Bottom-up and middle-out approaches to electronic patient information systems: a focus on healthcare pathways

Ken Eason, Mike Dent, Patrick Waterson, Dylan Tutt, Andrew Thornett


Background A study is reported that examines the use of electronic health record (EHR) systems in two UK local health communities.

Objective These systems were developed locally and the aim of the study was to explore how well they were supporting the coordination of care along healthcare pathways that cross the organisational boundaries between the agencies delivering health care.

Results The paper presents the findings for two healthcare pathways; the Stroke Pathway and a pathway for the care of the frail elderly in their own homes. All the pathways examined involved multiple agencies and many locally tailored EHR systems are in use to aid the coordination of care. However, the ability to share electronic patient information along the pathways was patchy. The development of systems that enabled effective sharing of information was characterised by sociotechnical system development, i.e. associating the technical development with process changes and organisational changes, with local development teams that drew on all the relevant agencies in the local health community and on evolutionary development, as experience grew of the benefits that EHR systems could deliver.

Conclusions The study concludes that whilst there may be a role for a national IT strategy, for example, to set standards for systems procurement that facilitate data interchange, most systems development work needs to be done at a ‘middle-out’ level in the local health community, where joint planning between healthcare agencies can occur, and at the local healthcare pathway level where systems can be matched to specific needs for information sharing.


electronic health records (EHRs); frail elderly, healthcare pathways; local design; local health communities; sociotechnical systems design; stroke

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