Tensions in large-scale electronic health record implementations: Insights from a meta-synthesis

Objective To synthesize knowledge on tensions characterizing large-scale electronic health record (EHR) implementations. Materials and Methods A qualitative meta-synthesis was conducted by searching Scopus, Web of Science, MEDLINE, and CINAHL databases to find studies focusing on large-scale EHR implementations in OECD countries. An extraction table was completed to describe key characteristics of cases, and instances of tensions were extracted within each study based on a conceptual definition. Results Twenty-six qualitative studies were included, covering eleven unique large-scale EHR implementation projects. Cases were in Europe (n = 6), North America (n = 4), and Southeast Asia (n = 1). Analysis yielded twenty-one types of tensions associated with five primary objects: people, power, resources, system, and vision. Twelve tensions were found in multiple cases while fifteen were associated with more than one object. Discussion Results are aligned with the notion that tensions are inherent to organizational phenomena, showcasing their enduring nature across geographic, temporal, and technological contexts. The diversity of these tensions and their associated object(s) refer to critical, interrelated components of EHR systems implementation that are exacerbated in large-scale projects, and which can affect the implementation across its entire lifecycle. Conclusion Stakeholders involved in projects to modernize healthcare through the large-scale implementation of EHRs are prone to experience multiple tensions. Attention to the emergence of the tensions identified in this study helps to understand their impacts on projects and stakeholders. Tensions and their associated objects undergird the sociotechnical nature of these complex projects and the need to manage them effectively.