‘Trying to find information is like hating yourself every day’: The collision of electronic information systems in transition with patients in transition

Abstract

The consequences of parallel paper and electronic medical records (EMR) and their impact on informational continuity are examined. An interdisciplinary team conducted a multi-site, ethnographic field study and retrospective documentation review from January 2010 to December 2010. Three case studies from the sample of older patients with hip fractures who were transitioning across care settings were selected for examination. Analysis of data from interviews with care providers in each setting, field observation notes, and reviews of medical records yielded two themes. First, the lack of interoperability between electronic information systems has complicated, not eased providers’ ability to communicate with others. Second, rather than transforming the system, digital records have sustained health care’s ‘culture of documentation’. While some information is more accessible and communications streamlined, parallel paper and electronic systems have added to front line providers’ burden, not lessened it. Implementation of truly interoperable electronic health information systems need to be expedited to improve care continuity for patients with complex health-care needs, such as older patients with hip fractures.

Keywords

Canada documentation electronic health records ethnography transitions

Introduction

Continuity of care is particularly important for frail older patients and others with multiple chronic or complex conditions. Yet their multidisciplinary health-care teams struggle to coordinate health information exchange within and across care settings^1–3 and are more likely to have missing clinical information.⁴ Health records play a key role in care continuity by facilitating the exchange of patients’ clinical and demographic information among providers managing or assuming their care. They may also serve to transfer accountability,⁵ help avoid preventable adverse events that might occur during transitions,⁶ satisfy regulatory requirements^7,8 and influence the quality of follow-up care.⁹

Schrag and Donaldson¹⁰ identified a ‘culture of documentation’ in health care that consumes up to 25 per cent of providers’ time in some cases.^11,12 Improving the documentation process and inter-provider information exchange – making it faster, more accurate, more secure, and allowing users to capture information from different sources – facilitates care coordination,^13–15 improves care quality, and reduces care duration.^16,17 However, deficiencies in inter-organisational information exchange, such as missing, delayed, or poor quality data are well documented;^18–20 one study found that physicians had information about their patients’ visits with other physicians at only 22 per cent of visits.¹⁷

Paper-based clinical information systems are increasingly limited in their ability to meet expectations of contemporary evidence-based practice, team-based care,^21,22 and successful care transfers. Patient transfers between care settings rely on concise summaries of information to provide a snapshot of the patient at the time of transfer. With a paper record, in what can be a time-consuming process, the provider manually searches for relevant information, collates, and transcribes it for transfer, often in a non-structured and unstandardised format. The volume of transfers, documents’ location across multiple sites, the transactional nature of information exchange, and high risk of transcription errors make this type of information exchange between providers a prime target for digitisation.

Electronic information systems have been shown to improve inter-provider communication.²³ However, Schoen et al.’s study²⁴ illustrated wide disparities in basic electronic medical record (EMR) adoption across primary care physician practices in 11 developed countries. Only 37 per cent of physician respondents in Canada reported use of an EMR in their practice, in contrast to those in countries such as the Netherlands, New Zealand, and Norway, which reported near ubiquitous use (99%, 97%, and 97%, respectively). Another survey of Canadian physicians reported exclusive use of electronic records at 21.5 per cent and those using a combination of electronic and paper records at 27.5 per cent.²⁵ Clearly, a large proportion of Canadian health-care providers are unable to send or receive digitised clinical information to other authorised users. This situation exists despite the considerable investments made by federal and provincial governments as well as by health-care providers themselves, towards the adoption of EMRs. Adoption of digitised documentation is inconsistent across health-care sectors, and interoperability between information systems is limited.

It is against this backdrop that we conducted a multi-site ethnographic field study from January 2010 to December 2010 in both Ontario and British Columbia, to describe and identify key factors that impact information exchange. Older patients with musculoskeletal disorders often experience high-risk transitions between care settings;^18,26,27 we chose older adults with hip fractures as the focus of the research. One of the goals of this study was to examine the impact of parallel information systems (paper and electronic) on communication exchange to support transitions across the care continuum. A multi-case approach was used to assist with pattern matching and explanation building.²⁸

Methods

Multi-site ethnographic field study

In the larger study, we purposively recruited patients, their family caregivers, and health-care providers (p. 45).²⁹ Patients from acute and subacute orthopaedic units, who had undergone surgery for a hip fracture, were 65 years old or older, and could participate in an interview in English, were asked to participate. While continuity of care is a construct often associated with the roles and responsibilities of the family practitioner and the primary care setting,^30,31 increasingly the roles of other health-care providers, organisations, and care settings are considered instrumental to the coordination of patient care.^32,33 For this reason, any examination of informational continuity, particularly related to documentation, should be conducted in the context of the entire system supporting an episode of care. In this study, at each care setting in the patients’ journey, an effort was made to interview at least two front line health-care providers, the patient, and an informal caregiver. Field protocols and interview guides for the larger study were developed using 27 key informant interviews conducted across the sites with a purposive sample of health-care providers (nurses, physiotherapists, occupational therapists, social workers, physicians, kinesiologists, and administrative staff) working with hip fracture patients across a variety of settings (acute care, inpatient rehabilitation, primary care, long-term care/nursing homes, and community care). After the key informant interviews were completed, a total of 23 patients were interviewed 51 times, 19 family caregivers were interviewed 24 times, and 92 health-care providers were interviewed 96 times. These interviews tracked the discharges and admissions of specific patients across their continuum of care.

