Abstract
Human–computer interaction and computer-supported cooperative work have long examined how users adjust, customize, and repurpose technologies following implementation. However, the understanding of such design-in-use approaches as collective efforts remains underdeveloped. This paper presents a case study of healthcare professionals at a Norwegian municipal rehabilitation center who collectively engaged in a design-in-use approach in relation to a newly implemented electronic health record system. Drawing on interviews with staff and management, we examine the workflow challenges encountered during adoption, the user-driven adaptations that emerged, and how these adaptations were developed and perceived. Findings show that staff enacted both improvised workarounds and structured repair efforts to sustain care responsibilities amid usability issues, limited training, and coordination breakdowns. These local adaptations were shaped by individual initiative, available local competencies, management support, and cultural practices of collaboration, shared responsibility, and workplace democracy, highlighting both enabling and constraining conditions of collective design-in-use. The study demonstrates that design-in-use is both inherent and consequential in large-scale IT implementations, positioning users as proactive problem-solvers while also revealing potential tensions. In doing so, the study advances understanding of design-in-use by framing it not as incidental activity, but as an inherent process through which the adoption of large-scale IT systems in day-to-day work practices is shaped by local and contextual factors.