The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: A tale of two countries

Abstract

Through electronic health record implementation, national healthcare systems are aiming for care integration and enhancement. However, the path to large-scale electronic health record implementation is seldom smooth, involving multiple stakeholders with diverse interests and influences. This study proposes a framework that draws on both stakeholder and institutional theories to understand the complex dynamics of stakeholder interactions and institutional pressures over time during electronic health record systems implementation. This framework is utilized to analyze the national electronic health record programs of Singapore and England, which provide contrasting perspectives on how two top-down system implementations took place with different outcomes. Our results suggest that in the Singapore case, the presence of boundary spanners, supporting implementation agency that included IT staff from healthcare organizations, and greater engagement with medical professionals were associated with more positive dynamics of stakeholder interactions (e.g. limited pushback from professionals or the press) during electronic health record implementation than in England. Differences in the healthcare structures and systems, electronic health record project organization, and the combined influences of institutional pressures shed light on the varying implementation paths and outcomes in the two cases. This study adds to the health information technology literature through a comparative examination of the organizational and social processes during complex national healthcare integration projects. It also contributes to the institutional and stakeholder literatures in several ways, in particular by depicting the processes and outcomes of the dynamics of isomorphic pressures played out under different institutional conditions. Finally, our proposed framework provides a useful conceptual tool for analyzing such complex IT implementations across multiple stakeholders.

Implementation of large-scale health information systems

“…In this context, the British Large-scale health information systems Considered one of the most significant initiatives ever documented, it involved a total of 168 hospitals and 73 health care environments, corresponding an investment of £ 12.7 billion (Robertson et al, 2010). Such initiative, however, did not achieve the expected success, being discontinued in 2011 (Klecun, Zhou, Kankanhalli, Wee & Hibberd, 2019). Apart from the countries that make up the United Kingdom, the other most studied countries are the United States (eight articles) and Canada (seven articles).…”

“…EHRs are defined as longitudinal medical records of patient health information, utilized as a basis for the integration of health care (Klecun, Zhou, Kankanhalli, Wee & Hibberd, 2019). These records follow pre-established patterns that take into consideration the possibility to share the patient history with other health organizations geographically dispersed, providing an integrated view of the patient's health (Klecun, Zhou, Kankanhalli, Wee & Hibberd, 2019;Ludwick & Doucette, 2009). Improvements in the quality of health services are among the benefits expected by the national programs of the 24 countries identified in this research.…”

Framing Research Questions Intersecting Information Systems and Health: A New Research Perspective at Micro- and Macro-Level

“…Research in this area is primarily concerned with the implementation of electronic health records. While Adjerid et al [29] argue that health records reduce medicare spending and frictions in information sharing, Klecun et al [62] pinpoint that forcing the introduction of such in a top-down approach thus exercising institutional pressure on medical professionals will yield negative outcomes rendering the benefits. In line with the research of Klecun et al [62], Findikoglu et al [61] find that the goal alignment between governments and medical professionals is critical for the success of electronic health records enabled transformations of health care services.…”

“…For example, this could be addressed by an examination of various outcome types, such as social phenomena that drive adoption of health IS, or impact on society of mHealth applications in place. The publications of, Hansen [1], Klecun et al [62], and Adjerid et al [29] for example, cover all formation stages but leave out the consideration of the role of the individual. Therefore, we call future research to work on outcome investigations that isolate BAO link 3 and 3'.…”

“…When looking at the societal perspective, research is commonly showing the positive impact of IS on health outcomes, especially in low-and middle-income countries. Moreover, researchers agree upon the necessity to align institutional and organizational goals [62]. However, research addressing the necessary structures to overcome such obstacles is lacking.…”