Experiences and Outcomes of Using e-Prescribing for Opioids: Rapid Scoping Review.

BACKGROUND: e-Prescribing is designed to assist in facilitating safe and appropriate prescriptions for patients. Currently, it is unknown to what extent e-prescribing for opioids influences experiences and outcomes. To address this gap, a rapid scoping review was conducted. OBJECTIVE: This rapid scoping review aims to (1) explore how e-prescribing has been used clinically; (2) examine the effects of e-prescribing on clinical outcomes, the patient or clinician experience, service delivery, and policy; and (3) identify current gaps in the present literature to inform future studies and recommendations. METHODS: A rapid scoping review was conducted following the guidance of the JBI 2020 scoping review methodology and the World Health Organization guide to rapid reviews. A comprehensive literature search was completed by an expert librarian from inception until November 16, 2022. Three databases were electronically searched: MEDLINE (Ovid), Embase (Ovid), and Scopus (Elsevier). The search criteria were as follows: (1) e-prescribing programs targeted to the use or misuse of opioids, including those that were complemented or accompanied by clinically focused initiatives, and (2) a primary research study of experimental, quasi-experimental, observational, qualitative, or mixed methods design. An additional criterion of an ambulatory component of e-prescribing (eg, e-prescribing occurred upon discharge from acute care) was added at the full-text stage. No language limitations or filters were applied. All articles were double screened by trained reviewers. Gray literature was manually searched by a single reviewer. Data were synthesized using a descriptive approach. RESULTS: Upon completing screening, 34 articles met the inclusion criteria: 32 (94%) peer-reviewed studies and 2 (6%) gray literature documents (1 thesis study and 1 report). All 33 studies had a quantitative component, with most highlighting e-prescribing from acute care settings to community settings (n=12, 36%). Only 1 (3%) of the 34 articles provided evidence on e-prescribing in a primary care setting. Minimal prescriber, pharmacist, and clinical population characteristics were reported. The main outcomes identified were related to opioid prescribing rates, alerts (eg, adverse drug events and drug-drug interactions), the quantity and duration of opioid prescriptions, the adoption of e-prescribing technology, attitudes toward e-prescribing, and potential challenges with the implementation of e-prescribing into clinical practice. e-Prescribing, including key features such as alerts and dose order sets, may reduce prescribing errors. CONCLUSIONS: This rapid scoping review highlights initial promising results with e-prescribing and opioid therapy management. It is important that future work explores the experience of prescribers, pharmacists, and patients using e-prescribing for opioid therapy management with an emphasis on prescribers in the community and primary care. Developing a common set of quality indicators for e-prescribing of opioids will help build a stronger evidence base. Understanding implementation considerations will be of importance as the technology is integrated into clinical practice and health systems.

Correction: Uncovering Important Drivers of the Increase in the Use of Virtual Care Technologies in Nursing Care: Quantitative Analysis From the 2020 National Survey of Canadian Nurses.

[This corrects the article DOI: 10.2196/33586.].

Finding the Right Balance in Virtual Care: Insights from Canadian Physicians.

Canadian physicians' perceptions on their use of and experience with virtual care offer important insights into finding the right balance in virtual care. Using data from the 2021 National Survey of Canadian Physicians conducted by Canada Health Infoway and the Canadian Medical Association (Canada Health Infoway and CMA 2021), we explored the mix of virtual care use by physicians, satisfaction with and challenges of virtual care and other perspectives around its continued use. We discuss how these data inform and enrich some of the key recommendations put forward by Falk (2022) in this issue.

Uncovering Important Drivers of the Increase in the Use of Virtual Care Technologies in Nursing Care: Quantitative Analysis From the 2020 National Survey of Canadian Nurses.

