Abstract Background While primary health care electronic medical record (EMR) adoption has increased in Canada, the use of advanced EMR features is limited. Realizing the potential benefits of primary health care EMR use is dependent not only on EMR acquisition, but also on its comprehensive use and integration into practice; yet, little is known about the advanced use of EMRs in primary health care. Objective To explore the views of advanced primary health care EMR users practising in a team-based environment. Methods A descriptive qualitative approach was used to explore the views of primary health care practitioners who were identified as advanced EMR users. Twelve individual semi-structured interviews were held with primary health care practitioners in Southwestern Ontario, Canada. Field notes were created after each interview. Interviews were audio recorded and transcribed verbatim. Researchers independently coded the transcripts and then met to discuss the results of the coding. We used a thematic approach to data analysis. Results Three themes emerged from the data analysis: advanced EMR users as individuals with signature characteristics, advanced EMR users as visionaries and advanced EMR users as agents of change. In any one participant, these elements could overlap, illuminating the important interplay between these themes. Taken together, these themes defined advanced use among this group of primary health care practitioners. Conclusions To realize the potential benefits of EMR use in improved patient care and outcomes, we need to understand how to support EMR use. This study provides a necessary building block in furthering this understanding. Computers in medicine, electronic medical records, practice management, primary care, quality of care Introduction As the care of patients in the primary health care setting becomes ever more complex, and system efficiencies are being sought, practitioners need tools that can help to support care. Primary health care practitioners are also being expected to measure and report on quality of care, both as individuals and as teams; this necessitates efficient data collection at the point of care. Electronic medical records (EMRs) are one example of the type of tools that are therefore becoming increasingly necessary in the primary health care context. While primary health care context EMR adoption is increasing in Canada, the use of advanced EMR features is limited (1). Realizing the potential benefits of primary health care context EMRs is dependent not only on EMR acquisition, but also on its comprehensive use by practitioners and integration into their practice (2,3). There is variable evidence regarding the association between EMR use and improvements in the quality of patient care (3). Researchers have speculated that this situation could be due to variation in how EMRs are configured and used in practice (2). We do have an understanding of the myriad barriers and facilitators of EMR implementation and adoption (4,5), yet little is known about the advanced use of EMRs in primary health care context practice. We identified one study that examined the use of EMRs among family physicians in Canada (6); however, the topic of ‘advanced’ EMR use remains to be fully explored. As the use of EMRs is becoming ubiquitous, it is important to understand how EMRs are being used and their possible impacts, so that their full potential may be realized. Therefore, we set out to explore the perspectives of primary health care context practitioners who were identified as advanced EMR users. Methods In this study, we used a descriptive qualitative approach (7,8), which allows the researcher to explore the thoughts or perceptions of participants regarding a particular topic or event and to summarize them in ‘everyday terms’, or to investigate the ‘who, what, and where’ of events (7). Setting and participant recruitment This study took place in the province of Ontario, Canada, and was conducted from September 2015 to March 2016. The study was conducted in partnership with administrative leaders (MO, JS) from the Thames Valley Family Health Team to co-create knowledge that would be useful in practice. Family health teams in Ontario are organizations that deliver primary care through inter-professional teams of practitioners. Potential participants were primarily identified by JS, whose role with the Thames Valley Family Health Team is quality improvement decision support specialist. The role of the quality improvement decision support specialist is heavily involved in quality improvement specific to EMR use, standardization and data extraction. As such, the quality improvement decision support specialist has a clear idea of Thames Valley Family Health Team practitioners who excel in EMR use. Participants were recruited from a group of 18 primary health care practitioners within the Thames Valley Family Health Team who were considered advanced EMR users, in keeping with an approximate Level 3 or 4 range of the Ontario MD Maturity Model (9). A letter of information and consent was sent by email to this group of practitioners, explaining the aims of the study and outlining our request for participation. We sought representation from different practitioner groups, including family physicians, nurses, pharmacists and social workers and included practitioners using different EMRs in different