Advancing understanding of scaling health information infrastructures: learning from EHR initiatives in England

Many countries are developing health information infrastructures (HII) such as integrated electronic health records (EHRs) as a means of improving healthcare efficiency and effectiveness. However, efforts to build and scale up HII are fraught with challenges, as exemplified by the well-known case of the National Health Service (NHS) in England. In particular, HII scaling initiatives give rise to tensions, such as across geographical boundaries of EHRs, which are often not effectively addressed in practice. At the same time, there have been calls for research on scaling IS through a practice perspective, which adds to the existing categorical analysis of scale. Thus motivated, we aim to conceptualize the scaling of HII, focusing on the tensions between scales, the practices to accomplish scaling, and their consequences for scaling outcomes. To do so, we undertook a case study of recent NHS efforts to integrate EHRs in England, where we analyzed these scalar concepts and their interrelationships. Our study further develops the notion that scaling not only involves increasing the scale of IS but entails constructing and reconstructing scales. We also offer theoretical contributions by conceptualizing the range of scalar tensions and practices, their interplay, and their influences on HII scaling outcomes. Tensions that we identify as associated with different scale boundaries (organizational, spatial, and technological), extend those recognized in prior research. Furthermore, we uncover the scalar practices of joining and differentiating, adding to the governance and architectural approaches for HII scaling examined in past work. Through deepening the understanding of HII scaling, we generate insights for practitioners by highlighting scalar tensions and practices that could address the tensions under different conditions. Overall, we draw attention to scaling phenomena as being integral to the development of HII and introduce a new vocabulary for thinking about HII scaling.