The case studies

For this article, in an effort to elicit literal replication and more comparable results,²⁸ three case studies were purposively drawn from the larger study’s data. The case studies include data from participants involved in three patients’ care transitions. These patients resided in one of the three research study locations that included a larger urban region (British Columbia), a smaller urban, and a rural region (both in Ontario). Patients with similar demographics, such as age (81–87 years) and gender, and number of transitions across care settings (at least three) were selected. These selection criteria are known mediators of the patient care process (e.g., Bertakis and Azari, 2007). The cases were also selected because the patients crossed institutional as well as jurisdictional boundaries, which highlighted the complexities of information exchange. Boxes 1 to 3 provide vignettes describing each woman’s journey through the health-care system from diagnosis to recovery, to illustrate the complexity of both their condition and networks of care providers (details and names have been changed to protect the identity of the subjects).

Box 1.

Mrs Robertson’s story

Mrs Dorothy Robertson, 87 years, fell in her apartment and sustained a right inter-trochanteric hip fracture. An elderly couple living in the same apartment building notified her emergency alert service.

Mrs Robertson’s transitions

Mrs Robertson was transported by ambulance to the local 495-bed community hospital. Following triage, she spent an hour in the corridor before being officially ‘admitted’ to the emergency department and undergoing a ‘secondary’, more comprehensive assessment by a nurse. Mrs Robertson was assessed by one orthopaedic surgeon, but due to emergency department volumes, a second surgeon repaired the fracture. Immediately post surgery, a case manager from the local community health services agency initiated the process for homecare services in anticipation of her discharge. Mrs Robertson’s family’s concerns that it was ‘not safe for her to return home’ prompted discussions about the possibility of interim care. On the planned discharge date Mrs Robertson was partial weight bearing using a rollator walker when she sustained a fall and left hip fracture. After 4 more days in the acute care hospital, Mrs Robertson was transferred to an inpatient rehabilitation unit owned by the same hospital but 10 km away. At the time of her discharge, she had orders for non-weight bearing on the left leg and partial weight bearing on the right leg. After 14 days of inpatient rehabilitation, she was cautiously ambulatory with a walker and was discharged to a convalescent home where she stayed for another 41 days. Mrs Robertson returned to her apartment where she received therapy focused on strengthening exercises and coping alone at home. Her total episode of institutional care lasted 90 days.

Epilogue: Mrs Robertson is currently paying for community physiotherapy services to assist with her recovery and has private household assistance each week. She has a discrepancy in leg length and ongoing right leg pain.

Box 2.

Mrs Rodgers’ story

Mrs Ophelia Rodgers, an 81-year-old female, lived in an assisted living setting (retirement home) in a rural community where she provided care to her frail husband. She was independent with all activities of daily living and mobility with aid of cane and/or rollator walker.

Mrs Rodger’s transitions

Mrs Rodgers fell on the stairs at a local mall and was transported to the emergency department of a small rural hospital where a right intra-trochanteric spiral femur fracture was diagnosed. After the health-care team unsuccessfully sought a transfer to an urban academic centre for surgery, she was admitted overnight. The following day she was transferred to a teaching hospital (100 km away) and underwent surgical repair. A day after surgery she complained of blurry vision; a head injury sustained at the time of her fall was thought possible, however documentation was inconsistent. A CT scan was reported as normal. On the third post-operative day, she suffered an acute drop in haemoglobin along with chest pain. The provisional diagnosis was a bleed into her hip secondary to surgery and anticoagulation; she received blood transfusions and required monitoring of her haematology results. She remained in the teaching hospital for 19 days and returned to an acute care bed at the rural hospital for another 10 days. There were no subacute inpatient rehabilitation services in this rural setting. Mrs Rodgers was discharged back to her retirement home after 29 days of institutionalised care.

Epilogue: Mrs Rodgers missed her follow-up appointment with the orthopaedic surgeon as the information was not passed to her or the retirement home on discharge; the appointment had to be rescheduled. She remains living at the retirement home with her husband; however, has not fully regained her previous level of mobility and independence.

Box 3.

Mrs Smith’s story

Mrs Esther Smith, aged 83 years old, was admitted to an urban, 955-bed teaching hospital with a left femoral neck fracture after experiencing a dizzy spell and falling while walking outdoors. Mrs Smith had a long history of epilepsy and within the same year as her hip fracture had been hospitalised for a stroke; she had many additional co-morbidities. Due to shiftwork and disabilities, her family provided limited support. Prior to the hip fracture Mrs Smith was walking with a four wheeled walker and received weekly home support services.