practice sites. Research team members included authors ALT, BLR, AT, KM, SM, JS and MO. Several study participants were known to researchers ALT, BLR, AT and SM in a professional capacity. KM was the project coordinator and did not have any relationship with the participants. JS’s role has been described earlier. MO had an arm’s-length relationship with participants in his administrative role at the Thames Valley Family Health Team, which is one of the largest family health teams in the province of Ontario. It serves over 155000 patients, and has over 110 family physicians and 120 interprofessional staff, located in 18 different sites. There were no differences in power in terms of the positions held by the researchers and those of the participants. Data collection Of the18 potential participants, 12 responded to our request to participate. Ten individual semi-structured interviews were conducted separately by study investigator ALT, and two separately by study investigator SM, either at the participant’s practice site or by telephone (see Supplementary material for interview questions). ALT is an assistant professor, and SM is an associate professor and associate chair, Department of Family Medicine, and a family physician at the Byron Family Medical Centre. Both interviewers are experienced primary health care researchers and have apprenticed with expert qualitative researchers. The interviews lasted an average of 25 minutes. Field notes were created after each interview. Interviews were audio recorded and transcribed verbatim. Data analysis We undertook an analysis that was iterative and interpretive. Two investigators (ALT, BLR) coded the initial interview transcripts independently and then met to compare their coding and to develop a coding template. The template was adapted as the interviews progressed. Analysis of subsequent interviews followed the same pattern, but included three investigators (ALT, BLR, KM). Other members of the team (SM, MO, JS) coded selected transcripts and participated in the analysis, allowing their broader understanding and reflections to be included. NVivo software was used to support the coding process. The techniques of immersion and crystallization were used throughout the analysis (10). Regular meetings of the research team were held to facilitate the data analysis and synthesis of the themes. Theme saturation was achieved. Credibility and trustworthiness of the data The trustworthiness and credibility of the data and the analysis was promoted through several steps. First, interview transcripts were reviewed for accuracy by the interview team. Second, field notes were taken after each interview and the team held de-briefing discussions. This facilitated adaptation of the interview guide and reflection on the concepts and themes emerging from the interviews (11). This reflexivity is an important component of a qualitative study (11). Finally, both individual and team data analysis techniques were utilized. Findings See Table 1 for participant characteristics. Table 1. Characteristics of study participants (n = 12) Characteristics Responses Age Mean = 44 years, range 31–60 years Length of EMR use Mean = 9 years, range 3.5–20 years Sex n (%) Male 7 (58) Female 5 (42) Total 12 (100) Type of practitioner n (%) Family physician 7 (58) Pharmacist 2 (17) Nurse practitioner 1 (8) Registered nurse 1 (8) Social worker 1 (8) Total 12 (99a) Characteristics Responses Age Mean = 44 years, range 31–60 years Length of EMR use Mean = 9 years, range 3.5–20 years Sex n (%) Male 7 (58) Female 5 (42) Total 12 (100) Type of practitioner n (%) Family physician 7 (58) Pharmacist 2 (17) Nurse practitioner 1 (8) Registered nurse 1 (8) Social worker 1 (8) Total 12 (99a) All participants self-identified as either advanced or intermediate electronic medical record users. EMR, electronic medical record aSums do not add to 100% due to rounding. View Large Table 1. Characteristics of study participants (n = 12) Characteristics Responses Age Mean = 44 years, range 31–60 years Length of EMR use Mean = 9 years, range 3.5–20 years Sex n (%) Male 7 (58) Female 5 (42) Total 12 (100) Type of practitioner n (%) Family physician 7 (58) Pharmacist 2 (17) Nurse practitioner 1 (8) Registered nurse 1 (8) Social worker 1 (8) Total 12 (99a) Characteristics Responses Age Mean = 44 years, range 31–60 years Length of EMR use Mean = 9 years, range 3.5–20 years Sex n (%) Male 7 (58) Female 5 (42) Total 12 (100) Type of practitioner n (%) Family physician 7 (58) Pharmacist 2 (17) Nurse practitioner 1 (8) Registered nurse 1 (8) Social worker 1 (8) Total 12 (99a) All participants self-identified as either advanced or intermediate electronic medical record users. EMR, electronic medical record aSums do not add to 100% due to rounding. View Large Emerging themes Three overarching themes emerged from the analysis: advanced EMR user as an individual with signature characteristics, advanced EMR user as a visionary and advanced EMR user as an agent of change. In addition to the themes that arose from the participants’ perspective on advanced EMR use, we report on specific recommendations made by advanced EMR users to help non-advanced users and teams to improve. Advanced electronic medical record user as an individual with signature characteristics Specific individual characteristics were identified across advanced EMR users including their