The NHS in England comprises multiple organisations, systems and actors working in co-ordination to deliver healthcare to the population. Transfers of care from primary care organisations is facilitated by an electronic booking system that is provided nationally, and utilised regionally and locally. The success of such system is dependent on the co-operation of actors and organisations in the health economy in affecting its impact and usefulness. Such a system can be seen as an ‘artefact’ where multiple worlds collide. The theory of boundary objects is approached from a critical realist paradigm to conceptualise the role of the focal system. Organisational semiotics is used to provide an analytical method to interpret the behaviours and perceptions surrounding the artefact. Understanding of these factors provides recognition of the tensions in adoption of the system. Implementation and expert use of systems considering these invisible factors can benefit from greater intellectual buy in and value co-creation.