Our adapted ‘sociotechnical changing’ framework has three main dimensions: the constantly evolving nature of the contexts: i.e. environment, organization, perceptions, and consequences of the implementation of EHR systems; the performative nature of evaluating the implementation and adoption of EHR to explore how it ‘worked out’ and was ‘made to work’; and finally exploring and narrating the implementation of EHRs ‘in the making’, beyond the potentially misleading dichotomy of success or failure. Such an approach enabled us to learn how the EHR was formed, translated and reproduced in various entities at Beta  and the different meanings it embodied for various stakeholders, at different times and locations . Our study revealed the usefulness of this approach to shed light on empirical aspects of the implementation and adoption and to plan for improving the process.
The decisions to procure EHR, the selection of the specific software (RiO), the process of implementation and the attempts to make RiO work at Beta, all proceeded in a rapidly changing NHS environment. NPfIT was dismantled in 2011. If Beta had decided not to join NPfIT, the organization may have lost the opportunity of being an ‘early adopter’ of NHS-centrally procured EHR systems. At the time of making the decision to proceed in 2008, the financial and non-fiscal incentives to be early adopter, and Beta’s desire to seize the opportunity of integrated EHR to get closer to the Foundation c status to help the organization survive, were constantly and quickly changing over time. For stakeholders at Beta, EHR embodied certain interests of (e.g. senior managers, doctors, IT staff, managers, etc.) that was linked to systems of politics and power relations , which shaped perceptions and actions, as opposed to a discrete and contextual resource deployed in planned processes of change [42, 61]. In hindsight, irrespective of shortcomings of the implementation and some negative experiences by the users, Beta’s decision was a right choice for the organization and the quality of care for its patients.
Our performative and social construction view helped explore the implementation of RiO in the making and portray how users from various disciplines shifted their perceptions and attitudes towards the EHR system in use, and became generally positive to make it work for their organization. In this way, change is rarely a fast or direct movement from ‘the old’ to ‘the new’, rather the new is born within the old and co-exists with it, and the old and the older still remain sedimented within the most new [35, 54]. In addition to capturing what people said they did versus what they were doing, we managed to reconcile between the state of being (e.g. being a nurse, or doctor, or computer, etc.) and practice of doing (e.g. order entry, putting notes, etc.) . Our longitudinal evaluation allowed us to understand the implementation process through engaging with actors who experienced changing in their daily interaction with EHR, and who also were being changed by it.
Initially, the users expressed mixed feelings about RiO and perceived it as being somewhat inadequate. They complained that it lacked some key clinical functionality versus loads of useless functions on RiO, and the significant cultural and work environmental changes that EHR brought to mental health settings. For instance, in line with the literature, some clinical users were concerned about adverse effects of EHR on healthcare practitioner-patient relationship [14, 15, 62, 63]. However, a lot of users’ initial anxiety, negative attitudes, and stress were replaced with hope and satisfaction. This partly happened as a result of attempts to make RiO work and appropriate preparation to adopt EHR, which led to experiencing and recognizing some early benefits. Modest early benefits led users change their behaviour in substantial ways, many of whom, including doctors and nurses mentioned the greater degree to which they paid attention to creating more accurate and meaningful notes on RiO, because they were constantly seen and judged by their colleagues.
Our theoretical perspective helped ensure that we did not reduce the EHR to delivery, implementation and immediate use , but understand it as both cause and consequence of longer-term processes of changing, during which people and EHR came together to perform actions and tasks  as co-constitutive entities [43, 55]. Such a social and cultural shift did not happen serendipitously and over a night. Rather, we noticed that the vision of change management , the leadership of the organization who made the decision to join the NPfIT despite the negative climate and the uncertain future of NPfIT, and constant support and help from senior management who invested in appropriate infrastructure, were the main reasons behind changing towards improvement, and reducing degrees of resistance to adopt EHR, and making RiO work at Beta.
The process of the implementation of RiO, as we understood it, involved multiple intricately woven moments of changing including inter alia combinations of the organizational, technical, social, professional and care, which was materialized as it was performed by various stakeholders with different sets of attitudes and perceptions, at different times and locations, across our context of investigation: Beta. This led us to learn insights that could be obtained from approaches that sought to ‘tell the whole story’ not just the ending [30, 65]. Our ‘sociotechnical changing’ framework enabled us to manifest changing by capturing stakeholders’ perceptions of EHR as instances of both projection (what is possibly becoming new) and remembrance (what is old and difficult to give up) . For us, studying implementation and adoption of EHR was inevitably and eternally a process or performance, suspended between what was and what might one day be. The EHR thus comes into being as and when it is performed (not when software is delivered and installed) even to the extent that it ‘vanishes when it is no longer performed’ . In addition, we observed redistribution of professional responsibility and degrees of job change as users attempted to inscribe their interests into EHR . Initially, there were complaints about extra burden of administrative job. Some users, senior doctors in particular, for whom administrative job was conducted by junior doctors or nurses traditionally, were reluctant to put notes on RiO. Nurses, in contrast, were generally more compliant as they projected EHR as a chance to take more control over their work (remembrance).