Mrs Smith’s transitions

Mrs Smith received a hemiarthroplasty within 48 h of fracturing her hip. Mrs Smith spent 4 weeks at the acute care surgical facility after her surgery (a short period of time in the acute orthopaedic unit then several weeks in a subacute unit), after which she was discharged home. One and a half weeks post discharge, Mrs Smith was voluntarily readmitted on the advice of community care workers because of escalating pain in her operative hip. After three weeks in a subacute unit, she moved to a rehabilitation hospital for three weeks. The rehabilitation hospital was located in a different health-care region which used different documentation systems. During her stay at the rehabilitation hospital she returned to the surgical hospital for a day procedure due to a coexisting condition. She was again discharged home, under the care of the original health-care authority, to live alone in her apartment. Her total episode of institutionalised care lasted 61 days.

Epilogue: Mrs Smith is living at home. She continues to experience the same level of hip pain and has developed bi-lateral leg infections. Therapy services are gradually being reduced. Despite increasing pressure from community care providers to relocate to a more supportive environment, Mrs Smith is determined to live alone in her apartment.

The subset of data used for the case studies included 30 semi-structured interviews, numerous field notes, and documentation collected from the three patients’ care networks. Data from the 27 key informant interviews were also analysed. The documentation included printed packages of information sent from one site to another, faxed clinical and administrative records, and chart notes from the patients’ health records at each care setting. Where patients’ transitional documentation was digitised in an EMR, anonymised screen shots were collected or points of interest noted.

The data from each case were reviewed by J.M., E.H., H.J., and J.E. Several analysis discussions were necessary to map out the case contexts before comparing them. The group studied the patterns found in the paper documents collected. J.M., E.H., and H.J. coded each of their respective case’s interview data, using NVivo 8 software (QSR International, Melbourne, VIC, Australia). J.M. integrated the data, linked concepts, and created topical themes using conventional content analysis.^34,35

All participants provided informed consent. The study received ethics clearance from the Research Ethics Boards at the University of Waterloo, Western University, the University of British Columbia, and from the organisations involved in the study.

Findings

Due to the multiple morbidities of each of the case study patients, their lengthy stays in the care of numerous provider organisations, and round-the-clock care shift changes, dozens of health-care providers were either recording or requiring clinical information as the patients either entered or left their care in what Coiera³⁶ describes as ‘large and complex communication spaces’. Examination of the interactions between care providers in each of the case studies revealed two emergent themes: (1) partial interoperability between electronic information systems has complicated not eased the ability to communicate across settings and disciplines and (2) while some information is more accessible and communications streamlined, parallel paper and electronic systems have added to front line providers burden, not eased it.

Partial interoperability between electronic information systems has complicated not eased the ability to communicate across setting and discipline

During the course of this study Canada achieved a target of providing an electronic health record for 50 per cent of the population.³⁷ Yet despite considerable investments in electronic information systems by governments and providers, in all study cases the predominant mode for exchanging transitional information was paper-based. Although the hospitals in the study used EMRs in some fashion, in general health information from the three case patients was either exchanged via fax or transported by the patient or attendant on the day of transfer. Where systems were interoperable, documentation and processes were still duplicated. In one instance, two facilities with common ownership both cared for Mrs Robertson and shared an EMR. Electronic patient information was available at both facilities, yet staff continued to fax requests for admission and discharge documentation to each other and maintained separate paper charts. Both Mrs Robertson’s and Mrs Smith’s community caseworker maintained digital records; however, neither was interoperable with external systems. In Mrs Robertson’s case, duplicate clinical information from the caseworker’s hospital EMR was routinely manually re-entered in its entirety into a separate external database.

Different disciplines expressed varying degrees of support for the value of digital charts. Some were resigned to their use, others were negative; however, many were positive, particularly when entire departments or disciplines committed to their adoption and use. For example:

The therapists only do the electronic charting … I like the electronic personally, it’s usually easier to access because there’s computers all over the floor. The paper chart is sometimes harder to access, and doesn’t always have all the information in it. – Occupational therapist

None of the long-term care homes in this study used EMRs. Much of the clinical information in these organisations was inaccessible to outside organisations or providers in the patients’ circle of care until it was either transcribed into summary paper documents for transfer with the patient, selectively faxed, mailed, or provided verbally. Some hospitals or community care organisations permitted selective access to information through portals or interoperable information systems, most did not. This situation created a patchwork quilt of communication strategies that required each provider have expert knowledge of other provider’s unique capacity and preferences in sharing information resulting in duplication, delays, and elaborate workarounds to ensure information was received:

They’re not on the computer system yet, and along with our information that we do in the computer, then we’ll fax through the pre-discharge form… to the receiving health unit … If they’re not in our [electronic information] system … then we print it out and … fax it through, because they have no way of accessing that. So there is a lot of faxing that goes on. And then we make a phone call to make sure that everything is in order and they got it. – Physiotherapist

In only one case was minimal ‘read-only’ functionality available for community family physicians to access information at their local hospital (interestingly, the same hospital had an advanced patient portal and personal health record for patients and care providers in their regional cancer care facility). Approximately 80 per cent of care was delivered to residents in that home community; however, post-discharge summaries rarely arrived in the physician’s office before patients’ follow-up appointments. For the 20 per cent of patients who received treatment outside the area where there was limited or no EMR interoperability, important information was not available if key paper documents were late, lost, or misplaced:

