by Chelsea Finn, RN, BScN, MScN,
Registered Nurse, Laurentian University, Sudbury, Ontario, Canada.

Sitra Bekri, RN, BScN, MScN,
Registered Nurse, Laurentian University, Toronto, Ontario, Canada.

Anisa Bekri, CCRN, BScN, MScN,
Registered Nurse, Laurentian University, Toronto, Ontario, Canada.

Theonilda Koiengu, RN, BScN, MScN,
Registered Nurse, Laurentian University, Sudbury, Ontario, Canada.

Robyn Gorham, NP-PHC, MN, EdD,
Associate Professor, School of Nursing, Laurentian University, Sudbury, Ontario, Canada.

Citation: Finn, C., Bekri, S., Bekri, A., Koiengu, T. & Gorham, R. (2025). From paper to platform: Nurses’ lived experience across dual EHR transitions in urban and rural tertiary care environments. Canadian Journal of Nursing Informatics, 20(4). https://cjni.net/journal/?p=15666

Abstract

Aim: This case study examines four registered nurses’ (RNs’) experiences during two electronic health record (EHR) transitions in tertiary care: paper to EHR and between EHR platforms. It aims to generate evidence-based recommendations for future EHR implementations.

Background: EHRs are vital to healthcare modernization, enhancing safety, communication, and documentation. Implementation is complex, and gaps remain in understanding frontline nurses’ experiences and impacts on workforce readiness and patient care during integration. 

Methods: The experiences of four RNs who participated in both EHR transitions at a tertiary hospital in Canada were analyzed to support roles, training approaches, staff preparation, and workflow adaptation. 

Findings: Successful EHR implementation relied on Super-Users, peer training, planning, and collaboration. Challenges encompassed limited role-specific training, gaps in digital literacy, technical difficulties, and increased workload and stress for frontline staff. Resource and informational technology disparities, especially in rural areas, also hindered implementation efforts and contributed to unequal integration outcomes.

Conclusion: Successful EHR implementation requires tailored training, staff support, and resources. Early user engagement and ongoing technical help boost confidence and care quality. Tackling infrastructure and staffing issues, especially in low-resource settings, is vital for smooth transitions and benefits.

Key Words: Electronic Health Records, global health systems, nursing, tertiary care. 

Introduction

In recent decades, there has been a significant increase in the adoption of technology within the healthcare system, aimed at enhancing the timeliness of patient care and ultimately yielding improved patient outcomes (Adeniyi et al., 2024; Gatiti et al., 2021; Hamade et al., 2019). A substantial form of technological advancement in the tertiary care setting is the introduction of Electronic Health Records (EHRs), which are designed for the storage, management, and sharing of patient health information (Adeniyi et al., 2024; Berger et al., 2024). This health information includes medical history, allergies, medication details, such as historical usage and administration specifics, laboratory results, vital sign trends, and treatment plans, along with documented progression of treatment among various healthcare professionals (Adeniyi et al., 2024; Berger et al., 2024).

This case study summarizes the experiences of four registered nurses (RNs) working in Ontario, Canada, who underwent the transition from paper record-keeping to EHRs, and from one EHR system to another. The insights obtained through working as RNs in a tertiary healthcare setting during EHR implementation will be discussed. Finally, recommendations will be provided for future implementation and integration of EHRs in the tertiary care setting.

Background and Review of Literature

The integration of EHRs within the hospital environment yields numerous advantageous impacts on patient care outcomes (Adeniyi et al., 2024; Gatiti et al., 2021). These benefits encompass improved accessibility to patient health data, facilitating expedited care delivery as well as more efficient documentation and record-keeping; thereby enabling rapid and comprehensible access to legible information regarding a patient’s health status and history (Adeniyi et al., 2024; Gatiti et al., 2021). A systematic review conducted by Gatiti et al. (2021) identified patient safety as a significant advantage associated with the integration of EHRs, as hospitals with EHRs reported fewer instances of patient falls, a reduced prevalence of hospital-acquired pressure ulcers, and a lower incidence of ventilator-associated pneumonia. These patient safety advantages are attributed to the design of EHR worklists, which incorporate evidence-based standards of care that facilitate decision-making at the point of care (Gatiti et al., 2021). A significant advantage of EHR for nursing professionals is the decreased time allocated to administrative tasks, including documentation, organization, and preparation of the patient’s chart during the hospital admission process (Berger et al., 2024). The reduction of time allocated to administrative tasks ultimately results in an increased amount of time available for patient care, thereby enhancing the overall quality of patients’ experiences and care outcomes (Berger et al., 2024; Bottega et al., 2025). Another substantial advantage of EHRs for healthcare professionals is the improved communication among various healthcare practitioners involved in a patient’s care, as well as between departments within a tertiary care setting (Berger et al., 2024).

