Implementation Of Electronic Medical Records In Hospitals Two Case Studies

1. Health Policy 84 (2007) 181–190
Available online at www.sciencedirect.com
Implementation of electronic medical records
in hospitals: two case studies
John Øvretveita,b,∗, Tim Scottc, Thomas G. Rundalld,
Stephen M. Shortelle, Mats Brommelsa,f
a Medical Management Centre, Karolinska Institute, Stockholm, Sweden
b Faculty of Medicine, Bergen University, Norway
c Department of Organisation, School of Management, University of St Andrews, Scotland
d Henry J. Kaiser Professor of Organized Health Systems, School of Public Health,
University of California, Berkeley, USA
e Blue Cross of California Distinguished Professor of Health Policy and Management and Dean
School of Public Health University of California, Berkeley, California 94720, USA
f School of Public Health, Helsinki University, Finland
Abstract
There is evidence that health information technology can improve quality, safety and reduce costs but that health care providers
needed more information about how to implement these technologies to realise its potential. This paper summarises the research
and proposes a theory of implementation based on the research evidence. The second part describes two implementations of
electronic medical record systems and compares the theory against the findings of these two case studies. The paper provides
implementers with research-informed guidance about effective implementation, contributes to developing implementation theory
and notes policy implications for current national strategies for IT in health.
© 2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Information technology; Electronic medical record; Implementation; Health care
1. Introduction
Health services do not have a good history of
cost effective implementation of health information
∗ Corresponding author at: The Karolinska Institute Medical Man-
agement Centre, Floor 5, Berzelius väg 3, Stockholm SE-171 77,
Sweden. Tel.: +46 31 69 39 28; fax: +46 31 69 1777.
E-mail addresses: jovret@aol.com (J. Øvretveit),
jts1@st-andrews.ac.uk (T. Scott), trundall@uclink.berkeley.edu
(T.G. Rundall), shortell@berkeley.edu (S.M. Shortell),
Mats.Brommels@ki.se (M. Brommels).
technology systems (HIT), or of electronic medical
records (EMR) which are at the center of such systems.
The potential for increasing safety and productivity is
largely unrealised. Many countries and services have
policies for introducing EMRs, but there is a wide gap
between policy and practice. Implementation experi-
ence has been varied and sometimes negative, notably
inpublichealthsystemswheretheremaybethegreatest
benefits from EMR systems which allow connections
between services. The ambitious and well-funded UK
policy for all NHS hospitals was to have electronic
0168-8510/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2007.05.013

2. 182 J. Øvretveit et al. / Health Policy 84 (2007) 181–190
patent records by 2005. In 2003, 3% of NHS hospitals
had implemented the policy [1], and by mid 2006 the
EMR implementation date was estimated to be “2007
at the earliest”. Some of the challenges are technical,
but mostly they are professional and political. There are
also large financial and commercial interests at stake,
some of which have national strategic policy impli-
cations. A recent USA review noted that most health
care providers needed more information about how
to implement IT successfully, as well as the limited
researchonthissubject[2].Implementationtheorypro-
vides explanations of why certain actions were taken
to carry out an idea or policy, and of the conditions
which help and hinder the actions. It can sometimes
predict the actions and conditions necessary in a par-
ticular situation to get the results desired from a change.
IT implementation theory in health care is at an early
stage of development, in part because of the few stud-
ies, but also because of the complexity of healthcare,
the many different settings and the types of IT which
are developing at a rapid pace.
The purpose of this paper is to provide evidence
for implementers and policy makers to make more
informed decisions about EMR implementation, and to
contribute to theory of EMR implementation in health-
care. To do this, the paper:
• Provides a description of two implementations; one
of a full conversion from a paper to an EMR sys-
tem (USA), another of an upgrade-integration from
many older different systems to one integrated EMR
system (Sweden);
• Derives an evidence-based theory of EMR imple-
mentation in health care from a review of research,
and by refining the review through comparison to
empirical data from the two case studies.
2. Methods
A review of research was undertaken using a Med-
line search and papers referenced in retrieved studies
whichwerenotshowninthesearch.Tworecentreviews
of research were also used [2,3]. Twenty one papers
were finally selected for a short summary of features
which helped and hindered the implementation and
successful operation of an EMR system.
The empirical research were two case studies of
implementation, using the same methods. One has
already been reported of a conversion in one hospi-
tal and fifteen clinics of one USA Kaiser Permanente
system [4]. The other implementation of an upgrade-
integration in a Swedish teaching hospital is described
below.