If the hospital doesn’t send the paper work with the patient then I’ll never know the answer … who did you see while in hospital … why did you see a breathing type doctor while in hospital. Here they say oh I saw a breathing doctor in hospital, I just go to the computer and then I look up the consult because I’m hooked up to the two hospitals here but if its [city] … I don’t have that ability. – Physician

Furthermore, where limited interoperability did exist, updates were not completed in ‘real-time’ and the likelihood of incomplete information increased, as did a subtle mistrust of its accuracy:

The interesting piece with Pharmanet [system-wide electronic medication management] is that you can have meds ordered, but if – so a physician’s ordered, take one tablet and then in the next appointment has said, well, take half a tablet, your Pharmanet doesn’t reflect that. – Nurse

While some information is more accessible and communications streamlined, parallel paper and electronic systems have added to front line providers’ burden, not eased it

One acute care physiotherapist in this study commented, ‘the physios spend the morning treating and the afternoon charting’; ironically, these therapists charted almost exclusively electronically. An examination of Mrs Robertson’s physiotherapy records revealed highly detailed assessment and treatment records from therapists arriving on shift, each requesting the same information and regathering data that were previously recorded in the EMR or elsewhere. This hospital was representative of others in the study with a parallel paper chart kept in the nursing station, a paper Kardex system for key patient information at the nursing station, and white boards in both the nursing station and the patient’s room. Providers occasionally complained of difficulty finding information; awkward user interfaces and lack of summary records in the facility’s EMR might have accounted for this. However, it was clear that gathering information was directed by what most staff believed to be their regulatory and professional ‘duty of care’, rather than the information’s added value:

… if someone admitted my patient I’d go in and do the same thing. Do a complete head to toe and just because they did it and things were fine, doesn’t mean I didn’t … see that. So I’ll do another one. – Nurse

There had been a verbal transfer of basic information related to the patient’s functional status, but neither nurse consulted the EMR (which was shared with the transferring acute care facility) before seeing the patient. In this transfer, as with others in the study, we observed neither electronically generated transfer records such as discharge summaries, nor summary records of care in use.

Maintaining hybrid records results in information being held in multiple locations, placing an enormous burden on care providers to maintain up-to-date and accurate information for exchange:

I think computers and paper records are fraught with error, and, I don’t think the two should be used – you should be moving to one, or stick with the other. Because it’s, it’s, you know, you have a paper chart sitting at the patient’s bedside, you have the MARs sitting on top of the med cart somewhere, you have the chart of the patient, and then you have the computer chart, and then you have the nurses chart in her pocket, where the vitals are really on, and not on the bedside chart where they’re supposed to be. – Physician

A physician also pointed out the impact, both good and bad, of key documentation residing in disparate formats and locations:

I have to say for the huge conglomeration that it is, [hospital] tends to use [the EMR] very poorly. There are often histories and physicals missing, there’s often discharge summaries missing. Here, almost always we will have a discharge summary from our own institution, so if that’s available it can be quite helpful. The medical record, the old paper chart, often quite helpful as well, progress notes and that sort of thing, previous admissions can be helpful, if you can read the writing (smiles).– Physician

Electronic health information exchange improved inter-provider communication across some care settings. In one community, physicians were able to access information from their offices, where previously a discharge summary faxed a week after the patient was discharged was the first they would know that a patient had been hospitalised. A variety of tactics were used to ensure they had information for care management:

If it’s really critical then I’ll actually have to try to contact the physician [specialist] which is a huge time burden for all of us busy people. Sometimes I’ll be able to glean some of it from going on the computer. I can maybe get a specialist consultation letter off the computer and that might shed light on what’s going on a bit more. Those would be the two most common ways. – Physician

The same family physician felt strongly that patients benefit from bidirectional information flows with specialists:

You know the other thing that would be interesting - I never, I have never once had the flow come the other way. Never once had a consultant, a surgeon, anyone ask is this really her full list of medications that she’s on, does she have any other issues or problems? So I think it would work very well if they could also have access to my database at some point in time because I’m sure there’s, I mean I did emergency medicine for 15 years, I know there’s times when we missed medications, where we missed sometimes minor, sometimes significant past medical histories because the patient never told us and it’s not on our medical record at that hospital. – Physician

Yet this was not universally popular. Some health-care professionals felt that electronic systems compromised their clinical autonomy:

Every single nurse documents differently, I find this [EMR] takes away our autonomy. We want to give the patients autonomy; this is taking away our own autonomy. When we can’t document, yes it’s giving the same but each person documents different and if you’re just having [documentation] within defined limits, you’re taking away – like how do you know that assessment was done. – Occupational therapist

Some providers continued to express a preference for paper-based documentation and suspicion of digital documentation, such as this occupational therapist:

I hate it. Oh my god! If this is on here I’m sorry! But I absolutely hate it, absolutely. I am not – it’s not that I’m not computer … because I’m young and I know how to work computers. I feel it’s best to document in handwriting. Yeah it’s quicker and faster, but I have the biggest fear in the back of my head that these computers are going to crash, and they try to tell you that it’s backed up somewhere but I don’t know.

Despite these caveats, many of the providers interviewed in this study reserved high hopes for the potential of electronic information systems:

Interviewer:

How would you use it to improve hip fracture care and navigation through the system?

Physician:

Is the money unlimited?

Interviewer:

Sure.