It is estimated that approximately 95% of Canadian and American hospitals have integrated EHRs (Assistant Secretary for Technology Policy/Office of the National Coordinator for Health IT, n.d.). In Australia, 91% of publicly funded hospitals have adopted EHRs, whereas only 67% of privately funded hospitals have integrated EHRs into their operations (Australian Digital Health Agency, 2024). Countries in Latin America and the Caribbean have also recognized the significance of EHRs, and their policymakers have deemed this adoption essential for enhancing patient care within their respective nations; however, only a limited number of countries in this geographical region have successfully implemented EHR systems (Nelson et al., 2020).

The lived experiences of four RNs who navigated the transition from paper charting or another EHR to a new EHR within a Canadian tertiary care setting can provide valuable insights derived from the lessons learned during these transitions, facilitating an improved implementation process in other tertiary care settings.

Implementation

The implementation of EHRs in tertiary care hospitals is operationalized through two primary streams: the first entails facilities transitioning from paper-based documentation to digital charting, while the second involves hospitals migrating from one EHR platform to another. Although both processes share the overarching goal of enhancing clinical efficiency, improving patient outcomes, and providing the required support staff, the practical needs, staff preparation, and resource allocation differed significantly between the two approaches.

Paper to EHR

In sites transitioning from paper to EHRs, emphasis was placed on building digital literacy from the ground up. A substantial number of frontline nurses had limited exposure to EHRs, necessitating fundamental training in system login, patient chart creation, barcode scanning, medication administration processes, order entry, and documentation of patient care. This training was conducted during educational sessions organized by the hospital in collaboration with the EHR company’s operational team. Subsequently, the clinical educators from each department conducted introductory sessions utilizing simulated patients within a trial version of the EHR system, and reinforced important concepts from training sessions prior to its implementation in the hospital.

Training sessions were supplemented by on-unit coaching provided by nursing super-users (NSUs) during the first six weeks of implementation. The NSUs were selected from the staff of each department and received supplementary in-class training in system functionality to enhance their support for frontline nurses. The authors’ experiences as an NSU during this additional training was characterized by frustration, as department-specific worklists and other integral interfaces of the EHR were not fully developed and were subject to continuous alterations, resulting in challenges in learning the system. Furthermore, on go-live day, entirely new interfaces appeared that had not been seen during training, resulting in tension with staff who expected real-time guidance. To alleviate this situation, NSUs were frequently required to provide reassurance that tickets had been submitted to information technology (IT) personnel to address any issues concerning the EHR system and had to demonstrate temporary workarounds until the resolution was implemented.

Tension also arose with physicians with whom the NSUs worked alongside daily, as they would seek their assistance, only to be informed that they were designated for nursing support rather than for physician support. NSUs would try to locate one of the limited physician super-users who could assist; however, they were frequently unavailable on the floor, or calls would go unanswered, which exacerbated the physicians’ frustration and contributed to their reluctance to utilize the system. This diverted NSUs from providing support to frontline nurses regarding their inquiries and challenges associated with using the new EHR platform and ultimately increased the workload of frontline nursing staff. 

Managers from each department were tasked with evaluating their teams’ preparedness, overseeing the training progress of staff members, addressing concerns raised by their staff regarding the EHR system, and increasing the bedside nursing staff during the first six weeks of EHR system implementation to ensure adequate patient care while staff members learned the system. Administrative clerks were tasked with transferring patient demographic information from paper records to the EHR system and ensuring the accuracy of the data prior to go-live. IT staff set up hardware, including mobile workstations, which include computers on wheels and barcode scanners, while also resolving access and login issues, and assisting staff members with limited digital proficiency. Help desk technicians offered troubleshooting support, reset passwords, and escalated major issues within the EHR system.

