Table 5 Barriers to achieving EHR interoperability

Subtheme 1: Poor EHR systems usability

 “So I think it's worth calling out that most systems were never designed with interoperability in mind, so when you retrofit interoperability inevitably there are going to be some major challenges.” – Participant 2

“Most people either don't know to look in there for information, can't be bothered because it's an extra system on which to log into’ so that's fairly moderately penetrated I would say probably.” – Participant 2

 “We have single sign on in our practice and in the hospital, since they're in their own record for the Trust, they just click on a button and it brings, it automatically signs them into the shared care record, so that makes it easy. The login process is easy, it's not a problem. Hinders are generally when you can't log on, or you have to have a separate password to log on somewhere else.” – Participant 10

 “The immediate one for us is to get social care on, because that's the one bit we really don't have, but I think they're on board. Mental health is a different issue, and I don't quite know why we can't get them engaged. They seem to be much more worried about sharing their data.” – Participant 1

 “For us, it's finding a balance between structuring data and making it easy to enter. There's a balance between having structured data that people are prepared to reuse, because they trust, and then finally, theirs is ultimately a system challenge. We've got lots of stuff that's been coded in different ways and undertaking the exercise to harmonise that to one version of the truth, without a lot of data loss or re-work, I think is a challenge.” – Participant 12

Subtheme 2: Institutional barriers

 “It's more a verbal networking, but there doesn't seem to be a way of viewing what projects are ongoing or what stage they're at, who's involved with them, who to connect to, to talk about them. Or if you see a certain issue, or if you do this, then you're taking this out, and did you realise our workflow was dependent on that? So that kind of transparency I don't think is there.” – Participant 10

 “I think that it's a big issue. One of your barriers which you probably want to talk about is communication between different organisations. […] The other problem is I think’ you don't always know what other organisations are already doing. The projects aren't being, aren't transparent enough, an’ you can't see what the user requests are for each project, what's their expectation of how it should work, and there's probably a significant overlap which most, a lot of organisations could, are just duplicating work.” – Participant 10

 “The local example, [trust name], massive hospital, they're spending £100 million, over ten years, on [EHR system name]. The solution to interoperability, moving forwards for us, is well you guys could buy it. So they've decided that that's the course of action. The Greater Manchester may be different because Greater Manchester is a highly politicised environment, ever since devolution, it's caused lots of interesting politics. I think people say well look, we are doing this and if you want to play, you play our way. So there's a bit of a power struggle vibe.” – Participant 12

 “I think firstly, the business case process doesn't support or reward it. So for me saying, I will spend extra time or money, or what have you, to ensure that I can share my records with another hospital, no. My finance director and my board, they might understand why I'd want to do it, but they will not understand why we should pay for it. […] So I'm going to deploy an EPR and I want to make sure the guys at [name] can see everything that the’ want. That's going to cost me. That's going to benefit staff at [name]. If [name] are not doing the same for us, we are supporting them, and that's a good thing, but we're paying to make their lives better and they're not prepared to pay to make our lives better. There's a bit of a, I'm fixing someone's problem, mentality.” – Participant 12

 “[…] Whereas most of them just think that system will work for us, then it's up to everybody else to cope, and often it involves doing extra work and extra expense. […] Along similar lines, we're finding now that local tertiary centres like the cardiology centre, the pl’stics, they're all developing their own portals and none of this is integrated a’ our end. I'm not sure whether they'll all be integrated at the other end’ither. They're all stand-alone systems and really, to me, they should be joined up.” – Participant 15

Subtheme 3: Data management-related barriers

 “I think it's about ownership of an accountability for care delivery. So for your condition. Let's say you have a diagnosis. What are the associated actions to address that? Who owns them? Do you? Does your primary care provider? Does your secondary care provider? Being able to understand what other people have done in response to things. I think we can solve interoperability, it's a technical challenge’ big one. I'm still not sure it gets us to where we think it will, because I think you will persistently have separation of records. There will always be bits that we cannot share because they are not codable. Actually, interoperability is a—it's a really fancy workaround for creating a patient centred record.” – Participant 12

 “I guess my framing is that we sit somewhere with this, between data and information and knowledge. If you achieve complete universal interoperability, you solve a data challenge. Healthcare and health delivery, generally, there is an element of nuance and it's your interpretation of it and what you're going to do with that piece of data, and how I have interpreted may be justifiably different to yours or someone else's interpretation, but the actions then hang from that. So I do not think a fully interoperable record will ever, in its own, get us passed that.” – Participant 12

 “I think the junior ones [doctors] wouldn't be here for an extended period of time, so it may’e that they're not involved in going to that patient again, and they just keep repeating what they do. It will b’ people who've got a longer-term perspective who are following that patient through with their pregnancy, like me, who would be much more aware of it the importance of structuring data for the future users.” – Participant 6

 “Now, in terms of data generation, as I say, I am fundamentally against the idea of putting an intermediary in there.” – Participant 13

Subtheme 4: Finance and business-related barriers

 “Well, actually, this is a no-brainer. If you are not willing to have a free flow of data between our systems and the hospital systems, then you lose the contract.” – Participant 4

 “In part, there's never been a financial incentive. Primary care probably have more potential to share data, because of their approach to structure. Secondary care has never been held to account on the quality or the value of i’s data that's collected. So we are in a payment-by-results world, I'm paid for delivering your care, none of the other stuff around it. […] I think there's never been a national financial incentive. So if we're looking to sign off a business case, no one has ever been held to account for whether this supports data sharing. Every business case has been inward focused, never outward focused.” – Participant 12

 “We've always bought an American EPR, and they have a business model which has historically been lock you in, lock you in. So we're engaged with providers who are disincentivised to support it. We have never been given an incentive to challenge that.” – Participant 12

 “Often working with these small companies, they will get things done in weeks, whereas when you're trying to do something with a big company like [EHR vendor name], that supply us with [EHR system name], you're talking about years. I think most of them won't have done it deliberately. […] Should there be some sort of national system that all these referrals can be plugged into? So that we can say to the suppliers, we could issue a ISM to say, 'You've got to be compatible with this system.'” – Participant 15