Physician:

Okay. Electronic medical records. I just can’t emphasise enough that flow of information between institutions would be helpful through electronic medical records. – Rehabilitation physician

And:

I truly believe electronic medical records to be shared between institutions is the way to go. I cannot believe that in this day and age we’re still relying on pencil and paper and that is definitely where the cracks are … So, to me, that’s the number one issue is information flow is poor between institutions because we’re not on – all on the same EMR … not to say that electronic communication is foolproof because, of course, it is also dependent on humans. But nevertheless I think that’s a big important first step. – Occupational therapist

Discussion

Aristidou et al.³⁸ identify the multiple levels of analysis required to understand successful transitions (at the individual, team, and organisational level). This study contributes to the domain through its system-level perspective and a longitudinal cross-setting design that is ironically lacking in continuity of care literature. The large and diverse number of providers interviewed in each case offers rich data on information contained in documents that either facilitate or ironically complicate a patient’s recovery journey.

In 2001, the Canadian government created Canada Health Infoway, a federally funded quasi-autonomous non-governmental organisation with the goal of developing a pan-national electronic information network – a health information ‘superhighway’.³⁹ A decade later, many providers are still unable to electronically share basic patient information with providers in a patient’s circle of care. Adoption of health information technology in health care has lagged that of other industries^40,41 and continues to experience numerous barriers to adoption,⁴² despite demonstrated benefits such as workflow efficiency and improved patient safety.⁴³

Our examination of documentation contained in the health records of patients with hip fractures and interviews with their caregivers confirmed that the industry is struggling with health information systems in flux. From providers at tertiary-level acute care hospitals to solo practitioners, each approached the documentation of transitional care differently using different systems; sometimes an entirely paper record, but most often a hybrid of paper and electronic information systems. Others have noted the danger of maintaining such parallel systems.^44,45

Combinations of paper and electronic (or hybrid) medical documentation systems are a common phenomenon as financially constrained health-care systems slowly adopt EMRs.⁴ As with Hamilton et al.,⁴⁶ we found different sources and versions of the same data in both types of records. Each documentation mode held unique information; providers developed considerable skill in tracking down that information for transitioning patients.⁴⁶ No one clinician took responsibility for transitional care, thus a patient’s safety was dependent upon accurate, complete summary information being available. However, few organisations utilised clinician order entry and decision support that are believed by some to be instrumental in improving the management of patient information and care quality.⁴⁸ There was considerable heterogeneity in EMR applications across health-care organisations and settings consistent with previous studies.⁴⁹ This and the hybrid systems observed in this study were heavily reliant upon human intervention and duplicative practices and did not always support principles of effective care transitions.⁶

Few standards or guidelines on minimum transitional data elements were evident in this study. Health records examined for this study were universally rather loosely organised and generally structured by discipline, that is, physician orders, nurses’ notes, and laboratory results. This approach perpetuates the disciplinary silos that have interfered with effective communication between health-care professionals in the past⁵⁰ and is counter to the notion of interdisciplinary, patient-centred, and integrated care, which is expected to sustain systems in the future.⁵¹ Health-care professionals in this study valued their role as autonomous professionals and many rankled at the standardisation required when digitising health-care documentation.⁵²

Our study of transitional documentation and processes revealed a rather chaotic system of information flows between organisations. These consisted of some standardised paper forms, transcribed information used to initiate patient services or transfer care, and copies of historic care events such as discharge summaries and medication records. Some records of care contained key information with value in the short to medium term; however, many of the documents had time-limited value and if not available to providers immediately lost much of their power and ability to influence clinical decision-making. In short, they added ‘noise’ and volume to medical records but offer little other than historic or legal value. Because of these shortcomings, the providers we observed often devised their own methods to accommodate inefficiencies, manoeuvre the system to accommodate their communication preferences, and selectively ignore non-value-added information in order to optimise care for their patients.

Ferranti et al.⁵³ describe efforts to create a human and machine readable continuity of care record; more recent efforts have created a standardised shared summary record built on negotiated international guidelines from Integrating the Healthcare Enterprise (IHE), an organisation developing international digital standards for exchanged patient information (www.ihe.net). The desire for maximum interchange between electronic systems requires technical and clinical standards that must be negotiated and relevant to all disciplines. This process is long and costly. However, until relevant standards are incorporated into paper transfer documentation or electronic systems migrate entirely to agnostic applications that seamlessly exchange data, many of the consequences of poor inter-setting information exchange will remain.

