Why is your doctor still using a fax machine? Barriers to electronic health records in Canada

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by Katie Compton, Policy & Politics editor

In our day-to-day lives, we access digital information with such ease that we don’t really stop and think about the underlying infrastructure that makes it all possible. When we encounter the edges of this digital ease—say, when one of our trusted messaging apps goes offline unexpectedly—it can be frustrating, and even costly.

One space that has been slow to embrace digitization is healthcare. Clinics and hospitals are migrating from paper to digital records, but the systems in place at different institutions generally can’t “talk” to one another. Information about each encounter we have with the healthcare system doesn’t travel with us. Instead, it is locked up in paper charts or separate electronic health records (EHRs) that are specific to individual healthcare organizations.

This “siloing” of information means that each healthcare provider we interact with is only seeing part of our medical history. In some cases, this is appropriate—not all of your medical information is relevant to each doctor or nurse you meet. However, the lack of communication between EHR systems can result in delays and errors in medical care, and an increased burden on patients to recall and share their health information.

Both healthcare providers and the Canadian government have recognized the need for better EHRs. Back in 2001, Canada Health Infoway (CHI) was formed with the goal of improving Canada’s digital health infrastructure. A federally funded not-for-profit, CHI focuses on several initiatives, including interoperability, i.e., improving the flow of information across the healthcare system. The idea is to create a more interoperable system, allowing patients greater continuity of care, and therefore, improved health outcomes. However, the actual creation and implementation of an interoperable system remains a challenge.

Researchers have been looking for possible solutions to this challenge. Dr. Mana Azarm, an adjunct professor at the University of Ottawa, published a paper in 2017 with some colleagues proposing a framework for a system that could help address the barriers to interoperability. Within this framework, patient information could be stored in a platform-independent, cloud-based web portal. The portal could be accessed by healthcare providers at different institutions as well as patients, who could see their own health information and contribute to it. This could even include adding data they’ve collected using devices like an Apple watch.

“The technology is there to transfer data very securely. I mean, credit card companies, financial companies, they all do that,” says Dr. Azarm. “So, I think technology-wise, we’re there.”

She points to successes in countries like Denmark, Norway, and Sweden, where nationwide healthcare data sharing systems are in place.

“It all comes down to governance,” Dr. Azarm says. “We collaborated with researchers in Norway, where their research was funded by their Ministry of Health. So, the Ministry of Health really supports those researchers and funds the research and uses them.”

Governance: Who’s in Charge?

So why is the governance piece more complicated in the Canadian context?

One of the main barriers here in Canada is the way our healthcare system is funded and governed. While the Canada Health Act defines essential services and funding comes from the federal government, healthcare systems are operated by provincial governments. Canada does not have one national healthcare system, making it tricky for the federal government to step in.

“That’s a big part of the problem because there’s really no national standard for interoperability. Canada Health Infoway has done a lot of work on that, but they haven’t actually developed a national standard for health system interoperability that defines both the structures and the behaviors for how the health system should work that everyone needs to abide by,” says Dr. Craig Kuziemsky, Associate Vice-President, Research and Interim Dean, School of Business at MacEwan University. Dr. Kuziemsky’s research focuses on information and communication technology design in the context of collaborative healthcare delivery.

“There are some very good success models of digital health, be it in individual clinics or even across consortia of hospitals,” says Dr. Kuziemsky. “But the challenge has been they haven’t scaled up very well.”

The federal–provincial divide in governance is one barrier to scalability, but Dr. Kuziemsky points out that the complexity of the healthcare system also makes it difficult to design a single EHR platform that will work for everyone.

“People always will make an analogy, say, between digital banking…[if] I can get my money out of any bank machine, and banking has been online for a lot of years, why can’t health care be the same?”

An interoperable EHR that could be accessed by healthcare providers at different institutions and by patients could help improve healthcare outcomes, but there are challenges to creating such a system. Image by CentralITAlliance, iStock.

An interoperable EHR that could be accessed by healthcare providers at different institutions and by patients could help improve healthcare outcomes, but there are challenges to creating such a system. Image by CentralITAlliance, iStock.

Scalability: Can One Platform Work for All?

Dr. Kuziemsky points out that the types of “transactions” that patients and healthcare providers need to complete are much more diverse than just moving money around, making them harder to automate. A family doctor seeing a patient with high blood pressure, a pharmacist filling a prescription, and an emergency room nurse who is triaging a patient all have different information needs and are interacting with EHRs in very different ways—even if they are all treating the same patient.

“We’re still figuring out how to work well in health care through team-based care delivery, how different types of specialties collaborate, how different types of centers collaborate,” says Dr. Kuziemsky. “It’s always harder when you’re trying to scale something up technologically while at the same time trying to develop the underlying rules of engagement for how the system is going to work.”

This complexity means that there will likely never be one perfect tech solution to creating an interoperable health record system. Any system put into place will need be adaptable to the needs of different users and able to evolve over time.

At some point in the future, will you be able to go to your family doctor or visit an ER and feel confident that they have access to all the information that is relevant to your care? Dr. Azarm and Dr. Kuziemsky both agree that such a system is a desirable goal.

“Right now, in Canada, everybody wants [a national interoperable EHR], ultimately. And there are different task forces working on it right now. We need someone to coordinate all these different efforts,” says Dr. Azarm.

While there may never be a single, one-size-fits all EHR for all Canadians, we can work to build regional, or even national, systems that improve access to health information. However, to get there, researchers and decision makers at all levels of government will need to start talking to one another and moving in the same direction.

Feature image: In our digital age, many hospitals and medical clinics are still struggling to adopt electronic health records. Image by jat306, iStock


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