Best practices for EHR implementation: A BC First Nations community’s experience

Abstract

First Nations and other health leaders are looking to Electronic Health Records (EHRs) to improve the quality of health information, efficiency of health services, and health outcomes for Indigenous people in Canada. This study used qualitative and quantitative methods to identify the success factors in an EHR implementation at a First Nations health centre in British Columbia, Canada. The Best Practices EHR Implementation Framework (EHRIF) was used to analyze the success factor data and found that all of the success factors from the planning and implementation phases in the framework were important. Provincial and federal government commitment and collaboration with key stakeholders including a local physician champion were also critically important for the electronic medical record implementation to proceed. This study suggests the EHRIF can be used to promote successful EHR implementations in Aboriginal communities and can contribute to building health informatics expertise and capacity in First Nations communities.

Introduction

Indigenous people in Canada experience a disproportionate burden of poor health that is rooted in social, economic, cultural, and political inequality.^1,2 Underlying factors include historical and intergenerational trauma attributed to colonialism and discriminatory policies such as creation of the reserve system, forced relocation of communities, forced removal and placement of children into residential schools, and social determinants of health, the current legislative and policy frameworks, and gaps in existing federal programming.^3,4 There is also a lack of clear government accountability for provision of healthcare services for Indigenous people, which has resulted in a disconnected system of care delivered by Health Canada, on-reserve health organizations, and provincial health ministries or health authorities⁵ and fragmented, incomplete health records.

Significant gaps in the availability of health data for Aboriginal people in Canada have also been identified.^6

–10 Better data and data quality relating to use of hospital and other health services, local-level health status, and health outcomes are needed to better understand and address health and social inequities for Indigenous people. In recognition that high-quality information about First Nations (FN) people for FN people should ideally be collected by FN people, the First Nations Health Governance Centre was formed in 2010.¹¹ Its mission is to assert data sovereignty and support the development of information governance at the community level in order to improve the health and well-being of FN people living in their 634 communities across Canada. The British Columbia (BC) First Nations Health Council and First Nations Health Directors Association identified that implementation of Electronic Medical Records (EMRs) would assist FN health centres with the burden of accountability reporting, promote access to services, and address issues of fragmented health records and low levels of interoperability.¹² The BC First Nations Health Authority is working with the BC Ministry of Health and Regional Health Authorities to address the fragmentation of FN health records in 198 FN communities in BC.¹³

The Best Practices EHRIF

While the opportunities associated with Electronic Health Record (EHR) use are widely recognized, there are many barriers to implementation and reports of failed implementations.¹⁴ The Best Practices EHR Implementation Framework (EHRIF) was developed to promote greater success in HIS implementations (Figure 1).¹⁵ It was formed through the integration of several well-established information system implementation theories from the information technology, business, and organizational development literature and then validated retrospectively against 47 published reports of successful EMR implementations.¹⁵ The EHRIF identifies 17 success factors and positions them over the life cycle of the EHR implementation.

Figure 1.

Adapted best practices EHR implementation framework.¹⁵ The adapted best practices EHRIF consists of 18 success factors that have been described as important for successful EHR implementations in Aboriginal community health settings. The framework describes the approximate timing for each success factor over the life cycle of EHR implementation and categorizes each as being people-, process-, technology-, or First Nations-related. The meta-framework presents these concepts together to provide a more accurate representation of the complex nature of the interaction of these factors. EHR indicates electronic health record; EHRIF, electronic health record implementation framework.

Study purpose

The objective of this study was to validate the EHRIF in the implementation of a community EHR in a BC FN community. The study asked the following questions:

Which success factors were present and missing in the pre-implementation and implementation phases of the EHR implementation?

How do the implementation team members rate the importance of the success factors in their contribution to the EHR implementation?

Methods

A retrospective, mixed methods study was conducted to identify success factors in an EMR implementation at an FN Health Centre in BC, Canada. There are few published reports describing EMR implementation in FN communities and a qualitative method was chosen to promote collection of broad, comprehensive data. The FN community’s territory is adjacent to two cities with populations 33,000 and 9,000, and most of the FN community’s 1,000 members live within 4 km of the larger city. The FN health team consists of eight part-time staff and one health director and services are focused on home care services; child, family, and youth health; chronic disease; substance use; crisis intervention; and communicable disease. The study used purposive and snowball sampling approaches to recruit participants who were involved in the planning for or implementation of the EMR. Ethics approval was granted by the University of Victoria’s Human Research Ethics Board on December 14, 2012.

