A qualitative study exploring electronic health record optimisation activities in English hospitals

Hospitals increasingly implement complex electronic health record (EHR) systems to improve quality, safety and efficiency. Whilst many aspects surrounding implementation and adoption processes have been researched, the benefits of such enterprise-wide systems may take decades to materialise. Existing work on optimisation processes has focused on technological, workflow and organisational aspects of optimisation within individual clinical settings, mostly in the United States of America. We here sought to explore how a range of hospitals with different EHR systems have approached the optimisation of EHRs over time and in relation to technology, socio-organisational and health system factors.

We conducted an in-depth qualitative interview study with technology leads from purposefully sampled hospitals across the country who had implemented a range of EHRs. We explored reflections on the journey of implementing and optimising systems over time, optimisation activities, and perceived lessons learned. Data were transcribed and analysed with NVivo 14 software, using the Technology, People, Organizations, and Macroenvironmental factors (TPOM) frameworkto facilitate coding.

We interviewed 28 individuals from 21 sites with eight different types of EHRs. We observed various optimisation activities across different technological, social, organisational and health system factors. These included improving usability and information technology infrastructures; process optimisation of clinical and administrative workflows; organisational optimisation strategies and relationships with suppliers; and wider system factors such as the need for overall strategic direction and allocation of associated funding. Optimisation activities within these areas stood in some instances in contrast to one another. For example, national activities inhibited local optimisation efforts and organisational optimisation in some instances impacted adversely on usability.

This work emphasises that EHRs are not finished solutions but components of broader information systems needing continuous technological and organisational development. Effective optimisation requires a delicate balance between navigating technological affordances and characteristics to improve usability and organisational processes, as well as regional and national integration to achieve larger-scale interoperability.