The operations team coordinated an EHR implementation timeline across departments and ensured that contingency plans were in place for departments that experienced delays or malfunctions with the EHR platform. Based on the experience of RNs during this implementation, these contingency plans were found to be inadequate, as they demonstrated a lack of preparedness when the medication administration interface of the EHRs became non-operational on the go-live day. This failure led to frustration, confusion, and chaos within the units, as there was no alternative method available for medication administration. This prompted the operational team to further enhance their contingency plans for EHR system downtime, where the system is taken offline at regular intervals for system updates. The collaborative focus on digital onboarding and clinical workflow support allowed staff to adjust to the new documentation process successfully.

EHR to New EHR 

Hospitals transitioning from one EHR system to another encounter a different set of challenges. Although numerous frontline nurses were already proficient in digital documentation, the alterations in platform functionality and interface necessitated specific, scenario-based training that was meticulously designed and organized by each unit’s clinical educators. These sessions were designed to emphasize workflow transitions, including how to locate patient histories, enter orders, use updated documentation templates, and troubleshoot common navigation errors. Super-Users (SUs) played a pivotal role in facilitating nursing and physician support, particularly for nurses adjusting to the variances between platforms.

The IT personnel successfully executed the migration of patient data from the legacy system and effectively resolved issues pertaining to credential conflicts and module integration. Help desk technicians handled ticketed system issues and escalated software bugs related to system migration. Administrative clerks validated the accuracy of transferred records and facilitated real-time modifications during the initial weeks of use. Operational leads maintained direct communication with vendors and internal stakeholders to supervise the phased implementation and post-launch feedback. Department managers were responsible for planning their transition, supporting the resolution of clinical concerns, and increasing bedside staffing during the first six weeks of the new EHR platform implementation. Table 1 provides a comprehensive and comparative summary of the roles of support staff specific to the integration of EHRs from paper records or a different EHR system.

Table 1

Support Staff Roles and Responsibilities for the Integration of EHRs

Discussion

Paper to EHR 

Areas of Success

A notable success stemming from the transition from paper records to EHRs was the improvement in clinical efficiency, as authors encountered a reduction in the time spent searching for paper charts and an increase in the time dedicated to patient care. The authors further observed that the implementation of electronic test ordering, in conjunction with the sharing of patient records across various medical disciplines, significantly expedited the diagnostic process and improved overall patient care coordination. These positive outcomes for nurses were similarly acknowledged by Adeniyi et al. (2024) and Gatiti et al. (2021) in their review of EHR integration within tertiary healthcare settings.

Uslu and Stausberg (2021) highlighted that the implementation of EHRs within hospital settings significantly improves medication administration and patient safety. EHRs mitigate medication errors by ensuring accurate and legible documentation while minimizing risks associated with manual transcription and lost charts (Albagmi, 2021; Uslu & Stausberg, 2021). This observation has been noted in various studies, which indicate that integrated clinical decision support systems alert nurses to potential drug interactions, allergies, and dosing inaccuracies (Legat et al., 2018; Uslu & Stausberg, 2021). The integrated clinical decision support enhances monitoring and coordination of medication administration, thereby preventing adverse events and promoting safer patient care in tertiary care settings (Uslu & Stausberg, 2021). 

EHRs have substantially enhanced the security of patient data when compared to conventional paper records, which, from the experiences of various authors, these paper records often remained in unmonitored or readily accessible locations, such as cubbyholes outside patients’ rooms (Basil et al., 2022). Healthcare providers are required to log in and authenticate their identity to access patient health information contained within EHR (Basil et al., 2022; Kechta & Odeh, 2021). This added security reassures patients, reduces privacy concerns and fosters greater trust in their care team.