Procedure

Participants provided written consent to participate in the study. They completed a demographic questionnaire,¹⁶ a success factor importance questionnaire, and a telephone interview consisting of semi-structured and open-ended questions that asked participants to identify the presence or absence of the success factors from the pre-implementation and implementation phases of the EHRIF. Data collection began 8 months after the EHR go-live date in order to promote good participant recall of pre-implementation and implementation activities.

Data analysis

The demographic and success factor importance data were analyzed using descriptive statistics. Audio data and notes from participant interviews were transcribed electronically and coded using the EHRIF success factors to identify the presence or absence of each success factor.

Results

Participant demographics

There were six participants in the study who represented five out of the seven groups that were involved in this EMR implementation: FN Health Department manager, FN Health Department clerk, Provincial Physicians Information Technology Office (PITO) Lead; physician champion; Health Authority nurse; and the EHR vendor. Six of the participants were female and their self-rated computer proficiency was equally distributed across average, advanced, and expert categories. Most of the participants reported using an EMR to help them complete their work and EMR experience varied from less than 1 year to more than 5.

Importance of EHRIF success factors

Participants were asked to respond to the question “This factor was an important part of bringing the EMR to the Wellness Centre” using a five-point Likert scale. All of the factors were associated with EMR implementation success and most (10/14) were strongly associated with success, as described in Table 1.

Table 1.

Importance of success factors^a

Success factor	Mean^b	Median	Mode
Governance	5	-	5
Project leadership	5	-	5
Involving stakeholders	5	-	5
Choosing software	5	4	5
Selling benefits	5	-	5
Data preload and integration	4	-	-
Early planning	5	4	5
Privacy and confidentiality	5	4	5
Technology usability factors	4	4	4
Workflow redesign	5	-	5
Implementation assistance	5	-	5
Training	5	-	5
Feedback and dialogue	4	-	4
Incentives	4	-	5

^aLikert scale: 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree), 5 (strongly agree).

^bMean is rounded to the nearest value.

Interviews

Participant interviews were coded according to the success factors in the EHRIF. Definitions of these factors and sample comments are provided in Table 2, and related activities are summarized below.

Table 2.