The methods and design of the Swedish study was
similar to the US study: a case study with prospec-
tive and concurrent interviews of a selected sample of
thirty informants, halfway through and three months
after implementation. Details of the methods and anal-
ysis are given in the full report and are available
to download from the MMC web site [5] and [6].
The informants were: a project leader, four part-time
project leaders, three personsfrom a supervisorygroup,
four heads of division, seven heads of clinics, one
instructor, five nurses, four doctors and one doctor
secretary. These data were supplemented by hospital
documentation and observation visits. The methods
and questions of the Kaiser case study were replicated
using semi-structured interviews [4–6]. The interviews
were transcribed, coded and collated to create themes.
Unclear responses and contradictory reports were clar-
ified with informants. Themes were only retained when
more than four respondents described the same items.
3. Previous research
Studies of implementation and impact of EMRs are
relatively few, mostly retrospective, without controls,
with most data from informants’ self-reports and often
from surveys. Many of the limited studies are of a few
US health systems which have developed EMRs suited
to their needs over a number of years, which makes
the experience less generalisable. A review of research
was carried out for this study and is summarised below.
It concentrated on the more recent empirical studies of
EMR hospital implementations with the strongest evi-
denceaboutimplementationandaboutwhathelpedand
hindered. The review found that the research spans a
number of years and that many oft-cited studies are
frequently five years or older and do not reflect expe-
rience with some more user-friendly EMR systems
developed in recent years in this fast-moving field.
Even with these review limits, there were large differ-
ences in the settings, implementation processes and the

3. J. Øvretveit et al. / Health Policy 84 (2007) 181–190 183
type of EMR system studied. “Successful implemen-
tation” is defined in different ways, with some studies
not gathering data from multiple stakeholder perspec-
tives, or recognising any process redesign as part of
implementation or as a benefit. Studies define the start,
finish and scope of “implementation” differently, with
some including factors, such as “physician champion”
actions, as part of the intervention and others separating
these as “conditions” which help or hinder implemen-
tation. These differences mean that comparisons and
generalisations need to be made with caution.
This study defines “the intervention” as both the
actions taken to implement the EMR which would not
have otherwise been carried out, and the EMR itself:
how it differs from what was used before [8]. It defines
the conditions or “the context” as the organisational
and wider environmental factors which may help and
hinder implementation [7]. It defines implementation
as actions to select, plan, introduce and achieve “rea-
sonable use” of the new EMR by 90% of the personnel
for 90% of patients intended.
Although the strength of evidence from the better
designed studies selected for review is weak, and gen-
eralisations have low validity, there are a number of
repeatedly reported findings, especially about factors
for successful implementation and which may be used
to guide data gathering. These factors are features of
the EMR system, the implementation process, leader-
ship, resources and the recipient organisation’s culture
[9]. This research can be summarised as a set of factors
which previous research has shown to be important for
different types of EMRs in different settings. This can
be used as a starting point for designing data gather-
ing for research, or for policy-makers or implementers
to assess different systems or implementation plans
(Table 1).
4. Findings from two case studies
Methods and data from the USA Kaiser imple-
mentation have already been reported and will only
be summarised here [4]. This implementation may
be characterised as a “centralised conversion” from a
paper to an electronic medical record. The data from the
Swedish Karolinska hospital implementation, which
were gathered using the same methods, have not been
presented and are given in more detail below. This
Table 1
Initial EMR implementation theory
Factor important for implementation
The EMR system
Ease of navigation, efficiency in use and accessibility
Physician acceptance and implementer’s responsiveness to
concerns
Absence of system failures
No conflicting suitability (managerial/clinical)
Relative advantage (perceived as better)
Compatibility (consistent with values and needs)
Complexity (ease of understanding and use)
Trialability (possibility of experimentation)
Observability (visible examples elsewhere)
Implementation process
User involvement in selection and development
Education provided at the right times, amount and quality
Previous computer or EMR experience
Leadership
Strong management support
Physician champions
Resources
Adequate people and financial resources
Organisation culture and climate
Familiarity with change (“change readiness”)
implementation was a “decentralised integration” of
a number of older EMR systems to one new system.
