. Developing and testing softwaree. Designing the consent model

3. ‘Hard’ aspects of implementation, including:a. Project management, e.g. liaising across organisa-

tions and sectors; managing and prioritising thevarious interacting tasks and sub-projects

b. Mobilising funding streams for the different sub-projects

c. Improving and maintaining data quality in therecords from which the summary will be drawn

d. Accommodating the competing interests, priori-ties, values and practical constraints (e.g. budgets)of different stakeholders

4. ‘Soft’ aspects of implementation (promoting accep-tance and use), including:a. Informing patients and answering questions from

the publicb. Engaging clinicians and encouraging active use of

the recordc. Managing concerns about privacy and data protec-

tion e.g. civil liberties lobby, professional groups5. Evaluating, monitoring and learning

a. Defining and measuring “success”b. Monitoring uptake and usec. Demonstrating clinical and other benefitsd. Maintaining an over-arching narrative of coherence

and progress (and in some cases, countering nar-ratives of “failure” generated by the press or otherstakeholders)

e. Generating and incorporating organisational and sys-tem learning

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2. Brief description of the four schemes

2.1. Scotland

The basic version of Scotland’s Emergency Care Summary(ECS) lists current and discontinued medication and adversereactions. It was piloted in two Health Boards in 2004 androlled out across Scotland by 2006. By 2011, it was connected in100% of general practices across Scotland. A new national datastore was built to host the records and pre-existing electroniclinks (‘e-links’) with practices were used to connect with this.Patients’ medical and demographic details are automaticallyupdated from GP record systems twice each day. As each local-ity became involved, practices and patients were informedabout the new system via local and national publicity cam-paigns, and patients were informed of their right to opt outand how to do so (by notifying their practice). Only around2000 people (0.03% of the adult population) chose to opt outin the early months of the programme, and this proportionhas not changed subsequently, despite widespread use of thesystem.

Scotland’s Emergency Care Summary can be accessed bystaff in NHS24 (Scotland’s national telephone triage system) aswell as those in Accident and Emergency Departments, AcuteReceiving Units, and Out of Hours Centres. In 2011, it wasmade available to paramedics in Emergency Ambulances. Allpatients using these services are routinely asked whether theclinician may view their ECS record. More than 96% of Emer-gency Care Summary accesses are via secure integrated accessfrom the user’s clinical system. Clinicians are permitted to‘break the glass’ and access the summary record without con-sent if the patient is too ill or unable to consent; all emergencyaccesses are audited.

In Scotland, there are currently 230,000 accesses to theEmergency Care Summary every month and this number issteadily rising as new users are added, e.g. prison service,hospices, and other emergency admission units. Audit logsof all accesses are available to practices and to every user onrequest; these logs are also checked regularly for fraudulentaccesses. Surveys suggest that clinicians working in emer-gency situations value the Emergency Care Summary andregard it as a key data source. It is perceived to be especiallyuseful in the medicines reconciliation process when patientsare admitted to hospital. For example, 34% of 118 cliniciansin a survey of NHS24 users said that it had changed a clinicaldecision and at the time of submission no episodes of harmdirectly linked to use of the Emergency Care Summary hadbeen reported (unpublished data). It is currently being pilotedby ambulance services and emergency dental departments,and proposals have been drawn up for its use in planned clin-ical care such as outpatient appointments. New developmentsinclude additions of a Key Information Summary and an inter-face for patient access to their record.

The Emergency Care Summary programme was clinicallyled from the outset. The first year of the programme mainlyconsisted of meetings and workshops within clinical groupsto build consensus about the format and clinical content. Aseries of patient focus groups was undertaken by the Scot-tish Consumer Council and their views helped inform strategic

decisions. There was close liaison with the Information Com-missioner, General Medical Council and professional defencesocieties, and each stage of work started once all were in agree-ment. This approach appeared to build strong clinical supportfor the project at all stages, and this support has persistedsince. The various new developments in the programme alloriginated within the clinical community and had strong back-ing from the Scottish General Practitioners’ committee of theBritish Medical Association.

2.2. Northern Ireland

Northern Ireland began to introduce a very similar EmergencyCare Summary to Scotland in April 2008, using an identicaltechnology and near-identical information sources for bothclinicians and the lay public. It was initially piloted in one NHStrust; Southern HSC Trust, with information being availablefrom 50 local GP Practices and accessed by one Out of HoursDepartment and one Accident and Emergency Department.As in Scotland, the programme was clinically led and therewas close (and largely informal) liaison with the Scottish groupwho had developed it. Much of the success of the programmehas been attributed to the fact that the solution being adoptedwas already implemented nationally in Scotland and hadalready won the support of clinicians. The dataset in North-ern Ireland was similarly restricted to demographic details,medications and allergies. Following the successful comple-tion of the pilot, the HSC ICT Programme Board recommendedthat the programme be rolled out across the region. The pro-gramme is now on target for completion by end 2012 whichwill see data being extracted daily from all 365 GP Prac-tices and being available for access by appropriate staff inall five Northern Ireland Out of Hours Centres, all ten Acci-dent and Emergency Departments and at hospital pharmacydepartments. The project board is also considering the pos-sible extension of use to other professionals e.g. AmbulanceService.