Interview coding and participant comments

Success factor	Definition	Examples of participant comments
Governance	Concerned with mission, vision, and senior management’s activities in the management of the implementation.	“There were presentations made at Chief and Council (meetings) about what an EMR is, which was very important and they had opportunity to ask questions. We also did a (demonstration) of the EMR that we were proposing.”
Leadership	Encompasses the roles of a project manager and project champion.	See results in Table 3.
Involve stakeholders	Refers to having stakeholders understand the need and vision for the EMR and ensuring that stakeholder concerns are understood and addressed during the planning and implementation process.	“That (occurred) at what we called a ‘Current Reality’ workshop. (This) is where flip charts go on the wall, and you empty your brains onto the paper. The LPNs, RNs, the immunization nurse, (and) everyone involved in seeing the clients, (described) what they (needed) the EMR to do. (We answered the question) ‘how is the medical record tool going to best work for us; what do we need to capture?’ So it was really refining who is using it, what they needed it for, and then everything that went on those flipcharts. This was a 3-hour process.”
Privacy and confidentiality	EMR implementations must meet privacy and confidentiality requirements and provide appropriate and access.	“When we first started discussing the EMR, I know it was a huge factor for Chief and Council. They had to be reassured that health department employees would not be sharing any of the information. They were very concerned and didn’t want any community member’s information to be shared. They had to be confident, they even went as far as to ask if the system would be hacked, would someone go in and gain access to confidential health files. (The) EMR vendor had to assure Chief and Council that that was not possible and was not going to happen.”
Choose software	Represents the multi-faceted process whereby senior leaders, operational leaders, and end users come to agreement that a given EMR provides the best overall solution to address the strategic and operational challenges in the health organization.	“Yes, the goal was to (establish) clinics. The issue is a lot of the community members don’t have a family physician. So, a lot of the community members rely on the local walk-in clinics. So…Council knew that we had to do something to get support for our community members, thus the clinics came up. So that’s the goal, to get doctors in for the clinics.”
Selling benefits	Preparing for effective change management, including assessment of organizational priorities, stakeholder concerns, and end user needs.	“(The EMR benefits)…a First Nations community (because) staff aren’t always in the office together at the same time. Some of our nurses are part time, some are full-time and…there are programs that they hold out in the community. So (now we have) the ability to be able to communicate with each other, where before there was a barrier to that. Also, if the (LPN who does the prenatal program) is away, but our RN is in, (she can help) a prenatal client with questions. Now the RN can go and actually look on the EMR and see any of the notes that the LPN had in that client’s file, where before she wouldn’t have been able to help them, or she would have to go through all the paper files. Now it’s all in the EMR system.”
Data preload and integration	Includes entry of patient information into the new EMR and completion of systems integration prior to EMR implementation.	“Well for over 1,000 members, it was a few months, several months, and we still aren’t done. We type in as we go and we (often) don’t have full information on a client. We (have time to) only type in so much and then we come back (later) and update.”
Early planning	Involves the introduction of computers into the work environment and planning for technology deployment, process redesign, and addressing anticipated problems.	“We just talked about what the clinic would look like, who would need access to computers, do they need access to computers all at the same time, (when) does the printing (happen). It was basically a discussion on (how) they would (use) the computer; are they more comfortable sitting face to face with their clients and having the conversation and maybe jotting down a few notes, taking a few measurements and so on. (Or) Do they enter the information (into the computer) during the visit encounter (and enter) after the visit is done. And so it was determined we are going to enter the information while we’re visiting with the patient.”
Technology and usability factors	The ability of the technology to support users with carrying out their tasks safely, effectively, efficiently, and enjoyably.	“Well I think from what I see from staff and their fluidity of work, it’s been great. I’ve seen how they’re using the scheduling and (communicating) with each other a lot better. The scheduling of appointments for clinics and stuff flows so much better.”
Workflow redesign	The relationship between human factors, how people work, and technology.	“Yes, the workflow did change, because with the EMR, now when specific clients call in…I can send tasks to the program coordinators, and I know when they’ve gotten them. So it made positive changes for us and we communicate this way (now). With any kind of concern the client has, I can attach the note or the concern (electronically to their file).”
Implementation assistance	Helping users in the early implementation period by resolving technical issues and modifying or improving the EMR, quickly and competently.	“The service provider was (a) huge support during implementation. (They helped by) working with the staff on building the templates they needed; coming in for follow-up training if there were any issues. After go-live, there was some extra training (because) once they’re using it…things pop up. And there’s always that call-in line. This service provider has a 7 (days per week) helpline.”
Training	The action of teaching a person a particular skill or type of behaviour.	“The (staff) had opportunity to use the system and put in make-believe clients and play around with it before the trainer came in. They were provided with templates and samples for to use and then the EMR provider brought in a trainer who did classes with the staff. They would do a walk-through of the actual program and then the staff would go to their workstations and implement some of the things that she showed them, and she would be there to help them.”
Feedback and dialogue	Providing opportunities for EMR users to discuss and resolve any problems that emerge following implementation with project leaders and champions.	“They provided feedback to me about how they were using it (EMR) and how it was working. There was feedback provided to the EMR provider. If some things didn’t work, they would let her know, or give the feedback to me. As a team I think they worked well on problem solving.”
Incentives	Items that motivate or encourage the use of the EMR, including the provision of support and an environment for sharing best practices and the benefits.	“It would be the incentive that if they adopt the EMR they’re going to be able to bring a physician into their community, and have that (electronic) interface so that all of the staff at Wellness Centre have access to lab results and investigation results. So the information is readily available to be able to provide (better) quality of care to their members. I think that was the biggest incentive for them.”

Abbreviation: EMR, electronic medical records.

Governance

At the time of this study, health services governance was shared between the FN Band and Council, the Province of BC, and the Government of Canada. Chief and Council held primary authority for approval of the EMR and obtained government commitment and support in the form of human and financial resources for the EMR implementation. Regional FN leaders, representatives from the health authority, and a local primary care physician met with all three governance partners to demonstrate the EMR, discuss potential benefits and privacy issues, and obtain support for the EMR project.

