Knowledge Transfer as Contested Practice: Professional Hierarchy and the Mechanisms of Electronic Patient Record Implementation in an NHS Hospital Trust
Drawing on a longitudinal case study of Electronic Patient Record implementation in an NHS hospital, this paper argues that knowledge transfer in professionalized healthcare settings is a contested practice where technical and managerial goals clash with clinical realities, leading to system abandonment due to a mismatch between declarative system design and procedural clinical knowledge, compounded by the reinforcement of existing professional hierarchies.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the complex world of modern hospitals, a vast amount of information is generated every second: test results, medication lists, and the subtle observations of a nurse watching a patient's breathing. For decades, the promise of technology has been to gather this scattered information into a single, clear picture, making it easier for doctors and nurses to share what they know and make better decisions. This idea rests on a simple assumption: that knowledge is like a package that can be packed up, moved from one person to another, and unpacked without losing its shape. However, in the messy reality of a busy emergency room, knowledge often feels less like a package and more like a skill. It is the intuitive sense of when a patient is getting worse before the machines show it, or the quick judgment of which task to do first when everything is urgent. Understanding the difference between moving facts around and supporting these deep, practical skills is crucial, because when hospitals try to digitize their records, they are not just changing a filing system; they are changing how people work, think, and trust one another.
A recent study at a large hospital in the United Kingdom, known in the research as BP Trust, explored what happens when a new electronic patient record system is introduced. The researchers, led by Firas Masri, wanted to understand why these systems often struggle to deliver on their promises, even when everyone agrees they are necessary. They spent eight months inside the hospital, watching how staff used the new system, listening to their stories, and reading the official plans for the project. They spoke with thirty people, ranging from the computer experts who built the software to the managers who paid for it, and the doctors and nurses who had to use it every day. What they found was not a simple story of bad technology or stubborn workers, but a deeper clash of ideas about what knowledge actually is.
The system was designed with a specific view of knowledge in mind: as a collection of facts that could be written down, stored, and checked later. This is what the researchers call declarative knowledge. It includes things like a blood test result or the name of a drug, which are clear, fixed, and easy to audit. The people who managed the project and the computer engineers saw the system as a success if it captured these facts accurately and helped the hospital save money by coding treatments correctly. However, the doctors and nurses operated with a different view of knowledge, one based on procedure and action. This is procedural knowledge. It is the "know-how" of medicine: the ability to read a patient's face, to prioritize a chaotic room, or to decide that a standard rule does not apply in a specific situation. The researchers found that the new system was built to capture the first kind of knowledge but was completely blind to the second.
As the system was rolled out, this mismatch created a hidden problem. The new software required doctors to type in far more details than they ever had before, turning a quick note into a long, multi-screen process. Because the system was so rigid, it did not fit the way doctors actually worked. Instead of stopping the doctors from doing their jobs, the system simply changed who did the typing. The doctors, who held more power and status in the hospital hierarchy, began to delegate the extra paperwork to the nurses. The nurses, who had no one else to pass the work to, found themselves buried under a mountain of administrative tasks. They had to enter the data that the system demanded, often while still trying to care for patients, with no extra time or support given to them. The technology did not disappear the work; it just moved it down the ladder of professional rank.
The study also looked at why the system failed to connect with other parts of the hospital. The computer experts found that the new electronic record could not talk to the older systems used in the operating theater or the laboratory. Because the systems could not share data automatically, staff had to manually copy information from one screen to another. This defeated the entire purpose of the new system, which was supposed to make information flow freely. The managers, focused on the financial benefits of accurate coding, saw the project as a success because the data was being captured. The doctors and nurses, however, saw it as a burden that slowed them down and took them away from their patients. The researchers concluded that the project was not a failure of engineering or management alone, but a failure to understand that the hospital is a place where different groups see the world in fundamentally different ways.
One of the most striking findings was how the existing structure of the hospital determined who suffered the most. The new system created a demand for more documentation. In a workplace where doctors are senior to nurses, that extra demand was naturally pushed downward. The doctors could say, "I need this done," and the nurses, bound by their role and the hierarchy, had to do it. The technology did not fix this imbalance; it actually reinforced it. The researchers noted that if the system had been designed to support the practical, intuitive skills of the staff rather than just to capture facts for a database, the outcome might have been different. But because the design was driven by the need for auditable data and cost savings, it ended up serving the managers' need for control rather than the clinicians' need for support.
This story matters because it shows that introducing new technology into a hospital is never just a technical upgrade. It is a social event that reshapes relationships and workloads. The researchers suggest that for these systems to work, the people designing them must listen to the practical, day-to-day reality of the staff, not just the official goals of the administration. They must understand that knowledge in a hospital is not just a list of facts to be stored, but a living process of judgment and care. If a system ignores the human skill required to do the job, it will not make work easier; it will simply make it harder for the people at the bottom of the chain to keep up. The study serves as a reminder that in the rush to digitize, we must not forget the human dynamics that hold a hospital together.
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