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BMC Medical Informatics and Decision Making
Volume 9

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Open AccessResearch article

Access to electronic health records by care setting and provider type:
perceptions of cancer care providers in Ontario, Canada
======================================================================

Margo C Orchard1 email, Mark J Dobrow1,2 email, Lawrence Paszat1,3
email, Hedy Jiang4 email and Patrick Brown4,5 email

1. Department of Health Policy, Management & Evaluation, University of Toronto, 1 University Avenue, Suite 300, Toronto, Ontario, M5J 2P1, Canada

1. Cancer Services & Policy Research Unit, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario, M5G 2L7, Canada

1. Institute for Clinical and Evaluative Sciences, 2075 Bayview Avenue, Room G1-46, Toronto, Ontario M4N 3M5, Canada

1. Population Studies and Surveillance, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario, M5G 2L7, Canada

1. Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada

author email corresponding author email

BMC Medical Informatics and Decision Making 2009, 9:38doi:10.1186/1472-6947-9-38

The electronic version of this article is the complete one and can be
found online at: http://www.biomedcentral.com/1472-6947/9/38

Received:

18 December 2008

Accepted:

10 August 2009

Published:

10 August 2009

© 2009 Orchard et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Abstract

Background

The use of electronic health records (EHRs) to support the
organization and delivery of healthcare is evolving rapidly. However,
little is known regarding potential variation in access to EHRs by
provider type or care setting. This paper reports on observed
variation in the perceptions of access to EHRs by a wide range of
cancer care providers covering diverse cancer care settings in
Ontario, Canada.

Methods

Perspectives were sought regarding EHR access and health record
completeness for cancer patients as part of an internet survey of 5663
cancer care providers and administrators in Ontario. Data were
analyzed using a multilevel logistic regression model. Provider type,
location of work, and access to computer or internet were included as
covariates in the model.

Results

A total of 1997 of 5663 (35%) valid responses were collected. Focusing
on data from cancer care providers (N = 1247), significant variation
in EHR access and health record completeness was observed between
provider types, location of work, and level of computer access.
Providers who worked in community hospitals were half as likely as
those who worked in teaching hospitals to have access to their
patients' EHRs (OR 0.45 95% CI: 0.24–0.85, p < 0.05) and were six
times less likely to have access to other organizations' EHRs (OR 0.15
95% CI: 0.02–1.00, p < 0.05). Compared to surgeons, nurses (OR 3.47
95% CI: 1.80–6.68, p < 0.05), radiation therapists/physicists (OR 7.86
95% CI: 2.54–25.34, p < 0.05), and other clinicians (OR 4.92 95% CI:
2.15–11.27, p < 0.05) were more likely to report good access to their
organization's EHRs.

Conclusion

Variability in access across different provider groups, organization
types, and geographic locations illustrates the fragmented nature of
EHR adoption in the cancer system. Along with focusing on
technological aspects of EHR adoption within organizations, it is
essential that there is cross-organizational and cross-provider access
to EHRs to ensure patient continuity of care, system efficiency, and
high quality care.

Background

The aim of this paper was to examine perceptions of access to
electronic health records (EHRs) by different types of cancer care
providers in a wide range of care settings. The real-world
perspectives of an array of cancer care providers, including
physicians, nurses, case managers, radiation therapists, and
dieticians, provide insights on factors that may influence adoption or
use of EHRs and the integration and continuity of care. The data focus
on access within and across organizations and the completeness of
health records.

In the context of this research, Electronic Health Records (EHR) refer
broadly to the use of health information technology (HIT), including
patient health information and data, clinical decision support,
results management and central data repositories, and order entry
management technologies such as computerized physician order entry
(CPOE), to support the organization and delivery of care 1-3. The
use of EHRs to support healthcare systems internationally is evolving
and expanding. It has been suggested that these systems increase
efficiency, improve patient safety, and are associated with improved
health benefits 1 and more efficient use of physician time 4

