{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,9,2]],"date-time":"2025-09-02T16:40:05Z","timestamp":1756831205510,"version":"3.44.0"},"reference-count":51,"publisher":"MIS Quarterly","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,6,1]]},"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.25300\/misq\/2024\/17307","type":"journal-article","created":{"date-parts":[[2024,9,11]],"date-time":"2024-09-11T18:52:13Z","timestamp":1726080733000},"page":"759-776","source":"Crossref","is-referenced-by-count":1,"title":["Advancing Understanding of Scaling Health Information Infrastructures: Learning from EHR Initiatives in England"],"prefix":"10.25300","volume":"49","author":[{"given":"Ela","family":"Klecun","sequence":"first","affiliation":[{"name":"Department of Management, London School of Economics and Political Science London, U.K."}]},{"given":"Atreyi","family":"Kankanhalli","sequence":"additional","affiliation":[{"name":"School of Computing, National University of Singapore Singapore"}]},{"given":"Ya","family":"Zhou","sequence":"additional","affiliation":[{"name":"School of Management, Xiamen University Xiamen, China"}]}],"member":"10933","published-online":{"date-parts":[[2025,6,1]]},"reference":[{"issue":"2","key":"2025090212073021800_b1-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"161","DOI":"10.1016\/j.jsis.2011.03.006","article-title":"Building nation-wide information infrastructures in healthcare through modular implementation strategies","volume":"20","author":"Aanestad","year":"2011","journal-title":"Journal of Strategic Information Systems"},{"issue":"4","key":"2025090212073021800_b2-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"834","DOI":"10.1287\/isre.2014.0557","article-title":"Infrastructuring work: Building a state-wide hospital information infrastructure in India","volume":"25","author":"Aanestad","year":"2014","journal-title":"Information Systems Research"},{"key":"2025090212073021800_b3-13_rn_10_25300_misq_2024_17307","unstructured":"Alderwick, H., Dunn, P., McKenna, H., Walsh, N., & Ham, C. (2016). Sustainability and transformation plans in the NHS: How are they being developed in practice? The King\u2019s Fund. https:\/\/assets.kingsfund.org.uk\/f\/256914\/x\/9e43ad07f4\/sustainability_transformation_plans_nhs_2016.pdf"},{"issue":"1","key":"2025090212073021800_b4-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"467","DOI":"10.25300\/MISQ\/2021\/15434.1","article-title":"Scale matters: Doing practice-based studies of contemporary digital phenomena","volume":"45","author":"Barrett","year":"2021","journal-title":"MIS Quarterly"},{"issue":"2","key":"2025090212073021800_b5-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"crossref","first-page":"381","DOI":"10.2307\/25148796","article-title":"Developing health information systems in developing countries: The flexible standards strategy","volume":"31","author":"Braa","year":"2007","journal-title":"MIS Quarterly"},{"issue":"4","key":"2025090212073021800_b6-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"591","DOI":"10.1191\/030913201682688959","article-title":"The limits to scale? Methodological reflections on scalar structuration","volume":"25","author":"Brenner","year":"2001","journal-title":"Progress in Human Geography"},{"key":"2025090212073021800_b7-13_rn_10_25300_misq_2024_17307","unstructured":"Carding, N.\n           (2020). Exclusive: NHSX to loosen grip over care record boundaries. HSJ. https:\/\/www.hsj.co.uk\/technology-and-innovation\/exclusive-nhsx-to-loosen-grip-over-care-record-boundaries\/7028344.article"},{"key":"2025090212073021800_b8-13_rn_10_25300_misq_2024_17307","unstructured":"Charles, A., Ewbank, L., Naylor, C., Walsh, N., & Murray, R. (2021). Developing place-based partnerships: The foundation of effective ICS. The King\u2019s Fund. https:\/\/www.kingsfund.org.uk\/publications\/place-based-partnerships-integrated-care-systems"},{"issue":"3","key":"2025090212073021800_b9-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"271","DOI":"10.1197\/jamia.M3183","article-title":"Building a national health IT system from the middle out","volume":"16","author":"Coiera","year":"2009","journal-title":"JAMIA"},{"issue":"1","key":"2025090212073021800_b10-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1287\/isre.2014.0542","article-title":"Information infrastructure development and governance as collective action","volume":"26","author":"Constantinides","year":"2015","journal-title":"Information