Because there were no standardised, synoptic records of patients’ health system encounters available to those in our patients’ circles of care, it was often difficult for providers discharging them to know what, beyond the most obvious details, would be helpful information for downstream caregivers. For that reason, we observed either a feast or famine of data transferred across settings, most often at the discretion of the sender. With few exceptions, most of the care providers we interviewed were dissatisfied with the quality and quantity of information they received from a previous care provider or setting. The majority of providers interviewed advocated for the increased use of electronic information systems that would help to untether patient information from proprietary health records at each care site. This finding is contrary to common folklore that health providers are unwilling adopters of electronic information exchange.⁵⁴

Electronic systems have the capacity to provide the ‘structured flexibility’ required by professional regulators⁸ and economy of effort needed by organisations, to ensure that transfers of accountability between settings are successful for staff and the patients they serve. Accessible and comprehensive information systems allow for the sharing of appropriate data among those in the circle of care at the planning, exchange, and post-transfer stages of transitions. Yet electronic systems are far from perfect when it comes to coordinating care,⁵⁵ and their current human–computer interfaces struggle to emulate the ease and simplicity of paper records, as related by one provider in our study regarding their electronic records:

Trying to find [information] is like hating yourself every day. And that’s probably why people get frustrated and don’t do it. If they made things simple like paper – flip here, you find it. – Nurse

Most of the providers in this study had partial EMRs, thus providers had to remain familiar with both paper and electronic documentation in order to quickly locate relevant information when patients were transitioning into or out of their care. Front line staff expressed frustration at this patchwork quilt of information sources; at the least, it represented significant inefficiency of effort considering the number of patients entering and leaving organisations daily, and at worst, it represented an enterprise risk that should attract the attention of regulators and professional societies.

Conclusions

Health care is a knowledge industry,^56,57 yet much activity is focused on the collection and processing of patient information for the use of individual providers and their clinical judgments; little attention has been paid to the aggregation, synthesis, and sharing of knowledge, a process we believe has the potential to radically change our conception of optimal care. EMRs are the building block for improving shared knowledge and have enormous potential to improve care transitions,^58,59 yet key barriers to widespread adoption of seamless electronic information sharing continue to exist: lack of standards, high costs of implementation and maintenance, a weak business case for adoption by community physicians, privacy concerns, and ongoing questions of legal liability.⁶⁰ Providers, organisations, and policymakers must critically examine the total costs of owning partially implemented electronic information systems; on people, systems, accuracy, and workflows. Coiera⁶¹ goes so far as to suggest that an orderly process of apoptosis, or orderly death, should be applied to legacy information systems that increasingly constrain innovation. An honest assessment of enterprise and patient risk, and lost opportunities for efficiency and care quality, might expedite the implementation of truly interoperable systems in the Canadian health-care system and elsewhere. Liberating patient information to make it readily available to providers within a patient’s circle of care will facilitate care continuity. Furthermore, it may bring about a shift that enables downstream care providers to control the amount, timing, and content of information they receive, thereby diminishing ‘information chaos’ (p. 746).⁶² Finally, it may substantially improve productivity by providing the ‘right information at the right time in the right context’,⁶³ which is crucial to improving care continuity for patients with complex health-care needs, such as older patients with hip fractures.

Footnotes

Acknowledgements

The authors gratefully acknowledge the support of the InfoRehab research team members who contributed to this study, and the patients, their caregivers, and providers who graciously shared their experiences with them.

Funding

This study was supported by an Emerging Team Grant from the Canadian Institutes of Health Research (grant no. ETG 92249).

References

Woodward

What is important to continuity in home care? Perspectives of key stakeholders. Soc Sci Med 2004; 58(1): 177–192, http://linkinghub.elsevier.com/retrieve/pii/S0277953603001618 (accessed 19 August 2010).

Reid

Wagner

. Strengthening primary care with better transfer of information. CMAJ 2008; 179(10): 987–988.

McLeod

McMurray

Walker

. Care transitions for older patients with musculoskeletal disorders: continuity from the providers’ perspective. Int J Integr Care 2011; 11.

Smith

Araya-Guerra

Bublitz

. Missing clinical information during primary care visits. JAMA 2005; 293(5): 565–571, http://www.ncbi.nlm.nih.gov/pubmed/15687311

Cohen

Hilligoss

. Handoffs in hospitals: a review of the literature on information exchange while transferring patient responsibility or control. 2009, http://hdl.handle.net/2027.42/61522

Snow

Beck

Budnitz

. Transitions of Care Consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College Of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med 2009; 4(6): 364–370, http://www.ncbi.nlm.nih.gov/pubmed/19479781 (accessed 25 June 2010).

Hellesø

Lorensen

Sorensen

. Challenging the information gap–the patients transfer from hospital to home health care. Int J Med Inform 2004; 73(7–8): 569–580, http://www.ncbi.nlm.nih.gov/pubmed/15246037 (accessed 18 August 2010).

Tregunno

Transferring clients safely: know your client and know your team. College of Nurses of Ontario in partnership with the Ontario College of Pharmacists and College of Physicians and Surgeons. Toronto, Canada. http://www.cno.org/Global/docs/policy/TransferringClientsSafelyApril2009.pdf

Kane

RL.

Finding the right level of posthospital care – ‘We didn’t realize there was any other option for him’. JAMA 2011; 305(3): 284–293.

10.

Schrag

Donaldson

. The cancer treatment plan and summary: re-engineering the culture of documentation to facilitate high quality cancer care. In: Hewitt

Banz

(eds) Implementing cancer survivorship care planning: workshop summary. Washington, DC: National Academies Press, 2007, http://doi.wiley.com/10.1002/pon.1237

11.

Leaf

Homel

Factor

. Relationship between ICU design and mortality. Chest 2010; 137(5): 1022–1027, http://www.ncbi.nlm.nih.gov/pubmed/20081100 (accessed 28 June 2011)

12.