HIT is being used to improve health system efficiency, integration,
and the patient experience in developed nations across the world 5,6
Germany, the United Kingdom, Norway, and Australia have all
established or initiated major HIT programs with varying levels of
clinician involvement 5,6 In contrast, Canada has been slower to
adopt HIT and EHRs. The 2006 Commonwealth Fund International Health
Policy Survey of Primary Care Physicians shows Canada falling behind
the UK, Germany, the Netherlands, Australia, New Zealand, and the
United States in the use of information systems to support patient
care 6. Canadian primary care physicians report lower rates of EHR
use for communication both within and outside of their practices.
Compared to these other countries, Canadian primary care physicians
also report lower rates of electronic test ordering and prescribing,
reduced electronic access to patient test results and hospital
records, and lower rates of the use of computerized prompts to
indicate drug safety concerns, test results, and reminders 6.
Furthermore, only 4% of Canadian primary care practices have the
technological capacities that allow for advanced clinical information
functions 7, thus leaving Canadian primary care physicians poorly
equipped to improve the management of patients with chronic disease 6.
Patient surveys echo these results. For example, only 9% of Canadian
patients can communicate with their primary care doctors by email,
compared to 20% in the US and 22% in New Zealand 8. Although the
Commonwealth Fund survey describes primary care physician adoption of
the EHR, less is known about Canada's adoption of EHR and information
technologies in other domains of healthcare, and by other types of
providers (such as nurses and pharmacists).

The province of Ontario represents one of the world's largest publicly
funded and managed health systems (e.g., $40 billion annual budget).
Despite local advances in EHR technology such as the Laboratory
Information System, emergency room access to medication profiles, the
Wait Time Information System 9, diagnostic imaging systems, and drug
information systems, 26% of physician specialists in Ontario report no
internet access in their main patient care setting, only 30% have
access to their patients' EHRs, and just 20% have an electronic
interface to other external systems for accessing or sharing patient
information 10. There is considerable variation among Ontario
hospitals in the use of information technologies, with a trend towards
higher rates of adoption in academic institutions compared to
community hospitals 11. However, this trend does not pertain to all
types or settings of care. For example, Lapinsky and colleagues
conducted a survey on intensive care units (ICUs) across Ontario and
found no relationship between ICU size or university affiliation and
IT availability 12. These inconsistent trends reflect the complexity
of issues influencing access to EHRs by types and settings of care,
supporting the need for more specific analyses of access to EHRs.

The use of EHRs in cancer systems is a case in point. Cancer systems
are a microcosm of broader healthcare systems. They represent a
diverse and complex range of delivery system entities, from academic
to community hospitals, and from comprehensive cancer centres to
community-based home care. Cancer patients receive care from a variety
of providers, including medical oncologists, radiation oncologists,
surgeons, radiation therapists, social workers, dieticians, and
nurses. These providers work in many different types of environments
and cancer patients cross boundaries both within care settings (e.g.,
from surgery, to pathology, to the systemic treatment suite, to the
radiation treatment facility) and between care settings (from the
home, to a local hospital, to a comprehensive cancer centre). In
Ontario, cancer services are coordinated centrally by the provincial
cancer agency (Cancer Care Ontario), organized regionally by 14
regional cancer programs, and delivered locally by more than 80
hospitals, 14 Community Care Access Centres and numerous organizations
providing community care services 5.

EHRs for cancer services can include computerized physician order
entry (CPOE), diagnostic information systems, scheduling systems, and
patient portals that can play a critical role in improving service
integration and continuity of care 13,14. While Ontario currently
lacks system-wide EHR infrastructure or capabilities, relying on a
number of institution-specific systems, the cancer system is
developing tools and information systems to help increase the use of
EHRs in the province. For example, 62% of all systemic treatment
visits are supported by CPOE and 43% of lung cancer patients complete
a web-based symptom screening tool when they visit the cancer centre 15.
However, with the complex context for cancer services, little is known
about cancer care providers' access to organizations' existing EHRs or
the completeness of these EHRs across the many care settings in the
province.

Along with evidence that an EHR improves efficiency, patient safety,
and health outcomes 1, there is also evidence that an EHR can
improve functional and clinical integration 16,17 Having an EHR that
is accessible to providers across multiple facilities (including
access to online appointment scheduling, and HIT innovations to
improve access to information) is an important part of improving
cancer system performance 18. Although this requires the
participation of more than just physicians, the collaborative
multi-professional requirements for EHRs are often overlooked 19.
For example, CPOE involves nurses, pharmacists, physiotherapists,
radiologists and laboratory technicians 20 and requires that each of
these groups have access to the technology before it can be used
efficiently. Although communication should be bi-directional, a study
of Dutch physicians, nurses, and pharmacists found that these groups
only used CPOE for one-way communication 19. In reality, a physician
or nurse enters the drug order, a pharmacist checks the dose and
processes the order, and then returns a medication sheet and the
prepared dose to the nurse for dispensing 20. CPOE allows for
centralized decision-making and streamlined communication between
groups 21, however unless all of the providers involved have access
to the technology, the benefits of CPOE and other EHR-supported tools
cannot be achieved.

