Large-scale electronic health record (EHR) implementations are central to the digital transformation of healthcare systems in high-income countries. Faced with ageing populations and the growing prevalence of chronic conditions, many governments are adopting national EHR systems to enhance service quality, efficiency and coordination. These systems aim to unify patient data across institutions and care settings, enabling real-time access for healthcare professionals. Yet, implementation in public health settings often proves complex and disruptive. A rapid review of 24 empirical studies highlights three interrelated factors—stakeholder engagement, institutional alignment and process standardisation—as critical to achieving successful outcomes.
Stakeholder Engagement and Governance
One of the most consistent findings across the reviewed studies is the pivotal role of stakeholder involvement in NEHR success. Clinicians, particularly hospital-based physicians and nurses, are the primary users of these systems, yet they are frequently under-involved in strategic decisions. Failure to incorporate their input leads to misaligned expectations, workarounds and resistance. Effective governance therefore requires a shift from top-down mandates to participatory models that emphasise collaboration among policymakers, hospital managers, IT vendors and frontline staff.
Leadership at both the national and local levels must remain adaptive. Initiatives that adopted rigid top-down approaches often encountered usability issues, unmet timelines and poor system adoption. Conversely, those employing “middle-out” strategies—combining central vision with local input—tended to realise smoother transitions. These approaches allowed for stakeholder consultation while retaining a degree of national coordination, striking a balance between broad interoperability goals and the flexibility needed at the institutional level.
Institutional and Cultural Alignment
NEHR implementations do not occur in a vacuum; they must contend with the established cultures and operational dynamics of healthcare institutions. Studies found a recurring tension between national imperatives for standardisation and local needs for autonomy and customisation. Misalignment in this area led to dissatisfaction among users, erosion of professional identity and challenges in change management.
To mitigate such outcomes, project leaders should account for the diversity of institutional contexts within the public health system. Hospitals differ widely in terms of their digital maturity, administrative processes and clinical workflows. Recognising these differences early and adjusting roll-out strategies accordingly is critical. Cultural alignment also extends to the way technology is introduced. NEHR projects that imposed changes without a clear rationale or failed to demonstrate tangible benefits to clinical practice often faced resistance. Transparent communication and realistic expectations about short-term disruptions and long-term gains are necessary to secure buy-in and promote sustained use.
Technology and Process Standardisation
A third pillar of successful NEHR deployment is achieving the right balance between system standardisation and adaptability. While interoperability is a cornerstone objective of national systems, the studies highlighted that excessive centralisation can stifle innovation and compromise usability. Off-the-shelf solutions may not align with local practices and can exacerbate operational inefficiencies if not adequately configured.
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Moreover, the implementation timeline and the degree of vendor involvement were crucial in shaping project outcomes. Sudden go-live deadlines, insufficient testing phases and inadequate post-implementation support were common issues in many reviewed initiatives. To address these gaps, phased rollouts and iterative learning processes—where configurations are adjusted based on feedback—proved more effective than one-size-fits-all deployments.
The studies also pointed to the importance of integrating clinical, administrative and communication functionalities. Systems that prioritised only clinical functions or treated implementation as a purely technical exercise struggled with end-user acceptance and performance measurement. A comprehensive approach that spans clinical decision support, patient scheduling, teleconsultation and data analytics is more likely to generate systemic value and long-term sustainability.
Implementing NEHR systems in public health settings is an inherently complex undertaking, involving multiple stakeholders, diverse institutional needs and evolving technological frameworks. The review of past initiatives underscores that success depends not solely on technology, but on governance structures, stakeholder participation and strategic alignment. Policymakers and project leaders must adopt flexible, inclusive strategies that balance national objectives with local realities. By fostering collaboration, recognising contextual differences and embracing iterative learning, future NEHR implementations can achieve their goals of improving care quality, operational efficiency and health system resilience.
Source: Health Informatics Journal
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