Canadian Journal of Nursing Informatics

The History of Technology in Nursing: The Implementation of Electronic Health Records in Canadian Healthcare Settings

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Claire Boothe, BSc – Kin
Jobanmeet Bhullar, BSc Dent Surg
Navrose Chahal, BSc – Mol Bio
Andrea Chai, BSc – HSc
Kristin Hayre, BSc – Biomed Phys
Mindy Park, BA – Psych
Cassie Ragan, BSc – Geo
Camille Ramirez, BSc – HSc
Dahee Suh, BSc – Integ Sc
The History of Technology in Nursing: The Implementation of Electronic Health Records in Canadian Healthcare Settings

Introduction

Electronic Health Records (EHR) have revolutionized the healthcare industry, transforming paper-based records into digital ones. EHR are defined as “a longitudinal electronic record of patient health information [such as patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports,] generated by one or more encounters in any care delivery setting” (Menachemi & Collum, 2011. p. 48). The importance of EHR is evident in the function they provide. We aim to evaluate the historical development of EHR in an attempt to identify aspects that have been improved by the implementation of technology over time.

A Brief History of Electronic Health Records in Canada

The earliest recorded form of EHRs were available in the mid 1960s to 1970s as the foundation of development was just beginning (Chauvette & Paul, 2016; Evans, 2016). EHR development evolved with the emergence of computerized technology and personalized networks. The invention of the internet and enhanced portable devices allowed for advancements in EHR systems. As technology began improving, better hardware became available and was also increasingly affordable. The expansion of the internet throughout the 1980s and early 1990s led to user interface features that were incorporated into EHR systems, which improved ease of access (ex. pop-up menus, scrolling, buttons, and multi-page forms) (Evans, 2016). In 1992, the American Nurses Association acknowledged nursing informatics as a specialty, as compared with Canada, which founded the Canadian Nursing Informatics Association in 2001 (Chauvette & Paul, 2016). Since 1992, there has been a hybrid use of paper and electronic records (Evans, 2016). In Canada, the Kirby report and the Romanow report published in 2002, advocated for the application of electronic medical records and also other technological advancements across the country through the organization of Canada Health Infoway (Chauvette & Paul, 2016). By the 2000s, technology had become a standard communication tool in healthcare, with nurses expected to use EHR along with other point-of-care data (Chauvette & Paul, 2016).

In early times, computers did not have the storage that could provide efficient use of EHRs, and so were seen by many as ineffective and not worth the hassle (Evans, 2016). By 2015, there were still major key technical issues concerning security and compliance to the standardization of EHRs (Evans, 2016). Throughout the years, research has increased in places such as Asia, Australia, North America, and Europe, along with increased sharing of information throughout the healthcare system (Evans, 2016). Since 1992, large vendors have been replacing the earlier providers of the EHR system (Evans, 2016). As EHR and other technology enhance communication between healthcare providers, increased recognition of their value is seen by health organizations and the government.

Presently, EHR have improved health care by allowing authorized healthcare providers to access client health records from anywhere in BC (Ministry of Health Services, 2009). This increases efficiency in healthcare as it reduces physical labour, prevents errors, and increases accessibility, which results in a better workflow. Several laws are in place that protect personal health information, such as the eHealth Act, Freedom of Information and Protection of Privacy Act, and Personal Information Privacy Act (BC Freedom of Information and Privacy Association, 2011). These laws are implemented to ensure privacy and confidentiality. According to Menachemi & Collum (2011), there are several advantages of utilizing these systems, which can be divided into three categories: clinical, organizational, and societal outcomes.

The advantageous clinical outcomes include improved quality of care and patient safety achieved through a reduction in medical errors and improvements in measures at the client-level. Efficiency and effectiveness in health care delivery have been linked to EHRs (Devkota & Devkota, 2013) through the prevention of redundant diagnostic testing, which helps to reduce delayed diagnosis and care. As well, patient safety is through the reduction of medical and medication errors. A study by Bates et al. (1998) showed EHRs supported a reduction in medication errors in a hospital setting caused by poor penmanship. EHRs increased efficiency by reducing the need to seek missing information from incomplete orders (Menachemi & Collum, 2011) resulting in improved efficiency and effectiveness of care.

Organizational outcomes involve improved financial and operational performance. EHRs have been linked to increased revenue through a reduction of billing errors, reduced cost for supplies needed to maintain paper files, reduced redundant testing, and no longer needing to mail hard copies of results to different providers (Menachemi & Collum, 2011). These outcomes resulted as EHRs allow authorized health care providers to access client health information electronically (Ministry of Health Services, 2009).