ability to take on roles as an EMR learner, ‘You really just have to kind of play with it…, just time doing it over and over again…It just kind of becomes your second nature over time’ [Participant 5]; as a teacher, ‘…when you have to start to explain things to people, then you have to kind of know how things work’ [Participant 6]; and as a detective, ‘I’m also an excellent detective. So nothing stops me from looking for something a little bit more’ [Participant 1]. Participants described a level of tenaciousness when approaching their use of the EMR, as one participant indicated, ‘What has taken me there is stepping outside the fear of breaking something’ [Participant 1]. There were high levels of knowledge and comfort with computers, as one participant indicated, ‘I’m an early adopter from childhood. So I was doing EMRs before EMRs were even available’ [Participant 7]. Participants expressed a generally positive orientation towards this technology: ‘There are a lot of positives that have happened because of the EMR and a few negatives too. For myself, the positives outweigh the negatives’ [Participant 3]. These advanced users embraced the technology and sought to maximize its potential in practice. Advanced electronic medical record user as a visionary Advanced EMR users had the ability to envision how current EMRs could be optimally used (proximal vision) and how to help others advance their use. These users pushed against existing boundaries of use (limits of technology, vendors and time) to ensure that the EMR was not used as a paper chart would be: ‘There are a lot of features in an electronic chart that are available to you but it doesn’t mean using every piece of function of that EMR is optimal use...We need to push ourselves to make sure that we are “doing” optimal use’ [Participant 3]. ‘Get people used to the concept of the system is not for storing data, the system is for using data’ [Participant 7]. This visioning extended beyond the individual’s practice to that of the team, ‘I finally basically got a group of us together and I’m like “We’ve got to do this differently”. So for me, that was like let’s make our life easier and come up with a way to actually use our EMR to data mine the information that we’re not getting’ [Participant 4]. Participants also envisioned the EMR of the future (distal vision), where an intuitive EMR would be able to respond to the actual nature of primary health care context practice, ‘It’s a very difficult EMR to work with, it’s not intuitive. Whoever programs things, you have to think like them, which is not necessarily the way clinicians think, and I’d really, really, really like an EMR to start to think like physicians think because I think it should be done and it can be done’ [Participant 6]. Therefore, this forward thinking extended beyond the immediacy of the practice setting to focus on what the possibilities were for EMR evolution and use from a broader and more futuristic perspective. Advanced electronic medical record user as an agent of change Advanced EMR users acted as motivators of change, mobilizing team members to come on board with activities such as data standardization and workflow changes, which would support advanced EMR use, ‘So it’s also changing workflows that we’ve used before… and really thinking outside the box. You’re not doing the exact same workflow in the paper based world because you’re not going to get the optimal use of an EMR if you don’t change your workflow. So that’s really crucial’ [Participant 3]. ‘It’s actually trying to convince people that we need to do things in a standard way’ [Participant 2]. Participants were therefore describing the necessity of trying to help team members understand the importance of these activities within the context of clinical care. Recommendations As part of the exploration of participants’ perspectives on advanced EMR use, we specifically sought out participants’ recommendations for helping non-advanced EMR users and teams move forward. The recommendations offered by advanced EMR users were related to EMR training and education, EMR planning and EMR integration. Electronic medical record training and education Participants recommended non-advanced EMR users receive training and attend EMR user conferences, as well as consult with peers who shared the same professional role and were more advanced. They also suggested newer users attempt problem solving within the EMR—thus engaging in experiential learning. Electronic medical record planning Recommendations pertaining to EMR planning involved defining priorities for accurately recording information and running queries to assess the quality of the data. It was recommended that non-advanced EMR users start with small changes that had a good likelihood of success and that they implement regular structured time into team meetings for discussions about the EMR. Electronic medical record integration Participants recommended non-advanced users engage in self-reflection about how the EMR could support their own practice. Teams were encouraged to identify and nurture individuals in the practice who show early signs of the potential for advanced EMR use. Finally, participants suggested that newer users initiate feedback cycles where they could look at reports based on their own EMR data. Discussion This research highlighted the important role that advanced users play in