4.1. Preparation for implementation
In 2003, two 700-bed Stockholm teaching hospi-
tals started a merger to form the Karolinksa University
Hospital (KUS). Interviewees reported that there was
a need to form a common electronic medical record to
increase integration and allow communication between
the two sites, and ultimately, other services. The aims
of the project were to improve patient care and safety,
and save time and costs. The new system would need
to be installed in 40 clinics with 7000 users at the Solna
site, which would need to change the system they used.
Most of the existing hardware could be used, but some
new hardware had to be installed, as well as consid-
erable changes to software. The intervention was not
to “computerise” a paper system, but to change a set
of five old systems to one new system. The new “Take
Care” (TC) system contained patient administration,
clinical medical records, and referral (and replies to
referral information), but it was not an entirely paper-

4. 184 J. Øvretveit et al. / Health Policy 84 (2007) 181–190
less record: there were still many documents such as
EKG and pictures (e.g. radiology). Neither the old or
new systems provided access to guidelines from within
the patient record.
TheUSAKaisercase,bycontrast,wasofconversion
from a paper to an EMR system. Researchers found
a different preparation. The selection decision about
which EMR system to use was made by the Kaiser HQ,
notthecasestudysite.A“CIS”systemwaschosenafter
a reasonably successful small pilot in Colorado. One
hospital and 15 clinics then began implementation in
the Hawaii Kaiser division [4].
4.2. Implementation
At the Karolinska hospital, implementation was
observed and investigated by the researchers over one
year in 2005, and for four months after. In total, approx-
imately 450 persons were actively involved part- or
full-time on the implementation (out of about 7000
employees including physicians).
Once the decision was made in 2004 about which
system to introduce, interviewees reported that senior
leadership made it clear that departments could not
“opt out”, but did have a choice about when they made
the change in the next year and about details of the
video screens. A temporary structure of groups was
established, reporting to senior management. Staffs in
each department were nominated to form a departmen-
tal project group to work with the IT department to
fine-tune the system for their department and carry out
implementation.
The implementation plan built on the plan used to
implement the system at the other hospital site, and to
some extent the much earlier plan for introducing orig-
inal EMRs at the hospital. Changes were introduced in
each of the 40 departments in an overlapping sequence.
The implementation included these interventions to the
hospital and departments:
• Hospital-wide planning and preparation (August–
September 2004), including identifying head of
department and the personnel within their depart-
ment who would play a role in implementation;
• Piloting the system (winter 2004);
• Agreement with head of department about imple-
mentation date, and to establish an implementation
project group (October 2004);
• Departmental implementation: three months for
each department, covering all departments in
2005:
◦ One “instructor” assigned to the department, and
training of a department project group (4 days)
(different dates for different departments);
◦ Hardware and software installation and changes
planned and carried out;
◦ Departmental personnel instruction (varied from
none to 4 h);
◦ Change-over day;
◦ Follow up problem solving and training.
A post implementation phase was planned to
develop the potential of the system, for example to
include order entry (which was part of the old system)
and to develop a more structured record for different
clinics, which would include checklist approaches for
guidelines.
The Kaiser experience was different, in part because
the change from paper to electronic system was more
substantial, and in part because the software was under-
developed and the pilot experience was of limited
relevance to the implementation site. The start was
delayed for 12 months by software problems. After
two years, implementation was 33% complete mainly
because of substantial design and operation problems
and delays. Implementation was then stopped because
of these problems and a new system (“EpicCare”) then
chosen and successfully implemented after a number of
years. The case study findings only covered the three-
year CIS period.
4.3. Impact
An analysis of the interviews carried out halfway
through implementation (June 2005) through to three
months after implementation (March 2006) identified
common themes which are listed below and illustrated
with typical quotes from informants. Approximately
95% of the comments were positive about the imple-
mentation process and the new system.
• Time savings (for example, far fewer telephone calls
as a result of the whole hospital using the same
system);
“Emergency room personnel are very positive as the
new system allows them to follow patients minute

5. J. Øvretveit et al. / Health Policy 84 (2007) 181–190 185
to minute and see which part of the department the
patient is in. This saves work”
• New and better ways to work were being discovered;
“In the emergency room the new system allows a
real-timelistofpatientsinERwithbasicinformation
which doctors easily and quickly see. This is very
useful where two or more doctors are involved with
a patient – before one patient’s information could
have been held on five different systems, many of
which could not be accessed”
• Morecompleteandbetterinformationonthesystem;
• Likely increase in patient safety (e.g. clearer medi-
cation information);
“A lot easier to find patient information. I am certain
it saves time because of this, and improves patient
care because we don’t have to wait to get the infor-
mation from another system”
• Improved integration of the two merged sites;
• Potential for development (e.g. clinics could use
electronic prescriptions and electronic dictation in
the future).