BACKGROUND: Canadian nurses are at the forefront of patient care delivery. Although the use of digital health technologies for care delivery is gaining momentum in Canada, nurses are encouraged to integrate virtual care into their practice. In early 2020, more Canadian nurses delivered care virtually compared with 3 years ago. OBJECTIVE: This study seeks to uncover the professional characteristics of Canadian nurses accessing virtual care in 2020, understand how these characteristics differ across types of technologies, investigate whether the nurses accessing virtual care possess the skills and knowledge needed to use these technologies, and determine the important drivers of the uptake of virtual care observed in 2020. METHODS: We used data from the 2017 and 2020 National Survey of Canadian Nurses. This survey collected data on the use of digital health technologies in nursing practice. It concerned regulated nursing professionals working in different health care settings and from different domains of nursing practice. We combined the chi-square independence test and logistic regression analysis to uncover the most relevant drivers of virtual care uptake by nurses in 2020. RESULTS: In early 2020, before the declaration of the COVID-19 pandemic, nurses who delivered care virtually were predominantly nurse practitioners (135/159, 84.9%) and more likely to work in a primary or community care setting (202/367, 55%) and in an urban setting (194/313, 61.9%). Factors such as nursing designation (P<.001), perceived quality of care at the health facility where the nurses practiced (P<.001), and the type of patient record-keeping system they had access to (P=.04) had a statistically significant effect on the probability of nurses to deliver care virtually in early 2020. Furthermore, nurses' perception of the quality of care they delivered through virtual technologies was statistically associated with their perception of the skills (χ24=308.7; P<.001) and knowledge (χ24=283.4; P<.001) to use these technologies. CONCLUSIONS: This study emphasizes the critical importance of nursing designation, geographic location, and type of patient record-keeping system in predicting virtual care integration in nursing practice. The findings related to geographic location can be used by decision-makers for better allocation of digital health resources among care settings in rural and urban areas. Similarly, the disparities observed across nursing designations have some implications for the digital training of nurses at all levels of practice. Finally, the association between electronic medical record use and uptake of virtual care could accelerate the implementation of more modernized record-keeping systems in care settings. Hence, this could advance interoperability and improve health care delivery.

Socioeconomic Disparities in the Demand for and Use of Virtual Visits Among Senior Adults During the COVID-19 Pandemic: Cross-sectional Study.

BACKGROUND: The COVID-19 pandemic has limited the provision of in-person care and accelerated the need for virtual care. Older adults (65+ years) were 1 of the highest user groups of in-person health care services prior to the pandemic. Social distancing guidelines and high rates of mortality from coronavirus infections among older adults made receiving in-person health care services challenging for older adults. The provision of virtual care technologies can help to ensure continuity of care and provide essential health care services during the pandemic to those at high risk of contracting the COVID-19 coronavirus, including older adults. It is also essential to understand and address potential socioeconomic, demographic, and health disparities in the demand for and use of virtual care technologies among older adults. OBJECTIVE: The objective of this study is to investigate socioeconomic disparities in the demand for and use of virtual visits during the COVID-19 pandemic among older adults in Canada. METHODS: A cross-sectional web survey was conducted with 12,052 Canadians over the age of 16 years, selected from Leger's Léger Opinion panel from July 14 to August 6, 2021. Associations between socioeconomic factors and the demand for and use of virtual visits were tested using χ2 tests and logistic regression models for telephone visits, video visits, and secure messaging. Weighting was applied using the 2016 census reference variables to render a representative sample of the Canadian population. RESULTS: A total of 2303 older adults were surveyed. Older adults expressed the highest demand for and use of telephone visits, following by video visits and secure messaging. eHealth literacy was positively associated with the use of all 3 virtual care modalities. Higher income was negatively associated with the use of video visits (odds ratio [OR] 0.65, 95% CI 0.428-0.974, P=.03). Having no private insurance coverage was negatively associated with use of secure messaging (OR 0.73, 95% CI 0.539-0.983, P=.04), but living in a rural community (OR 0.172, 95% CI 1.12-2.645, P=.01) and being born outside of Canada (OR 0.150, 95% CI 1.041-2.173, P=.03) were positively associated with the use of secure messaging. Higher education (OR 0.078, 95% CI 0.633-0.97, P=.02) and being non-White (OR=0.054, 95% CI 0.312-0.92, P=.02) were negatively associated with the use of the telephone. CONCLUSIONS: This study found that compared to video visits and secure messaging, the demand for and use of telephone visits were more prevalent among older adults during the pandemic. The gaps between the demand for and use of video and secure messaging services remain substantial. Our results highlight socioeconomic disparities among older adults that could potentially explain this trend. Lower income and a lower education level may act as barriers for older adults in acquiring the skills and technologies necessary to use more complex solutions, such as video and secure messaging. In addition, higher eHealth literacy was found to be critical for older adults to successfully navigate all types of virtual visit technologies.

