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Understanding contrasting approaches to nationwide implementations of electronic health record systems: England, the USA and Australia.

Morrison, Zoe; Robertson, Ann; Cresswell, Kathrin; Crowe, Sarah; Sheikh, Aziz


Ann Robertson

Kathrin Cresswell

Sarah Crowe

Aziz Sheikh


As governments commit to national electronic health record (EHR) systems, there is increasing international interest in identifying effective implementation strategies. We draw on Coiera's typology of national programmes - ‘top-down’, ‘bottom-up’ and ‘middle-out’ - to review EHR implementation strategies in three exemplar countries: England, the USA and Australia. In comparing and contrasting three approaches, we show how different healthcare systems, national policy contexts and anticipated benefits have shaped initial strategies. We reflect on progress and likely developments in the face of continually changing circumstances. Our review shows that irrespective of the initial strategy, over time there is likely to be convergence on the negotiated, devolved middle-out approach, which aims to balance the interests and responsibilities of local healthcare constituencies and national government to achieve national connectivity. We conclude that, accepting the current lack of empirical evidence, the flexibility offered by the middle-out approach may make this the best initial national strategy.


MORRISON, Z, ROBERTSON, A., CRESSWELL, K., CROWE, S. and SHEIKH, A. 2011. Understanding contrasting approaches to nationwide implementational of electronic health record systems: England, the USA and Australia. Journal of healthcare engineering [online], 2(1), article ID 203059, pages 25-41. Available from:

Journal Article Type Article
Acceptance Date Nov 1, 2010
Online Publication Date May 31, 2011
Publication Date May 31, 2011
Deposit Date Aug 25, 2020
Publicly Available Date Aug 25, 2020
Journal Journal of healthcare engineering
Print ISSN 2040-2295
Publisher Hindawi Publishing Corporation
Peer Reviewed Peer Reviewed
Volume 2
Issue 1
Pages 25-41
Keywords Electronic health records; Implementation; Information technology; International approaches
Public URL


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