Two categories of negative comments were identi-
fied from the interviews:
• The speed of implementation prevented developing
new procedures;
“People did not get time and help to adjust their
routines to the new system. It would have been much
better to change routines while changing the system.
There was no time for development. Mostly, we just
put what we did on the computer”
• Personnel time was diverted from clinical work
for implementation. (Difficulties getting the time of
physicians and personnel to attend training and help
adapt the system to their department needs).
“Some local project groups had difficulties getting
time for working with TC. Not all head of clinics
and head of units understood that it had to take time
to prepare for TC”
“It was difficult to be able to prepare for TC and at
the same time do the ordinary work”
“Staff had to work overtime to be able to do all that
was expected of them”
These findings contrasted with the findings from
the Kaiser study. Physicians reported lower produc-
tivity, which was also shown by records of changes to
throughput, due to extra time demands entering data,
processing lab result reports, entering orders, and navi-
gating through the system. This created resistance from
the beginning because physicians were only able to get
minor redesign changes and did not believe the assur-
ances that they were given that they would become
faster as they learned how to use the new system. Four-
teen clinicians reported that the CIS demanded an extra
30–75 min per day which persisted even after the initial
learning period, and affected patient care—for exam-
ple, making it difficult to fit in “overload patients”.
The reasons varied: eight respondents thought CIS was
poorly designed and required too many steps; twelve
that the system was cumbersome and not designed
for a range of clinical needs or multiple problems;
and nine reported a lack of clinical capacity to absorb
changes during implementation [4]. The system also
required clarification of clinical roles and responsibil-
ities, which was traumatic for some individuals but
not wholly negative. Resistance and conflict grew but
remained submerged due to a culture which avoided
overt conflict.
4.4. Assessment of necessary conditions for
implementation
Part of the Karolinska case study was to ask infor-
mantswhichfactorsandconditionstheythoughthelped
and which hindered introducing and using the system.
The following were the main factors reported:
4.4.1. Factors helping implementation
• Many were dissatisfied with their previous system
and with having five different medical record sys-
tems in the hospital;
• Personnel were already used to electronic medi-
cal record systems—it was not a change-over from
a paper system, but adjusting to a new EMR
system;
• Personnel saw the benefits of having the same sys-
tem covering two sites (e.g. allowing easy staff and
patient information transfer);
“Once the merger was decided and we could see it
was happening, we were all motivated to get a com-
mon record for all departments and sites: everyone
could see the benefits and necessity for this”

6. 186 J. Øvretveit et al. / Health Policy 84 (2007) 181–190
• The other site was already using the EMR and had
developed it to be user-friendly. The IT department
did not have to make major changes, apart from
increasing the capacity of the system;
• The system had a good reputation and many people
did not like the old systems. The new EMR was said
by users to be a very easy and usable;
“The system itself is intuitive and can be fitted to
the medical work which is done now and also to the
work if it is reorganised”
“This new system saves time because it is quicker to
see where to go for information and to access it”
• The system needed little time-off for training, or to
adjust to it, and little extra work was demanded in
the new system;
• Senior management said the EMR was the highest
priority project and made it so, as did heads of clin-
ics. There was no problem getting resources. The
hospital management group continually pointed out
the importance of the project;
• The project leader was said by many to be very
competent and it was reported that the project was
well planned and organized, in part because of pre-
vious experience of introduction at the other site and
familiarity with the system. A well-functioning local
IT-department in the hospital helped in the imple-
mentation process. They and personnel commented
that there were no problems with the hardware
servers.
4.4.2. Factors which hindered implementation
One interviewee thought that the earlier experience
implementing EMRs in 2000 was a hindrance because,
“it was complicated. It took a lot to learn the new
system, and there were many problems. So our expe-
rience with large IT changes like this was not entirely
positive”.
The merger had happened recently, so new unit
heads were covering both sites and other personnel had
been changed. Some clinics were still reorganising and
this made additional demands on time and a less sta-
ble situation. The time spent by department personnel
on implementation was taken from ordinary work time
and it was sometimes difficult to involve doctors in
the preparation work. There were also some initial dis-
agreements about whether or how much departments
should pay for the system.