2.3. England

England’s shared electronic record, the Summary Care Record(SCR), was introduced as part of the National Programmefor IT (NPfIT) via a Programme Board within Connecting forHealth (the IT arm of the Department of Health); a full eval-uation of the early roll out phase has been published [8,9].There was a detailed national implementation plan within theDepartment of Health and a centrally coordinated monitoringscheme. Summary Care Records were introduced in two local-ities (Bolton and Bury) known as ‘early adopters’ from 2007.National roll-out of the programme began in 2009. A large-scale public information programme sought to inform peopleabout the SCR and their right to opt out. It comprised individ-ual letters, local mass media and talks to third sector groups.This programme was locally led but had extensive input and‘branding’ from Connecting for Health; its success in raisingawareness of the Summary Care Record was limited [10]. Par-ticipating NHS primary care trusts were required to produce aProject Initiation Document with milestones; named staff allo-cated to key tasks; and a ‘benefits realisation plan’. Individualgeneral practices were encouraged to work with the supplier

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of their practice software to upload selected data fields fromtheir surgery-based system to the central N3 Spine. Englandhas a number of different suppliers of general practice soft-ware, only some of whom were able to develop functionalityto create Summary Care Records. Some general practition-ers considered the programme unethical because personalmedical data were to be shared without the patient’s explicitconsent, hence they refused to participate, though resistancefrom clinicians appeared gradually to lessen as more and morepractices joined the scheme.

Use of Summary Care Records by clinicians was low inmost though not all emergency and unscheduled care set-tings for a variety of reasons, including non-availability ofrecords (“low hit rate”), technical glitches (e.g. slowdowns,‘bugs’ leading to partial or complete incompatibility betweensoftware packages, temporary loss of access to Spine), lowlevels of training and motivation, information governanceissues (such as forgotten passwords or lost clinician iden-tity smart cards) and fear of surveillance by staff (especiallyjunior nurses and pharmacists). Resistance from civil lib-erties groups and negative press coverage exacerbated theprogramme’s political sensitivity, which was associated in theminds of many citizens with a wider ‘surveillance state’ (e.g.it was linked to the contemporaneous but separate debateabout universal ID cards [11]). Our independent evaluationreport in June 2010 raised a number of concerns, includingthe high complexity of the programme, slow overall pace ofprogress, scope creep, persistent technical challenges, greaterthan anticipated workload for front-line staff, and whether theambitious information governance plans were workable andsustainable [12]. By the end of August 2012, approximately 40million of England’s 51 million population had been sent aletter about the Summary Care Record and over 18 millionrecords had been created, with 250,000 new records createdper week. While this was considerably slower than the paceof progress originally anticipated by policymakers, the pro-gramme appears to have become less politically contentiousover time and the low opt-out rate (1.3%) appears to reflecthigher than expected public confidence in the technology andthe programme.

Whilst the National Programme for IT was formally with-drawn in late 2011 in favour of locally-developed electronicrecord systems, at the time of writing the SCR remainsnational policy and efforts continue to create one for everyconsenting NHS-registered citizen. However, a previouslylinked programme to create a patient portal (HealthSpace)for the SCR was abandoned in 2012 because of very lowuptake.

2.4. Wales

The Welsh Individual Health Record (IHR) was developed witha dual vision – to merge the best of the NHS with the best thatcommercial systems can provide. Intentionally, there wereno large procurements and the modest initial budget for theproject (£4.7 million) was – again, intentionally – paid for fromexisting funding streams within the healthcare infrastructure.From the outset, the Individual Health Record was conceptu-alised as one component of a much wider work programmecomprising new clinical and business processes along with

new technological infrastructure and tools. The main techno-logical elements were:

(a) a public sector broadband network whose purpose was tolink organisations so as to share information securely,

(b) an email address and unique identifier for all NHS staff(this was later extended to local government),

(c) a Clinical Communications Gateway for referrals and dis-charges (“any to any”),

(d) the Individual Health Record described above, and(e) a patient portal for appointment booking, prescription

requests and self-management (‘My Health Online’).

The first Individual Health Records were created in May2007 in Gwent. Progress in the early months was rapid –the prototype covering 400,000 records was delivered in sixmonths and the consent model was broadly accepted by all keystakeholders over a similar time period. A setback occurredin November 2008 when the commercial supplier which hadbeen contracted to deliver to two further regions in Walesand deliver the national roll out went into administration. Arevised strategy was quickly developed in response to this set-back, based on direct involvement of the different GP systemsuppliers to supply software for creating Individual HealthRecords directly to their GP clients. By summer 2012 nearly65% of GP practices had gone live with the Individual HealthRecord – providing the IHR for over 2 million patients. Roll outto the remaining practices is continuing as part of the new GPsystems framework contract which will upgrade GP practicecomputer systems in Wales and support centrally hosted ser-vices.

3. Method

This study was a secondary, reflective analysis of data col-lected by us in our roles as participants in and/or evaluatorsof the national shared record programmes. The datasetconsisted of both quantitative data (letters sent, recordsuploaded, records accessed and similar metrics) and qual-itative data (documents such as strategies, business plans,minutes of meetings and so on; interviews with clinicians,project managers, commercial software suppliers and serviceusers; press articles and other material from the public sphere;academic papers and commentaries; and ethnographic fieldnotes). These sources have been described in detail in previouspapers [2,8–10].

The secondary analysis consisted of four phases. In phaseone, we discussed informally our separate interpretations ofthe different programmes and compared and contrasted ourown roles in them. In phase two, we developed the analyticframework shown in Table 1 , by considering the differentdimensions of the programmes and in which key aspectsthey were similar (or dissimilar). This phase was helped byadapting a previously developed multi-level theoretical modelfor considering the diffusion of complex service innovations[13]. In phase three (overlapping with phase two), we returnedto the original data sources and extracted data to populate thetable; these data sources were a mixture of formally collectedresearch data and routinely collected data on various aspects

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Table 1 – Comparison of the implementation of four national shared electronic record schemes in UK (reproduced with permission from MSc course materials for GlobalHealth MSc Programme at QMUL).

Broad aspect Specific factor Scotland EmergencyCare Summary

England SummaryCare Record

Wales IndividualHealth Record

N. Ireland EmergencyCare Summary

National context Population ONS 2007 (%of UK)

5.1 million (8%) 51.1 million (84%) 3.0 million (5%) 1.8 million (3%)

Key geographic anddemographic features

Some geographicallyremote areas. Very largepublic sector. High publictrust in clinicians and theNHS.