Hollingsworth

Chisholm

Giles

. How do physicians and nurses spend their time in the emergency department? Ann Emerg Med 1998; 31(1): 87–91.

13.

Leatt

Pink

Guerriere

. Towards a Canadian model of integrated healthcare. Healthc Pap 2000; 1(2): 13–35.

14.

Hofmarcher

Oxley

Rusticelli

. Improved health system performance through better care coordination. OECD Health Working Papers 2007; 30, http://www.oecd.org/dataoecd/35/11/30455292.pdf

15.

Ham

De Silva

. Integrating care and transforming community services: what works? Where next? HSMC Policy Paper 5, University of Birmingham, Birmingham, UK, September 2009.

16.

Stiell

Forster

Stiell

. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ 2003; 169(10): 1023–1028.

17.

Van Walraven

Taljaard

Bell

. Information exchange among physicians caring for the same patient in the community. CMAJ 2008; 179(10): 1013–1018.

18.

Anderson

Helms

. Home health care referrals following hospital discharge: communication in health services delivery. Hosp Health Serv Adm 1993; 38(4): 537–555, http://www.ncbi.nlm.nih.gov/pubmed/10130612

19.

Arora

Farnan

. Care transitions for hospitalized patients. Med Clin North Am 2008; 92(2): 315–324, viii, http://www.ncbi.nlm.nih.gov/pubmed/18298981 (accessed 14 October 2010).

20.

Kergoat

M-J

Latour

Julien

. A discharge summary adapted to the frail elderly to ensure transfer of relevant information from the hospital to community settings: a model. BMC Geriatr 2010; 10(1): 69, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2955597&;tool=pmcentrez&rendertype=abstract

21.

Rodrigues

RJ.

Information systems: the key to evidence- based health practice. Bull World Health Organ 2000; 78(11): 1344–1351.

22.

Young

Chaney

Shoai

. Information technology to support improved care for chronic illness. J Gen Intern Med 2007 22(Suppl.3): 425–430.

23.

Institute of Medicine.Crossing the quality chasm: a new health system for the 21st century. Washington, DC, 2001, http://www.nap.edu

24.

Schoen

Osborn

Doty

. A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences. Health Aff 2009; 26(6): w1171–w1183.

25.

College of Family Physicians of Canada. National physician survey. Mississauga, ON, Canada, 2010, http://nationalphysiciansurvey.ca/wp-content/uploads/2012/05/NPS2010-National-by-Prov-Binder.pdf (accessed 7 November 2011).

26.

Simpson

Clinical outcomes in transition program for older adults with hip fracture. Outcomes Manag 2002; 6(2): 86–92, http://www.ncbi.nlm.nih.gov/pubmed/11949519

27.

Van Walraven

Taljaard

Bell

. A prospective cohort study found that provider and information continuity was low after patient discharge from hospital. J Clin Epidemiol 2010; 63(9): 1000–1010, http://www.ncbi.nlm.nih.gov/pubmed/20656194 (accessed 26 August 2010).

28.

Yin

RK.

Case study research: design and methods. Thousand Oaks, CA: SAGE, 2003.

29.

Patton

MQ.

Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA: SAGE, 2002.

30.

Hansen

MF.

Continuity of care in family practice. Part 3: measurement and evaluation of continuity of care. J Fam Pract 1975; 2(6): 439–444.

31.

RA Malatest & Associates Ltd. Primary care and family medicine in Canada: a prescription for renewal. Mississauga, ON, Canada, 2011, http://www2.cfpc.ca/English/cfpc/communications/healthpolicy/primarycareandfamilymedicine/default.asp?s=1 (accessed 8 March 2011).

32.

Bodenheimer

Coordinating care – a perilous journey through the health care system. N Engl J Med 2008; 358(10): 1064–1071. http://content.nejm.org

33.

Nugus

Greenfield

Travaglia

. How and where clinicians exercise power: interprofessional relations in health care. Soc Sci Med 2010; 71(5): 898–909, http://www.ncbi.nlm.nih.gov/pubmed/20609507 (accessed 5 October 2010).

34.

Graneheim

Lundman

. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24(2): 105–112, http://www.ncbi.nlm.nih.gov/pubmed/14769454

35.

Hsieh

H-F

Shannon

. Three approaches to qualitative content analysis. Qual Health Res 2005; 15(9): 1277–1288, http://www.ncbi.nlm.nih.gov/pubmed/16204405

36.

Coiera

Communication systems in healthcare. Clin Biochem Rev 2006; 27(2): 89–98, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1579411&;tool=pmcentrez&rendertype=abstract

37.

Canada Health Infoway Toward critical mass: moving from availability to adoption. Canada Health Infoway: Toronto, ON, Canada, 2011.

38.

Aristidou

Oborn

Barrett

. Healthcare transitions: managing across boundaries. In: The Crisis: challenges for Public Management 14th IRSPM conference, Berne, Switzerland, 2–7 April, 2010, pp.1–31.

39.

Canada Health Infoway. EHRS Blueprint: an interoperable EHR framework. Canada Health Infoway: Ottawa, ON, Canada, 2006.

40.