“We needed better information about how much time
and money we should have set aside in the department
for this project”.
The education and information for all staff was
reported by two interviewees to be not as good as it
could have been. The short time for implementing the
system hindered the possibility to give all staff bet-
ter preparation. In some teaching groups, there was
reported to be no time for people to ask questions:
“If you had a detailed doctor- or, clinic-specific ques-
tion you did not ask it because there were too many
different people there—secretary nurses etc. and peo-
ple from different clinics.”
For our departmental implementation group we needed
more education in how to work in a project, how to
succeed, necessary conditions and so forth”.
Many interviewees also commented on the very
strong academic culture at the hospital, with national
clinical leaders who had built programmes of excel-
lence and expected a large degree of independence. It
is significant that none of the interviewees commented
on department heads using their power and indepen-
dence for hindering the choice of one system or in
implementation.
In the Kaiser case, the factors reported to help imple-
mentation were:
• A belief that EMR could save time and money and
make possible new research.
• Clearer accountability, and changes to work and
roles.
• Additional “backfill” personnel for an initial period
to reduce impact on workload.
• The later successful implementation of “EpicCare”
was helped by the failure of CIS, as participants had
learned what kind of system they needed.
Those hindering implementation were:
• No participation in selection and little in implemen-
tation.
• System not developed, and required extra time and
work to operate for clinical work.
• Consensus-seeking leaders may have unintention-
ally encouraged opposition and passive resistance.

7. J. Øvretveit et al. / Health Policy 84 (2007) 181–190 187
• No-conflict culture led to feedback and resistance
not being openly expressed or addressed.
5. Discussion
The study shares some of the limitations of much
research into EMR implementation in relying largely
on self-reports by a limited sample of informants. Also,
the analysis does not assess the relative importance of
the different factors in helping or hindering implemen-
tation, or synergies between the factors. The findings
are stronger than some studies because the research
was carried out prospectively and concurrently, drew
on detailed project documentation, and involved a com-
parison between two implementations. The interviews
and case study method made it possible to register other
changes taking place at the same time which may have
helped or hindered implementation: studies often do
not collect or report this “context” information. How-
ever, the limitations mean than the explanations for
the findings and the lessons for other implementations
discussed below need to be treated with caution, and
as suggestive hypotheses rather than as certain con-
clusions. A detailed costing of the project was not
made. In the Karolinska case, there are indications
that the system saved money overall because of the
reports of time saved, but this was not quantified and
costed.
Despite these limitations, there are some conclu-
sions which may be drawn with some degree of
certainty about why the two implementations took the
course they did, and about the lessons for others. One
conclusion is that EMR implementation is a “condi-
tional intervention” and success depends on many prior
and concurrent factors. These conclusions are devel-
oped below by comparing the key findings from the
two case studies, then with those of other studies noted
earlier.
First, Table 2 below summarises key points of com-
parison between the two case studies.
5.1. Comparison to implementation theory
Table 3 summarises evidence from the two studies
about the presence of factors which the review of pre-
vious research showed to be important to successful
implementation.
One reason for the lesser success of the Kaiser
implementation was the more complex change from
paper to EMR. However, the findings provide some
limited evidence of the validity of the earlier research-
based implementation theory. The only two factors
whichwerecommontobothcaseswerestrongmanage-
ment support and adequate resources, but these were
not able to make up for the absence of the other fac-
tors at Kaiser, which were all present in the Karolinska
case: management and resources could not overcome
a poorly designed system and physician opposition.
5.2. “Change capability” as a factor in EMR
implementation
One set of findings from these two cases have
not been reported in previous research. This is that
individual- and organisational- “change capability”
which is proportional the changes under consideration
are important in implementation. Employees have to
adjust cognitively, behaviourally and emotionally to
use a new EMR in everyday work—it affects work
tasks central to their practice [10]. Employees also
experience other changes in their work and surround-
ings due to the constantly changing nature of health
care. The EMR change may exceed people’s capacity
to cope with change, or other changes may combine to
exceed these limits, causing resistance, rejection and
other behaviours by employees trying to continue to
provide an adequate standard of care. The change at
Hawaii Kaiser Permanente from mostly paper to com-
puterdemandedfarmorethanthechangeatKarolinska.