Digital Health Value Realization Through Active Change Efforts.

Digital health has massive potential in health care but has been slow to evolve in comparison to other information-intensive industries, which have more readily taken advantage of new technology. One of the key barriers has been the complex relationship between the perceived return on investment for the investor and the resulting value to patients and caregivers. Those actors who pay for technologies do not always see an appreciable return for themselves, while those actors who must apply the technology to generate value are not always incentivized to do so. This misalignment across health system payers and administrators, clinicians and patients must be better understood and addressed to help accelerate digital health. This paper will examine this challenge through the clinician experience, using empirical case examples from Canada to illustrate opportunities for change. While many factors may influence digital health adoption, this paper specifically aims to explore the shifts in the balance of the perceived value of implementing digital health tools, vs. the efforts required to adopt them. It will explore two contrasting case examples: clinical adoption of EMRs in Canada from 2009 to 2015, and clinical adoption of virtual care technologies during the COVID-19 pandemic from 2020 to 2021. In 2006, Canada lagged peer countries significantly in the adoption of electronic medical records (EMR) in community-based care. Financial support and cooperation of multiple levels of government and clinical stakeholders were required to address the misaligned incentives, which led to significant uptake by care providers. The rapid adoption of virtual care in Canada in response to the pandemic provides another relevant example of the importance of alignment among the factors of clinical workflows, clinical appropriateness, technology integration and payment models. Experts have highlighted the need for standardization, regulation, and clear policy to ensure sustainable, high quality virtual care that complements in-person care. In both cases, the costs and effort of adopting new technologies outweighed direct clinician value, requiring change initiatives to catalyze progress. This imbalance could be unique to these examples in Canada, and may not be globally generalizable to the adoption of all digital health tools. However, how change efforts can be tailored to adjust to a rapidly evolving health care workforce, spanning diverse jurisdictions and stakeholder groups will be critical to the sustainability of virtual care adoption. Furthermore, what key elements must be considered to guide change initiatives for successful implementation, designed to influence change while adding value for patients, clinicians and Canada's health care systems? Using insights from successful change initiatives past and present, this paper aims to answer these questions to enable a smoother transition to digital health innovations of the future.

Interoperable Electronic Health Records and Health Information Exchanges: Systematic Review.

BACKGROUND: As the availability of interoperable electronic health records (iEHRs) or health information exchanges (HIEs) continues to increase, there is greater need and opportunity to assess the current evidence base on what works and what does not regarding the adoption, use, and impact of iEHRs. OBJECTIVE: The purpose of this project is to assess the international evidence base on the adoption, use, and impact of iEHRs. METHODS: We conducted a systematic review, searching multiple databases-MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)-with supplemental searches conducted in Google Scholar and grey literature sources (ie, Google, Grey Literature Report, and OpenGrey). All searches were conducted in January and February 2017. Articles were eligible for inclusion if they were published in English, were published from 2006 to 2017, and were either an original research study or a literature review. In order to be included, articles needed to focus on iEHRs and HIEs across multiple health care settings, as well as on the impact and effectiveness of iEHR adoption and use. RESULTS: We included 130 articles in the synthesis (113 primary studies, 86.9%; 17 reviews, 13.1%), with the majority focused on the United States (88/130, 67.7%). The primary studies focused on a wide range of health care settings; the three most prevalent settings studied included acute care (59/113, 52.2%), primary care (44/113, 38.9%), and emergency departments (34/113, 30.1%). We identified 29 distinct measurement items in the 113 primary studies that were linked to 522 specific measurement outcomes. Productivity and quality were the two evaluation dimensions that received the most attention, accounting for 14 of 29 (48%) measurement items and 306 of 522 (58.6%) measurement outcomes identified. Overall, the majority of the 522 measurement outcomes were positive (298/522, 57.1%). We also identified 17 reviews on iEHR use and impact, 6 (35%) that focused on barriers and facilitators to adoption and implementation and 11 (65%) that focused on benefits and impacts, with the more recent reviews finding little generalizable evidence of benefit and impact. CONCLUSIONS: This review captures the status of an evolving and active field focused on the use and impact of iEHRs. While the overall findings suggest many positive impacts, the quality of the primary studies were not evaluated systematically. When broken down by specific measurement item, the results directed attention both to measurement outcomes that were consistently positive and others that were mostly negative or equivocal.