promoting optimal EMR use and identified key aspects by which this happens. Advanced EMR users in this study were visionaries. This vision allowed these users to push against current boundaries of EMR use to maximize the potential of the current technology in practice, and to see possibilities for new EMR designs in the future. Advanced EMR users also acted as agents of change; since they could see the value in using the EMR to its fullest potential, they sought to motivate those around them to take steps that would support this use. While these participants embraced the technology, they also had the tenacity and a willingness to learn, thereby ensuring that they had individual competence in EMR use. Thus, the twin dimensions of competency in EMR use and possessing a visionary perspective characterized advanced EMR users in this study. The three themes of advanced use—individuals with signature characteristics, users as visionaries, and users as agents of change—are not mutually exclusive. In any one participant, these elements could overlap, illuminating the important interplay between these themes. Taken together, these themes defined advanced use among this group of primary health care practitioners and allowed these individuals to transcend the boundaries of more typical EMR use. Much of the existing literature focuses on the initial stages of EMR implementation and adoption (12) or the impact of EMR use on practice outcomes (3). However, as EMR use has recently increased, particularly in Canada and USA, researchers have turned to (i) measuring levels of EMR use and (ii) understanding how EMRs are used in practice. In the following, we focus primarily on these areas of the literature as they relate to EMR use in the primary health care context. Typically, studies focused on ‘measuring levels of use’ operationalize this concept by quantifying the EMR functions used by individual primary health care context practitioners. In the Canadian context, EMR use has been assessed using this approach (6,13,14). The EMR Adoption Framework developed by Price et al. extends this assessment to encompass additional dimensions beyond the use of functions, including the availability of e-health infrastructure (14). In this study, we found that EMR users were more advanced not just because of their level of competency in using the software itself, but also because of their ability to envision how current and future EMRs could be optimally used. In contrast to the aforementioned research, other studies seeking a ‘deeper understanding’ of EMR use have (i) interpreted practitioners’ experiences of the implementation and use of new primary health care context EMR systems (15); (ii) created a model of adoption and used this to define archetypes of health information technology use (16); (iii) analysed patterns of EMR use and associated cognitive aspects (17); (iv) explored the relationship between communication patterns and EMR use (18); and (v) examined differences among physicians in their views about uncertainty and the role of information in patient care (19). Our study fits into this latter body of literature, but extends the evidence by focusing on the advanced EMR use of individuals and their reflections on their own interactions with the EMR. The findings of this study link with the Clinical Adoption Meta-Model (16), which posits that achieving ultimate change in patient outcomes through health information technology use is dependent on three preceding dimensions—ability of users to interact with the system, their use of the system, and changes in practitioner and patient behaviour supported by the system (16). As advanced users, the participants in this study exhibited a mastery of their EMR and the ability to maximize its use, while recognizing the software’s limitations. Thus, although the participants’ realization of optimal use could potentially be limited by the system they were using, because of their experience and the nature of their use, they were in a position consistent with the last stage of the meta-model—that of achieving impact on patient outcomes. Although we did not identify any study similar to ours within the literature, there are parallels that can be drawn from previous work, which are focused within three areas. The first focuses on data quality. Price et al. highlighted the fact that the presence of poor quality data would make taking advantage of advanced EMR features (such as decision support) a problem (20). In our study, participants recognized the critical role that aspects of data (such as the quality provided by standardized data) played in advanced EMR use. The second parallel centres on experience and EMR use. Length of time using a primary health care context EMR (2 years or greater) has been associated with greater ease in using specific functions in the EMR and lower concerns about the software (21). Since the participants in our study had all used their EMRs for more than 2 years, they may have had the opportunity to develop advanced EMR use skills and a positive orientation simply as a function of time. However, the nature of the participants’ EMR use went beyond skills and a positive attitude—they were visionary users who also acted as change agents. Finally, the last area is the value of the EMR. Within this vein, Lanham (2014) found that physicians who had an ‘uncertainty reduction perspective’ (they managed uncertainty in clinical practice through the collection and processing of information) viewed the EMR as containing information that was vital to the care of their patients; they also had high levels of EMR use (19). These results resonate with the findings of this study, where primary care practitioners valued the use EMR in supporting patient care, emphasized the importance of the data themselves and sought to mobilize others in the use of the information in the EMR. Further work on measuring EMR use might also take into account how the EMR is used in the patient encounter for example, or how a team uses an EMR, or how the EMR is used with individual types of patients. There is a need for greater understanding of EMR use, with a view to supporting movement along the continuum from basic to advanced use. Indeed, there are calls to explore the constellation of factors that impact the potential of family physicians to achieve advanced EMR use (6). Building on the knowledge of advanced EMR users gained from this study, strategies to support the transfer of these learnings to those who are not as advanced could be developed. For example, the findings could be used by decision makers who seek to inform potential system-wide initiatives to improve EMR use, primary health care practitioners and organizations who wish to enhance the use of EMRs and researchers who want to inform future work, including the development of interventions to improve EMR use. In particular, sharing the approach that advanced EMR users take with other primary health care team members may assist in increasing these team members’ EMR skill level. This could specifically assist in alleviating apprehensions regarding EMR use, developing a long-term vision for EMR data use and moving towards a general standardization of information. Indeed, advanced EMR users in this study made specific recommendations about how to improve EMR use among individuals and teams who were not as advanced. What ultimately occurs in terms of the actual use of EMRs in primary health care context is a complex interplay between patients; the individuals using the technology; the teams, organizations and the contexts within which they work; and the technology itself. A comprehensive understanding of EMR use needs to take all these elements into account. Three additional areas of research emerged from our reflections on the findings of this study. First, subsequent qualitative studies could explore the perspectives of practitioners at the other end of the spectrum—EMR users at a stage of basic EMR use and the role of different team members in terms of their EMR use. Second, a larger-scale quantitative study could assess patterns of advanced EMR use across jurisdictions in Canada and explore the reasons for potential differences among these jurisdictions. Third, based on the findings from this study and others currently in progress, interventions such as training and feedback sessions to improve levels of confidence in EMR use could be developed and tested. Limitations The central limitation of this study is the small number of participants (n = 12). However, we were able to explore the views and perspectives of a variety of advanced EMR users who differed based on gender, professional roles, geographic location and the EMR software they used. Most importantly, we were able to describe the nature of advanced EMR users in the primary health care context setting. Conclusions This study illuminated dimensions of advanced EMR use not currently present in the literature. To realize the potential benefits of EMR use in improved patient care and outcomes, we need to understand how to support optimal EMR use in practice. This study provides a necessary building block in furthering this understanding. Supplementary Material Supplementary data are available at Family Practice online. Acknowledgements AT holds a Canada Research Chair in Health Services Research. We thank the participants in this study. Declaration Funding: The ‘Towards Optimal Use: Perspectives of Advanced EMR Users’, Applied Health Research Question was supported by a grant from the Government of Ontario (#06547). The views are those of the authors and do not necessarily reflect those of the funder. The funder had no role in the design of the study, analysis, interpretation or writing of the manuscript. Ethical approval: This study received approval from The University of Western Ontario’s Review Board for Health Sciences Research Involving Human Subjects No. 107167. Conflicts of interest: None. References 1. Osborn R, Moulds D, Schneider ECet al. Primary care physicians in ten countries report challenges caring for patients with complex health needs. Health Aff (Millwood) 2015; 34: 2104– 12. Google Scholar CrossRef Search ADS PubMed 2. Friedberg MW, Coltin KL, Safran DGet al. Associations between structural capabilities of primary care practices and performance on selected quality measures. Ann Intern Med 2009; 151: 456– 63. Google Scholar CrossRef Search ADS PubMed 3. Lau F, Price M, Boyd Jet al. Impact of electronic medical record on physician practice in office settings: a systematic review. BMC Med Inform Decis Mak 2012; 12: 10. Google Scholar CrossRef Search ADS PubMed 4. 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Published: Feb 10, 2018
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