View source for Adoption of Electronic Health Records (EHR) in Canada: A Review

This is a review on the adoption of EHR in Canada as of 2018 based on  two articles, Progress in electronic medical record adoption in Canada [1] and Canadian Medical Association (CMA) workforce survey [2].

== Background ==
In Canada, there is a decentralized administration of health care from the federal government with individual provinces responsible for delivering healthcare.  As a result, there are patchwork electronic health record (EHR) systems that lack interoperability.  Organizations such as Canada Health Infoway (CHI) [3] sought to improve patient safety through establishment of baseline EHR for patients and health care workers.  

This review aim to provide current state of EHR adoption across Canada, identify interoperability issues and barriers to EHR adoption.  


== Methods ==
Chang et al. [1], searched peer-reviewed literature including CINAHL, MEDLINE, PubMed, EMBASE, Cochrane along with provincial EHR websites and gray literature organizational websites: Health Council of Canada CHI, CanadianEMR, Canadian healthcare Technology and National Physician Survey (NPS) [4].  Chang et al. found 12 documents.   As an update, the Canadian Medical Association (CMA) [2] developed and conducted a workforce questionnaire in 2017.  The survey was developed based on previous surveys, in particular NPS with similar questions for electronic health records to ensure continuity and comparability.  


Chang et al. (2015) reported EHR adoption based on survey data collected by 3 organizations include Canadian Institute for Health Information (CIHI) [5], Commonwealth Fund and provincial EHR organizations.  CIHI with collaboration with NPS performed the largest survey data collection in 2013 by sending surveys electronically or mail to Canadian physicians.  Response rate was 17.5% (10,487 responses of total 60,044) and roughly 40-70% respondents from each province.  The other surveys had responses of less than 2500 physicians.


CMA (2017) conducted the survey through contracted third party and sent 59,320 email surveys with up to 4 reminders between January to Mar 2017.  7,184 responded with a response rate of 12%.  The specialty distribution of respondents was similar to the population of physicians (e.g. across provinces), however, there was slight underrepresentation of specialists in the survey (57% family doctors and 43% specialists) compared to population (52% family doctors and 48% specialist).  Weight-based analysis was performed to account for non-response bias and adjusted for age group, sex and specialty.  


== Results ==
As of 2015, overall adoption has increased from 20% to 62%.  16% of Canadian physicians reported using EHRs exclusively and 34% used combination of paper and EHR.


The 2017 survey reported 85% of primary care physicians used EHRs.  On average, 80% of primary care physicians used EHR across provinces (55% to 91% range).  85% of primary care physicians used EHR for lab and notes retrieval and less than 50% used EHR for reminders or provincial information systems.  Patients able to view health records were reported at 10% while only 2% had personal health record (PHR) reported.  


79% of specialists use EHR in their practice, across all settings with provincial comparisons ranging between 63% to 83%.  Patients viewing their own record was reported at 6% and only 1% had PHR capability.     


== Discussion ==
Overall, use of EHR across Canada has been increasing, as of 2017, 80%.  Majority of EHR use (80%) is for lab and notes retrieval.  The current rates of computerized order entry or clinical decision support adoption is unclear.  Lastly, personal health record use is very low.  


Barriers identified included: lack of leadership and direction in early years, lack of computer literacy and training, time spent to learn new systems and commitment of EHR organizations were common barriers to adoption.  Recommendation was made for having trained superusers and champions for late-stage adopters.  Interestingly, Chang et al. (2015) concluded despite the variation in funding across provinces, funding had minimal effect on rate of EHR adoption.


Interoperability barriers are plagued by the fragmentation of healthcare delivery in Canada as delivery of healthcare has significant provincial variation.  The variability was attributed to different funding supports, variety of EHR vendors eligible for funding.  In addition, bilingual requirements of certain provinces, Quebec and New Brunswick reduces the choices for possible systems.  


== Comments ==
Chang et al. (2015) and CMA Survey (2017) are the only comprehensive studies that evaluated EHR adoption in Canada across healthcare (primary, secondary, tertiary and quaternary care).  The important lessons identified such as barriers to adoption and interoperability are specific to Canada and provide good overview of challenges ahead.  


Despite both studies having low response rates (17.5% and 12%), they were adjusted for non-response bias using weight-based analysis.  This analysis improves the validity and reliability of the findings and can be generalized to the population.  Thus, the increasing adoption rates are likely true representation of current state.  One limitation was that both surveys did not explore EHR functionalities in-depth as only one question was asked regarding functionality.  This results in lack of clarity for the current maturity level of EHR in Canada.    


== References ==

# F. Chang and N. Gupta, “Progress in electronic medical record adoption in Canada.,” Can Fam Physician, vol. 61, no. 12, pp. 1076–1084, Dec. 2015.
# CMA Physician Data Center, “Use of Electronic Medical Records among Canadian Physicians,” Aug. 2017. Available from: www.cma.ca/En/Pages/physician-workforce-surveys.aspx
# Canada Health Infoway.  www.infoway-inforoute.ca/en/about-us/about-canada-health-infoway/board-of-directors Accessed April 25, 2018.
# National Physician Survey (NPS).  nationalphysiciansurvey.ca/surveys/2014-survey/.  Accessed April 25, 2018
# Canadian Institute for Health Information (CIHI). www.cihi.ca/en.  Accessed April 25, 2018



Submitted by Siddhartha Srivastava
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