The adoption and use of the KIS vary across regions in Scotland. Lothian, a region of Scotland, serves as an exemplar of how the KIS can be used for future care planning, linking multiple health and care providers through distinct locally developed mechanisms. In Lothian, the KIS is used across multiple care pathways to share key information concerning an individual’s care needs, resuscitation status, and medication history. While most of the information in the KIS is automatically updated from the electronic records held in GP practices, the special notes section in the KIS requires periodic review and manual entry of care needs and plans by the GP. In Lothian, health and social care partnerships, specifically the Edinburgh Health and Social Care Partnership (EHSCP), use customized templates that enable community workers, social workers, and care home carers to share updates with GP practices. GP practices also share the KIS as a PDF file with social workers involved in care pathways and provide paper-based versions to carers and residents in care homes. The KIS thus functions as an artifact shared across multiple health and care providers, with different actors using it in distinct ways to address their respective information needs. Its use in Lothian offered a valuable case for examining digitally mediated collaborative work and integration efforts, in which actors from diverse professional backgrounds adopted and domesticated a standardized digital technology embedded within the information infrastructure to meet varied informational needs and support the delivery of integrated care.

Using the biography of artifacts and practices (BoAP) [17], and the technology-people-organization-macroenvironment technology people organization and macroenvironment (TPOM) framework [18], this multisited ethnographic study aimed to explore the adoption and contextual use of the KIS in different health and care settings. Multisited ethnography as a methodological approach allows the researcher to explore the diverse settings of technology development, adoption, and use [19]. BoAP, as a methodological tool, enabled navigation across different times and spaces, exemplified phases of technology adoption and use, and supported reflection on the choice of setting, time, and focus of enquiry [16,18]. TPOM is an evaluation framework designed to capture technological (eg, usability and performance), socio-organizational (eg, leadership and management practices over time and organizational routines), sociotechnical (eg, user satisfaction, engagement, and work processes), and macroenvironmental factors (eg, political and economic contexts and vendor management) that shape the real-time implementation, adoption, and use of digital technologies [18]. While BoAP helped examine various stages of technology adoption and use over time, providing a longitudinal view, TPOM supported contextual enquiry into how the KIS was adopted and used across different health and care settings.

Ethics approval for this study was granted by the Edinburgh Medical School Research Ethics Committee (EMREC). Approval for interviews with participants in Scotland was obtained on April 17, 2024 (24-EMREC-012), and approval for observations of meetings, events, and training sessions involving technology use was granted on June 17, 2024 (24-EMREC-043). The study also received approval from the NHS Lothian Quality Improvement (QI) team. Informed consent was obtained from all participants prior to their participation in interviews and observations. Participants were informed of the purpose of the study, their right to withdraw, and how their data would be used. No prior relationship was established between the researchers and participants before recruitment. The researchers did not have a role in the implementation or operational delivery of the KIS. Participant data were deidentified and anonymized in the analysis and reporting, and identifying information was removed or omitted to protect participant confidentiality. Participants were not compensated for their participation.

BoAP and TPOM guided the sampling strategy, enabling the identification of technology developers, users across various health and care settings, social workers from local councils, social care workers, policymakers, and academics. Recruiting participants informing various stages of technology development, adoption, and use, across various time frames and settings, enabled a longitudinal view of KIS’s adoption and factors affecting contextual use. Here, BoAP was used to identify participants with experience across different stages of KIS’s conception, adoption, and use in various time frames and settings, allowing the capture of a longitudinal view of its adoption. TPOM’s focus on technological, sociotechnical, socio-organizational, and macroenvironmental contexts guided the recruitment of diverse stakeholders. This enabled the inclusion of participants who could provide insights into factors shaping adoption and use at the macro-, meso-, and microlevels, including usability challenges, organizational and professional practices, and the influence of national policies [18].