Systems Research"},{"key":"2025090212073021800_b11-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"146","DOI":"10.1108\/17410391111106284","article-title":"The policy-practice nexus of electronic health records adoption in the UK NHS","volume":"24","author":"Currie","year":"2011","journal-title":"Journal of Enterprise Information Management"},{"key":"2025090212073021800_b12-13_rn_10_25300_misq_2024_17307","unstructured":"DHSC (Department of Health and Social Care)\n          . (2013). NHS challenged to go paperless by 2018. GOV.UK. https:\/\/www.gov.uk\/government\/news\/jeremy-hunt-challenges-nhs-to-go-paperless-by-2018--2"},{"key":"2025090212073021800_b13-13_rn_10_25300_misq_2024_17307","unstructured":"DHSC, & NHS England\n           (2022). A plan for digital health and social care. GOV.UK. https:\/\/www.gov.uk\/government\/publications\/a-plan-for-digital-health-and-social-care"},{"key":"2025090212073021800_b14-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1108\/S0733-558X20220000079016","article-title":"Scale in research on grand challenges","volume-title":"Organizing for societal grand challenges","author":"Dittrich","year":"2022"},{"key":"2025090212073021800_b15-13_rn_10_25300_misq_2024_17307","unstructured":"Dobson, S.\n           (2017). Meeting notes: 8\u2014IM&T strategy and architecture. Greater Manchester Health and Social Care Strategic Partnership Board. https:\/\/democracy.stockport.gov.uk\/documents\/s120317\/08%20_IMT_Strategy_and_Architecture_-_SPB30_06_17.pdf"},{"issue":"2","key":"2025090212073021800_b16-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"332","DOI":"10.1068\/a4299","article-title":"The craft of scalar practices","volume":"42","author":"Fraser","year":"2010","journal-title":"Environment and Planning A"},{"key":"2025090212073021800_b17-13_rn_10_25300_misq_2024_17307","unstructured":"GMCR (Greater Manchester Care Record)\n          . (2023). Realising the potential of the GM Care Record in secondary care\u2014Final report. https:\/\/healthinnovationmanchester.com\/wp-content\/uploads\/2023\/03\/GMCR-Report-FINAL.pdf"},{"issue":"3","key":"2025090212073021800_b18-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"crossref","first-page":"611","DOI":"10.2307\/25148742","article-title":"The nature of theory in information systems","volume":"30","author":"Gregor","year":"2006","journal-title":"MIS Quarterly"},{"key":"2025090212073021800_b19-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"645","DOI":"10.1057\/ejis.2015.1","article-title":"Flexible generification: ICT standardization strategies and service innovation in health care","volume":"24","author":"Hanseth","year":"2015","journal-title":"European Journal of Information Systems"},{"key":"2025090212073021800_b20-13_rn_10_25300_misq_2024_17307","unstructured":"Hoeksma, J.\n           (2019). A tug of war over LHCREs is underway. Digital Health. https:\/\/www.digitalhealth.net\/2019\/02\/a-tug-of-war-over-lhcres-is-underway\/"},{"key":"2025090212073021800_b21-13_rn_10_25300_misq_2024_17307","unstructured":"HSSC (Health Strategic Support Committee). (2023). Digital transformation in the NHS. https:\/\/committees.parliament.uk\/publications\/40637\/documents\/198145\/default\/"},{"key":"2025090212073021800_b22-13_rn_10_25300_misq_2024_17307","unstructured":"Lewis, T.\n           (2022). Regions in the NHS: What are they good for? The King\u2019s Fund. https:\/\/www.kingsfund.org.uk\/blog\/2022\/12\/regions-nhs-what-are-they-good-for"},{"issue":"1","key":"2025090212073021800_b23-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"64","DOI":"10.1057\/ejis.2014.40","article-title":"Transforming healthcare: Policy discourses of IT and patient-centred care","volume":"25","author":"Klecun","year":"2016","journal-title":"European Journal of Information Systems"},{"issue":"4","key":"2025090212073021800_b24-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"292","DOI":"10.1177\/0268396218822478","article-title":"The dynamics of institutional pressures and stakeholder behavior in national electronic health record implementations: A tale of two countries","volume":"34","author":"Klecun","year":"2019","journal-title":"Journal of Information Technology"},{"issue":"3","key":"2025090212073021800_b25-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"crossref","first-page":"553","DOI":"10.25300\/MISQ\/2016\/40.3.02","article-title":"Electronic health records: How can IS researchers contribute to transforming healthcare?","volume":"40","author":"Kohli","year":"2016","journal-title":"MIS Quarterly"},{"issue":"3","key":"2025090212073021800_b26-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"221","DOI":"10.1287\/isre.14.3.221.16560","article-title":"Generalizing generalizability in information systems research","volume":"14","author":"Lee","year":"2003","journal-title":"Information Systems Research"},{"key":"2025090212073021800_b27-13_rn_10_25300_misq_2024_17307","unstructured":"Lowell, T.