Areas Needing Improvement 

Despite the advantages associated with EHRs, the transition from paper-based records presented considerable challenges affecting staff experiences, workflow processes, and overall patient care. On-site support during go-live was notably insufficient across healthcare disciplines. NSUs reported feeling inadequately prepared due to the evolving characteristics of the system, and they were often expected to assist physicians, despite lacking appropriate training (Tsai et al., 2020). Similarly, McCrorie et al. (2019) found that insufficient preparation and limited staff engagement hindered readiness and confidence, a sentiment echoed by multiple authors in the initial days of EHR implementation. The inconsistent availability of educators, NSU, SU and IT support, particularly around the clock, intensified the stress experienced by frontline nurses.

The NSU author noted that staff with limited pre-existing digital literacy, particularly older clinicians, faced greater difficulties adapting to the EHR system. Tsai et al. (2020) and Baniulyte et al. (2023) underscored the inadequacy of a one-size-fits-all training approach in accommodating the diverse levels of digital literacy skills, thereby exacerbating the challenges faced by individuals who are less adept at utilizing digital tools. All authors who underwent the transition from paper-based records to EHRs observed that several nurses and physicians, nearing or having surpassed retirement age with limited digital literacy, left their profession as a direct consequence of the EHR system implementation, primarily due to their reluctance to endure the associated stress of the transition.

EHR to new EHR

Areas of Success

The transition to the new EHR platform was largely successful due to a structured rollout and the involvement of digitally experienced staff familiar with previous EHR implementations (Aguirrer et al., 2019; Rinne & Dominis, 2024). Most clinicians were already accustomed to electronic documentation, enabling training efforts to focus on scenario-based workflows such as order entry and navigating updated templates (Aguirrer et al., 2019; Huang et al., 2020). SUs played a crucial role by offering real-time, on-the-floor support, assisting colleagues in adapting to new interfaces and fostering a collaborative learning environment (Rinne & Dominis, 2024; Huang et al., 2020).

Operational leads ensured consistent communication with vendors and oversaw the phased implementation of the go-live. Float nurses were deployed to support units during the adjustment period, allowing frontline staff additional time to adjust to and learn the new EHR platform. Overall, the success of implementation was attributed to targeted training, peer-based support, and strong technical and operational oversight, all of which helped staff rebuild confidence and efficiency over time (Aguirrer et al., 2019; Huang et al., 2020; Rinne & Dominis, 2024).

Areas Needing Improvement

Although the transition between EHR systems was facilitated through a structured implementation process, several aspects required further enhancement. Training, though scenario-based, often lacked depth for more complex workflows and was not always tailored to specific roles (Vos et al., 2020). Many staff encountered a steep learning curve, which contributed to fatigue, especially in the absence of scheduled downtime or follow-up training sessions (Vos et al., 2020). Technical issues, such as data migration errors and login credential conflicts, further disrupted early workflows (Huang et al., 2020). Support coverage varied across units, with limited availability during evenings and weekends, leading to inconsistent assistance during critical periods. Table 2 presents a summary of both the successes and areas for improvement in these EHR implementation cases.

Table 2

Summary of EHR Implementation Successes and Areas for Improvement

Recommendations for Future Practice

The dual transitions from paper-based documentation to EHRs, and later from one EHR system to another, highlight both the potential and the complexities of digital transformation in tertiary healthcare settings. EHRs offer considerable advantages, including enhanced clinical documentation, interdisciplinary accessibility to patient records and improved patient safety outcomes through features such as the electronic medication administration record (eMAR) (Berger et al., 2024; Gatiti et al., 2021). However, the realization of these benefits is highly dependent on several foundational elements: adequate staffing, intentional infrastructure investment, structured training, and coordinated implementation strategies (Boothe et al., 2020). Without these supports in place, EHR rollouts may lead to disrupted workflows, increased staff burden and reduced trust in digital solutions (Moore et al., 2025).

Global Considerations: Barriers and Facilitators

In low and middle-income countries, implementation is further challenged by systemic barriers. These include limited access to reliable electricity, low internet bandwidth, absence of data backup infrastructure and a shortage of cybersecurity safeguards (Baumann et al., 2018; Basil et al., 2022). Additionally, many healthcare facilities lack trained IT staff and clinical informatics specialists, which reduces their capacity to support and troubleshoot EHR systems (Aguirrer et al., 2019; Adeniyi et al., 2024). In such environments, even minor technical issues can severely disrupt care delivery and documentation.