Snowballing and purposive sampling methods were used to recruit participants for the study. Purposive sampling enabled the recruitment of participants capable of providing context-rich insights from multiple settings, based on their involvement in the development, implementation, adoption, and use of the KIS at different points in time. QI teams of NHS Lothian and Lothian Unscheduled Care Services acted as gatekeepers for the study, assisting in identifying participants from across different health and care settings. Recruitment proceeded iteratively through purposive and snowball sampling until sufficient depth and breadth of perspectives had been obtained and saturation was achieved. Gatekeepers supported purposive sampling by identifying relevant stakeholder groups, multidisciplinary team (MDT) meetings, and care settings where the KIS was used for future care planning. They facilitated access to observations of MDT meetings and training sessions involving KIS use across different health and care contexts. The sampling strategy aimed to capture variation in perspectives and experiences of KIS adoption across professional roles and organizational settings. MDTs constituted GPs, OOH staff, clinicians and specialists from hospitals, community nurses and workers, social workers from various care pathways, and care workers from social care homes.

With respect to interviews, participants were sampled to represent a range of health and social care settings, including all 4 Lothian councils. Policymakers working in the domain of health and social care were purposively identified through national policy documents to understand how the policy landscape has evolved since the KIS was first developed and implemented. These documents were identified from the NHS and Scottish government websites via Google using the search term “Key Information Summary in Lothian and Scotland.” National and international technology vendors were also purposively included to examine the factors influencing technological development, implementation, and adoption, as well as to gather insights into user support provided over time. In addition, a snowball sampling approach was used, whereby participants were invited to suggest others involved in the development, implementation, adoption, or use of the KIS.

VS (male) is trained as an IT engineer, with research experience in medical informatics, health and social care information systems, and qualitative research. KC (female) and RW (male) have research experience evaluating large-scale digital transformation initiatives across the NHS, including the Global Digital Exemplar program, which supported digital transformation across acute hospital settings in England, and NHS AI Lab programs.

Data collection was undertaken by VS between April 2024 and March 2025 under the supervision of KC and RW, using multiple qualitative methods, including semistructured interviews, ethnographic observations of KIS use in practice, and documentary analysis of materials related to KIS implementation, training, and operational processes. These methods were integrated within a qualitative case study design to develop an in-depth understanding of the technological, sociotechnical, socio-organizational, and macroenvironmental factors shaping the adoption and use of the KIS within its real-world context.

One-to-one, semistructured interviews were carried out with a range of stakeholders, including users, policy leads, data scientists, academics, technology developers, and health and social care providers, to explore their perspectives on the development, implementation, adoption, and use of the KIS. Interviews lasted between 40 and 60 minutes, were conducted online via Microsoft Teams, audio-recorded, and transcribed verbatim. For a small number of participants, follow-up interviews were conducted, where participants were willing to engage further, and additional discussion was needed during the analysis. These conversations were used to clarify points raised in the initial interviews and to explore emerging questions from the ongoing analysis.

Topic guides for the interviews, informed by the TPOM framework [18], explored how system usability and performance, leadership and governance practices, organizational routines, user engagement and everyday work practices, and wider political-economic and vendor-related conditions shaped the adoption and domestication of KIS across health and social care settings. Tailored topic guides were developed for users from different settings, vendors, academics, and policy leads to capture insights regarding their role in the conception, adoption, and use of the KIS (Multimedia Appendix 1).

Nonparticipant observations were undertaken to examine how MDTs and national planning groups engaged with the KIS to support future care planning. Observations included MDT meetings involving NHS Lothian and the EHSCP, as well as national planning group meetings, to explore interprofessional collaboration across health and care organizations at both regional and national levels. Use of the KIS by different users was also observed to understand how its adoption and use varied across settings. Observation sessions lasted between 1 and 2 hours. Meetings and patterns of technology use were observed online via Microsoft Teams. In addition, in-person training sessions delivered by the EHSCP in care homes were also observed. Field notes were systematically documented using a structured observation protocol (Multimedia Appendix 2).

Study participants were also asked to provide relevant documents regarding the implementation, adoption, and use of the KIS. Internal case studies, user guides for different professionals, contingency plans during technology breakdown, and software update notifications were shared by participants. Documents were purposively selected based on their relevance to understanding the evolution of the KIS as an information infrastructure. Selection focused on materials describing the development, implementation, and use of the KIS in Scotland and Lothian; health and social care integration initiatives; the intended functions and uses of the KIS; related health and social care information systems supporting KIS access; and implementation strategies and anticipated benefits at local and national levels (Multimedia Appendix 3). Historical documents were treated as empirical artifacts that provided insights into how standards, practices, and infrastructural arrangements were developed, negotiated, and embedded over time. These documents were examined qualitatively to understand challenges surrounding the adoption and use of KIS in different settings over time and to explore the similarities and differences between national goals, technological claims, and regional narratives.