\n           (2021). NHSX confirms 37 of 42 ICSs have integrated digital health records. Healthcare IT News. https:\/\/www.healthcareitnews.com\/news\/emea\/nhsx-confirms-37-42-icss-have-shared-care-records"},{"issue":"11","key":"2025090212073021800_b28-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"757","DOI":"10.1016\/j.ijmedinf.2009.07.001","article-title":"The outcomes of regional healthcare information systems in health care: A review of the research literature","volume":"78","author":"M\u00e4enp\u00e4\u00e4","year":"2009","journal-title":"International Journal of Medical Informatics"},{"key":"2025090212073021800_b29-13_rn_10_25300_misq_2024_17307","unstructured":"MedConfidential\n          . (2018). More detail than you (probably) ever wanted to know about LHCR systems. https:\/\/medconfidential.org\/wp-content\/uploads\/2018\/08\/LHCRs-august-2018.pdf"},{"issue":"2","key":"2025090212073021800_b30-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"203","DOI":"10.1177\/0309132507087647","article-title":"Rethinking scale as a geographical category: From analysis to practice","volume":"32","author":"Moore","year":"2008","journal-title":"Progress in Human Geography"},{"key":"2025090212073021800_b31-13_rn_10_25300_misq_2024_17307","unstructured":"National Audit Office\n          . (2020). Digital transformation in the NHS. https:\/\/www.nao.org.uk\/wp-content\/uploads\/2019\/05\/Digital-transformation-in-the-NHS.pdf"},{"key":"2025090212073021800_b32-13_rn_10_25300_misq_2024_17307","unstructured":"National Information Board\n          . (2014). Personalised health & care 2020: Using data and technology to transform outcomes for patients & citizens. GOV.UK. https:\/\/www.gov.uk\/government\/publications\/personalised-health-and-care-2020"},{"key":"2025090212073021800_b33-13_rn_10_25300_misq_2024_17307","unstructured":"NHS England\n          . (2013). Safer Hospitals, Safer Wards, https:\/\/www.rcslt.org\/-\/media\/Project\/RCSLT\/safer-hospitals-safer-wards.pdf"},{"key":"2025090212073021800_b34-13_rn_10_25300_misq_2024_17307","unstructured":"NHS England\n          . (2014). NHS Five Year Forward View. https:\/\/www.england.nhs.uk\/publication\/nhs-five-year-forward-view\/"},{"key":"2025090212073021800_b35-13_rn_10_25300_misq_2024_17307","unstructured":"NHS England\n          . (2018). Local Health and Care Record Exemplars. https:\/\/www.england.nhs.uk\/wp-content\/uploads\/2018\/05\/local-health-and-care-record-exemplars-summary.pdf"},{"issue":"5","key":"2025090212073021800_b36-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"364","DOI":"10.1080\/01972243.2022.2105999","article-title":"Digital public goods platforms for development: The challenge of scaling","volume":"38","author":"Nicholson","year":"2022","journal-title":"The Information Society"},{"key":"2025090212073021800_b37-13_rn_10_25300_misq_2024_17307","unstructured":"Nickson, S.\n           (2019). The private sector and the NHS: not \u201con the table,\u201d but already in the market. Institute for Government. https:\/\/www.instituteforgovernment.org.uk\/blog\/private-sector-nhs-not-on-table-already-in-market"},{"key":"2025090212073021800_b38-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"901","DOI":"10.1007\/s12525-021-00518-8","article-title":"Keeping pace with the healthcare transformation: A literature review and research agenda for a new decade of health information systems research","volume":"31","author":"Ostern","year":"2021","journal-title":"Electronic Markets"},{"issue":"5","key":"2025090212073021800_b39-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"1060","DOI":"10.1177\/0308518X16687764","article-title":"The practice of scalecraft: Scale, policy and the politics of the market in England\u2019s academy schools","volume":"49","author":"Papanastasiou","year":"2017","journal-title":"Environment and Planning A"},{"issue":"2","key":"2025090212073021800_b40-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"107","DOI":"10.17705\/1jais.00421","article-title":"Entangled