High population mobility. Mixedhealth economy with complexlocal arrangements. Low levels ofpublic trust in government. Strongcivil liberties lobby.

Small population; strongprofessional networks. Somegeographically remote areas. Highpublic trust in clinicians and theNHS

Small and geographicallycontained area covered by(e.g. only 5 GP out of hourscentres and 11 A&Edepartments)

Scoping and set-up Scheme initiated by Clinicians Government and IT industry Collaboration (“Team Wales”) Scheme initiatedcollaboratively

Designated leader General practitioner Senior civil servant General Practitioner/ProfessionalInformatician

Predominantly clinically led

Programme philosophy Thrifty and restrainedapproach, maximising useof existing systems andmaterials. Emphasis onsimplicity and fitness forpurpose.

Large, up-front investment tocreate an integrated national ITsystem. Emphasis on due process,formal contracts, highest securitystandards.

Humility in the face of the user,Follow simple rules to manage acomplex healthcare system, Solvereal world problems and supportpeople. Listen and learn fromothers’ mistakes. Build andmaintain collective confidence,credibility and commitment.

Adopt a tried and testedlow-tech solution fromScotland

Set-up budget £0.5 million £200 million £4.7 million £240K (for pilot)Scope and purpose ofshared record

Tightly defined andnon-negotiable clinical usecase: emergency care.

Initially, emergency andunscheduled care. Later,broadened to include communitybased services and end of life care.

Improve quality, safety andconvenience of emergency and outof hours care.

As Scotland

System designissues

Approach torequirements definition

Predominantly social: wideconsultation defined as“getting everyone onboard”, including earlypatient consultation

Technical: expert-led ‘engineering’model, includes seeking ideas andfeedback from defined stakeholdergroups

Socio-technical. Technologydesign should, first and foremost,enable and support front-lineclinical work

Win support for Scotlandapplication

Key design principles Emergent and intuitive:“keep it simple andpractical”. Ambiguitytolerated and/or addressedin a pragmatic,common-sense way.

Centrally modelled based onassumption that all problemsshould be ‘fixed’ (hence multiplecommittees working on solutionsand producing guidance)

Grow a locally-relevant systemwithin a national architecture.Create the potential for any NHSclinician to see the medical recordwherever the patient is seen.

Use what is already workingand supported in Scotland

Approach to privacy andconsent

Seen as a pragmatictrade-off against access todata

Seen in absolute, technical andlegal terms hence initial modelwas complex and confusing

National database rejectedbecause of patient, clinician andpublic concerns about security andprivacy. Pragmatic consent modelsimilar to Scotland

As Scotland

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Table 1 (Continued)

Broad aspect Specific factor Scotland EmergencyCare Summary

England SummaryCare Record

Wales IndividualHealth Record

N. Ireland EmergencyCare Summary

Approach to softwaredevelopment

Recycle and extend: use anexisting government-builtinfrastructure and addminimal new componentsto extend its function

“Waterfall”: contract the ITindustry to produce astate-of-the-art new system

Eclectic: buy some, build some Use Scotland’s product anddeploy on existinginfrastructure

Implementationprocess

Stakeholder alignment Co-evolved from the outset Multiple interest groups withdifferent goals, norms and values.Began to co-evolve relatively latein the programme

Co-evolved from outset As Scotland

Change model/intendedpace of progress

Organic, with strongemphasis on going at thepace at which stakeholderswere comfortable

Managerial, civil service driven(‘PRINCE 2’: tightly managed viaGantt charts with a view to‘realising benefits’)

Socio-technical and responsive tocontingencies e.g. procurementmodel was changed when one ITsupplier went into administration

As Scotland

Approach to ensuringbaseline data quality ofGP record

Data quality of practicerecords was high buttechnical and operationalchallenges wereencountered whenpractices went live with theECS. Practices areencourages to addmedications prescribed‘elsewhere’ but this aspectsremains a challenge.

Baseline data quality was variable.Initially LES (‘locally enhancedservice’ – financial incentives andfacilitation) but funding for thiswas withdrawn in mid 2009. Smartcard requirement (but low actualuse of smart cards) led toinaccuracies in data quality

Data quality of GP records wasvariable but improving, driven byQOF and professional pressure. AData Quality System (DQS, similarto LES in England) was introducedin 2007 with the aim of improvingquality for electronic recordinitiatives referral and dischargeand medicines management andthe IHR

Demographic data on GPclinical systems wasconsidered good followingimplementation of uniqueidentifier (Health and Carenumber) to all records andData Quality Initiative in2004–2006.

Actual pace of progress Steady Variable (slow in some areas butrapid in areas where stakeholderalignment strong)

Steady to begin with then staticfollowing a setback in 2008; morerecently steady progress resumed

Slow during pilotimplementation andevaluation and early rollout – full roll out on targetfor completion by end 2012

Promotingacceptance and use

Approach to patient andpublic engagement

Clinicians wrote letters andled information campaigns.

Communications Department ofConnecting for Health set ‘housestyle’ and supported informationcampaign

Widespread clinical and publicconsultation. Website and leafletgive information and FAQs

Active communicationsgroup established led byclinicians withrepresentation from GPs,Patient Client Council, Outof Hours staff and Trustcommunications staff.

Approach to clinicalengagement

Clinicians seen as centraldriver

Clinicians seen as a hurdle toovercome

Clinicians were a key stakeholdergroup in a wider partnership

As Scotland

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Table 1 (Continued)

Broad aspect Specific factor Scotland EmergencyCare Summary

England SummaryCare Record

Wales IndividualHealth Record

N. Ireland EmergencyCare Summary

Approach to ensuringon-going data quality ofthe summary record

Feedback to practices toencourage them to addmedications prescribed‘elsewhere’ to the ECS butthis remains a challenge.