This research aimed to determine the real-world perspectives of an
array of cancer care providers in a wide range of care settings. More
specifically, we wanted to explore the relationship between provider
type, location of work, and level of access to a computer/the
internet, and cancer care providers' perceptions of health record
completeness and access to patient EHRs (both within and across
organizations).

Methods

As part of a larger survey, cancer care providers and administrators
were surveyed for their perceptions regarding access to EHRs, access
to computers, and access to the internet. The Cancer Services
Integration (CSI) Survey is an annual internet-based survey of cancer
care providers and administrators representing all 14 regional cancer
programs in Ontario 22,23 Regional cancer programs in Ontario are
responsible for coordinating cancer services across multiple service
provider organizations within geographically defined and mutually
exclusive regions. A list of cancer care providers and administrators
was compiled using the Canadian Medical Directory, Cancer Care
Ontario's list of clinical and administrative cancer program leaders
and direct contact with individual hospitals and Community Care Access
Centres. For the 2008 survey, all identified cancer care providers and
administrators in the province (n = 5663) were sent an email
invitation with a web link to the online survey. Up to three email
reminders were sent to non-responders over a three week period. Survey
responses were captured electronically at the time of response and
were subsequently downloaded for analysis. Only data for cancer care
providers (N = 1247) were included in the analysis.

The three questions considered in the analysis were: 1) I have access
to my organization's electronic health records for the cancer patients
that I am responsible for; 2) I have access to other organizations'
electronic health records for the cancer patients that I am
responsible for; 3) Health records (either paper or electronic) for
the cancer patients I am responsible for are usually complete.

Descriptive summary statistics were tabulated for respondent
characteristics. For univariate comparisons, responses for the three
questions were dichotomized as positive ('strongly agree', or 'agree'
from Likert scale) or negative (all other valid responses).
Proportions were calculated for all positive and negative responses
for each question.

A multilevel logistic regression model was fit for each question to
assess the marginal contribution of each variable. A random effect
term was included at the region level to account for clustering of
respondents within regional cancer programs. Consideration of
respondent clustering within regions was important as regional cancer
programs were at varying stages of development at the time of the
survey. A separate model was created for each of the three questions
as follows:

Yij is the response from respondent j in region i, Xij is a vector of
covariates for this respondent, β is a vector of regression
coefficients, Ui is the region-level random effect, and σ2 is the
variance of this random effect. Missing and 'not applicable' responses
were excluded. Self-identified respondent position/role (profession),
primary location of work, and access to computer or internet were
included as covariates in the model representing possible confounders
in the Xij term. The reference groups for each variable were assigned
as follows: position/role = surgeons; primary location of work =
teaching hospital with cancer centre; computer access = access to
computer and the internet. These reference groups were generally
chosen to be the largest groups, to minimize correlation between
estimated parameters. For profession, surgeons were chosen as the
reference group because they work in more varied care settings
compared with the other professions. Odds ratios and their 95%
confidence intervals were calculated for each variable and a p-value <
0.05 was considered statistically significant.

The software SAS 9.1 (SAS Institute, North Carolina, US) was used for
performing descriptive and univariate analyses. The SAS procedure
GLIMMIX was used for model fitting and estimation; random effects were
normally distributed, a Dual Quasi-Newton optimization technique was
used; and the estimation method was residual log pseudo-likelihood 24.

Results

Respondent characteristics

Of 5663 email invitations distributed, a total of 1997 (35%) valid
responses were collected. Because we wanted to capture the
perspectives of cancer care providers, the administrator responses (n
= 750) were not included in the analysis.

Overall, 23% of physicians and 36% of other clinicians participated in
the survey. A similar pattern of response rates was seen in the 2007
CSI survey 22. The distribution of demographic characteristics of
respondents included in the sub-analysis is shown in Table 1.
Non-responders and responders were comparable on two key
characteristics, region and profession. Regionally, non-responders and
responders differed minimally, while non-responders were more likely
to be physicians. Questions 1, 2, and 3 had 10%, 11%, and 9% missing
data respectively.