NVivo (version 14; Lumivero) was used to code the interview transcripts, observation notes, and documentary materials. Data analysis was conducted by VS under the supervision of KC and RW. VS was the primary and sole data coder, while KC and RW provided ongoing oversight of the analytical process and contributed to discussions of coding, emerging themes, and interpretations. The analysis adopted an interpretive approach that recognized the researcher’s positionality and subjectivity. Credibility was strengthened through the search for disconfirming evidence and the use of data triangulation. Triangulation involved integrating insights from all qualitative data sources to situate the case study within the broader context of integrating health and social care through digitalization while also capturing the microlevel practices of individual users and the mesolevel organizational processes and interactions that shaped the adoption and use of the KIS.

Data analysis followed a hybrid approach, that is, a combination of inductive and deductive approaches [20]. Deductive thematic analysis, informed by the TPOM framework, was applied to interviews, documents, and observational notes to examine the challenges around technology usability, user and organizational practices, as well as the wider macroenvironmental factors influencing the adoption and use of the KIS across different settings [18]. Related codes that emerged were clustered into themes and compared across sites, professional roles, and time periods to identify relevant subthemes following an inductive analysis. Concepts and theories from science and technology studies, including information infrastructures [3-6,21-23] and domestication [24,25], alongside theories and concepts on workarounds [10-12], were used to further interpret how the KIS was adopted across different settings over time as the regional information infrastructure evolved. These approaches enabled a systematic analysis of KIS’s adoption and use over time, the tensions emerging during its adoption across diverse settings, and the various adoption strategies and workarounds enacted by users and organizations to mitigate constraints imposed by the system. The coding process involved organizing codes into second-order and aggregate themes, with the resulting coding structure provided in Multimedia Appendix 4.

This study was reported in accordance with the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines [26]. The completed COREQ checklist is provided in Multimedia Appendix 5.

Data consisted of 54 interviews; notes from observing technology use, MDT meetings, and national-level meetings regarding the use of KIS for future care planning (20 hours); and documentary analysis of 59 documents and 2 archived websites (Table 1).

The KIS was designed to enable the sharing of key patient information from GP with other service providers to support continuity of care and provide an overview of patients’ health status and care plans. However, expectations regarding the content and level of detail required varied across professional groups and care settings, and the functionality and design of KIS did not accommodate the full range of tasks it was expected to support. Consequently, tensions emerged between different user groups (such as OOH and hospital staff) and those responsible for maintaining and governing the information recorded in the KIS (GPs). These tensions were exemplified following top-down policy initiatives by the government that repurposed the KIS to identify vulnerable patient groups during the COVID-19 pandemic. As a result, many KISs were created without substantive information on future care plans and were instead flagged as having been generated as part of COVID-19 protocols. In turn, formal workarounds were used by health boards to provide social workers and carers access to the KIS and to ensure that relevant and updated information regarding future care is shared with the GP practices. Informal user-driven repair strategies were used in different health and care settings to update the KIS with relevant information and realign the KIS with its intended use. Here, repair work was conceptualized as the ongoing, often invisible labor through which users maintain, adapt, and render technologies usable in practice. Figure 1 provides an overview of identified themes.

The analysis identified several interconnected challenges that influenced the adoption, use, and ongoing maintenance of the KIS across health and social care settings. These challenges related to information quality, interoperability, professional responsibilities, and organizational capacity. Rather than representing discrete implementation failures, these challenges reflected tensions that emerged as the KIS evolved from a health care–focused summary record into an information artifact supporting wider health and social care integration. Users and organizations responded to these challenges through formal workarounds and informal repair practices that sought to maintain information quality, extend access, and align the KIS with changing care needs.