Technical solution: wheneversomeone uses a smart card, alldata in relevant fields added to therecord since previous uploadwould be added to SCR

Audit incentives plus trainingprogramme and engagement ofclinical and professional leaders toprioritise issue of data quality

Some issues with accuracyof medications on ECSidentified. Full regionalreview conducted of howmedication is recorded andstandards agreed. Changesto clinical systems beingagreed.

Evaluating,monitoring andlearning

“Success” defined interms of

Everyone on board;accessing shared records ispart of business-as-usual ofunscheduled care

Records created; records accessed;benefits realised

Effective, efficient and safe system;widespread confidence in the IT;high staff morale and productivity

As Scotland

Official evaluation by In-house team Academics under contract Local teams as part of ongoingaudit

In house team as per ICTProgramme governancearrangements

Approach toorganisational/teamlearning

Much learning was tacit,often shared informallyamongst key players

Knowledge seen as codified facts;documented on ‘lessons learnt’spread sheets

Explicit focus on a learningcommunity and “progress throughpartnership” from the outset

As Scotland

Approach to evaluation Identify clinical successstories and criticalincidents; producepragmatic audits whichgave an overview of keyindicators

Internal: implement a “benefitsrealisation strategy” and collectexamples of benefits External:commission an independentacademic team to produce a reportto demonstrate transparency

External international advisorygroup undertook public peerreview on annual basis. BenefitsRealisation strategy andcompilation of a benefits register

As per HSC ICT programmegovernance arrangements

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of the schemes’ performance. In phase four, we discussedsimilarities and differences across cases so as to generatehigher-order insights. The essential analytic method wascross-case comparison from an interpretivist social practiceperspective (i.e. explicitly considering the personal, socialand political context as well as the material properties andfunctionality of the technologies under scrutiny) [14].

4. Main findings

The contrasting characteristics and fortunes of the four pro-grammes are summarised in Table 1. Whilst there were manydifferences between them, it is clear that – whatever the set-ting and the particulars of the programme – implementationof a nationally shared electronic summary record is a highlycomplex challenge which requires multiple overlapping tasks(Box 1). These implementation challenges were common to allfour programmes, but they played out very differently becauseof significant differences in contextual variables. We considereach of the main tasks and relevant contextual issues in turnbelow.

4.1. Scoping and set-up

‘Naming and framing’ is key to implementing a technologyprogramme with social or political significance [15,16]. Peo-ple make sense of technology programmes by generating andexchanging stories about them. Through these stories, thetechnology acquires a shared social meaning (or, in somecases, how a truce about its contested social meaning isnegotiated). In the Scottish programme, a small number ofenthusiastic clinicians led the programme from the outsetwith minimal input from government. Early and continuingconsultation with groups representing service users createda master narrative of ‘improving clinical care and assuringquality and safety’ with which the name “Emergency CareSummary” quickly became associated, and within which addi-tions to the programme (e.g. the Palliative Care Summary,introduced later) were contextualised and worked towards.Managerial and technical expertise was supplied by key orga-nisations holding national contracts.

In Northern Ireland a similar approach has been taken forboth the technology design and adoption. The implementa-tion was led by clinicians familiar with the programme inScotland. The implementation and initial pilot phase alsoallowed time for the system to be introduced and accepted.The Minister for Health officially launched the programme in2008. The programme was also keen to ensure that the datasetwould be kept restricted (to demographics, medications andallergies) and not to be seen as introducing a full electroniccare record ‘by the back door’. A very active communica-tions group with representation from GPs, consultants, Outof Hours staff and the Northern Ireland Patient Council wasestablished and this multi-stakeholder group developed andled the delivery of material to all stakeholders. The summaryis now available in secondary care for medicines reconciliationin planned admissions.

In England, the technology was not so very different, butthe ‘naming and framing’ unfolded very differently [17]. The

idea of the Summary Care Record was announced in 1998 bythe newly-elected Prime Minister with these words (whichsubsequently became widely-quoted and ridiculed by critics),“If I live in Bradford and fall ill in Birmingham then I wantthe doctor treating me to have access to the information heneeds to treat me.” [17]. That the technology and associatedvision was announced by a top politician as part of a ‘regimeof hope’ [18] reflected its positioning as a component of anambitious, government-led IT programme of unprecedentedscale, involving financially costly and inflexible contracts witha handful of IT suppliers. It became associated in the minds ofpress and citizens with other aspects of the ‘Database state’(notably the Blair government’s contemporaneous attempt tointroduce a national ID card) [2,11]. It is perhaps for this reasonthat civil liberties protests were especially vocal in England.Many commentators viewed New Labour’s focus on ‘big IT’ asa mechanism to bring about public sector reform, partly due totechnology’s potential to challenge organisational inertia andprompt transformational change. For example, the Chooseand Book programme for booking hospital appointments wasdescribed by Department of Health sources “as easy as bookinga plane journey”.

In Wales, the ‘Informing Healthcare’ strategy had beenwritten in 2002 by a consortium comprising clinicians andmanagers from NHS Wales. It was launched by the then Min-ister for Health so there was both a high degree of localownership and a high degree of national political commit-ment. The introduction of the Individual Health Record wasthe first major step in the implementation of the wider Inform-ing Healthcare strategy (in other words, the programme was achange programme underpinned by technology, not a technol-ogy programme). It was led by highly experienced cliniciansand managers who also had extensive technical knowledge,leadership experience and political connections. For example,several had previously worked on the English National Pro-gramme for IT and had made a personal choice to move todevote their energies to delivering a national strategy for elec-tronic patient records that was informed by lessons learnedfrom both the successes and disappointments of previousinitiatives. Partly as a result of their earlier experiences inEngland, they saw inherent risks in a strongly top-down andmilestone-heavy approach which was wholly or largely pro-curement driven.

