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implementation, to explore the effects of technological systems on human actors, and to explain why information systems may be rejected by users. Although based on paper systems, perhaps the most illuminating examples of employing ANT can be found in a series of three case studies by Marc Berg and colleagues. These, drawing on both single physician-patient encounters and multi- disciplinary care teams, explore how the medical record actively impacts on human action and interaction.[4-6] Berg and colleagues provide detailed accounts of how the record constructs the patient’s body/history and associated user practices, how it interconnects activities and actors through time and space, how it shapes relationships between actors and social processes, and how it serves different functions for different agendas. These agendas need to come together for the record to function. Berg at al. describe the complexity and situational ever-changing role of the record by focusing on detailed case scenarios. In doing so, they discuss connections between human actors and the record that capture the processes of how the two relate to each other in both formal and informal work practices. Compared to paper records, electronic systems tend to pose greater challenges. They can connect human actors beyond physical space and can mediate a greater range of medical activity in a much shorter space of time. ANT has therefore also been used to explain why information system implementations in healthcare fail or why their adoption is often slower than anticipated. For example, Doolin and McLeod describe the implementation of an executive information system in a hospital in New Zealand.[10] The authors argue that failure to build the new network (i.e. the information system) was due to “an inability to enroll the non-human actors” (p.259), which in this case consisted of a perceived lack of data quality in the new digital system. Hence, its use was rejected by doctors. Similarly, Whitley and Pouloudi use ANT as a framework for analyzing the introduction of NHSnet.[22] NHSnet is a Microsoft Outlook based Web App system that supports communications of medical information in the United Kingdom (UK) National Health Service (NHS). Implementation was completed on time but there were heated discussions with the medical profession over confidentiality and security issues surrounding medical information. In this context, ANT helped the authors to conceptualize how different human stakeholder groups (including doctors, professional groups and technologists) have different interests that are not easily aligned within a single technological solution. As a result of ongoing discussions, NHSnet’s design changed over time. This in turn had implications for how human actors were positioned in the network. 2.1. Drawing in Actor-Network Theory to explore the national implementation of electronic health records in English hospitals In our own work, we have used ANT to examine the implementation of electronic health records (EHRs) in hospitals as part of the English National Programme for Information Technology (NPfIT) (see Figure 1 and Box 3). This case study will be used to illustrate how ANT can helpfully be applied to inform data collection and analysis in studies of health IT implementation. K.Cresswell /UsingActor-NetworkTheory toStudyHealth InformationTechnology Interventions 91