Table 4 Facilitators of EHR interoperability

Subtheme 1: Recognition of need and possibility amongst healthcare workers

 “When you roll out an electronic health record, they don't actually really particularly think about interoperability with, say, a GP system. I think it's only as you progress through the use of health records that you begin to say, 'Well, actually, that will be really useful for me to have.” – Participant 4

 “As staff have moved and worked around different areas and they've seen the gradual adoption of electronic patient records, the logical question which everybody asks now is, well why can't I? Why can't I see that? Why can't I get that information? So the clinical narrative is changing. The clinical expectation is changing. I think that will become a more powerful lever than it has been in the past. If there is no clinical drive for something, from your users, it is very easy to discount it as a need.” – Participant 12

 “We created the population analytics platform quite quickly to support COVID-related population health. That was achieved. That's something that we've been talking about for years and then it actually happened in the space of about two months.” – Participant 13

 “Finally, because the market has been very immature in the past, clinicians have focused on the localised benefits, rather than the systematic benefits, because that is the world that we live in. If everyone else is on paper, right, what can I do with this here for me now. I think as staff—from trainees to senior roles—as staff have moved and worked around different areas and they've seen the gradual adoption of electronic patient records, the logical question which everybody asks now is, well why can't I? Why can't I see that? Why can't I get that information? So the clinical narrative is changing. The clinical expectation is changing. I think that will become a more powerful lever than it has been in the past. If there is no clinical drive for something, from your users, it is very easy to discount it as a need.” – Participant 12

Subtheme 2: Expectations from patients

 “Patients just think their information is all linked up and it's all there or we can access it, and we can access the GP record, and we'll write to the GP and things will be updated. They make these assumptions. If only they knew the truth sometimes!” – Participant 8

 “From the patient's point of view as well, a lot more power is going to go to the patient's side. They're going to expect doctors to know about them. They expect them to know. We have a system, quite a few hospitals use it, where it's a bit like TripAdvisor really for doctors where patients can write an online review anonymously about a doctor they've seen, or a hospital they've been to or a clinic they've been to.” – Participant 6

 “We typically get patients coming back from a hospital appointment going, 'A doctor's given me a new yellow pill: can you prescribe it?' 'What is it?'”—Participant 14

Subtheme 3: Centralised nature, strategic levers, and national oversight

 “I think probably UK has got the best opportunity, or the right levers in place, to produce a good go at interoperability because of the National Health Service. I don't believe any other service is as national as the National Health Service. I think insurance, you know, different models of care, delivery of care, and funding of care does potentially cause bigger challenges of commercial interests where the NHS should, if used properly, should be able to avoid a lot of those. I don't think that we should be looking elsewhere for solutions.” – Participant 2

 “Given that the NHS is pretty self-contained, I would say, even if it has to have foreign vendors for its software, I think it would make more sense to me for it to be mandated that it has to conform to some standards that are set here rather than global standards. I don't think you're going to get global standards in EHRs any time soon.”—Participant 6

 “Now I am definitely more optimistic because we've got really good national drivers… like healthcare record exemplar programmes. We're seeing in ICS (integrated care systems) objectives it's part of strategies I think at a local level and [at an organizational level]. Interoperability is on our roadmap. We are committed to making this happen for our clinical workforce and the people that use our services. There's a greater movement and dialogue around this, whether it's on national forums and conferences.” – Participant 11

 “I think that actually workflows across different Trusts are very similar. Whether they're exactly the same or not, they're very similar, and you could have everybody work in the same way.” – Participant 1