To address these challenges, global implementation efforts must prioritize several key strategies. First, sustained investment in digital infrastructure, including reliable internet, backup power systems, and secure data storage, is essential (Nelson et al., 2020). Second, comprehensive capacity-building initiatives should be established to train both healthcare and IT staff in the operation, troubleshooting, and long-term maintenance of EHR systems (Aguirrer et al., 2019; Adeniyi et al., 2024). Third, collaborative partnerships with experienced international organizations can provide technical mentorship, contextualized guidance and funding support (Hamade et al., 2019). Finally, a phased approach to implementation, starting with localized pilot testing, can help systems adapt based on real-time feedback, thereby minimizing disruption and enhancing stakeholder engagement.

Specific Recommendations: Lessons Learned

In both transitions from paper to EHR and from EHR to a new EHR system, several key lessons emerged. One of the most critical challenges was inadequate staffing during go-live periods, due to an insufficient number of additional nurses and NSUs for all shifts. Moy et al. (2021) noted that such dual demands contributed to increased stress and decreased care efficiency among healthcare providers, while Taneja et al. (2025) emphasized that insufficient support during implementation periods can undermine workflow and morale. Although NSUs and unspecified SUs were assigned to assist with the implementation, they were often underprepared due to last-minute system changes that rendered their training obsolete, as reported by Rinne and Dominis (2024) in their guidelines for effective EHR transitions. Incomplete documentation templates, missing worklists and delayed feature activation further hindered frontline adoption and contributed to staff frustration (Tsai et al., 2020).

To support more effective future implementation, Aguirrer et al. (2019) emphasized the importance of allocating additional staffing during the implementation period to ensure that clinical operations continue uninterrupted while a dedicated support team manages real-time troubleshooting and training. The authors collectively articulated the necessity for the extended presence of additional bedside nurses and NSUs beyond the six-week threshold following implementation. The authors also emphasized the necessity for a gradual reduction to pre-implementation staffing levels, rather than an abrupt cessation of all support, as they collectively conveyed challenges when all supports were withdrawn simultaneously. Role clarity is equally important, assigning specific tasks such as order entry support, documentation assistance and communication with IT to streamline problem resolution and reduce confusion (Aguirrer et al., 2019). Additionally, Boothe et al. (2020) advocated for early engagement of frontline staff in system testing and design processes, which can strengthen user trust and ensure alignment between digital tools and the realities of clinical care.

Summary of Barriers

The EHR implementation process was hindered by several interrelated barriers that disrupted clinical workflows and impacted staff morale. A significant challenge was the insufficient staffing on go-live day, which left nurses balancing patient care demands with the complexities of learning a new system. Taneja et al. (2025) noted that training efforts were undermined by last-minute system updates that altered previously taught procedures, resulting in confusion and a lack of preparedness. Compounding these issues was the absence of timely and accessible IT support during the first week of the transition period. Many users also struggled with unfamiliar documentation templates and navigation functions, particularly those with limited digital literacy (Taneja et al., 2025). Haggstrom et al. (2019) further emphasized that resource disparities between rural and urban sites further exacerbated these challenges, with rural hospitals experiencing limited technical support and slower adaptation due to under-resourced conditions. This inequality was evident among the authors when discussing the availability of support staff among authors who experienced the transition in a large urban center, as compared to those who underwent this change in a rural setting.

Summary of Facilitators

Despite these obstacles, several facilitators contributed to the relative success of both transitions. Peer support played a pivotal role, as described by Chishtie et al. (2023), who found that the presence of SUs and bedside nurses proficient in the EHR system helped guide colleagues through real-time challenges by offering support and encouragement. Staff demonstrated a high degree of adaptability and teamwork, which helped maintain patient safety and workflow continuity under pressure. Moore et al. (2025) emphasized that clear and continuous post-implementation communication between clinical and IT teams enabled the timely identification and resolution of system issues, fostering trust and reinforcing responsiveness across departments. Their findings further highlighted how daily debriefs and informal team huddles created opportunities for iterative learning, allowing staff to build both competence and confidence over time. Moreover, when leadership acknowledged unit-specific concerns and adapted support strategies accordingly, it contributed to a culture of psychological safety and collective problem-solving.