GPs were regarded as the main point of care for residents in Scotland, and the KIS was developed to share key information regarding a person’s future care plan to other primary, secondary, and community care providers. GPs identified individuals who would benefit from a KIS within their practice and documented their care plans and preferences. Consequently, the KIS enabled GPs to share information concerning a person’s medication, resuscitation status, and care plans with other health and care providers, who may not have had regular or long-term contact with the individual. Clinicians in OOH settings, who served a broader patient population than GPs and provided care outside regular GP hours, reported that the KIS gave them access to information they would not otherwise have, allowing them to understand the GP’s assessment of a patient’s condition and to make informed clinical decisions:

The KIS was developed to support GPs in engaging with individuals about their future care with primary, secondary, and community care providers. However, as the KIS was adopted across different care settings, expectations regarding the type, completeness, and level of detail required varied between professional groups. While GPs viewed the KIS primarily as a mechanism for documenting future care preferences, clinicians in other settings increasingly relied on it as a broader source of information to support decision-making. Conversations regarding future care between the GP and the individual were regarded as an ongoing, dynamic, and iterative process aimed at capturing an individual’s care preferences, as their conditions and care needs changed. GPs, acting as custodians of KIS data, were responsible for updating patients’ care preferences and future care needs, making the KIS a dynamic record, whose completeness and accuracy varied according to the extent to which individual GPs maintained it. However, this model of data stewardship also created a key challenge, as maintaining the accuracy and completeness of KIS information depended heavily on the capacity, time, and willingness of individual GP practices.

However, some GPs noted that they did not always maintain such long-term engagement with patients whose health and care needs had become complex, requiring them to gather relevant information from other sources to update the KIS. This variability represented an important challenge, as the usefulness of the KIS depended on sustained processes of information maintenance that were influenced by individual practice capacity, workload, and access to information from other care providers. In some cases, individuals required long-term care that could not be delivered in community settings and instead depended on ongoing support from hospitals, nursing homes, or care homes. To ensure the KIS reflected up-to-date information, GPs had to draw on multiple information sources, including updates provided by other health care professionals, social workers, and carers. For instance, discharge letters were provided by hospital-based clinicians to GPs after an individual’s discharge following hospital admission, which the GPs had to review to update the KIS. However, not all GPs adopted a systematic approach to reviewing documentation on patients’ future care needs, and maintaining these records required ongoing effort. Access to up-to-date information was particularly valuable for clinicians in hospital and OOH settings.

Findings illustrate how the KIS, as a shared object of collaboration across diverse health and care professionals within an information infrastructure, was adopted differently in various settings over time. Diverse health and care providers benefited differently from the information held in the KIS, with varying expectations regarding what constituted useful information based on their professional roles. These expectations varied, shaped by users’ professional roles as well as information needs, and only became evident as the KIS was adopted across different settings. They revealed how various providers’ specific requirements and perspectives influenced their expectations and use of the KIS. These expectations evolved as the expectations of integrated care evolved and more significantly after national initiatives diverted the use of KIS to new missions, necessitating workarounds and repair work to extend the health care–centric information infrastructure to new settings and to realign the KIS with its intended purposes.

Formal workarounds were used to extend the health care–centric information infrastructure to social care settings and to ensure access to the KIS during system outages. These workarounds included creating proxy access for a few nonclinical professionals (eg, social workers from councils and social care providers) involved in MDTs to view the KIS using hospital-based information systems. This allowed social workers and carers to access the KIS in a digital format and communicate with GPs using the secure emailing network. Formal workarounds also involved the development and sharing of contingency plans by vendors, health boards, and organizations with users to address unexpected technical barriers that hindered access to the KIS.

While formal workarounds facilitated access for new users and the development and sharing of contingency plans, informal user-driven repair work was used to gather and share relevant information from alternative sources to update the KIS. These user-driven repair works were subject to the affordances of the users, that is, their role and consequent level of access to the existing information infrastructure, digital skills, willingness, subjective perceptions of integrated care, organizational practices, and leadership. Users leveraged various interconnected systems within the information infrastructure, such as local datasets, other EHRs, and care plans, to fulfill their information needs, even though these systems were originally designed for different purposes. Over time, these locally developed repair strategies became embedded within practice, influenced patterns of the KIS’s adoption across settings, and contributed to shaping the evolution of the regional information infrastructure.