Further, by exploring EHR system (RiO in this case) in-the-making, we focused on real concerns of policy makers and managers – the causal texture within which the implementation happened. Our findings brought to the fore the intricate set of interlocking changes in practice that EHR implies, a more formative view than the image of discrete change, and a detailed stock of knowledge that informed key stakeholders at the time that it was, we believe, most needed. For illustrative purposes, we refer to feedback, recognizing that our ‘sociotechnical changing’ approach resulted in useful outputs that informed strategies and brought improvements to the implementation of RiO at Beta:
‘…excellent stuff that truly gave us insights we as a deployment team had not perhaps fully thought about or understood… I think a second phase review of perceptions of the system after it has settled down would be extremely beneficial, warts and all, and help with the formation of our future strategies and approach.’ (Senior manager).
Although not optimal, people worked hard around issues to make the system more compatible with their organizational needs. As a result, they harvested some modest benefits for both patients and the organization  and valued the system  eventually. From our perspective, non- or partial adoption but also rejection, mis-use, non-use, resistance to EHR and workarounds, all are not simply negative effects, pathologies or signs of failure, but are alternative enactments upon technology, which may pave the trajectory of organizational learning towards future smoother implementation process [42, 68, 69]. In this way, as an intertwined product of technology; work practices; and people who make them work, EHR is made to actively produce a fit system to the needs of organization .
All in all, the ‘sociotechnical changing’ perspective helped us move away from static before and after implementation ‘impacts’ or notions of discrete change. Instead, we focused on nominalism (rather than essentialism), crossing of temporalities (rather than before-after dualisms) and practice (rather than strategic or functional) orientation .
Our findings are in contrast to the claims that EHR may lead to impersonal and inaccurate clinical notes in mental health settings . Given a great desire of mental health patients to receive a copy of their summary notes (78% of patients reported that it was helpful to receive the letter, and 83% reported that they would like to continue receiving them) , EHR may lead to enhanced patient satisfaction by producing more accurate notes. The evaluation of the implementation of EHR in an NHS community mental health setting showed similar results: high degree of users’ satisfaction and some tangible benefits to clinical staff .
Lessons for implementers
On the basis of challenges encountered during the implementation of EHRs, and early benefits realized at Beta, we consider some policy implications below that may help facilitate the improved implementation of EHR systems into mental health settings.
First, stakeholders need to be identified prior to planning to procure and implement EHR software, and their computer literacy and ability to access the technology needs to be adjusted accordingly . Engaging with healthcare professionals from early stages of planning and as EHR partners is pivotal to maximize efficacy and improve patient care.
Second, although overlooked by the NPfIT, it is important to understand whether both mental health service providers and users would like to have EHR systems–and for what purposes–before embarking on the large-scale implementation of EHR systems.
Third, EHR needs to be seen as a sociotechnical entity by stakeholders, thereby ensuring a user-centred design of EHR [73, 74]. It is important to address concern of users who may present less interest and enthusiasm about EHR.
Fourth, contextualization and taking heterogeneity across mental health settings is crucial to implement EHR initiatives. This might also help identify areas in need of additional support when implementing EHR software.
Fifth, given a huge cultural shift that EHR brings  to heavily text-based notes in mental health, healthcare practitioners must be educated and protected with regards to transparency and observing confidentiality of patient notes.
Last but not least, the safety of EHR systems needs to be ensured prior to and during the implementation , and their efficacy requires to be evaluated using robust, independent, and forethought evaluation programs that employ reflexive and multidisciplinary research team .
Strengths and limitations of this work
Our findings need to be interpreted with caution. We evaluated one ‘early adopter’ mental hospital in England, during a relatively short period of EHR implementation and in the beginning of a long journey to full integration. We did not intend to evaluate the software specifications per se. Rather, we attempted to understand what was ‘going on’ in terms of the implementation and adoption of EHR in the studied settings, namely the process of implementation not outcomes. The in-depth case study approach [28, 30] was helpful to ensure an understanding of the contextual aspects of the implementation, however generalizable lessons can only be drawn with great caution. In addition, our adapted ‘sociotechnical changing’ perspective may have narrowed down our focus on the micro level, thus hindering the bigger picture to be portrayed. Nonetheless, we managed to collect data from various stakeholders from outside Beta, and compared our analytic themes with other case studies in our evaluation. This may have expanded our understanding of the phenomenon. We acknowledge that many perceptions and attitudes described here may be altered in times to come, as there is a natural learning and adoption curve in any organizational change initiative. Finally, we did not study patients in our evaluation. Other studies on the impact of EHR use on the quality of the patient-psychiatrist relationship found no change in satisfaction scores among adult psychiatric patients for whom EHR was used during outpatient encounters instead of paper charting .
Nevertheless, despite the above limitations, little has previously been published on EHRs in mental health settings, let alone in the context of national implementation endeavors. This paper may shed light on some practical dimensions of EHR implementation and things to consider when planning implementing integrated EHR systems in mental health settings. As such, we hope that will help in the many future implementation and adoption of EHR systems in mental health settings that are now underway or are planned in countries with similar healthcare systems, and possibly beyond.