Over the past 25 years, electronic health record (EHR) systems have undergone remarkable development, becoming an important element of modern health care [1]. Since their inception in the late 20th century, EHRs have advanced substantially, propelled by both technological innovations and critical policy reforms [2]. Key legislation, such as the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, was instrumental in accelerating the widespread adoption of EHRs, solidifying their role in enhancing health care delivery. Today, EHRs are indispensable for improving patient safety, improving operational efficiency, and ensuring that vital patient information is securely stored and easily accessible across health care settings [3].

Research to date has examined some of the key pre-implementation indicators of EHR adoption and success. Studies have revealed how certain organizational characteristics are likely to predict success, such as the size of the organization [4,5] and where it is located [6,7]. Other research has provided important details on postimplementation evaluations by users. These evaluations may include an increase or a decrease in the difficulty of tasks for the physician [8], the impact on patient care [9], and effects on privacy and security [10].

There is an extensive body of literature reviews published over the past 2 decades that explore the success factors and challenges associated with EHR implementation [11-20]. This has substantially and importantly improved our understanding of those factors that must be considered when planning EHR implementation. Fennelly et al [20], for example, identified 15 interlinked organizational, human, and technological factors that affect successful EHR implementation across primary, secondary, and long-term care settings. Our study built on this body of work by returning to the source literature with a process focus—digging beneath the success factors and challenges to examine the underpinning processes of EHR implementation. A process focus allows us to examine the connections between the factors already identified, unveiling new aspects, such as flow, activity, and temporality [21]. We, therefore, foregrounded and synthesized those papers that center on this vital process of implementing an EHR rather than delving into the technical intricacies of EHR technology itself.

The World Health Organization defines the EHR as “a longitudinal record of patient health information generated by one or more encounters in any care delivery setting” [22]. These records may include details such as demographics, progress notes, vital signs, medications, immunizations, lab results, and radiology reports, which all provide a comprehensive view of a patient’s health. Similarly, the Centers for Medicare and Medicaid Services (CMS) emphasizes that EHRs play a crucial role in helping health care providers maintain accurate and up-to-date patient data over time, ensuring that key clinical and administrative information is easily accessible and securely shared among authorized users [23].

Electronic medical records (EMRs), in contrast, are records created by practitioners for specific encounters, examples of which may be hospital visits or the use of facilities within ambulatory environments. Finally, a personal health record (PHR) is data controlled by the patient through the use of an electronic application that they are able to provide to their health practitioners. PHRs support patient-centered health care by making medical records and other relevant information accessible to patients, assisting patients in health self-management [24]. We focused exclusively on EHRs rather than EMRs or PHRs. The scope of EHRs is generally larger than that of EMRs or PHRs. They require a broad range of data types and need to be able to connect these across systems, whereas EMRs are generally confined to an individual practice [25], limiting their scope, and PHRs are generally subject to personal management [26]. This makes them less complex, and therefore less interesting from a research perspective, than EHRs. EHRs require higher levels of interoperability, regulatory challenges, stakeholder involvement, and cost and time investment than EMRs or PHRs, making them the ideal focus of this research.

Although the terms “EHR” and “EMR” are conceptually distinct, they are often used interchangeably in the literature. We recognize that the definitions we used for EHRs and EMRs in our review are not universally observed, and the terminology used in the literature and in practice often reflects the contexts in which these systems are implemented rather than the strict definitional boundaries placed upon them. In instances where studies, such as Felt-Lisk et al [27], have examined systems referred to as EHRs but may have operationally aligned with our definition of EMRs, we opted for a more inclusive approach. This definitional ambiguity may mean that some of our recommendations may equally apply to systems labeled as EMRs rather than EHRs. Addressing this overlap is essential for advancing a more unified understanding of electronic records in health care; however, it was not the purpose of this research.

Rather than the broader issue of EHR adoption, which relates to the widespread acceptance and use of the technology across health care settings, our focus was on implementation as the practical, often complex, process of integrating EHR technology into health care environments. Adoption is the “phase of investigation, research, consideration and decision making in order to introduce a new innovation into the organization” [28,29]. Implementation is the “phase of internal strategy formation, project definition and activities in which an adopted application is introduced within the organization, with the aim of removing reservations and stimulating the optimum use of the application” [29]. Although adoption can occur both prior to and after implementation, these terms describe separate, distinct actions. We discussed EHRs in terms of the process of implementation, as defined by Bouwman et al [29].