Connecting Families to Their Health Record and Care Team: The Use, Utility, and Impact of a Client/Family Health Portal at a Children's Rehabilitation Hospital.

BACKGROUND: Health care portals have the potential to provide consumers with timely, transparent access to health care information and engage them in the care process. OBJECTIVE: The objective was to examine the use, utility, and impact on engagement in care and caregiver-provider communication of a client/family portal providing access to electronic health records (EHRs) and secure, 2-way e-messaging with care providers. METHODS: We conducted a prospective, mixed-methods study involving collection of caregivers' portal usage information over a 14-month period (from portal introduction in January 2015 to the end of the study period in March 2016), a Web-based survey for caregivers administered after a minimum of 2 months' exposure to the portal and repeated 2 months later, and focus groups or individual interviews held with caregivers and service providers at the same points in time. The survey assessed caregivers' perceptions of the utility of and satisfaction with the EHR and e-messaging, and the portal's impact on client engagement and perceptions of caregiver-provider communication. A total of 18 caregivers (parents) completed surveys and 6 also took part in focus groups or interviews. In addition, 5 service providers from different disciplines took part in focus groups or interviews. RESULTS: Although usage patterns varied, the typical pattern was a steady level of use (2.5 times a month over an average of 9 months), which is higher than typically reported use. The portal pages most frequently accessed were the home page, health record main page, appointment main page, and reports main page. The Web-based survey captured caregivers' perceptions of usefulness of and satisfaction with the EHR and portal messaging, as well as the portal's impact on their engagement in care and perceptions of caregiver-provider communication. The surveys indicated a moderate degree of utility of and satisfaction with the portal features, and a low but emerging impact on engagement in care and caregiver-provider communication (survey scales measuring these outcomes displayed excellent internal consistency, with Cronbach alpha ranging from .89 to .95). Qualitative themes from focus groups and interviews supported and extended the survey findings. Caregivers and service providers saw appreciable information benefits and provided recommendations to increase portal use and utility. Caregivers focused on the scope of organizational adoption of the portal system and indicated their hopes for the future of the portal, whereas service providers were concerned about how to best manage their investment of time and effort in preparing client-friendly reports and messaging clients via the portal. CONCLUSIONS: Overall, the findings show the promise of the portal and the need for ongoing evaluation to show the portal's ultimate potential in enhancing engagement in care and communication with care providers.

Use and Maturity of Electronic Patient Portals.

This paper focuses on the adoption of electronic patient portals aimed at providing consumers with access to their own health records along with added functions aimed to improving convenience and access to care. A variety of Canadian patient portal implementations were analysed with evidence supplemented from international examples. Measures of adoption focused on active users and frequency of access. New portal implementations can achieve adoption at a rate of 5-10% of the overall population per year with larger, jurisdiction-wide deployments growing at a slower rate than smaller, more targeted deployments.

Novel Approaches to Digital Health Evaluation Capacity Building.

Exploration of the capacity for digital health evaluation in Canada reveals substantial progress, and much important evaluation work being conducted. Further progress can be achieved with innovative approaches to capacity building. Canada Health Infoway is implementing novel approaches around partnerships, resources, project integration and sharing knowledge.

The Need for Electronic Health Records in Long-Term Care.