In addition to individual change capability, organ-
isations have different formal systems for managing
change. Some organisations use project teams regu-
larly, have project management systems and personnel
with training and they can be called upon to can lead
or work in change projects: changes can be carried out
using a system and structure which many are famil-
iar with and trained for. Organisations vary in their
development and use of such change management
or learning organisation systems: the Karolinska is a
national centre of excellence and more familiar with
and organised for change than the Kaiser site.
An organisation’s ability to implement an EMR,
however, may be more than the sum of individual
and formal organisational change capability. Features
of the organisation which have been summarised as

8. 188
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Øvretveit
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al.
/
Health
Policy
84
(2007)
181–190
Table 2
Two EMR implementations
Kaiser Karolinska
Type of implementation
change
One hospital and 15 clinics began implementation of one
EMR system (“CIS”) but stopped and changed to
implement another EMR system (EpicCare)
Two-hospital merger led to a change of an existing EMR used
by Karolinska site to the EMR (“TC”) used at the other site.
Implementation successful
System selection “Selection detached from local environment” and made by
USA HQ
Selection local by the hospital
Design and testing Software design and development problems increased local
resistance
Already tried and tested at the other site, but also successfully
piloted locally
Implementation process 12 month start delay due to software problems Selection, planning and full implementation made as planned
and for half the budget
After 2 years implementation 33% complete, stopped and
EpicCare system introduced
Main factors helping
implementation
Belief that EMR could be better for different purposes Consultation before implementation
Clearer accountability, and allowed change to roles which
was mostly positive
Consensus about need for the system and which system was best
Competent IT project leader and team Prioritization and driving by management team
Additional “backfill” personnel provided for an initial
period to reduce impact on workload
Competent IT project leader and team
Tried and tested system
User-friendly intuitive system needing little training
Potential for development of system
Order entry not difficult to integrate
Main factors hindering
implementation
No participation in selection and little in implementation Recent merger not complete with new people in post
System not developed and required extra time and work to
operate for clinical work
Time spent by department personnel on implementation was
taken from ordinary work time
Leaders consensus seeking sometimes encouraged
opposition and passive resistance
Some had difficulties involving doctors in the preparation work
No-conflict culture led to resistance not being openly
expressed or addressed
Initial disagreements about much departments should pay for
the system
Main impact CIS reduced clinicians productivity No extra time burdens and increased efficiency
Better coordination of long term patients reported

9. J. Øvretveit et al. / Health Policy 84 (2007) 181–190 189
Table 3
Presence of factors identified in previous research as important for successful EMR implementation
Factor important for implementation Kaiser Karolinska
The EMR system
Ease of navigation, efficiency in use and
accessibility
No Yes
Physician acceptance and implementer’s
responsiveness to concerns
No Yes
Absence of system failures No Yes
No conflicting suitability (managerial/clinical) No Yes
Relative advantage (perceived as better) Yes (in theory) Yes (in theory)
No (in practice) Yes (in practice)
Compatibility (consistent with values and needs) No (EMR felt by physicians
to be chosen for business
needs not clinical work needs)
Yes
Complexity (ease of understanding and use) No Yes
Trialability (possibility of experimentation) Little (system not fully
developed). Pilot was a
different system and setting
to the implementation site
Yes
Observability (visible examples elsewhere) Yes (in theory). No (in
practice, apart for a few
personnel)
Yes (at the other
hospital site and pilot
department)
Implementation process
User involvement in selection and development No Yes
Education provided at the right times, amount and
quality
Yes Yes
Previous computer or EMR experience Little Yes
Leadership
Strong management support Yes Yes
Physician champion No Yes
Resources
Adequate people and financial resources Yes Yes
Organisation culture and climate
Familiarity with and capacity for change (“change
readiness”)
No Yes
“change readiness” or “change friendly culture” may
enhance individual and organised change capability as
well as being developed by the latter: these include
a climate of optimism about the future, trust in lead-
ership, good interprofessional, interdepartmental and
professional-management relations, shared experience
ofsuccessfullymanagedchanges,andalearningorgan-
isation culture and structures.
Finite change coping capability may also explain
why nearly all EMR implementations “fail to use the
opportunities for process redesign”. All EMR imple-
mentation involve some work redesign, but major
redesign at the same time exceeds the change cop-
ing capacity of most organisations and the tolerance
of most clinicians trying to keep a service running dur-
ing the change. Although it would be more efficient to
“computerise an improved process” it is more realistic
to treat this as a two-stage process, so long as the system
can be easily modified to support new work processes.