This scoping review examined the EHR implementation process over the past 25 years. The paper presented a qualitative thematic analysis of 90 relevant academic papers describing the EHR implementation process. Our review of 25 years’ worth of EHR implementation processes ultimately offers some advice and hope for more effective EHR implementations and those policies that support them.

A scoping review was conducted according to the 5-stage framework by Arksey and O’Malley [30]. Results were reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist (Multimedia Appendix 1).

The paper-screening process is illustrated in detail in Figure 1, while the distribution of the selected studies by year of publication is shown in Figure 2. Among the 90 papers, some discussed more than 1 country in their study. This included 37 (41.1%) studies conducted in the United States, 11 (12.2%) in England, 6 (6.7%) in Australia, 5 (5.6%) in Germany, 5 (5.6%) in Denmark, 3 (3.3%) in the Netherlands, 3 (3.3%) in Italy, 3 (3.3%) in Canada, 3 (3.3%) in Norway, 2 (2.2%) in Singapore, 2 (2.2%) in Kenya, 2 (2.2%) in the United Kingdom, and the remaining countries mentioned in only 1 (1.1%) study each. The majority of studies (n=59, 65.6%) were qualitative, while the remainder (n=19, 21.1%) were quantitative or used mixed methods (n=12, 13.3%). The selected papers begin in 1999 with 1 publication. Examining these figures showed initial inactivity on the topic, followed by steady growth starting in 2008 and peaking in 2017, with a slight decline in recent years. The peak years from 2014 to 2017 suggest a strong research interest during this time. Recently, from 2019 to 2024, there seemed to be a stabilization in research output, with around 4 publications annually. The main characteristics of the included studies are presented in Multimedia Appendix 3.

During the thematic coding process, sections of text within each paper were allocated to specific codes rather than entire papers being allocated to one code. As a result, multiple different codes may have appeared in one paper, as can be seen in the coding distribution table (Table 1). The full coding structure is provided in Multimedia Appendix 4.

EHR implementation problems often arise at the national level rather than at regional or health service–specific levels. This is a result of the increased complexity of national implementation [38]. Nationwide implementation requires a huge change from stakeholders [42]. In a national project, practitioners operating in public and private domains require different engagement strategies to secure their buy-in [51]. A national strategy is, therefore, needed for a national EHR implementation process [110]. National EHRs require adaptation with clinician practices nationwide to ensure workflow processes are consistent [91]. Further recommendations from the literature include changing from a top-down implementation model to increased involvement of local organizations in decision-making [35]. Planners need to ensure potentially unclear areas are clarified with program management and that clinicians are informed and consulted [51]. National-level implementation is not just simple system installation; it is discovering ideas from private institutions and using them to drive best practices across the system nationwide [49]. Bottom-up implementation is, however, time-consuming and may hinder future collaborations [94], whereas the top-down nature of some projects contributes to a lack of organizational and user involvement in decision-making [52].

The role of the government in initiating and maintaining momentum around EHR implementation processes came through strongly from our review. Government leadership is considered a strategic advantage when the goal is the sustained enforcement of EHR initiatives [31]. Mature EHR systems benefit from being well integrated into the national health-planning documents of the government [39], while national reimbursement policies can increase EHR dissemination [49]. To maintain momentum, government commitment must be both strong and continued and accompanied by political support [36]. eHealth experts are, therefore, generally in favor of a strong central solution for political regulation problems [62]. It is, however, not just the national government that matters. Support from the local government also plays a crucial role in terms of finances, provision of resources, and technical support [41]. Indeed, implementation processes suffer where they lack sufficient coordination with the local government [41]. However, strong national or local government policies mandating the use of specific eHealth solutions may support EHR implementation processes [41]. Excessive regulation may also hinder the long-term sustainability of EHR initiatives [31].

Changes in the government may lead to having to modify an overall implementation process [35]. Shifts in the government strategy affect the power dynamics between national branches of large IT companies compared to national information and communication technology companies [55]. A change in the government also has the potential to result in uncertainty about the future of national programs [52,58]. It is, therefore, advisable for system evaluators to form close relationships with policy makers [35]. Alternatively, if there is a lack of a government-level information policy at the time of design and development, the sustainability of the EHR implementation is endangered [48].

Governments are not, however, the only organizational actors who can manage or lead EHR compliance processes. Vendor organizations that have strong centralized administrative and medical structures are drivers of organizational policies and processes that are crucial to compliance [64]. Indeed, in some instances, large private vendors may enter a market specifically to provide unified access to health care data [49]. It is the process of compliance of large technology companies with uniform national standards and rules that enables EHR implementation in this instance [55,60].