Despite their reservations on how the programme wasimplemented, the leaders of the Welsh programme were com-mitted to the principle of clinical information being availablewherever an NHS patient was being treated, and of ensur-ing national-level interoperability and integration as far aswas technically possible. To this end, they worked to estab-lish a broad-based partnership under the banner of ‘InformingHealthcare’ which included Welsh Government, national andlocal-level NHS, local authority, and the IT industry. The mainstrengths and distinguishing features of the Informing Health-care Programme in Wales are: (a) strong national leadership;(b) extensive stakeholder involvement and engagement; (c)technical governance (via the National Architecture DesignBoard, NADB); (d) explicit acknowledgement of the tensionbetween technical design and clinical need (e.g. NADB ischaired by a clinician and has equal membership of tech-nical and clinical staff); (e) a mixed economy of technical

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systems; (f) incremental development and deployment; and(g) the principle of being user-led and benefits-driven, so asto provide clinicians with something better than they alreadyhave (relative advantage). These aspects of the Welsh systemare described in more detail in other sections below.

4.2. System design process

The four programmes differed strikingly in their overallapproach to system design. As Table 1 shows, the Scottishteam viewed the programme primarily in social terms anddefined the key preliminary task in terms of “getting everyoneon board”. The programme’s leaders did little else in the firstyear apart from building dialogue, negotiating with patientand clinician groups, and consulting with formal bodies suchas the Information Commissioner and professional defencesocieties. Issues such as security and privacy were discussed atlength, and qualitative research studies of the patient perspec-tive were commissioned, but the solutions that emerged werepragmatic and relatively light-touch (with scope for individ-ual judgements accommodated and based on clinical need),rather than weighed down by rigid information governanceprocedures.

The Emergency Care Summary programme in NorthernIreland was very similar to Scotland. Given the decision toimplement the same solution as in Scotland (which was pro-vided under Crown Copyright) much of the efforts were spentin agreeing the previously-developed patient consent modeland what data would be shared. Early discussions with BritishMedical Association, Local Medical Committees, patient rep-resentative bodies and the Information Commissioner, whilsttime consuming in the early stages, were considered to becritical to success and helped to ensure that the regionalimplementation was accepted.

The Summary Care Record programme in England alsoincluded early discussions with patients, clinicians and pro-fessional bodies. However here, the overall emphasis was onestablishing an infrastructure within the civil service in whicha series of committees and working groups were allocated par-ticular tasks, each of which was charged with ‘fixing’ one ofthe programme’s numerous problems and challenges. Perhapsbecause of dominance of the ‘civil service logic’, issues suchas security and privacy were constructed in absolute and pre-dominantly legalistic terms. Solutions were correspondinglytechnology- and procedure-focused and perceived by manyof the programme’s participants as bureaucratic. Under theLabour administration which lasted from 1997 to 2010, therewas a strong belief in the positive benefits of managementconsultancy [19]. The civil service sought to commission man-agement consultants to help implement change, and the NPfITin England aligned with this strategy by procuring short-termconsultancy to help develop the Summary Care Record pro-gramme. These management consultants typically broughtgeneric project management skills but had little or no previousexperience in the NHS.

In Wales, the idea of a centrally-held summary (stored onthe Spine) was rejected at an early stage on design grounds.The Individual Health Record technology therefore differsfrom other shared electronic record systems in the UK in thatit is not a summary at all. Rather, it is a full extract from

the patient’s GP-held record with certain “sensitive” fields(notably for sexual health and some mental health) obscured.The core design principle for this technology was to createa mixed economy of ICT systems that made the best useof existing NHS systems and the skills of established NHSstaff, and combining this with the ‘best of breed’ from thecommercial sector. The challenge of interoperability would beaddressed by stipulating compliance with the national archi-tecture and standards. Another key difference was how theconsent model for access to a patient’s record was developed.This model was based on the following principles: (a) The keytask was seen as solving real world problems in a specificcare setting (rather than, for example, becoming tangled upin a philosophical debate about privacy); (b) clinicians wereseen as professional people who, if they could be trusted toprovide patient care, could also be trusted to share informa-tion responsibly; (c) the key policies and principles that wereneeded to deal with professional conduct around informa-tion sharing were seen as already existing (for example, inprofessional codes of practice) rather than needing to be devel-oped de novo; (d) a complicated role-based access and controlmodel built into the software was seen as unnecessary; (e)it was acknowledged that human error or malice was likelyto occur somewhere in the system, so strong audit processeswould be put in place to identify those who had accessedpatient records and provide this information to patients ifrequested; and (f) the principles of the consent model wereseen as being developed and owned by the professional bodies(British Medical Association, Royal College of Nursing), prac-tising clinicians, patient representatives (Community HealthCouncils) and the Information Commissioner, rather than bytechnologists and managers.

4.3. ‘Hard’ aspects of implementation

Electronic records, especially when introduced nationwide,have multiple stakeholders including policymakers, clini-cians, patients, commercial IT companies, potential users ofsecondary data and civil liberties groups [14]. Each stakeholderbrings different interests, goals and values to the negoti-ating table, and people often feel strongly about particularissues either individually or on behalf of the organisation orsocial group they represent. For this reason, ‘implementa-tion’ is not a politically neutral project management exercisebut is steeped in contested meanings and conflicting narra-tives of power and control [9]. One way of conceptualising thecomplexities of such programmes is to consider the extentto which the various people (clinicians, project managers,service users, civil servants technical suppliers, civil liber-ties protesters, press and so on) and technologies (nationallyshared record, local record, supporting infrastructure, avail-ability of local terminals and so on) involved are aligned in amore-or-less stable socio-technical network [20]. This networkmay be destabilised if, for example, a major supplier pulls outof a contract, a security breach story emerges in the press or anew regulatory ruling (e.g. by the Information Commissioner)is made, since these events have knock-on effects on the widernetwork.

