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Advanced Electronic Medical Records (EMR) provide many potential benefits to hospitals. However, because of their broad scope, many stakeholders deal with the EMR and a continuous effort has to be made to keep up with internal and external change. Therefore, hospitals need to deliberately shape their organizational competencies considering the pursuit of alignment, i.e. making sure that the EMR remains optimally aligned with strategies, goals and needs of the hospital and its stakeholders. This paper aims to investigate the evolutionary paths of these alignment competencies and their drivers, from a theoretical perspective of co-evolutionary information systems alignment (COISA).

This paper reports on a longitudinal multiple case study of three Dutch hospitals which each recently implemented an advanced EMR system. The authors conducted 35 in-depth interviews in 2 phases (before and after go-live of the EMR), and studied documentation related to the EMR implementations.

The findings show that each hospital's COISA capability shows a different evolutionary path. However, two of the three case hospitals ended up coordinating part of their COISA capability to an ecosystem level, i.e. they incorporated other hospitals using the same EMR system to coordinate their alignment efforts, either from an operational perspective, or in terms of orchestration and strategy. The found evolutionary paths' key drivers include “stakeholder initiative”, “accumulating experience”, “driving events” and “emerging issues”.

The findings help healthcare practitioners to deliberately shape their organization's COISA capability in pursuit of EMR alignment. Furthermore, the authors add to the knowledge base on co-evolutionary approaches to alignment through the longitudinal approach.