Understanding variation in subunit adoption of electronic health records: facilitating and constraining configurations of critical dependencies

This interpretative case study demonstrates how the work system properties and roles of clinical departments are perceived to shape their adoption of an organisation-wide electronic health record. In hospitals, with their heterogeneous and powerful clinical departments, partial or non-adoption by some departments may jeopardise effective overall use. Viewing a hospital’s EHR adoption from a sociotechnical fit perspective, we unravel how clinical departments’ adoption of this organisation-wide system was primarily shaped by their critical work system dependencies rather than their role during its implementation. From the interviewees’ accounts, three orientations emerge: (1) organisation-oriented resulting in unconditional adoption; (2) department-oriented resulting in problematic or delayed adoption with high compromise costs; (3) environment-oriented resulting in at least partial non-adoption or extra design costs. Our subsequent analysis leads to the identification of four types of subunit-level characteristics influencing adoption. Their interplay informs departments in balancing between accepting compromise costs and negotiating design costs. We develop a diagnostic system model of subunit-level adoption that takes the embeddedness of the subunit into account and thereby complements individual- and organisation-level adoption theories. An accompanying heuristic may enable hospital managers to better anticipate the heterogeneity in departments’ adoption.