Long-term care (LTC) settings serve an important proportion of seniors and vulnerable populations that require 24-hour nursing care. Deployment of interoperable electronic health records (iEHRs) to these settings lag. There is little evidence on the availability of patient information from across the continuum of care. To fill this knowledge gap this study examines the prevalence and nature of information gaps experienced in LTC during patient encounters (n=1050). Overall, more than one-third (34%) of all LTC patient encounters were missing at least one item of information that was needed for the encounter. Approximately 59% of missing information during patient encounters was documented or ordered by a clinician external to the LTC facility; 41% were within the LTC facility itself. These information gaps have an adverse consequence for nearly 3 out of every 10 (31%) patient encounters in LTC. Extending iEHRs to LTC has the potential to support timely, appropriate, and better quality of patient care and improve provider experience.

The value of connected health information: perceptions of electronic health record users in Canada.

BACKGROUND: As health care becomes more complex, it becomes more important for clinicians and patients to share information. Electronic health information exchange can help address this need. To this end, all provinces and territories (PTs) in Canada have created interoperable electronic health records (iEHRs). These secure systems offer authorized users an integrated view of a person's healthcare history across the continuum of care. They include information such as lab results, medications, diagnostic images, clinical reports and immunization profiles. This study explores user experiences and perceived outcomes of iEHR use. METHODS: Surveys conducted between 2006 and 2014 asked iEHR users in six Canadian PTs about system, information and service quality; iEHR use and user satisfaction; and net quality and productivity benefits. The surveys had a core set of questions that used Likert-type scales. Results were synthesized across surveys for each evaluative dimension. Consensus among researchers and subject matter experts on whether to classify the outcomes as positive, mixed/neutral, or negative was established using a modified Delphi technique. RESULTS: A total of 2316 iEHR users responded to the six surveys. Information quality was the most studied area. Results varied across PTs, but positive outcomes were more common than mixed/neutral or negative outcomes by a 19:1:1 ratio across this dimension. The next most frequently studied aspects were user satisfaction, the impact of iEHR use on quality of care, and the impact on productivity. In all three areas, there were more positive than mixed/neutral or /negative results (ratios of 13:1:1, 14:3:1, and 15:2:1respectively). CONCLUSIONS: Overall, users of iEHRs that provide secure access to patient information collated from across the health system tend to report positive outcomes, including quality of care and productivity. This study is an important first step in understanding user perspectives on iEHRs and health information exchange more broadly.

Measuring interoperable EHR adoption and maturity: a Canadian example.

BACKGROUND: An interoperable electronic health record is a secure consolidated record of an individual's health history and care, designed to facilitate authorized information sharing across the care continuum.  Each Canadian province and territory has implemented such a system and for all, measuring adoption is essential to understanding progress and optimizing use in order to realize intended benefits. RESULTS: About 250,000 health professionals-approximately half of Canada's anticipated potential physician, nurse, pharmacist, and administrative users-indicated that they electronically access data, such as those found in provincial/territorial lab or drug information systems, in 2015.  Trends suggest further growth as maturity of use increases. CONCLUSIONS: There is strong interest in health information exchange through the iEHR in Canada, and continued growth in adoption is expected. Central to managing the evolution of digital health is access to robust data about who is using solutions, how they are used, where and when.  Stakeholders such as government, program leads, and health system administrators must critically assess progress and achievement of benefits, to inform future strategic and operational decisions.

The Effects of Web-Based Patient Access to Laboratory Results in British Columbia: A Patient Survey on Comprehension and Anxiety.

BACKGROUND: Web-based patient access to personal health information is limited but increasing in Canada and internationally. OBJECTIVE: This exploratory study aimed to increase understanding of how Web-based access to laboratory test results in British Columbia (Canada), which has been broadly available since 2010, affects patients' experiences. METHODS: In November 2013, we surveyed adults in British Columbia who had had a laboratory test in the previous 12 months. Using a retrospective cohort design, we compared reported wait-time for results, test result comprehension, and anxiety levels of "service users" who had Web-based access to their test results (n=2047) with those of a general population panel that did not have Web-based access (n=1245). RESULTS: The vast majority of service users (83.99%, 95% CI 82.31-85.67) said they received their results within "a few days", compared to just over a third of the comparison group (37.84%, 95% CI 34.96-40.73). Most in both groups said they understood their test results, but the rate was lower for service users than the comparison group (75.55%, 95% CI 73.58-77.49 vs 84.69%, 95% CI 82.59-86.81). There was no significant difference between groups in levels of reported anxiety after receiving test results. CONCLUSIONS: While most patients who received their laboratory test results online reported little anxiety after receiving their results and were satisfied with the service, there may be opportunities to improve comprehension of results.

