Through electronic health record implementation, national healthcare systems are aiming for care integration and enhancement. However, the path to large-scale electronic health record implementation is seldom smooth, involving multiple stakeholders with diverse interests and influences. This study proposes a framework that draws on both stakeholder and institutional theories to understand the complex dynamics of stakeholder interactions and institutional pressures over time during electronic health record systems implementation. This framework is utilized to analyze the national electronic health record programs of Singapore and England, which provide contrasting perspectives on how two top-down system implementations took place with different outcomes. Our results suggest that in the Singapore case, the presence of boundary spanners, supporting implementation agency that included IT staff from healthcare organizations, and greater engagement with medical professionals were associated with more positive dynamics of stakeholder interactions (e.g. limited pushback from professionals or the press) during electronic health record implementation than in England. Differences in the healthcare structures and systems, electronic health record project organization, and the combined influences of institutional pressures shed light on the varying implementation paths and outcomes in the two cases. This study adds to the health information technology literature through a comparative examination of the organizational and social processes during complex national healthcare integration projects. It also contributes to the institutional and stakeholder literatures in several ways, in particular by depicting the processes and outcomes of the dynamics of isomorphic pressures played out under different institutional conditions. Finally, our proposed framework provides a useful conceptual tool for analyzing such complex IT implementations across multiple stakeholders.

中文翻译：

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国家电子健康记录实施中制度压力和利益相关者行为的动态：两个国家的故事

通过电子健康记录的实施，国家医疗保健系统的目标是护理整合和​​增强。然而，大规模电子健康档案实施的道路并不平坦，涉及利益和影响各异的多个利益相关者。本研究提出了一个框架，利用利益相关者和机构理论来了解在电子健康记录系统实施过程中利益相关者互动和机构压力随时间的复杂动态。该框架用于分析新加坡和英国的国家电子健康记录计划，它们提供了两种自上而下的系统实施如何产生不同结果的对比观点。我们的结果表明，在新加坡的案例中，边界扳手的存在，与英格兰相比，在电子健康记录实施过程中，包括来自医疗机构的 IT 人员在内的支持实施机构以及与医疗专业人员的更多接触与利益相关者互动的积极动态（例如专业人士或媒体的有限抵制）相关联。医疗保健结构和系统、电子健康档案项目组织的差异以及制度压力的综合影响揭示了两种情况下不同的实施路径和结果。本研究通过对复杂的国家医疗整合项目中的组织和社会过程进行比较检查，为健康信息技术文献增添了新的内容。它还以多种方式为机构和利益相关者文献做出贡献，特别是通过描绘在不同制度条件下发生的同构压力动态的过程和结果。最后，我们提出的框架提供了一个有用的概念工具，用于跨多个利益相关者分析此类复杂的 IT 实施。