Vendor recommendations influence software choice processes [69]. EHR implementors cannot simply buy from the same vendor as their existing financial system and assume turnkey, seamless interoperability [71]. There are often limitations to existing vendor-based EHRs when compared with in-house systems, including autonomy of practice decisions at each hospital [70]. These limitations are also seen in difficult-to-assess EHR usability as a result of restrictive vendor license agreements [59].

EHR vendors are generally at least partly responsible for the amount of training received by users [69] and sometimes also responsible for providing technical support [27]. Indeed, vendors may use the provision of ongoing technical support as a form of training [77]. Both peer and technical support may be issued from these vendors, which can help end-users optimize their use of the EHRs and solve issues [67]. Even large vendors may need to consider EHR adaptations for small practices as part of the sale of the EHR, ensuring that a person within the practice conducts training and adapts it to the specific needs of the practice rather than relying on training by IT specialists [53].

This scoping review revealed 4 main areas for consideration in the EHR implementation process. These areas are compliance, collaboration, competence, and costs. Specific issues recurred in each area throughout the literature: the role of the government and the role of vendors in compliance processes, the importance of communication and relationships to facilitate collaboration processes, training and support to build competence; and the cost of financing throughout the implementation process. Many of the 19 interventions identified by Boonstra et al [13], and the 15 factors identified by Fennelly et al [20] pertaining to successful or effective implementation strategies featured within our findings. Rather than replicate the reviews of Fennelly et al [20] or Boonstra et al [13], however, we built on these to provide a focused exploration of the implementation process to complement the broader insights that these reviews offer. We built on these works to offer practical recommendations for use in the implementation process.

Our study and research question focused on the process of implementation of EHRs. The process of implementation deserves attention, especially when we consider that the implementation process influences implementation outcomes. Put differently, it is not just what system we implement, nor the recognition of challenges or facilitators, but also the process by which we navigate and manage these over time that ultimately decides how successful an EHR might be. There is, therefore, a need to understand how to approach these implementation processes in a way that is informed by previous implementations and the appropriate literature. To address this, we provide recommendations produced from our synthesis of the selected literature reviewed in this paper. Organizing our findings into compliance processes, collaboration processes, competence processes, and process costs allowed us to provide distinct actionable recommendations for stakeholders. Our recommendations emphasize implementation priorities in a way that facilitates targeted interventions. Our recommendations not only reaffirm established principles found in reviews, such as those by Boonstra et al [13] and Fennelly et al [20], but also provide a modernized roadmap for undertaking the implementation process.

Several limitations should be considered in this scoping review. This study focused on EHRs and did not consider the implementation processes of other eHealth systems, which may benefit from future analysis. Our findings also highlight the need for improved standardization in the terminology surrounding electronic records in health care to better differentiate between EHRs and EMRs in both research and practice. This improved clarity would allow for greater comparability across studies and guide more tailored implementation processes. The included studies tended toward the United States and Europe, centering our analysis in the Global North. The search strategy included studies from 1999 onward. The resulting studies selected were mostly from 2007 onward. It is unlikely that this date limitation largely impacted the selected studies; however. it is possible that due to the date limitation, this scoping review may have missed interesting studies conducted prior to 1999. Finally, our specific search terms, chosen with the intention of focusing the literature on the implementation process, may mean that the literature describing the same event but not using those specific search terms was not retrieved. Additionally, shifts in the language and naming of systems in health care mean that this study may apply to systems discussed under a name other than “EHRs,” which have not been retrieved during the search strategy of this research. As such, we did not retrieve or include any studies discussing EHRs under the recently emerging term of “digital health records.”

Completed implementation of EHRs is integral to improving health care delivery. The findings from this scoping review offer important insights into the complexities of the actual process of implementation and its subprocesses. Our review identified 3 key processes (compliance, collaboration, and competence building), as well as considering overall process costs. In doing so, we offered a new time- and action-based perspective on EHR implementation. Compliance processes reference the role of the government, policy, regulation, and vendors in shaping the implementation process. Collaboration processes promote the need for strong communication and the building of relationships across all stakeholders involved in the implementation process. Competence-building processes focus on ensuring that users are provided with the resources to be able to operate an EHR, centering around the importance of the timing of training and support. Finally, our discussion of process cost illustrates the importance of a time-focused financial approach during the implementation process.

We proposed 7 strategies in this review, which all provide a structured approach to navigating the different areas of implementation. Future research should focus on deepening our understanding of how these outlined strategies change and operate at different stages of the implementation process. This scoping review contributes to the intersection of management and health care research. We hope that the review results and recommended strategies provided will inform areas for future research and help develop future implementation processes.