Valuing national effects of digital health investments: an applied method.

This paper describes an approach which has been applied to value national outcomes of investments by federal, provincial and territorial governments, clinicians and healthcare organizations in digital health. Hypotheses are used to develop a model, which is revised and populated based upon the available evidence. Quantitative national estimates and qualitative findings are produced and validated through structured peer review processes. This methodology has applied in four studies since 2008.

Impact of information technology on information gaps in canadian ambulatory care encounters.

BACKGROUND: Specialist physicians require clinical information for patient visits in ambulatory encounters, some of which they may access via digital health solutions. OBJECTIVE: This study explored the completeness of information for patient care and the consequences of gaps for ambulatory specialist services provided in ambulatory settings in Canada. METHODS: A sample of specialist physicians practising in outpatient clinics was recruited from a health care provider research panel. The study (n=1800 patient encounters) looked at the completeness of patient information experienced by physicians who work in environments with rich health information exchange (Connected) and a comparison cohort with less information available electronically (Unconnected). RESULTS: Unconnected physicians were significantly more likely to be missing information they needed for patient encounters (13% of encounters for Unconnected physicians vs 7% for Connected physicians). Unconnected physicians were also more likely to report that missing information had consequences (23% vs 13% of encounters). Lab results were the most common type of patient information missing for both Unconnected and Connected specialists (25% for Unconnected physicians vs 11% Connected physicians). CONCLUSIONS: The results from this study indicate that Canadian physicians commonly experience information gaps in ambulatory encounters, and that many of these gaps are of consequence to themselves, their patients, and the healthcare system. Wasting physician and patient time, as well as being forced to proceed with incomplete information, were the most common consequences of information gaps reported.

Understanding the gap between desire for and use of consumer health solutions.

Modern healthcare is more complex than ever before, with a broader range of care providers, organizations, diagnostic approaches and treatments. The result is that accurate and timely information is more important than ever. In response, clinical use of health information technology has grown significantly in recent years and there is growing interest in the use of consumer health solutions. In this article, the authors discuss the current landscape of the latter in Canada, enablers and barriers to their adoption and our readiness for change.

Measuring Maturity of Use for Electronic Medical Records (EMRs) in British Columbia: The Physician Information Technology Office (PITO).

This article examines British Columbia (BC)'s Physician Information Technology Office's efforts to measure and improve the use of electronic medical records (EMRs) by select practices in BC with an assessment of their progress using a maturity model, and targeted support. The follow-up assessments showed substantial increases in the physicians' scores resulting from action plans that comprised a series of tailored support activities. Specifically, there was an increase from 21% to 83% of physicians who could demonstrate that they used their EMRs as the principal method of record-keeping.

Knowledge translation in eHealth: building a virtual community.

Knowledge can be powerful in eliciting positive change when it is put into action. This is the belief that drives knowledge translation. The University of Victoria (UVic) eHealth Observatory is focused on deriving knowledge from health information system (HIS) evaluation, which needs to be shared with HIS practitioners. Through an application of the Knowledge-to-Action Framework and the concept of a virtual community, we have established the virtual eHealth Benefits Evaluation Knowledge Translation (KT) Community. This paper describes the foundational elements of the KT Community and our overall KT strategy.

Drug information systems: evolution of benefits with system maturity.

Benefits from information and communication technology tend to grow over time as system use matures. This study examines pharmacists' experiences with provincial drug information systems (DIS) across Canada. At the time of survey, two provinces had more mature DIS (more than five years) and three provinces had less mature DIS (five years or less).