Moving Forward

Future implementations of EHRs, whether transitioning from paper to digital systems or migrating between EHR platforms, must adopt a comprehensive, systems-oriented and human-centred strategy. Successful integration hinges on striking a balance between technological readiness and frontline workforce preparedness. Across both scenarios, key implementation principles remain the same: staffing models must be flexible to accommodate training needs and account for temporarily reduced efficiency; clear role delineation among clinical, technical and operational teams must be established early; dedicated super-users should be assigned for both nursing and physician teams to offer real-time peer support; robust IT support and contingency planning must be in place for system errors and downtimes; and lastly, inclusive system design and usability testing must involve frontline staff prior to launch to ensure clinical relevance and buy-in.

The recommendations for changes to the roles and responsibilities of each support staff group are delineated in Table 3. By adhering to these principles, healthcare institutions can minimize disruption, support clinician engagement, and optimize the clinical benefits of EHRs. Ultimately, these coordinated efforts can transform EHR adoption into a catalyst for improved documentation quality, patient safety and interprofessional care delivery.

Table 3

Recommended Changes for Support Staff in Paper to EHR and EHR to EHR Transitions

Conclusion

The key to a successful integration of an EHR system, whether from a paper-based or a different EHR system, is having sufficient bedside support and resources for nurses and physicians, a well-structured, multi-level support system consisting of clinical educators, managers, IT staff and administrative clerks with defined roles and responsibilities, additional nursing staff so patient care is not impacted while learning the new system and adequate internet bandwidth for successful operation of the system. Recommendations for successful future EHR integration include incorporating frontline staff suggestions into the creation of worklists and workflows, specialty-specific, realistic mock patients for nurses to practice with before go-live, and adequate resources for all care providers in the form of designated Super-Users for nurses and physicians, as well as increased bedside staffing to ensure there is no disruption in patient care. Although low- and middle-income countries lack adequate IT infrastructure and cybersecurity, which impacts their technical ability to implement EHRs, further research is needed to address these issues. The recommendations outlined regarding the integration of EHR can be effectively utilized in these environments, as they pertain to the process of successfully implementing a predesigned EHR within a tertiary care setting.

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Biographical Statements of the Authors

Chelsea Finn, RN, BScN, MScN

Chelsea Finn is a Registered Nurse and Nursing Professor, possessing extensive experience in complex nursing content delivery, clinical instruction and surgical nursing. With a dedication to student achievement and patient care, she effectively integrates theoretical knowledge with practical application to support nursing students and ensure the provision of high-quality care. 

Theonilda Koiengu, RN, BScN, MScN

Theonilda Koiengu is a Registered Nurse, who works on a high-turnover acute surgical floor and in a long-term care home. She brings strong clinical, organizational, and informatics skills, with experience using electronic health records to support quality care in various settings. She is passionate about improving nursing workflows and outcomes through technology and evidence-based practice.

Anisa Bekri, CCRN, BScN, MScN

Anisa Bekri is a critical care Registered Nurse with clinical experience in the intensive care, emergency and coronary units across urban and rural hospital settings. As a dedicated nurse and educator, she brings a strong foundation in critical thinking and adaptability to diverse clinical environments. Her practice is guided by a dedication to fostering equitable and culturally safe approaches that support the holistic delivery of patient and family-centred care. 

Sitra Bekri, RN, BScN, MScN

Sitra Bekri is a Registered Nurse based in Toronto with hands-on experience in mental health, medical and surgical units. As a knowledgeable clinician and dedicated preceptor, she combines advanced assessment capabilities with a strong commitment to mentoring and supporting professional development. Her contributions to this case study reflect her commitment to advancing nursing knowledge through lived clinical experience and reflective practice. 

Robyn Gorham, NP-PHC, MN, EdD

Robyn Gorham is an Associate Professor at Laurentian University and a Primary Care Nurse Practitioner. Her work focuses on advancing nursing practice, primary care delivery, and health education through research, clinical leadership, and academic mentorship.