A qualitative exploration of workarounds related to the implementation of national electronic health records in early adopter mental health hospitals

PLoS One. 2014 Jan 16;9(1):e77669. doi: 10.1371/journal.pone.0077669. eCollection 2014.


Aims: To investigate the perceptions and reported practices of mental health hospital staff using national hospital electronic health records (EHRs) in order to inform future implementations, particularly in acute mental health settings.

Methods: Thematic analysis of interviews with a wide range of clinical, information technology (IT), managerial and other staff at two early adopter mental health National Health Service (NHS) hospitals in London, UK, implementing national EHRs.

Results: We analysed 33 interviews. We first sought out examples of workarounds, such as delayed data entry, entering data in wrong places and individuals using the EHR while logged in as a colleague, then identified possible reasons for the reported workarounds. Our analysis identified four main categories of factors contributing to workarounds (i.e., operational, cultural, organisational and technical). Operational factors included poor system integration with existing workflows and the system not meeting users' perceived needs. Cultural factors involved users' competence with IT and resistance to change. Organisational factors referred to insufficient organisational resources and training, while technical factors included inadequate local technical infrastructure. Many of these factors, such as integrating the EHR system with day-to-day operational processes, staff training and adequate local IT infrastructure, were likely to apply to system implementations in various settings, but we also identified factors that related particularly to implementing EHRs in mental health hospitals, for example: EHR system incompatibility with IT systems used by mental health-related sectors, notably social services; the EHR system lacking specific, mental health functionalities and options; and clinicians feeling unable to use computers while attending to distressed psychiatric patients.

Conclusions: A better conceptual model of reasons for workarounds should help with designing, and supporting the implementation and adoption of, EHRs for use in hospital mental health settings.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Attitude of Health Personnel
  • Electronic Health Records*
  • England
  • Evaluation Studies as Topic
  • Hospitals, Psychiatric / organization & administration*
  • Humans
  • Mental Health*
  • National Health Programs
  • Personnel, Hospital
  • Workflow

Grant support

This study involved the secondary analysis of a sub-set of data previously collected in an independent research programme commissioned by NHS. This report draws on a sub-set of data that were gathered in independent research commissioned by the NHS CFH Evaluation Programme (NHS CFHEP 005). It was undertaken as a post-graduate dissertation research project. Aziz Sheikh has a Harkness Fellowship in Health Policy and Practice and is supported by The Commonwealth Fund, a private independent foundation based in New York City. The funders of the initial, commissioned study and The Commonwealth Fund had no role in study design, data collection and analysis, decision to publish, or preparation of this manuscript.