Canada’s electronic health record (EHR) system is weak and uneven, potentially harming patients and overloading clinicians, new research reveals.

The lack of interconnected data is also estimated to cost Canadian taxpayers more than $9.4 billion annually, according to the study.

Before embarking on the research, principal author Braden Manns, MD, senior associate dean at the University of Calgary’s Cumming School of Medicine, was interim vice president at Alberta Health Services. “We couldn’t have set up this system in a more disconnected way if we tried,” he told Medscape News Canada. “There was zero connection between any community EHRs and hospital records, and we kept creating temporary and partial solutions, while clinicians and their staff spent hours every week trying to find the results of consults.” 

As a medical student, first author Sunand Kannappan, also at the University of Calgary, “kept running into a strange contradiction where I could order a ride, transfer money, or track a package in seconds on my phone, but getting a patient’s records meant hoping that they remembered their history,” he told Medscape News Canada. “It felt clinically dangerous. I wanted to understand whether this was an isolated problem or something systemic, and it turned out to be the latter.”

“What surprised me was that no province had put someone in charge of making sure that EHRs were connected,” added Manns. “It was a complete free-for-all. The only protections in place were to ensure patients’ data were kept private, and it seemed the easiest way to do that was to not connect systems.”

The authors’ experiences prompted the study, which confirmed that the lack of interoperability meant that patients’ health records were fragmented across separate systems, thus leaving clinicians overburdened and without access to the information they need.

The study was published online on May 4 in the Canadian Medical Association Journal.

‘Burnout and Wasted Effort’

For the study, researchers described the current state of EHRs in 10 provincial and three territorial jurisdictions in Canada and evaluated the maturity of their interoperability using a structured interoperability assessment model.

Their assessments were based on an environmental scan, or systematic review, of EHR use and interoperability across all provinces and territories using Canada Health Infoway documents, as well as structured interviews with 23 subject matter experts.

The researchers developed an interoperability maturity model to evaluate jurisdictions across enabler dimensions and interoperability status dimensions. The four enabler dimensions included governance, legislation and standards, incentives and capacity-building, and technical infrastructure. The four interoperability status dimensions included community EHRs, hospital EHRs, patient portals, and system analytics.

Although EHR adoption was high, the maturity of EHR interoperability was low and uneven across Canada. Specifically, integrated EHR data exchange was limited, and nearly all jurisdictions lacked EHR interoperability among hospitals, community specialists, and primary care.

In every jurisdiction, data exchange between primary care and specialists and between hospitals and community settings was done mainly by fax or mailed letters.

Patient portal contents and system-level analytics using EHR data were underdeveloped nationally. “Patients have effectively become the custodians of their own medical histories, carrying information in their heads that should be living in a system,” Kannappan said. “When clinicians act on incomplete information, the consequences are duplicated investigations, missed diagnoses, and preventable drug interactions.”

Most jurisdictions showed strength in at least one area, but none showed strength in all.

The result? “Many harms to patients,” Manns said. “Prescribing is less safe because we don’t know about past allergies, and information isn’t available to the emergency room, meaning treatments and testing aren’t guided by the information that exists in family doctor’s office. Clinicians have to do extra work to find information, and it’s leading to more burnout and wasted effort.”

Kannappan spoke of two parallel burdens. The first is administrative — that is, time spent chasing records, reentering data “and sending faxes that belong in another decade.” The second burden “is real clinical risk, where physicians are making high-stakes decisions on incomplete [information] and carrying the legal and moral weight of that. The disconnected system has normalized both [burdens] today.”

Barriers to Overcome

The researchers identified the following eight barriers to interoperability, each of which they said can be overcome: weak governance structures, resulting in fragmented records; absent legislation and standards; misaligned incentives (ie, no financial incentive for physicians to share information) and lack of funding; technical challenges (eg, few data repositories or patient portals); low physician technical literacy and resistance to change; privacy and cybersecurity risks; limited vendor innovation and data blocking; and inconsistent data and workflow standards.

“Strengthening governance, legislation, standards, incentives, and technical infrastructure — supported by national legislation to mandate interoperability across different EHRs — will be essential to advancing connected care across Canada and realizing widespread benefits for patients, clinicians, and health systems,” the authors concluded.

‘Loud and Relentless’

“The findings match what I would expect and what most physicians, decision makers, researchers, and other users of health data would experience,” said Fahad Razak, MD, Canada Research Chair in Healthcare Data and Analytics at the University of Toronto, and internist at St. Michael’s Hospital in Unity Health Toronto.

“There is an unacceptable level of disconnectedness within health data repositories and complex and poorly organized governance and access protocols,” he told Medscape News Canada. “The harms to patients are diverse and important — everything from critical safety events because of clinical decision-making that does not have access to all relevant data, diagnostic and therapeutic delays in care, repeat testing, and deep frustration at the inability to be more engaged with their own healthcare data and the decisions that are made.”

Furthermore, said Razak, who was not involved in the study, “Physicians are deeply distressed and disillusioned by the inability to get the information they need to make the best patient care decisions in a timely and efficient way.

“We need to be loud and relentless [in stating] that the status quo is unacceptable,” he urged. Creating a connected system for health data will be a collective effort of the technology providers and government, he continued. Physicians and patients also must be involved, emphasizing “the many harms that come from our current fragmented system and the opportunities we are missing out on as Canadians.”

This work was supported by a Canadian Institutes of Health Research Foundation Award. Kannappan reported being a member of the Digital Health Interoperability Task Force, a partnership between the Canadian Medical Association and Canada Health Infoway. Manns and Razak declared having no relevant financial relationships.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDEdge, The Lancet (where she was a contributing editor), and Reuters Health.