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Building a house on shifting sand: methodological considerations when evaluating the implementation and adoption of national electronic health record systems

Amirhossein Takian15*, Dimitra Petrakaki2, Tony Cornford3, Aziz Sheikh4, Nicholas Barber5 and On behalf of the National NHS Care Records Service Evaluation Team

Author affiliations

1 Division of Health Studies, School of Health Sciences & Social Care, Brunel University, Uxbridge, UB8 3PH, UK

2 Department of Business and Management, School of Business, Management & Economics, University of Sussex, Brighton, BN1 9QF, UK

3 Department of Management, London School of Economics & Political Science, London, WC2A 2AE, UK

4 eHealth Research Group, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, EH8 9DX, UK

5 Department of Practice and Policy, UCL School of Pharmacy, London, WC1H 9JP, , UK

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Citation and License

BMC Health Services Research 2012, 12:105  doi:10.1186/1472-6963-12-105

Published: 30 April 2012



A commitment to Electronic Health Record (EHR) systems now constitutes a core part of many governments’ healthcare reform strategies. The resulting politically-initiated large-scale or national EHR endeavors are challenging because of their ambitious agendas of change, the scale of resources needed to make them work, the (relatively) short timescales set, and the large number of stakeholders involved, all of whom pursue somewhat different interests. These initiatives need to be evaluated to establish if they improve care and represent value for money.


Critical reflections on these complexities in the light of experience of undertaking the first national, longitudinal, and sociotechnical evaluation of the implementation and adoption of England’s National Health Service’s Care Records Service (NHS CRS).


We advance two key arguments. First, national programs for EHR implementations are likely to take place in the shifting sands of evolving sociopolitical and sociotechnical and contexts, which are likely to shape them in significant ways. This poses challenges to conventional evaluation approaches which draw on a model of baseline operations → intervention → changed operations (outcome). Second, evaluation of such programs must account for this changing context by adapting to it. This requires careful and creative choice of ontological, epistemological and methodological assumptions.


New and significant challenges are faced in evaluating national EHR implementation endeavors. Based on experiences from this national evaluation of the implementation and adoption of the NHS CRS in England, we argue for an approach to these evaluations which moves away from seeing EHR systems as Information and Communication Technologies (ICT) projects requiring an essentially outcome-centred assessment towards a more interpretive approach that reflects the situated and evolving nature of EHR seen within multiple specific settings and reflecting a constantly changing milieu of policies, strategies and software, with constant interactions across such boundaries.

Electronic health record (EHR); Evaluation; Methodology; Sociotechnical; Changing; NHS CRS; Adaptation; Reflexivity