Leadership

Leadership for this EMR project was shared between the FN health team, the PITO, the EMR vendor, and a local primary care physician. The FN Health Director was the central point of contact for all leadership activities and linked the other leaders to the Band Council and the health department staff. Project leaders and their roles are described in Table 3.

Table 3.

Leadership roles and activities

Leader	Role and important activities
First Nations Health Director	Brought project leaders together to develop EMR proposal. Facilitated gatherings with project partners to obtain support for EMR implementation. In collaboration with other project leaders, supported Chief and Council to understand the EMR and its potential benefits. Supported Wellness Centre staff to understand the EMR benefits and implementation process and created opportunities for staff mutual support and implementation preparations.
Health Department Nurse	Collaborated with other project leaders to develop EMR proposal. Supported Wellness Centre staff to understand EMR benefits and address fears about use of the EMR.
Physician Champion	Collaborated with other project leaders to develop EMR proposal. Promoted this EMR implementation to government officials and Chief and Council. Supported Chief and Council and Wellness Centre staff in their understanding of EMR benefits. Addressed EMR-related questions and concerns.
PITO Project Manager	Assisted Wellness Centre staff to define how the EMR would be used in their work. Assisted with development of privacy and confidentiality policies and processes. Compiled this information into the transition plan. Supported Chief and Council to understand how the EMR would be used.
Vendor Implementation Manager	Developed the EMR implementation plan. Provided consultation regarding preparation of work environments and equipment. Provided EMR training and on-site support during go-live period.

Abbreviations: EMR, electronic medical records; PITO, Physicians Information Technology office.

Involve stakeholders

Wellness Centre staff were engaged in EMR planning as soon as the decision had been made to proceed and this continued through to implementation. Activities included EMR demonstrations, discussion of potential benefits, EMR user group meetings, training sessions, FN community meetings, future state workflow planning, and data-preload activities.

Choose software

The selection was made from a pre-approved list of EMR vendors and the decision was driven by the strategic benefit of improved connectivity to the regional group of physicians who were already using the same software product.

Selling benefits

Participants identified many benefits of the EMR including more complete client and community health information, improved client care, more efficient team communication and health service reporting, and scheduling. Electronic medical record practice exercises that occurred well in advance of go-live were identified as important in helping the staff come to accept the use of the EMR.

Data preload and integration

In the pre-implementation period, staff manually entered client demographic information and uploaded certain scanned documents into the EMR. This activity took longer than anticipated and was ongoing into the post-implementation period. Lack of preloaded data on the first visit for inactive and new clients was a barrier for electronic clinical documentation.

Early planning

To prepare for the EMR, existing workstations were upgraded, new laptop computers were purchased, and the Internet service was upgraded. The PITO and vendor project managers collaborated with the health centre staff and the FN technology lead to discuss work environment adaptation for optimal EMR use.

Technology usability factors

At 8 months following go-live, most of the participants indicated that the EMR was meeting with their expectations, most notably with respect to easier scheduling and improved communication between team members. One participant indicated usability problems related to lack of preloaded data for new clients and inability to locate the client record in the EMR.

Workflow redesign

Health centre staff had meetings with the PITO and vendor project managers to discuss current workflow and plan for the future state. This led to successful adoption of the EMR, reduced use of paper, and more efficient, electronic team communication for client care.

Implementation assistance

The EMR vendor provided on-site support during the go-live period and telephone and e-mail support in the following months. Implementation assistance was also provided by the physician champion, the PITO project manager, and the regional EMR peer mentors.

Training

Health centre staff had early opportunities to learn about the EMR through regional EMR user group meetings. The vendor provided three, half-day, on-site training sessions in the 3 months leading to go-live. Staff practiced using the EMR with mock clients and pre-populated EMR templates. It was suggested that training could have been improved by scheduling the sessions closer together and planning for replacement training sessions.

Feedback and dialogue

Study participants described that Wellness centre staff provided informal EMR feedback to each other, the project team, and to other EMR users in the region. It was reported that formal meetings between project leaders and staff following implementation would have been desirable.

Incentives

The key incentives for this EMR implementation were improved clinical care (better care and connections with clients and physicians and attracting physicians to work on the clinic), more efficient workflow and health reporting, better linkages with other electronic health systems, and availability of provincial resources to assist with costs of the EMR and its implementation.