This research aligns with existing literature, showing that information infrastructures evolve over long periods, gradually embedding new technologies within user groups and becoming shaped by established organizational practices, information needs, and existing information systems [3,4,7,21,27]. Previous evaluations of summary care records have highlighted challenges associated with information quality, interoperability, and aligning shared records with the information needs and workflows of different professional groups [1,3,5,7]. However, these evaluations have often examined summary care records at particular points in time, providing limited insight into how such technologies evolve as part of broader information infrastructures [1]. Our previous research examined how the KIS and associated infrastructures developed through successive waves of infrastructural growth [7]. This study extends that work by examining what happens after infrastructural expansion, focusing on how users domesticate, maintain, and transform established infrastructures through everyday practices of repair and workaround. Building on this perspective, this study illustrates how the KIS continued to evolve as it became embedded across diverse health and care settings, where different professional groups developed context-specific interpretations of its purpose, functionality, and information requirements. Jarrahi et al [27] further emphasize that information infrastructures are open and generative, developing through interaction with new settings where they combine with existing practices and information needs. By examining a digital technology used for collaborative work [5-7], this study illustrates how the KIS was translated across different settings over time and embedded within the installed base, highlighting the generative nature of the information infrastructure as it evolved to support health and social care integration. Across these settings, user groups differed in their understanding of the usability of the KIS, which changed over time, as they started to adopt the KIS. For instance, the KIS was designed to share information from GP records with other people involved in delivering care. However, as the KIS was implemented and adopted across settings over time, user groups developed differing interpretations of what constituted key information. OOH staff, for instance, benefited from having up-to-date future care plans recorded in the KIS, but this required GPs to collate information from various information sources to update the KIS. Consequently, their views on how the KIS should be updated and what it should contain varied according to the users’ professional roles and information needs, informing the repair work they used, such as referring to other EHRs and datasets to which they had access. Findings from the study illustrate the range of strategies organizations and users used to update information in the KIS, including formal workarounds to extend the KIS into new settings and informal, user-driven repair work to access and update with relevant information. These findings demonstrate that information infrastructures integrating health and care providers are open and evolve generatively over extended periods, with workarounds and user-driven repair practices shaping their extension and adoption across settings [3-7,27].

This study also aligns with the literature highlighting that workarounds are an integral part of technology implementation and adoption [10,11]. Several workarounds observed in this study are consistent with the literature describing formal, interim measures used to address limitations around technology usability [11]. Formal workarounds identified in the study included the development of contingency plans and the provision of interim user guides by vendors, offering temporary instructions to support users in navigating the technology during periods of limited system functionality. Contingency plans involved using alternative information systems and paper-based records as intermediaries to maintain continuity of care in the event of system failures. Finally, formal workarounds were also used to extend the health care–centric information infrastructure to nonclinical settings. These findings illustrate that workarounds are strategies used by individuals and organizations to navigate technological or procedural constraints, and that they play a critical role not only in technology implementation and adoption but also in the evolution of information infrastructures [8,10-12].

Information infrastructure and the repair work it entails have been examined from various perspectives. Scholars note that information infrastructures are prone to breakdown and require repair as part of their maintenance [28,29]. However, existing studies focus on visible and invisible repair activities, the use of material tools, and the power dynamics during infrastructural failure, but pay limited attention to repair work in the context of the long-term evolution of infrastructures for integrating health and care providers [28,29]. This study contributes to the literature by highlighting that the evolution of information infrastructures for integrating health and social care providers necessitates user-driven repair work for its maintenance. User-driven repair work involved drawing on local datasets and other EHRs—containing overlapping information but designed for different purposes—to identify and share relevant information for updating the KIS. These datasets and information present in different systems can be conceptualized as digital assemblages or personal information infrastructures, which users engaged with to support their information needs [30]. A digital assemblage is a combination of digital and physical resources that users interact with to achieve specific objectives [27,30,31]. By analyzing how users engaged with digital assemblages during infrastructural breakdowns to meet their information needs, this study shows that infrastructural growth is also driven by bottom-up strategies and enacted through user-driven repair work.

