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

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Abstract

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 implications, 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’ management appears key to managing such programmes.

Highlights

► National scale electronic record programmes bring technical challenges but also personal, social and organisational ones. ► This secondary analysis compared attempts to introduce a nationally shared electronic summary record. ► England, Scotland, Wales and Northern Ireland approached the challenge differently. ► The four countries differed widely in the available budget and approach to implementation. ► More money and tighter deadlines did not produce faster implementation.

Section snippets

Background

Most citizens, and clinicians, are positive about the idea of a secure summary of key medical details, accessible from wherever the patient seeks care [1], [2], [3]. Many European countries, and others such as Australia, USA and Canada, are currently seeking to establish such a summary [4], [5], [6]. The potential benefits of a nationally-accessible electronic record (known in the USA as health information exchange), assuming such a system to be fully secure, perfectly accurate and universally

Scotland

The basic version of Scotland's Emergency Care Summary (ECS) lists current and discontinued medication and adverse reactions. It was piloted in two Health Boards in 2004 and rolled out across Scotland by 2006. By 2011, it was connected in 100% of general practices across Scotland. A new national data store was built to host the records and pre-existing electronic links (‘e-links’) with practices were used to connect with this. Patients’ medical and demographic details are automatically updated

Method

This study was a secondary, reflective analysis of data collected by us in our roles as participants in and/or evaluators of the national shared record programmes. The dataset consisted of both quantitative data (letters sent, records uploaded, records accessed and similar metrics) and qualitative data (documents such as strategies, business plans, minutes of meetings and so on; interviews with clinicians, project managers, commercial software suppliers and service users; press articles and

Main findings

The contrasting characteristics and fortunes of the four programmes are summarised in Table 1. Whilst there were many differences between them, it is clear that – whatever the setting and the particulars of the programme – implementation of a nationally shared electronic summary record is a highly complex challenge which requires multiple overlapping tasks (Box 1). These implementation challenges were common to all four programmes, but they played out very differently because of significant

Conclusions

This secondary data analysis has demonstrated the added value of reflecting collectively on the successes and disappointments across the shared electronic record programmes in the four UK countries. We hope that the lessons described above will also resonate outside the UK to countries such as the USA, which are just beginning to implement regional and national electronic records [28].

The very different fortunes of the four programmes were only partly explained by differences in the

Author contributions

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

Funding

No specific funding was allocated for the secondary data analysis or writing of this paper. The research study into the Summary Care Record programme was funded by a research grant from the UK National Institute of Health Research (ref CFHEP002 and 007) and the Medical Research Council (‘Healthcare Electronic Records in Organisations’, ref 07/133). The other countries’ evaluations received no external funding.

Competing interests

The authors’ interests in the different technologies and programmes are set out in the paper. In brief, TG evaluated the English programme; LM was involved in delivering the Scottish and Northern Irish programmes; JW was involved in delivering the Scottish programme and GT was involved in delivering the Welsh programme. No authors have personal finanical interests in the technologies described.

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