Privacy and confidentiality

Privacy and confidentiality was a highly important element in this EMR implementation and related issues were important to clarify before any other pre-implementation planning could begin.

The FN leaders and the community members had many concerns about the member information that would be stored in the EMR, including who would have access to the information, how would access be controlled, where would the information be located, and what security was in place to protect it. Information and education about health privacy requirements in provision of health services and standards of practice for health professionals was included as part of these discussions. There were multiple meetings held over several months devoted to answer questions about privacy and confidentiality. Once concerns were addressed and EMR approval was granted, the PITO and vendor project managers assisted with the development of related policies and procedures and adaptation of the work environment to ensure workstations, monitors, and printers were positioned to ensure client confidentiality.

Discussion

The EMR best practices meta-framework was found to be an accurate depiction of this EMR implementation in several ways. Fourteen of the 17 success factors from EHRIF were present and rated as important in this EMR implementation. Participants were easily able to describe experiences and provide examples of how each success factor was represented in the implementation. There was good alignment with the time period over which most of the success factors were most active, with the exception of privacy and confidentiality, where related activities occurred much earlier in the pre-implementation period.

Lessons learned

Study participants did not identify any additional factors that were missing from the EHRIF. They did identify things they would do differently next time, including the following:

Planning more time for data preload and manual entry of patient demographic information;

Scheduling more alternative training dates to support training of staff;

Dedicating more time to review workflow processes after go-live; and

Investing more time to inform the community members about the EMR and its benefits to them.

First Nations perspectives

Privacy and confidentiality emerged as the most important issue to address in order to secure approval for the EMR. This finding is not surprising when one considers the history of Indigenous people in Canada which includes the intentional destruction of families, communities, and culture, along with imposed legislation and loss of traditional lands over many generations. Clarity regarding rights of ownership, control over, conditions of access, and possession of health information were important achievements in this EMR implementation. It is therefore a recommendation that privacy and confidentiality matters be introduced early in the planning processes for HIS in FN communities and adequate resources and discussion time should be dedicated for these discussions.

Another finding relates to limited capacity of staff to participate in the EMR planning activities. Dedicated time set aside from usual work was critical to support participation, however scheduling of EMR meetings remained a challenge. Ongoing communication and creating flexible ways to participate are important considerations for FN health organizations.

Findings also suggest that the EMR would not have been implemented without the collaboration and commitment that was demonstrated between the FN community and their partners. The EHRIF does not appear to capture the importance of collaboration with other health system partners as a success factor. The governance success factor reflects the structure of a traditional medical clinic or health service organization where authority for strategic decisions tends to be centralized. The reality for most FN communities is that health governance is largely controlled by the federal government. Smaller FN communities may not have the resources or level of expertise necessary to implement the projects successfully. We propose to add a success factor entitled Collaboration and Commitment when the EHRIF is used in a FN community.

Limitations of the research

Participants may have had different perspectives on what constituted a successful EMR implementation. The EMR was indeed being used by all staff in the early post-implementation period, and participants described several intended EMR benefits that were being realized at the time of the interviews, which suggests the implementation was successful. Governing leadership was not represented in the study participant group and key perspectives may be missing from the study. Researcher bias may have been introduced into the findings because the audiotapes and notes were transcribed and coded by a single individual, the primary investigator.

Conclusions

This study found the EHRIF was valid in the context of an EMR implementation in a FN community. It identified that resolution of privacy and confidentiality issues was critically important for the EMR implementation to proceed and that collaboration with a local physician champion, and provincial and federal governments, combined with demonstrated commitment from all parties was necessary for the EMR implementation to occur.

Significance of the study

This study is focused on an EHR implementation in a BC FN community and adds to the literature relating to FN HIS implementation. It may also be the first attempt at validating the integrated best practices EHRIF in an implementation. The results of this study have the potential to assist other Aboriginal health leaders as they continue on their journey toward greater ownership and control of their health services and improvement of the health status of Indigenous people in Canada.

Footnotes

Acknowledgments

The authors respectfully acknowledge the ancestral, traditional, and unceded territory of the Syilx Nation, upon which this study was conducted.

ORCID iD

Susi Wilkinson

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