Finally, this research contributes to the theory of workarounds by further elucidating the relationships between environment, strategies, and infrastructure [10-12]. The theory of workarounds seeks to classify the different types of workarounds used by users, identify the conditions under which workarounds emerge, and explain how sociotechnical systems evolve through the continued use of workarounds [10]. Central to this theoretical perspective is the argument that the enactment of workarounds by users, organizations, developers, and implementers arises from the dynamic interplay between environment, strategies, and infrastructure. According to Alter [10], environment refers to the broader organizational, cultural, technical, and regulatory context in which a technology is implemented, whereas strategies denote organizational- and vendor-level approaches to technology development, implementation, and customization. While the theory of workarounds emphasizes the relationship among these elements, subsequent studies have largely focused on the interplay between environment and strategies [11,12], giving limited attention to infrastructure. This study demonstrates that access to the information infrastructure enabled users to undertake repair work aligned with their specific information needs, thereby generating new affordances. For instance, access to the information infrastructure allowed clinical users to draw on multiple information sources that contained information analogous to the KIS. Examples include hospital staff accessing other EHRs and local datasets to retrieve information related to multimorbidity, polypharmacy, and risk of hospital readmission, which were then used to inform their clinical decision-making needs. Similarly, access to the information infrastructure enabled nonclinical (social workers and social care workers) users to leverage the infrastructure to access the KIS and communicate relevant updates to GPs via the secure email system. These cases demonstrate how users used the information infrastructure to undertake diverse repair work across different settings, thereby creating affordances. In turn, this contributes to theorizing how users leverage the infrastructure to implement different types of workarounds and repair work within specific contexts, where organizations and vendors pursue distinct approaches to technology development, customization, and adoption.

This study offers a methodological contribution by demonstrating the value of combining longitudinal and contextual analytical approaches with a multimethod qualitative case study design to examine the evolution of information infrastructures. The integration of the BoAP and TPOM frameworks enabled examination of both the historical trajectory of the KIS and the contextual factors shaping its adoption and use across different settings. While BoAP supported reconstruction of the KIS’s development and evolution over time, TPOM facilitated analysis of the technological, sociotechnical, organizational, and macroenvironmental conditions influencing its adoption in practice. By triangulating historical and contemporary documentary evidence with interviews and ethnographic observations, the study further strengthened this longitudinal perspective by reconstructing the development, adoption, and use of the KIS across multiple settings and time periods.

This approach enabled examination of how contextual factors, historical trajectories, organizational dynamics, and evolving understandings of integrated care shaped technology adoption over time, while capturing long-term trends that are difficult to observe through cross-sectional or short-term implementation studies [3-5]. Combining documentary evidence with participants’ retrospective accounts and observations of contemporary practice allowed different sources of evidence to be compared and contextualized, providing a richer understanding of how information infrastructures evolve through successive phases of development, implementation, domestication, and everyday use. This perspective made it possible to examine how challenges relating to usability, organizational practices, and macroenvironmental conditions changed over time and across settings, dynamics that are often overlooked in snapshot evaluations of digital technologies [19].

However, reconstructing longitudinal processes primarily through retrospective accounts and documentary evidence, rather than prospective longitudinal ethnography, constitutes a limitation. Although triangulation with observations strengthened the analysis, the study could not fully capture the granular, real-time negotiations, decision-making processes, and implementation activities that occurred during the early phases of KIS development and adoption. Additionally, while BoAP enabled examination of historical trajectories and TPOM supported contextual analysis across settings, the use of retrospective data meant that changes in workforce digital skills, organizational practices, and technological arrangements could not be systematically observed as they unfolded.

Adoption strategies mentioned in the study are specific to users in the Lothian region, and this contextual specificity also limits the generalizability of the findings. The various care pathways, health and care professionals involved, and technological arrangements may differ in other regions of Scotland. Studying adjacent contexts would enable comparative insights into how local contingencies shape both processes and outcomes and would also allow the findings to be situated more robustly within the broader context of integration. Finally, responsibilities for care provision and approaches to digital integration vary internationally, limiting the direct transferability of these insights to health system contexts beyond Scotland. However, the study offers valuable and transferable theoretical contributions: it demonstrates how the domestication of digital technologies evolved over time and highlights the ongoing repair work and workarounds required to maintain and extend information infrastructures.

