The value of connected health information: perceptions of electronic health record users in Canada

The complexity of health care is growing. On average, we see more health care providers, take more medications, and access a broader range of health services than in the past. This means that it is increasingly important that health care providers who care for the same patient share information. As a result, electronic health information exchange is becoming more common around the world with the aim of supporting better access to care, quality, productivity, and patient experiences.

In Canada, the federal and provincial/territorial (‘PT’) governments began investments in the creation of interoperable electronic health records (iEHRs) more than a decade ago. These secure and private systems available to authorized users offer an integrated view of an individual’s health and health care history. Information in iEHRs can come from PT databases, as well as point of care electronic systems in primary care, public health, hospitals, and elsewhere. Lab results, medications, diagnostic images, clinical reports, and immunization profiles are stored and shared by iEHRs. These iEHRs are closely related to what is often referred to as “health information exchange” (HIE) in other countries [1]. More specifically in the United States, HIE refers to the reliable and interoperable electronic sharing of patient’s vital medical information securely among a variety of health care stakeholders (clinicians, laboratories, hospital, pharmacy, health plans, payers and patients) [2, 3].

Canada Health Infoway (Infoway) measures iEHR adoption across the country. This includes digitization of client and provider registries and four clinical components (diagnostic images, laboratory test results, dispensed drugs and clinical reports/immunizations) [4]. Twelve out of the thirteen PTs in Canada have fully digitized registries in place. The clinical components of iEHR are at varying levels of availability across Canada; all PT’s have at least two clinical components available and five PTs have all four clinical components available. About 250,000 health professionals, approximately half of Canada’s anticipated potential physician, nurse, pharmacist, and administrative users, indicate that they electronically access data from outside their main practice setting, such as those found in PT lab or drug information systems. As of January 2015, there were more than 91,000 active iEHR users accessing two or more of the clinical components in a given month [5]. Many more clinicians would access only one clinical component, such as a comprehensive medication profile.

Evaluation of the value of health information exchange is relatively new. A handful of reviews have been published from the US assessing the impact of HIEs. In 2010, a systematic review of the evidence of HIE was published but focused only on primary care. The authors found improvements in referrals and access to test results based on 3 articles but underlined the shortage of empirical evidence to draw conclusions [6]. Subsequently in 2011, a review on the impact of HIE on healthcare outcomes found 5 relevant studies that mostly focused on health care utilization. The authors did not find conclusive evidence on HIEs given the early stages of HIE operation and the paucity of well-designed published research [7]. In the following 3 years, there has been an increase in the published literature but limitations on the generalizability of the resulting evidence remain. A systematic review in 2014 found 85 relevant papers that addressed a mix of health outcomes, efficiency, utilization, costs, satisfaction, usage, sustainability, and/or attitudes and barriers related to HIEs [8]. Most focused on specific care settings and a few HIEs. This limited the generalizability of findings. The review reported low-quality evidence of reduced emergency department use or costs, but effects elsewhere were uncertain. The authors also indicated that “all stakeholders claim to value HIE, but many barriers to acceptance and sustainability exist.” Another review published in 2015 focused on a narrower set of outcomes (costs, use, and quality). It identified 27 studies and came to similar conclusions, highlighting the lack of high quality studies comparable across settings to provide generalizable benefits of HIE [9]. The most recent systematic review of HIE to come out of the US, builds on the evidence from earlier studies identifying 34 studies reporting clinical, economic, population outcomes as well as patient and clinician perceptions of outcomes. The authors concluded there was low-quality evidence to support the value of HIE in reducing duplicate testing, emergency department costs, hospital admissions and improving public health reporting, ambulatory quality of care and disability claims processing. In addition, the review found that clinicians perceptions of the value of HIE were positive. The review also concluded that there was insufficient evidence on the impact of HIE on patient outcomes [10].

In Canada, a number of researchers have examined the iEHR and its components. A recent discussion paper summarizing the benefits of ehealth investments in Canada identified a number of studies that have studied the value of sharing specific types of information (components of iEHR clinical domains) across care settings [11]. For example, evaluations of the benefits of diagnostic imaging information systems (DI) have found that picture archiving communication systems (PACS) provide benefits for health providers such as better access to information, quicker turnaround time, reduced time searching for films, as well as better care, cost savings and productivity improvements for radiologists and technologists particularly in remote, rural locations [12]. Another study focusing on costs of DI found mixed evidence [13]. Similarly, pan-Canadian evaluations of drug information systems (DIS) across the country found benefits such as fewer adverse drug events, improved medication compliance, reduced medication abuse, reduced inappropriate prescription filling, enhanced quality of admission reconciliation practices, and increased productivity for providers [14–17]. DIS studies also found that benefit realization was driven by clinician efforts, sound change management, solution design, interoperability, and accuracy of medication histories [14, 16, 18]. These types of studies provide increasingly rich understanding of the value and success factors related to sharing of particular types of information among authorized clinicians, but the impact of iEHRs as an integrated approach to sharing many different types of clinical data has not been studied as extensively.

This study targets this gap in the literature, with a particular focus on the Canadian experience. It synthesizes iEHR user views from six PTs assessed by surveys. The surveys include user perspectives on system, information, and service quality; iEHR use and user satisfaction; and net quality and productivity benefits. The goal is to improve understanding of how iEHR users perceive the effects of these information sources, with a view to helping advance future use, benefit, and evaluation of iEHRs.