In Scotland, one of the major primary care system suppli-ers was part-owned by the Scottish Government and deployed

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in 80% of practices. This somewhat circumstantial alignmentof interests meant that development for this system was pri-oritised and proceeded rapidly. Other suppliers working inScotland had to fall in with the requirements for ScottishEnhanced Functionality, which included the ability to exportdata to the Emergency Care Summary. At the time, the infor-matics community had strong links with the Scottish GeneralPractitioners Committee of the British Medical Association,the Royal College of General Practitioners, nursing networksand patient groups. The atmosphere was one of cooperationand improvements to patient care. Another largely circum-stantial realignment which helped create a supportive contextfor the Emergency Care Summary implementation was thenew GP contract, which devolved responsibility for out ofhours care to Health Boards and away from individual GP prac-tices.

Northern Ireland’s implementation of the Emergency CareSummary required the development of an interface with theclinical systems in use in general practices. UnfortunatelyNorthern Ireland did not use the system used by the major-ity of practices in Scotland and was in a weaker negotiatingposition with commercial suppliers because of its smaller size.Northern Ireland did replace existing contracts with its fourprimary care system suppliers in 2009, making the require-ments for the Emergency Care Summary system mandatory.Northern Ireland used the same out of hours computer systemas Scotland, so was able to benefit from this development.

In England, the key socio-technical alignments required forsmooth implementation were very different and, many wouldargue, unstable or non-existent. For example, Connecting forHealth was tied into very large, legally binding contracts withmajor IT suppliers, in which small changes to specificationcame with large price tags, making the programme cumber-some and inflexible. Professional bodies such as the variousRoyal Colleges and the British Medical Association alignedrather awkwardly with these players, perhaps because theystruggled with the trade-off between risks and benefits ofnationally shared records. Clinical engagement and fit to NHSrequirements and workflow at the outset was considered bymany to be poor, because of a strong technology focus. Whilstthese improved somewhat as the programme unfolded, thisoccurred too late in its life cycle to influence pre-existing con-tracts. The government was unpopular and a general electionwas looming.

In Wales, the national agency Informing Healthcare madean early strategic decision to build the single electronic recordincrementally via what was described as a “national pro-gramme for local implementation”. The strategy was to workwith local NHS organisations on a region by region basis;seeking to avoid disruptive, unaffordable and (they felt) unnec-essary ‘rip and replace’ approaches; and learning lessons ateach stage. The strategy was introduced with what the chiefexecutive of Informing Healthcare described as “no arbitrarilydictated timescales” so that progress could follow the paceof technical development and clinical and public engage-ment. Importantly, ‘incremental’ in this context was definedas ‘small’ rather than ‘slow’: the aim was to take tightly-scopedbut rapid steps, with the initial Individual Health Record pro-totype being delivered locally in 6 months at a cost of under£1 per patient.

4.4. ‘Soft’ aspects of implementation

Research on diffusion of technology-based innovations showsthat their uptake depends to a large extent on their attributes– such as whether potential adopters perceive them as use-ful and easy to use; whether benefits are rapidly seen;whether they can be implemented with minimal infrastruc-ture; whether they can be tried out with minimum investment;whether the mechanisms that generates benefits are clear tousers; and whether they are customisable to local circum-stances (‘potential for reinvention’) [21,22]. Even the simplestnationally shared electronic record is in reality technicallyvery complex (the more so as more functions and securityfeatures are added). In addition, such records inevitably comewith, or presuppose, a complex supporting infrastructure –including the ‘locked down’ computing environments of thetypical NHS organisation. The impacts of shared electronicrecords typically occur at some distance in time and placefrom the people who undertake the initial implementationwork [23,24]. One computer science academic observed thatin relation to IT programmes, “One can (with difficulty) achieveany two of (a) high security, (b) sophisticated functionality, and (c)great scale – but achieving all three is currently (and may wellremain) beyond the state of the art.” (page 230) [25]. Scotland’sexperience with the modest functionality of the early Emer-gency Care Summary suggests that clinicians may be happy tocompromise on these competing ideals if there is significantbenefit to patient care, service delivery or more efficient useof time.

The vast scale of the Summary Care Record programmein England created multiple interdependencies and logisti-cal challenges. Some stakeholders perceived substantial scopecreep as central committees chose to add new functionalityand potential use cases, partly in an attempt to increase useof the technology and demonstrate its benefits. Initial plansfor the consent model were complicated and unwieldy. TheBritish Medical Association came out in strong opposition tothe ‘implied consent’ model.

In contrast, Scotland’s Emergency Care Summary teamadopted a highly pragmatic approach of “keep it simple”:they resisted efforts by stakeholders to extend the contentand scope of the new technology; all stakeholders (clini-cians, patients, technical designers, policymakers) agreedin broad terms what the record was for (emergency care),what it would contain (drugs and allergies) and who woulduse it (clinicians delivering emergency and unscheduledcare). A two-stage consent model (initial implied consentfor data upload, followed by explicit consent to view) wasproposed and gained the support of all key stakeholders.Consent to view at the point of care has been perceived bystaff as simple and easy to administer and been incorpo-rated into their workflow with no major problems. Initialconcerns from secondary care clinicians that this consentmodel would be unworkable proved unfounded. Indeed,the question “Are you happy to give permission to all clini-cians looking after you to have access to your GP records?”appears to have driven a change in culture by encourag-ing clinicians to involve patients in decisions about whomay access their record, and to respect their views on thisissue.

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Northern Ireland adopted the same approach as in Scot-land with a view “If is already working; why change it”? Thedataset remains restricted and it is noteworthy that partici-pating GPs insisted from the outset that there would be noextension of the minimal dataset (which is seen as provid-ing sufficient information in almost all cases) without a fullconsultation. Perhaps because of this clear containment ofscope, Northern Irish general practitioners have been verysupportive of the initiative. The consent model from Scot-land was also shared with all stakeholders and was agreed.Northern Ireland is exploring the possibility of taking up Scot-land’s Palliative Care Summary when implementation of ECSis completed.