Adoption of digital technologies for integrating health and care providers is a dynamic process, shaped by broader macroenvironmental conditions, evolving user needs, and organizational practices. Consequently, policies aimed at supporting digital technologies in integrated care must incorporate mechanisms for continuous feedback and periodic evaluation, particularly following major changes relating to their use. Such iterative assessments enable implementers, policymakers, and vendors to identify emerging challenges, understand the strategies that users develop in practice, and adjust technologies or implementation approaches accordingly. Findings from the study highlight a range of user-driven repair practices undertaken to maintain the infrastructure. Identifying such local practices is useful, as it provides insight into shortcomings in design and can support further iterations of technology development and infrastructural growth, as well as the streamlining and regulation of these practices. These repair practices can also serve as indicators of implementation and adoption barriers, highlighting where additional resources, training, governance mechanisms, or changes to existing workflows may be required.

The findings suggest that continuous quality improvement should not focus solely on increasing user adoption, but also on identifying where repair work and workarounds emerge during routine use. These practices provide valuable indicators of mismatches between the intended use of digital technologies and evolving expectations of integrated care, organizational arrangements, and users’ information needs over time [7,32]. Rather than viewing repair practices simply as deviations from intended implementation, they can be used to identify challenges, reveal areas where technologies no longer align with everyday practice, and inform iterative improvements of digital infrastructures. Table 2 summarizes the key implementation and adoption challenges identified in this study, their impact on KIS use, the formal workarounds and user-driven repair practices that emerged in response, and the associated implications for policy and practice.

Importantly, improvement efforts should not seek to eliminate all workarounds, as some locally developed practices enabled users to overcome limitations within the existing infrastructure and supported continued use of the KIS in different settings. Instead, organizations should identify which workarounds represent valuable context-specific solutions and which indicate persistent system limitations requiring intervention. This requires balancing standardization of digital infrastructures with flexibility to accommodate differences in organizational contexts, professional roles, and local workflows.

Moreover, national and regional initiatives must aim to strengthen the digital competencies of health and care professionals and establish networks for knowledge exchange, which are crucial to sustaining adoption and use at different settings over time. These initiatives must recognize the heterogeneity of stakeholders: different organizations vary considerably in their digital maturity, resource availability, and leadership capacity. Therefore, policy interventions should avoid uniform approaches and instead provide long-term support tailored to organizational contexts. This includes ensuring that sufficient workforce capacity, training, and organizational support are available to sustain information-sharing practices over time. The analysis also demonstrates the importance of communities of practice and intermediary organizations in sharing locally developed strategies and supporting wider adoption across settings.

Findings from the study also illustrate how users relied on multiple digital assemblages to meet their information needs when existing infrastructures did not fully support their activities. Future adoption strategies should therefore anticipate how emerging sources of information, such as AI-supported documentation tools or patient-generated data from wearable devices, may interact with existing information infrastructures. Policies must consider how these sources can be incorporated while maintaining appropriate governance arrangements, interoperability, and alignment with the needs of diverse users.

Using the KIS in Scotland as a case, this study illustrates how regional information infrastructures for integrating health and care providers evolved over time, embedding technologies within local routines, practices, and existing systems, while being shaped by professional roles and information needs. Adoption occurs incrementally, with formal workarounds extending health care–centric infrastructure to new settings and informal user-driven practices facilitating adaptation across diverse local contexts and supporting ongoing infrastructural maintenance. The study offers theoretical insights into how users domesticate digital technologies across diverse health and care settings over time and how infrastructural growth is facilitated through workarounds and user-driven repair work. Importantly, policymakers and technology vendors must recognize that technology deployment alone is insufficient; they need to account for evolving user needs and the diverse strategies users use to make technologies functional in practice. This requires continuous evaluation of implementation challenges, including resource constraints, interoperability limitations, and changing information needs, while supporting locally developed solutions that enable technologies to remain useful across diverse settings. Understanding these practices can inform how technologies become embedded within the infrastructure, identify and manage workarounds as well as user-driven strategies that support infrastructural growth, and guide future innovation.