Implementation of a nationwide electronic health record (EHR): The international experience in 13 countries

Leonidas L. Fragidis (School of Engineering, Democritus University of Thrace, Xanthi, Greece)
Prodromos D. Chatzoglou (School of Engineering, Democritus University of Thrace, Xanthi, Greece)

International Journal of Health Care Quality Assurance

ISSN: 0952-6862

Publication date: 12 March 2018



The purpose of this paper is to identify the best practices applied during the implementation process of a national electronic health record (EHR) system. Furthermore, the main goal is to explore the knowledge gained by experts from leading countries in the field of nationwide EHR system implementation, focusing on some of the main success factors and difficulties, or failures, of the various implementation approaches.


To gather the necessary information, an international survey has been conducted with expert participants from 13 countries (Denmark, Austria, Sweden, Norway, the UK, Germany, the Netherlands, Switzerland, Canada, the USA, Israel, New Zealand and South Korea), who had been playing varying key roles during the implementation process. Taking into consideration that each system is unique, with each own (different) characteristics and many stakeholders, the methodological approach followed was not oriented to offer the basis for comparing the implementation process, but rather, to allow us better understand some of the pros and cons of each option.


Taking into account the heterogeneity of each country’s financing mechanism and health system, the predominant EHR system implementation option is the middle-out approach. The main reasons which are responsible for adopting a specific implementation approach are usually political. Furthermore, it is revealed that the most significant success factor of a nationwide EHR system implementation process is the commitment and involvement of all stakeholders. On the other hand, the lack of support and the negative reaction to any change from the medical, nursing and administrative community is considered as the most critical failure factor.


A strong point of the current research is the inclusion of experts from several countries (13) spanning in four continents, identifying some common barriers, success factors and best practices stemming from the experience obtained from these countries, with a sense of unification. An issue that should never be overlooked or underestimated is the alignment between the functionality of the new EHR system and users’ requirements.



Conflicts of interest: the authors declare that they have no conflicts of interest in the research.


Fragidis, L.L. and Chatzoglou, P.D. (2018), "Implementation of a nationwide electronic health record (EHR): The international experience in 13 countries", International Journal of Health Care Quality Assurance, Vol. 31 No. 2, pp. 116-130.

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