In Wales, the leaders of the programme began with a con-viction that the complexities of implementing ICT at scalecannot be managed centrally. They felt that creating the nec-essary “social architecture” at both local and national levelwas just as important as developing the technical architec-ture. For example, the difficulties that England had faced ingaining and maintaining the trust of patients, the public andclinicians led the leaders of the Welsh programme to rejectthe idea of a single large database (the Spine) containing allpatient records. Development of the consent model in Waleswas seen as an essentially social challenge, not a technologi-cal one; this work package had a high degree of professionaland patient involvement and ownership and also benefittedfrom studying what could be learned from Scotland’s success.

4.5. Data quality

A key feature of any electronic record is the quality and com-pleteness of data it holds. This is important both from anabsolute perspective (a missed penicillin allergy or out-of-datemedication list might have life-threatening implications) butalso because if the records are widely perceived to containinaccurate or unreliable data, clinicians will be reluctant toaccess them or act on the information they provide. There isa tendency for greater reliance to be placed on computer-helddata (such as medication lists) rather than equivalent data inmanual form (e.g. a handwritten letter or plastic bag of medi-cation), particularly by junior staff who may lack experience inquestioning the provenance and accuracy of medical records.This tendency is called automation bias [26].

A warning screen on the initial page of Scotland’s Emer-gency Care Summary advises caution when interpreting themedication list, as it may not include drugs prescribed inthe last few hours, prescriptions which were handwrittenon home visits or prescribed elsewhere (e.g. in a hospital,drug clinic or mental health clinic). Early feedback from usersof the Emergency Care Summary identified ‘medication pre-scribed elsewhere’ as a significant problem, so GP practiceswere encouraged routinely to add such medications manuallyso they would be uploaded onto the central summary. Generalpractice electronic record systems are all able to record a field‘medications prescribed elsewhere’ but this is time consumingand can add significant workload, particularly when patientsare discharged from hospital on multiple medications, hence achange in culture was needed. Recent evaluations of the Emer-gency Care Summary show that this issue remains significantand has only partly been addressed (unpublished data).

Whereas Scotland’s and Northern Ireland’s EmergencyCare Summary is automatically updated twice daily, England’sSummary Care Record is updated only when the generalpractice clinician inserts their identifying smart card. If theclinician logs on without his or her smart card, the record isnot updated with the latest medication or other data. Thismeans that significant medication changes can sometimesfail to be uploaded to the Summary Care Record, for exam-ple when locums (who may not have a smart card) prescribemedication, or when a regular clinician’s card is forgotten orfails to “work”.

In the Welsh system, the quality of GP record data wasvariable but improving, driven by the Quality and OutcomesFramework (QOF – a national financial incentive to recordcertain key data in agreed fields) and peer pressure amongprofessionals. A financial incentive scheme, the Data QualitySystem (DQS, similar to the locally enhanced service or LESin England) was introduced in 2007 with the aim of improv-ing data quality on electronic records; referral and discharge;medicines management and the Individual Health Record.

4.6. Evaluating, monitoring and learning

The approach to evaluation and monitoring differed substan-tially across the four programmes. In England, there waspolitical pressure on Primary Care Trusts and Strategic HealthAuthorities to demonstrate “benefits realisation”. When ben-efits were not as evident as policymakers had anticipated,enthusiasm waned significantly. This illustrates the perilsof a ‘technological determinism’ approach (assuming thatthe technology itself will cause the benefits), since whenany system implementation is linked to a required “bene-fits realisation” strategy, participants may tend to look forthese benefits once the technology goes live rather than takingactive steps to achieve them (e.g. by actively trying to promoteand support use of the technology). Our cautious approach to‘benefits realisation’ is not to deny the need for an evaluationplan to help ensure that the system is accepted, actually usedand that usage has the desired impact [27].

Somewhat negative press coverage tended to portray theNPfIT on the whole as inefficient and monolithic, and theSummary Care Record programme as ill-conceived and uneth-ical, because civil liberties campaigners had contested the‘implied consent’ model. The Communications Department ofConnecting for Health managed press releases about the NPfITand monitored and responded promptly to all press coverage.The Summary Care Record programme was the subject of aformal, independent evaluation which was commissioned bycompetitive tender at a cost of almost £1 million; the 235-pageacademic report was “welcomed” by Connecting for Healthbut its key message, that the SCR programme was charac-terised by unwieldy political and technical complexities whichstacked the odds against its smooth implementation, was noteasily actioned. The official evaluation report was submittedjust before the 2010 general election; the new Conservativegovernment quickly commissioned two smaller inquiries intothe consent model and the clinical content of the SCR. On thebasis of these, the Department of Health stipulated a morelimited clinical content similar to the Emergency Care Sum-mary in Scotland and a modified consent procedure. This

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change, whose impact on uptake rates appeared to be show-ing an upward trend as this paper was submitted, appearedto result in a more acceptable technology with a simplifiedcontent and consent model and to have reduced the contro-versies surrounding it sufficiently to allow slow but steadyuptake, though no information on its actual use was availableto us.

In Scotland, there was no official independent evaluation(no budget had been allocated) – partly because the pro-gramme was less politicised and civil liberties protests lessprominent, so neither politicians nor the public were askingfor one. Feedback from users of the Emergency Care Summarywas gathered as part of a small-scale in-house evaluation; itwas apparent from this that the system had quickly becomepart of ‘business as usual’ and a proposal for a randomised trial(in which some localities would have access to the EmergencyCare Summary but others would not) was deemed unethical.Ongoing collection of staff reports has produced many anec-dotal stories of improvements in patient care and perceivedtime saving, but because of the pragmatic study design it isdifficult to attribute these perceived improvements solely tothe use of the Emergency Care Summary. Feedback from phar-macists who use the Emergency Care Summary for medicinesreconciliation in unscheduled admissions has been positive(unpublished data). Press coverage of the introduction of theEmergency Care Summary was limited, but in one incidentwidely reported in the national news, a hospital doctor lookedat records of celebrities and colleagues, a breach which wasrapidly picked up via routine audit procedures. A decision wasmade not to respond formally to the press stories on this inci-dent, on the grounds that there was no control over whatwould be printed. As it turned out, publicity from this inci-dent raised public awareness in a positive way by highlightinghow rapidly the breach was detected.

