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Table 4 Emerging themes from our study

From: Integration of a nationally procured electronic health record system into user work practices

Software characteristics and their consequences Design did not reflect reality of clinical practice
  Lack of customizability
  Perceived lack of fitness for purpose and lack of usability resulted in increased workloads for users
  Implementation strategy soft: initially parallel use of paper: intended workarounds
Coping strategies by users in different contexts Some more powerful users resisted use
  Embedding of the system over time in smaller scale implementations that allowed intensive user involvement in software design
  Users who could not avoid using the system devised various ways to compensate for the increasing demands on their time and perceived shortcomings of the technology
  Often workarounds were unintended by management
Direct and indirect knock-on effects Collaborative working-hierarchical structures and communication
  Time spend with patients and quality of interactions
  Paper: more distributed across geographical locations
  Managerial outputs became unpredictable often not reflecting the reality of what actually happened
  The medical record itself-delayed data entry