Lastly, improved societal outcomes are realized through the achievement of improved population health through better research. There is an increasing volume of data and information available electronically from different populations that are accessible for further research and analyses (Samuels, et al, 2015).

Challenges of Electronic Health Record Implementation

One of the main goals of the introduction of EHRs was to provide safer, higher-quality, more efficient patient care. While there are many positive effects of EHRs, there have also been many challenges that have accompanied the implementation of EHRs in nursing practice in Canada.

The advancement and adoption of EHRs across Canada vary within each province, with Alberta being the most advanced and Ontario being the least advanced. The differences are due to a lack of coordination between provincial and regulatory authorities. According to Rozenblum et al. (2011), in order to have full cooperation between the provinces, there needs to be more ”effort devoted to achieving effective regional interoperability both to support clinical adoption and to increase the speed of implementing systems to support the continuum of care” (p.284). It is easy to adopt a health care system within each province, but the issue arises when placed on a national platform. Currently, clinicians have difficulty accessing health records of Canadians that were born in another province, or tourists traveling across the country or clients that received health care elsewhere, which leads to migrating away from EHR because of its inefficiency and inaccessibility. Furthermore, this may put clients at risk of incorrect diagnoses and inadequate uncoordinated care.

Canada continues to face further challenges in the successful implementation of EHR because of the lack of engagement from clinicians who are intended to be the primary users of the EHRs. Additionally, there is a lack of push to move away from existing procedures and systems. The unsuccessful adoption of the EHR among clinicians across the province may be due to unfamiliarity with the current system, lack of training, and key aspects missing from the EHRs. In order for members of the health care team to optimize their usage in the delivery of care, they need to include “problem lists, clinical notes, and computerized decision-support” (Rozenblum et al. 2011, p. 285). If there are key component areas missing for documentation that may contain essential and critical information for a particular client, then a clinician may turn to previous methods of documentation for time convenience and minimization of errors.

In addition to the challenges in implementation, nurses and other health care providers have identified many flaws in EHR systems. Topaz et al. (2017) performed an international survey investigating nurses’ reported satisfaction with current EHR systems and current issues. The findings reported that overall, participants “ranked their satisfaction with the current state of nursing functionality in EHRs as relatively low” and “more than one half of the comments identified issues at the system level” such as poor interoperability, limited functionality, user-task issues, and poor system usability (p. 2016). Topaz et al. (2017), identified that the average satisfaction was 4.5 on a scale from 1 (not at all satisfied) to 10 (very satisfied), suggesting that there are many flaws in the current system. The greatest concerns reported were system issues (54.5%), followed by user-task issues (27.5%) and environmental issues (18%).

The biggest flaw reported in the use of current EHR systems was system issues, including but not limited to “poor system usability…non-integrated systems and poor interoperability…lack of standards and standardization [and] limited functionality/missing components” (Topaz et al., 2017, p. 2021). Participants identified that the existing systems being used did not allow them to accurately and efficiently complete their documentation tasks, required too many keystrokes, and often required duplicate documentation. This is a big concern in the field of nursing as accurate documentation is imperative to ensuring all clients are receiving proper care and errors are avoided. In addition, nurses are often balancing many different tasks and need to be as efficient as possible in order to stay on track. Respondents also indicated that the data inputted was not integrated into other systems, therefore, duplicate documentation was required to see client data across the care continuum (Topaz et al., 2017). Other flaws in the system itself included “lack of use of documentation standards…insufficient system standardization and [limited] coverage for specific content areas, such as pediatric nursing, home care or care management” (Topaz et al., 2017, p. 2021).

Participants also identified many challenges with user-task issues, including “systems fail[ing] to meet clinical nursing needs…and systems [that] are not nursing specific” (Topaz et al., 2017, p. 2020). A concern brought forward by many participants was the fact that the system did not allow them to complete their documentation in either narrative or structured formats, therefore, did not capture the full holistic picture of a client’s story (Topaz et al., 2017). In addition, Topaz et al. (2017), described how current EHR systems seemed to be designed more for billing or cookie cutter needs, rather than specifically for nursing practice, therefore, not effectively “capturing, storing and presenting nursing knowledge…and including critical decision making support [for] nurses” (p. 2020).

The third major concern outlined by Topaz et al. (2017) related to environmental issues, including “low prevalence of EHR systems [and] a lack of user training” (p. 2021). Many hospitals and health care settings, especially in developing countries, are still using manual records. If they are using EHR systems, they are not being used comprehensively. In order to have standardization and consistency, EHR systems must be implemented more widely in home care, public hospitals, and other healthcare settings. Where EHR systems are being implemented, nurses are reporting insufficient user training, therefore, “prevent[ing] full use of EHR system capabilities” (Topaz et al., 2017, p. 2021).