Table 1. Distribution of respondent characteristics

Question-specific responses

A summary of positive responses for each question is shown in Table 2.
Overall, 80% of respondents indicated that they had good access to
their organization's EHRs ('agree' or 'strongly agree'). In contrast,
participants reported unfavourable access to other organizations' EHRs
(22% reporting good access). Approximately half of respondents
indicated that their organization's paper or electronic health records
were usually complete (Table 2).

Table 2. Summary of question responses

Multilevel logistic regression model

Table 3 summarises the results from the mixed model fit to each of the
three questions. The respondent's self-identified profession and
primary work location had varying impact on the proportion of
individuals most likely to respond favourably to the three questions.
To validate the findings, we analyzed respondents' access to a
computer and the internet which we anticipated would be related to
favourable EHR access. As anticipated, having access to a computer or
the internet was associated with significantly better odds of
reporting good access to EHRs (both within and outside their
organization) and complete health records, thus providing a face
validity check.

Table 3. Results of multilevel logistic regression model

Perceptions of access to own organization's EHRs

Compared to surgeons, nurses (OR 3.47 95% CI: 1.80–6.68, p < 0.05),
radiation therapists/physicists (OR 7.86 95% CI: 2.54–25.34, p <
0.05), and other clinicians (OR 4.92 95% CI: 2.15–11.27, p < 0.05)
were significantly more likely to report good access to their
organization's EHRs. There was no significant difference between
surgeons and medical oncologists, radiation oncologists, other
physicians, or case managers. Respondents who did not report good
access to a computer were statistically less likely to report good
access to their own organization's EHRs compared to individuals who
reported having access to a computer and the internet (OR 0.29 95% CI:
0.19–0.45, p < 0.05). In terms of location of work, individuals who
worked in community hospitals were half as likely as respondents who
worked in teaching hospitals with a cancer centre to report good
access to their own organization's EHRs (OR 0.45 95% CI: 0.24–0.85, p
< 0.05).

Perceptions of access to other organizations' EHRs

Medical oncologists were more than twice as likely as surgeons to
report good access to other organizations' EHRs (OR 2.36 95% CI:
1.14–4.87, p < 0.05) while other physicians (such as
gastroenterologists, hematologists, and radiologists) were almost two
times as likely as surgeons (OR 1.80, 95% CI: 1.05–3.07, p < 0.05).
Although not statistically significant, radiation oncologists, nurses,
and case managers all reported higher odds of having access to other
organizations' EHRs. Respondents who did not have good access to a
computer were half as likely to report good access to other
organizations' EHRs compared to individuals who reported good access
to a computer and the internet (OR 0.56 95% CI: 0.38–0.83, p < 0.05).

In terms of location of work, individuals who worked in
community-based care settings were six times less likely than
respondents who worked in teaching hospitals with a comprehensive
cancer centre to report good access to other organization's EHRs (OR
0.15 95% CI: 0.02–1.00, p < 0.05). Similarly, respondents in community
hospitals that did not contain a comprehensive cancer centre were 1.5
times less likely than respondents in teaching hospitals with
comprehensive cancer centres to report good access to other
organizations' EHRs (OR 0.62 95% CI: 0.39–0.99, p < 0.05).

Perceptions of health record completeness (either paper or electronic)

Respondent profession did not influence perception of health record
completeness. However, good access to a computer and the internet was
associated with better health record completeness. Respondents who did
not have good access to a computer or the internet were 2.5 times less
likely to report that their organization's health records were
complete than respondents who had good access to both a computer and
the internet (OR 0.40 95% CI: 0.30–0.55, p < 0.001). Respondents who
did not have good access to the internet (but did have good access to
a computer) were two times less likely to report that their health
records were complete (OR 0.53 95% CI: 0.28–1.0, p = 0.05). Perceived
completeness of health records also varied depending on the
respondent's location of work. Respondents working outside of teaching
hospitals (such as community-based care settings or community
hospitals) were more likely to report that their health records were
complete. For example, respondents in community hospitals were 1.5
times as likely to report that their health records were usually
complete compared to respondents in teaching hospitals with a
comprehensive cancer centre (OR 1.47, 95% CI 1.01–2.13, p < 0.05).

Discussion

Using a multilevel model, this study demonstrates statistically
significant variability in access to EHRs across the Ontario cancer
system. Cancer care providers report variation in access to EHRs both
within and across their organizations. For example, although 80% of
respondents reported that they had good access to EHRs at their own
organization, only 22% reported having good access to other
organizations' EHRs. Cancer care providers also reported variation in
perceived access to EHRs and in the completeness of health records
across provider and organization types.

