Converging outcomes in nationally shareable electronic health records (NEHRs): An historical institutionalist explanation of similar NEHR outcomes in Australia, England and the United States of America

Abstract

The adoption of nationally shareable electronic health records (NEHRs) in Australia, England and the United States became major policy and political issues between c1998 and 2015. They continue to be so. As a policy issue, the benefits of ehealth, and subsequently NEHRs as mechanisms for institutional change, were rhetorically popular. Politically however, the development, implementation and regulation of NEHRs proved to be difficult and fraught with criticism from nearly all ehealth stakeholders. The NEHR programs each country pursued at the national level were exceptionally expensive and complex infrastructure undertakings. They involved institutional change management that produced tension amongst stakeholders, required the state to decide on trade-offs that produced winners and losers, and resulted in unintended consequences. Initially, each country approached these policy and political issues differently. Examining why they then had substantially similar outcomes is the substantive puzzle that lies at the centre of this research. This thesis adopts an historical institutionalist approach to explain why state efforts to pursue the development, implementation and regulation of NEHRs at the national level in Australia, England and the United States resulted in substantially similar outcomes despite adopting initially different approaches. The thesis first compares why each case study country pursued ehealth, embarked on organisational change in order to achieve its ehealth and NEHR goals, and adopted NEHRs, noting similarities and major differences. The thesis then compares the state's role in the development of NEHRs at the national level in each country, again noting similarities and differences. A comparative evaluation of the cases is then undertaken in order to explain why each state continued to pursue NEHRs, despite the significant barriers to institutional change they faced. Here, the theoretical concepts of path dependency, critical junctures and incremental change are used to enhance the explanation. The thesis will then explain why the outcomes, as assessed through the lens of public policy evaluation, were substantially similar in each country. Finally, the thesis details the findings of the research through the lens of historical institutionalism and states the significance and implications of the research. The research found that while each case study country approached the policy and political issues of ehealth and NEHRs differently, the outcomes were substantially the same because their goals, and the barriers they faced in trying to achieve them, were very similar. Australia started with a decentralised national health information network (NHIN) then changed to a centralised NEHR. England started with, and continued to pursue, a centralised NEHR. The United States eschewed government development and implementation of an NEHR and took the path of incentivising and regulating electronic health records (EHRs) in an effort to make them nationally shareable. Similar goals across the three countries included moving from a paper to an EHR system; giving patients more control over their health information; making EHRs interoperable; increasing EHR usability and the meaningful use of patient health information; and improving the efficiency and effectiveness of care. Similar barriers included: cost, privacy, trust, stakeholder preferences, and the state attempting to drive change too quickly producing stakeholder resistance and negative outcomes. The thesis findings also provide support for theoretical explanations of institutional stasis and change within the context of path dependency, critical junctures and incremental institutional change.