Canada Health Infoway

Canada Health Infoway (Infoway) is the top national organization for EHR implementation in Canada. Infoway is a non-profit organization created and funded by the federal government in 2000 to accelerate the implementation of EHR across Canada (Catz & Bayne, 2003). Infoway announced a seven-year plan that promote interoperable EHRs across 50 percent of Canada by the end of 2009, with the collaboration of provincial and territorial governments (Giokas, 2005). This plan was expected to cost between $10-12 billion over ten years, and once fully implemented, this “pan-Canadian EHR [would] allow clinician[s] or authorized provider[s] anywhere in Canada to electronically access the health records of any patient in the system in real time” (Cecutti, 2007, p. e1).

However, despite its commendable goal, Infoway has received much criticism from clinicians and informatics experts alike, for their ineffectiveness in creating an interoperable EHR system despite the amount of time and funding they were given. For example, Dominic Covvey, the President of the National Institutes of Health Informatics (NIHI) at the time, pointed out that “Canada was trailing behind other nations in eHealth development, despite 17 years of planning and at least $4 billion in federal and provincial spending” (Webster, 2011, p. 298). In 2011, Canada’s ICT (Information and Communication Technologies) Development Index was ranked 21st by the World Health Organization, lagging behind the Republic of Korea and many Scandinavian and western European countries (WHO, 2011). Canada’s deficiencies in eHealth included, “a lack of supportive federal laws and regulations, national procurement and technology policies, educational policies and scholarships, and evaluations to monitor progress on important areas such as the capacity to deliver health information to patients via mobile telephones,” (Webster, 2011, p. 299) that should have been addressed by Infoway’s seven-year plan.

Secondly, an external audit done on Infoway in 2011, revealed that despite Infoway’s positive contributions in developing EHR infrastructure, Infoway still missed their own established targets in all eight major program areas. In its defence, Dan Strasbourg, Infoway’s Director of media relations at the time, stated that the shortcomings were due to jurisdiction issues (Webster & Kondro, 2011). The audit also revealed that Infoway lacked “engagement with physicians” in their EHR blueprint that they were developing (Webster & Kondro, 2011)). More telling is that former Infoway officials had stated that the organization’s decisions were made by software industry veterans who did not have any clinical experience. which may have contributed to Canada trailing behind other nations in eHealth development. In a case study of EHR implementation in family practice in Quebec, Gagnon, et al., (2010) pointed out how the biggest factor of successful EHR implementation is having a project leader, who combines both clinical and technological experience to help their team transition from paper health records to EHR. Although this case study is not fully applicable to Infoway because of its scale, other literature supports the importance of having a champion of innovation in leadership for success. Hence, if Infoway had the kind of leadership found in the case study, EHR could have been implemented more smoothly with satisfaction from clinicians and patients alike.

While many issues have been highlighted in regard to the inadequate implementation of EHRs in Canada, some believe aspects of the EHR implementation have been successful to date. Interoperability, in reference to Canada, can be defined as the exchange of healthcare data between multiple organizations of varied disciplines located in different provinces. The comprehensive strategy that defines a national approach to EHR standards facilitating interoperability across jurisdictions was considered a success of Infoway. “An infrastructure established by the Canada Health Infoway arguably provides an essential foundation for both local and interprovincial exchange” (Rozenblum et al., 2011, p. e285).

On the other hand, Chang and Gupta (2015) interpreted Canada’s electronic medical systems as patchwork, lacking interoperability, developed as a result of the decentralized administration of health care from the federal government to individual provinces, and from the provinces to the local level. Interoperability was cited more often as a barrier than as a facilitator to EHR implementation in research conducted by McGinn et al. (2011). Having to deal with other organization’s IT departments was frustrating and often required sourcing paper documents for confirmation of information, which lead health care professionals to question the purpose of the electronic system.

The development of regional repositories for drug, laboratory, and digital imaging data was considered to be successfully implemented by Canada Health Infoway (Rozenblum et al., 2011). However, without easy user interface software and efficient hardware systems, the success of compiling regional repositories of medical data is futile because healthcare professionals cannot access and utilize the data. The most frequently mentioned barriers to EHR implementation were the technical limitations related to slow system speed and unplanned downtime (McGinn et al., 2011). When experiencing technical difficulties with EHRs, healthcare professionals may resort to conventional, familiar paper records. Lack of computer literacy and training, especially in older generations, was another common barrier identified for accessing online repositories of medical data. Without reliable and simple access to online medical data, EHR systems, successful compilation, and organization of medical data are negligible.