Canada Health Infoway. 2015: advancing the next generation of health care in Canada. 2007, https://www.infoway-inforoute.ca/index.php/resources/infoway-corporate/vision/doc_download/82-2015-canada-s-next-generation-of-health-care-full

41.

Imhoff

Webb

Goldschmidt

. Health informatics. Intensive Care Med 2001; 27(1): 179–186.

42.

Smith

Gifford

Kramer

. State e-health activities in 2007: findings from a state survey. The Commonwealth Fund: New York, 2008.

43.

Fontaine

Ross

Zink

. Systematic review of health information exchange in primary care practices. J Am Board Fam Med 2010; 23(5): 655–670, http://www.ncbi.nlm.nih.gov/pubmed/20823361 (accessed 6 October 2010).

44.

Rich

. Getting IT right. MDPulse 2008; 31–33. http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/News_and_Publications/MD_Pulse/2008/May/11-MDPulse08_sec3-IT.pdf

45.

Mikkelsen

Aasly

. Concordance of information in parallel electronic and paper based patient records. Int J Med Inform 2001; 63(3): 123–131, http://www.ncbi.nlm.nih.gov/pubmed/11502428

46.

Hamilton

Round

Sharp

Peters

. The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems. British Journal of General Practice, 53(December), 929–933.

47.

Sims-Gould

Byrne

Hicks

. Examining ‘success’ in post-hip fracture care transitions: a strengths-based approach. J Interprof Care 2012; 1–7, http://www.ncbi.nlm.nih.gov/pubmed/22251369 (accessed 12 March 2012).

48.

Halamka

JD.

Health information technology: shall we wait for the evidence?

Ann Intern Med 2006; 144(10): 775–776.

49.

Fonkych

Taylor

. The state and pattern of health information technology adoption. Santa Monica, CA: RAND Health, 2005.

50.

Conn

Lingard

Reeves

. Communication channels in general internal medicine: a description of baseline patterns for improved interprofessional collaboration. Qual Health Res 2009; 19(7): 943–953, http://www.ncbi.nlm.nih.gov/pubmed/19474415 (accessed 7 March 2011).

51.

Suter

Oelke

Adair

. Ten key principles for successful health systems integration. Healthc Q 2009; 13(sp): 16–23.

52.

Winthereik

Vikkelsø

. ICT and integrated care: some dilemmas of standardising inter-organisational communication. Comp Support Comp W 2005; 14: 43–67.

53.

Ferranti

Musser

Kawamoto

. The clinical document architecture and the continuity of care record: a critical analysis. J Am Med Inform Assoc 2006; 13(3): 245–252, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1513652&;tool=pmcentrez&rendertype=abstract (accessed 8 September 2010).

54.

Boonstra

Broekhuis

. Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions. BMC Health Serv Res 2010; 10: 231, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2924334&;tool=pmcentrez&rendertype=abstract

55.

Bates

DW.

Getting in step: electronic health records and their role in care coordination. J Gen Intern Med 2010; 25(3): 174–176, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2839327&;tool=pmcentrez&rendertype=abstract (accessed 14 February 2011).

56.

Wolfson

Health care is a knowledge industry, and should be more so.In: Gorbet

Sharpe

(eds) New directions for intelligent government in Canada papers in honour of Ian Stewart. Ottawa, ON, Canada: Centre for the Study of Living Standards, 2011, pp.249–282, http://www.csls.ca/festschrift/StewartFestschrift.pdf#page=257 (accessed 7 November 2011).

57.

Lenz

Reichert

. IT support for healthcare processes – premises, challenges, perspectives. Data Knowl Eng 2007; 61(1): 39–58, http://linkinghub.elsevier.com/retrieve/pii/S0169023X06000784 (accessed 18 July 2011).

58.

Arora

VM.

Tackling care transitions: mom and apple pie vs. the devil in the details. J Gen Intern Med 2009; 24(8): 985–987, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2710470&;tool=pmcentrez&rendertype=abstract (accessed 25 January 2011).

59.

Rudin

Salzberg

C a

Szolovits

. Care transitions as opportunities for clinicians to use data exchange services: how often do they occur? J Am Med Inform Assoc 2011; 1–7, http://www.ncbi.nlm.nih.gov/pubmed/21531703 (accessed 13 May 2011).

60.

Burton

Anderson

Kues

. Using electronic health records to help coordinate care. Milbank Q 2004; 82(3): 457–481. http://www.ncbi.nlm.nih.gov/pubmed/15330973

61.

Coiera

Why system inertia makes health reform so difficult. BMJ 2011; 342: d3693–d3693, http://www.bmj.com/cgi/doi/10.1136/bmj.d3693 (accessed 30 June 2011).

62.

Beasley

Wetterneck

Temte

. Information chaos in primary care: implications for physician performance and patient safety. J Am Board Fam Med 2011; 24(6): 745–751, http://www.ncbi.nlm.nih.gov/pubmed/22086819 (accessed 31 December 2011).

63.

Lee

Francis

. Rethinking our approach to disease management: technology and information flow considerations. Electron Healthc 2011; 9(4): 7–10.

64.

Bertakis

Azari

. Patient gender and physician practice style. Journal of Women’s Health 2007; 16(6): 859–68.