Access to a computer and the internet

Respondents that did not report good access to a computer or the
internet reported poorer access to EHRs and less complete health
records than those who reported good access to both a computer and the
internet. This provides face validity and is an indication that basic
information technology access is associated with more complete health
records. This also suggests that investments in HIT could result in
better and more complete patient health records.

Variation by provider type

Although good access to computers and the internet is necessary to
support the application of EHRs within and across organizations, these
data indicate that there is varying access to EHRs across provider
types, even for providers working within the same institution. For
example, radiation therapists are six times more likely to report good
access to their patients' EHRs than radiation oncologists. Because in
Ontario, they are limited to working at comprehensive cancer centres
with radiation treatment equipment/facilities, both radiation
oncologists and radiation therapists interact with the same types of
patients in the same settings. Although it is possible that radiation
oncologists could delegate computer-related tasks to radiation
therapists or nurses, therefore having potentially less need to access
EHRs, the survey question addressed perceived access to EHRs (rather
than actual use). This means that respondents who did not actually use
EHRs (e.g., because they were delegating tasks to others) could still
respond favourably to the question if they perceived the EHR system to
be functioning well. Therefore, it is possible that the EHR needs of
radiation oncologists and radiation therapists differ and that their
perceptions of access actually refer to specific EHR/HIT systems which
these data do not reveal. In general, non-physician providers report
better access to their own organization's EHRs than physicians. This
could be due to different applications of EHRs. For example, radiation
therapists may only use EHRs within their unit of the hospital,
whereas radiation oncologists may need access to EHRs for patients
referred from community care settings, particularly following surgery
or systemic treatment, which are provided in a wider range of health
care settings.

There is also variation among provider types in terms of perceived
access to EHRs outside of their organizations. For example, medical
oncologists and other physicians (such as gastroenterologists,
hematologists, and radiologists) were approximately twice as likely as
surgeons to report good access to EHRs outside of their organization.
It is possible that physicians such as medical oncologists interact
more directly with patients in other hospitals (such as systemic
treatment outreach clinics), and so have a more direct need to access
the EHRs of these patients.

In summary, nurses, radiation therapists/physicists and other
clinicians were more likely than surgeons to report good access to
EHRs within their organization, whereas medical oncologists and other
physicians were more likely than surgeons to report good access to
other organizations' EHRs. Because individual providers have different
needs for and applications of EHRs, some variation between provider
types is expected. However, it is unclear how much variation is
appropriate. It is clear that EHRs can increase collaboration among
care teams 25 but before they can contribute to increased
effectiveness and efficiency, further consideration is needed to
balance accessibility and privacy concerns. If placed in the wrong
context, EHRs could have little benefit in improving quality of care,
while reducing privacy of patient information 26. Likewise, if not
all of the relevant team members have access to EHRs, this could have
a negative impact on integration and continuity of care.

Variation by location of work

Providers working in community hospitals and those providing
community-based care report poorer access to EHRs both within their
organization and across organizations. Similar trends have been
reported in administrator-based surveys 11. It has been suggested
that larger teaching hospitals have better HIT support and in-house
capabilities to share and exchange data 27. Lower HIT- and
EHR-capabilities at community-based organizations may promulgate
fragmented care and could have implications for continuity of care and
system efficiency.

The results also indicate that it is possible for cancer care
providers to have good access to EHRs internally, but at the same time
have poor access externally. For example, individuals who worked in
community-based care organizations were as likely to report good
access to their internal EHRs as those in teaching hospitals, but were
significantly less likely to report good access to EHRs outside of
their organization. Because home care requires interaction with the
acute and outpatient care sectors, this lack of external connectivity
could have implications for integrated service delivery and
efficiency. This also indicates that even though an organization may
be "wired" and have internal access to EHRs, it may not have access to
the patient health records from other organizations, even if these
organizations are also electronic-based. Reasons for these
cross-institutional barriers to the sharing of EHRs could include
privacy issues and software heterogeneity or lack of cooperation due
to competitive or political issues. It should be noted that despite
the fact that community hospitals and community-based care providers
are less likely to report good cross-institutional access to EHRs,
they are more likely to report that their health records are complete
than teaching hospitals. This could partly be due to variations in
perception and expectations, as well as the relatively smaller size
and complexity of cases at these centres compared to teaching
hospitals.