Rozenblum et al. (2011) considered the funding strategies associated with the implementation of EHRs a success. Gated funding characterized by the release of funds based on performance benchmarks was the structure used to manage finances that funded implementation of EHRs in Canada. This structure was viewed as one of the reasons Infoway was able to secure provincial commitment and funds. However, this funding only covered portions of EHR implementation. Significant costs associated with ongoing software maintenance and updates, IT support, and training employees to understand and use the software were not included in the initial implementation funding. However, as Canada Health Infoway stated, the implementation of EHR enables healthcare professionals to complete administrative tasks more efficiently and easily. Infoway considered the application of EHR in Canada as successful, mentioning that “83 % of nurses indicate they are comfortable using digital health tools in practice” (Canada Health Infoway, 2014, para. 1).

However, in a study by Strudwick et al., (2018), the authors found that nurses have a problem utilizing EHR systems. They need to repeatedly navigate through screens to find the information they are looking for which is time-consuming. As well, end-user training is an issue. The benefit of EHR is timesaving on documentation and easy access to information. However, the lack of adequate guidelines and training can deter EHR implementation success.There must be clear guides and training for end-user to adapt to EHR to maximize the benefits of the EHR system.

Limitations

Future research should focus on the expectations and experiences of healthcare professionals and clients because their perspectives will both inform and enrich the development of effective methods to enhance the adoption of EHRs. Much of the historical data concerning the implementation of EHRs into practice were based on survey information collected from only a small percentage of the total physicians in Canada (Chang and Gupta, 2015). It is possible that the physicians responding to a survey on EHR use, might not be fully representative of the total population of Canadian physicians, either overestimating or underestimating the use of EHR in healthcare. Reliable information was not available from the territories, so these areas were not included in this study. The results were limited due to a small number of respondents from certain countries/geographic regions and an overrepresentation of nurses with higher professional positions/academic degrees who answered the open ended questions (Topaz et al., 2017). Respondents who answered the open ended questions had a lower mean EHR satisfaction score and were mostly from Europe and North and South America, with fewer responses coming from Asia and the Pacific region. When implementing EHRs, the uniqueness of all individuals should be taken into account. Although there are similarities present between the different groups of individuals involved in this research study, there are also differences, and these differences need to be taken into account in order for EHR to be implemented successfully. Even though useful data was collected, the generalizability of the findings to other situations is unknown. Also, some important information about nurses’ understanding of EHR was not communicated.

Conclusion

While progress has been made in developing and implementing an interoperable EHR for Canadians and British Columbians, it is still in its early days. One of the biggest problems is the use of several different vendors across regions and organizations and a historical lack of interoperability. However, now with API, voice recognition, and machine learning development that is beginning to change. Hybrid use of paper and electronic records is still seen across many health facilities. There are still many challenges which need to be addressed, such as usability for physicians and nurses and lack of appropriate EHR training. However, despite a number of challenges, so far, sufficient progress has been made. This is an incredibly important initiative in our healthcare system, and all of the necessary steps need to be taken to ensure that it gets appropriately implemented so EHR use becomes seamless and user-friendly. In addition, some of our findings implicate the pre-implementation of future technology in order to increase the efficiency and practicality of its application.

Overall, EHR have greatly transformed the health-care industry. Although there were multiple issues associated with its implementation, the integration of EHR as part of providing care has considerably impacted healthcare. Some aspects of improvement when considering the implication of EHR include, obtaining the input of physicians and health care professionals, standardization, and software design before implementation. To support a stronger impact of EHR, support by physicians and input should have been considered before application. Also, early standardization of systems and effective leadership to facilitate the integration of EHR software would increase the efficiency and efficacy of its development. This is where nursing informatics specialists fit in.

The lack of integrated hardware and evolution of technology at the time was also a major downfall to the implementation of EHRs. The health industry could have benefited from working with the technology industry to develop a more robust system. Another method that could potentially improve the implementation of EHR is ensuring interoperability before the application of the system. For an effective application of EHR, the sharing of health records across health-care settings is essential. Topaz et al. (2017) addressed poor interoperability due to issues at the systemic level. We believe that an improved selection process that ensures the product is interoperable across all systems can potentially enhance the implementation of EHR. Thus, by investigating the historical development of EHR, we can learn from the mistakes made when first implementing this technology and improve upon them to positively affect everyone in the health-care system, clinicians and clients alike.

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ABOUT THE AUTHORS

This paper was collaboratively done by nine Critical Inquiry: Qualitative Research students in the Fall of 2019 during their course work in the BSN-AE Nursing Program at Kwantlen Polytechnic University in British Columbia, Canada.

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