The policy-practice nexus of electronic health records adoption in the UK NHS

Purpose - This paper seeks to report the findings from a seven-year study on the UK National Health Service on the introduction of an electronic health record for 50 million citizens. It explores the relationship between policy and practice in the introduction of a large-scale national ICT programme at an estimated value of £12.4bn.Design methodology approach - Using a longitudinal research method, data are collected on the policy-practice nexus. The paper applies institutional theory using a conceptual model by Tolbert and Zucker on the component processes of institutionalisation.Findings - The findings suggest that institutional forces act as a driver and an inhibitor to introducing enabling technologies in the health-care environment. A process analysis shows that, as electronic health records force disruptive change on clinicians, healthcare managers and patients, culturally embedded norms, values and behavioural patterns serve to impede the implementation process.Research limitations implications - This research is limited in its generalisability to national, regional and local ICT implementations due to the complexity of the policy and practical issues at stake. Despite the longitudinal research approach, the use of institutional theory can only offer a flavour of how institutionalised values, norms and behaviours influence health IT policy and practice.Practical implications - The paper demonstrates the complexity of translating centralised ICT policy in healthcare to practical solutions for clinicians and other stakeholders. It shows how a large-scale ICT programme based on procurement of technology is unlikely to succeed where important issues of user engagement and a sound "business case" have not been achieved.Originality value - This research contributes to the theoretical literature on institutionalism by addressing the dichotomy between institutional and technical environments. While technology is often discussed in isolation of an institutional process, it may become embedded in organisational practices, reaching a process of sedimentation (institutionalisation) or fail to take hold and fade from view.