In Northern Ireland an in-house evaluation of the pilotimplementation in the Southern Trust was completed in 2009,in line with programme governance arrangements. This con-cluded that the system had met the objectives of collating andmaking available medications and allergy information to staffwith appropriate access controls, although there were con-cerns about the low usage of the application. Much of thiswas based on the fact that with only some general practicesparticipating in the pilot, the hit rate was low and it wastime consuming for clinicians to check whether the recordwas available. The HSC ICT Programme endorsed the regionalimplementation of the programme but asked for monitoringof the usage of the system. There are currently approximately1100 accesses to the ECS per week by staff at Out of HoursDepartments, Accident and Emergency Departments and hos-pital pharmacy. The project board are content with the steadyincrease and has allowed the system to be embedded toexisting work practices and used where necessary withoutstipulating the nature of this use.

In Wales, the programme’s organisers emphasised recog-nising and responding to the inherent conflicts betweenprofessionals, organisations, priorities and political reality fordelivering a major IT programme when financial resourcesare limited. Attention was paid to communication and stake-holder engagement – e.g. via regular meetings with localleaders and presentations to chief executives and their boards.

Nationally funded but locally based Informing Healthcare(IHC) project managers were appointed and trained as ambas-sadors and facilitators for the scheme. Significant stakeholdercommitment was built by running problem-solving, topic-based events (the first and longest lasted five days) involving arange of stakeholders including clinicians, ICT professionals,chief executives, Ministers, government officials and patientrepresentatives in real-time decision-making about require-ments and technical design that the Informing Healthcareprogramme would commit to acting on. This created a senseof common purpose, credibility and trust: the national ICT Pro-gramme was perceived to be genuinely owned and driven byits key stakeholders.

Whilst a formal independent evaluation of the Welshprogramme was not commissioned, the Informing Health-care International Advisory Group (whose members weredrawn from USA, Canada, New Zealand, Denmark, Finland,Netherlands, Republic of Ireland, Scotland and England) metannually to undertake a public peer review of the programme.This peer review was held in a culture of openness: ICTsuppliers and the national and local media were invited toparticipate. This had a number of benefits (a) it provided inde-pendent external benchmarking of the programme’s progress;(b) it identified areas where Wales was at the forefront ofinternational developments; (c) it also identified lessons thatWales could learn from the experience of others; (d) its recom-mendations were implemented via agreed action plans whichwere publicly reported and reviewed by subsequent advisorygroup conferences; and (e) it placed the Welsh ICT programmein an international context rather than simply comparing itwith the English equivalent. This last feature helped consid-erably to counter the bad press about the perceived failure ofEngland’s NPfIT (and also the implied adverse implications ofthis ‘failure’ for the credibility all national ICT programmes).This positioning was extremely important and valuable inmaintaining the strong and consistent Ministerial support ofthe Welsh Government, working NHS clinicians and technicaland managerial staff.

5. Conclusions

This secondary data analysis has demonstrated the addedvalue of reflecting collectively on the successes and disap-pointments across the shared electronic record programmesin the four UK countries. We hope that the lessons describedabove will also resonate outside the UK to countries such asthe USA, which are just beginning to implement regional andnational electronic records [28].

The very different fortunes of the four programmes wereonly partly explained by differences in the technologies. Atleast as significant were the widely differing histories of theprogrammes, their different stakeholder alignments, the orderof magnitude difference in scale (making logistics and stake-holder engagement considerably easier in some countriesthan others) and the different logics that drove decision-making and collective action. The findings have underlinedthe need to take a socio-technical perspective when consid-ering how and to what extent a national eHealth programmehas been a “success” [14].

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Summary pointsWhat is already known about this topic

• Technology programmes have personal, organisa-tional and social dimensions

• Many countries are in the process of introducinga nationally shared electronic record or summaryrecord; few have yet achieved this goal.

• England, Scotland, Wales and Northern Ireland eachbegan a programme to introduce such a recordbetween 2004 and 2008.

What this study adds

• Efforts to introduce a similar (but not identical) sharedrecord technologies met with very different fortunesin the four UK countries.

• Many of the differences were explained by personal,organisational and socio-political factors and theinterplay of these factors.

• The most evident disappointments appeared to beexplained by a ‘techno-bureaucratic’ approach inwhich ‘hard’ aspects of the programme (technologyand project milestones) were privileged over ‘soft’aspects (buy-in, stakeholder consensus, the symbolicsignificance of the new technology and concerns aboutethics or civil liberties).

Author contributions

All authors contributed to analysing the data, drafting themanuscript and checking the final version of the paper.

Funding

No specific funding was allocated for the secondary dataanalysis or writing of this paper. The research study intothe Summary Care Record programme was funded by aresearch grant from the UK National Institute of HealthResearch (ref CFHEP002 and 007) and the Medical ResearchCouncil (‘Healthcare Electronic Records in Organisations’, ref07/133). The other countries’ evaluations received no externalfunding.

Competing interests

The authors’ interests in the different technologies and pro-grammes are set out in the paper. In brief, TG evaluated theEnglish programme; LM was involved in delivering the Scottishand Northern Irish programmes; JW was involved in deliveringthe Scottish programme and GT was involved in delivering theWelsh programme. No authors have personal finanical inter-ests in the technologies described.

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