Limitations

A number of limitations associated with this research should be
considered. First, the response rate for this study was low. However,
the response rates obtained are common in surveys of clinicians 28.
In addition, the survey essentially represented the full population,
rather than a sub-sample, of cancer care providers in Ontario.
Furthermore there was little difference in the distribution of
respondents and non-respondents in terms of region, profession, and
organization type.

A second limitation of the research is the delivery method. The
internet survey delivery method required that respondents have access
to a computer, thus potentially biasing the results. However, in our
numerous interactions with provider organizations during the survey
development phase of the project, concerns that specific provider
groups would be disenfranchised due to the survey method were not
expressed. In addition, in the 2007 CSI survey, less than 3% of the
original sample was excluded because of lack of email or computer
access.

A third limitation is that there was potential for respondents to
misinterpret the survey questions. For example, the questions do not
differentiate between perceived access and actual access to EHRs, nor
do they differentiate between easy and difficult access. Likert scale
questions are based on perception, and their interpretation is
complex. Although it is possible that some provider types may have
interpreted these questions differently than others, problems of
interpretation of survey questions are an inevitable aspect of survey
research. In pilot testing of the survey questions, respondents did
not report any difficulty understanding or answering these questions.

Finally, there are two potential limitations regarding the
generalizability of our findings to other health system contexts.
Because this research is based on providers working in Ontario,
Canada, a publicly financed healthcare system, factors influencing the
generalizability to other types of health care systems must be
considered. However, many aspects of health services integration,
including informational continuity, have been shown to be consistent
across system types, thereby reducing this concern 22. The focus on
cancer care and the exclusion of primary care providers may also limit
the generalizability of the findings. However, there has been
considerable research exploring primary care access to EHRs 6,8. and
the current research fills a gap in identifying access to EHRs by a
range of providers across the cancer system.

Conclusion

This study explored the perceptions of EHR access by a wide range of
cancer care providers covering diverse cancer care settings. Although
cancer care providers in Ontario generally report good access to EHRs
within their organizations, gaps remain in access to EHRs from other
organizations. This emphasizes the fragmented nature of EHR adoption
and cross-communication in cancer systems. Along with focusing on EHR
implementation within isolated organizations, it is essential that
there is cross-institutional and cross-provider communication to
ensure patient continuity of care and system efficiency. Similarly,
reported completeness of health records, a possible indicator of the
quality of EHRs, varies across organization and provider-type.
Organizations and providers that report poorer access to EHRs also
report poorer completeness of health records, indicating that there
may be an association between access to EHRs and the completeness of
health records.

There are a number of potential solutions that could help to ensure
consistent and coherent EHR adoption. For example, a health system
could begin developing interoperability standards for consistent and
compatible EHR formats. A similar process of developing standards for
EHR implementation is underway in Europe 29. The ability for
providers to communicate with a common EHR system is especially
important for cancer care, as patients frequently cross between
hospitals and other care settings. Health systems should also adopt
policy approaches to integrate EHR development. For example, the
European Union is beginning to promote electronic health action plans
and research 30. Recently, Ontario has developed a coordinated
e-Health strategy and is focusing on using HIT to improve patient
care, access, and safety 31. Similarly, Canada Health Infoway is
working at the national level to accelerate the use of EHRs across the
country 32. By providing political pressure for consistent and
standard EHR adoption, health systems will be better equipped to
communicate both within and across organizations. Finally, further
research is required to identify provider-specific gaps in EHR access
and factors influencing cross-organization EHR access.

This study provides a baseline view of EHR access for cancer care
providers in a large healthcare system. There are a number of
challenges to the adoption of EHRs 33 but by understanding the
current differences in access by provider type and care setting, we
can begin to explore barriers to implementation and solutions to
improve continuity of care for patients. This knowledge will be
essential for exploring current uptake, applications, and gaps in the
use of EHRs across healthcare systems.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

MJD and LP helped to conceptualize the study. MJD, LP and MO
participated in the design and conduct of the survey. PB and HJ
performed the statistical analyses. MO wrote the initial draft of the
manuscript, which all authors reviewed and provided feedback. All
authors read and approved the final manuscript.

Acknowledgements

The authors acknowledge exceptional support for the project from
cancer care providers and administrators representing regional cancer
programs, hospitals, community care access centres and public health
units across Ontario. Funding for this project was provided by grant
RC1-1071-06 from the Canadian Health Services Research Foundation with
matching funds provided by Cancer Care Ontario.

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