6. Conclusions
Many countries have national policies for establish-
ing EMRs and many hospitals are selecting, planning,
implementing or upgrading their systems. There are

10. 190 J. Øvretveit et al. / Health Policy 84 (2007) 181–190
few independent descriptions of implementations, little
research into what helps and hinders, and no research-
based theories of EMR implementation. This paper
derived an EMR implementation theory from the avail-
able research and described implementations in two
case studies. These data provide some limited sup-
port for the theory and also suggest that a previously
unreported factor is important to implementation suc-
cess: “change capability” relative to the EMR and other
changes taking place.
Findings from the two case studies suggest that
EMR implementation is a “conditional intervention”
and success depends on many prior and concurrent
environmental factors. The findings also suggest a con-
cept and hypotheses for future research which are not
reported in earlier studies. The hypothesis is that, the
less change the EMR system demands and the fewer
the other changes which are occurring at the same time,
then the more likely implementation will be success-
ful. The second hypothesis is that four factors may be
amongst those which facilitate effective EMR imple-
mentation: the number and depth of changes demanded
by the EMR and other unrelated concurrent changes;
individuals’ change capacity; the organisations formal
system for managing changes; and a change-ready cul-
ture.
Some of the practical implementation and policy
guidance from the research includes:
• Choose a system which allows a range of needs to
be met, rather than make compromises for a clinical
or a business system, and an EMR which can serve
this system.
• Choose a tried and tested EMR which works for
clinical personnel and saves time. If personnel do
not think it will save time then implementation will
be significantly more difficult and possibly impossi-
ble.
• The system should be easy to modify and develop,
within limits, for different departments and uses.
• The system should be intuitive, requiring little or no
training.
• The decision about the system should be partici-
patory, but once made, implementation should be
directed and driven.
• Forsuccessfulimplementation,balancelocalcontrol
of selection, implementation and clinical participa-
tion with meeting higher-level requirements.
• Involve each level in different ways, with clear and
appropriate parameters about which decisions can
be made locally and which require higher-level deci-
sions about common standards.
• Assess and address the presence and absence of prior
and concurrent factors which have been repeatedly
shown in research to help and hinder implementa-
tion.
Future research is needed for different implemen-
tations of EMRs in different situations, reported in a
standardised way to allow comparisons. Knowledge
on the subject would be improved if studies built on
previous research to test hypotheses, especially about
which conditions are critical for successful operation
and how different parties define this.
References
[1] NHS Executive Information for Health: An information strategy
for the modern NHS 1998–2005. 1998, NHS Executive:Leeds.
[2] Shekelle PG, Morton SC, Keeler EB. Costs and benefits of
health information technology, 2006. E006. Rockville, MD:
Agency for healthcare research and quality. April 2006. Evi-
dence Report/Technology Assessment No. 132. (Prepared by
the Southern California evidence-based practice center under
contract No. 290-02-0003.).
[3] Brailer D, Terasawa E. Use and adoption of computer-based
patient records. Oakland, CA: California HealthCare Founda-
tion; 2003.
[4] Scott J, Rundall T, Vogt T, Hsu J. Kaiser Permanente’s experi-
ence of implementing an electronic medical record: a qualitative
study. BMJ 2005;331:1313–6.
[5] Øvretveit J. Methods and interview questions for EMR imple-
mentation study 2006 Karolinska Institutet Medical Manage-
ment Centre, Stockholm. From web site http://www.lime.ki.se/
mmc research projects.htm.
[6] Øvretveit J, Granberg C. Evaluation of the implementation of
an electronic medical record at the Solna site of Karolinska Uni-
versity Hospital, Stockholm. Stockholm: Karolinska Institutet
Medical Management Centre; 2006.
[7] Øvretveit J. A Framework for quality improvement translation:
understanding the conditionality of interventions. Joint Com-
mission Journal on Quality and Safety, Global supplement,
August 15–24, 2004.
[8] Øvretveit J. Action evaluation of health programmes and
change: a handbook for a user-focused approach. Oxford: Rad-
cliffe Medical Press; 2002.
[9] Øvretveit J. Electronic medical record implementation: sum-
mary of a review of research, Karolinska Institutet Medical
Management Centre, Stockholm, 2006. http://homepage.mac.
com/johnovr/FileSharing1.html.
[10] Berg M. Health information management. London: Routledge;
2004.