stakeholder roles and perceptions in health information systems: A longitudinal study of the UK NHS N3 network","volume":"17","author":"Pouloudi","year":"2016","journal-title":"Journal of the Association for Information Systems"},{"issue":"5","key":"2025090212073021800_b41-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"394","DOI":"10.17705\/1jais.00395","article-title":"Exploring the formation of a healthcare information infrastructure: Hierarchy or meshwork?","volume":"16","author":"Rodon","year":"2015","journal-title":"Journal of the Association for Information Systems"},{"issue":"1","key":"2025090212073021800_b42-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1145\/506740.506745","article-title":"Using an adapted grounded theory approach for inductive theory building about virtual team development","volume":"32","author":"Sarker","year":"2000","journal-title":"ACM SIGMIS Database"},{"issue":"2","key":"2025090212073021800_b43-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"crossref","first-page":"327","DOI":"10.2307\/25148794","article-title":"Fighting against windmills: Strategic information systems and organizational deep structures","volume":"31","author":"Silva","year":"2007","journal-title":"MIS Quarterly"},{"key":"2025090212073021800_b44-13_rn_10_25300_misq_2024_17307","unstructured":"Singh, I.\n           (2019, April\u20088). So, what is a local health and care record anyway?\u2008NHS Digital Blog. https:\/\/digital.nhs.uk\/blog\/transformation-blog\/2019\/so-what-is-a-local-health-and-care-record-anyway"},{"key":"2025090212073021800_b45-13_rn_10_25300_misq_2024_17307","unstructured":"Slone, S.\n           (2020). COVID-19 pandemic demonstrates need for electronic health record interoperability. The Council for State Governments. https:\/\/web.csg.org\/covid19\/2020\/04\/24\/covid-19-pandemic-demonstrates-need-for-electronic-health-record-interoperability\/"},{"key":"2025090212073021800_b46-13_rn_10_25300_misq_2024_17307","volume-title":"Basics of qualitative research: Techniques and procedures for developing grounded theory","author":"Strauss","year":"2014","edition":"4th"},{"key":"2025090212073021800_b47-13_rn_10_25300_misq_2024_17307","first-page":"222","article-title":"Abductive analysis and grounded theory","volume-title":"The SAGE handbook of current developments in grounded theory","author":"Tavory","year":"2019"},{"issue":"4","key":"2025090212073021800_b48-13_rn_10_25300_misq_2024_17307","doi-asserted-by":"publisher","first-page":"357","DOI":"10.1111\/j.1365-2575.2009.00328.x","article-title":"Putting the \u201ctheory\u201d back into grounded theory: Guidelines for grounded theory studies in IS","volume":"20","author":"Urquhart","year":"2010","journal-title":"Information Systems Journal"},{"key":"2025090212073021800_b49-13_rn_10_25300_misq_2024_17307","unstructured":"WYHCP (West Yorkshire Health & Care Partnership)\n          . (2018). Yorkshire & Humber to launch health and care partnerships to improve patient care. https:\/\/www.wypartnership.co.uk\/news-and-blog\/archive\/yorkshire-humber-launch-health-and-care-partnerships-improve-patient-care"},{"volume-title":"YHCR Interoperability Cookbook Abstract v1.5","year":"2018","author":"YHCR (Yorkshire & Humber Care Record)","key":"2025090212073021800_b50-13_rn_10_25300_misq_2024_17307"},{"volume-title":"June 2021 progress report","year":"2021","author":"YHCR","key":"2025090212073021800_b51-13_rn_10_25300_misq_2024_17307"}],"container-title":["MIS Quarterly"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/misq.umn.edu\/misq\/article-pdf\/49\/2\/759\/14525\/13_rn_10.25300_misq_2024_17307.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/misq.umn.edu\/misq\/article-pdf\/49\/2\/759\/14525\/13_rn_10.25300_misq_2024_17307.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,2]],"date-time":"2025-09-02T16:07:42Z","timestamp":1756829262000},"score":1,"resource":{"primary":{"URL":"https:\/\/misq.umn.edu\/misq\/article\/49\/2\/759\/3173\/Advancing-Understanding-of-Scaling-Health"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,1]]},"references-count":51,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2025,6,1]]},"published-print":{"date-parts":[[2025,6,1]]}},"URL":"https:\/\/doi.org\/10.25300\/misq\/2024\/17307","relation":{},"ISSN":["0276-7783","2162-9730"],"issn-type":[{"type":"print","value":"0276-7783"},{"type":"electronic","value":"2162-9730"}],"subject":[],"published":{"date-parts":[[2025,6,1]]}}}