Adoption of digital health records
What is adoption?
Adoption refers to healthcare providers or individuals registering as users of an electronic health record (EHR) or personal health record (PHR). Adoption is measured as the proportion of users registered or linked to a system relative to the overall target user group. This can be used to demonstrate growth over time in the adoption of an EHR or PHR system.
How is the Australian Digital Health Agency supporting adoption of My Health Record?
My Health Record provides a secure online summary of an individual’s health information. The Australian Digital Health Agency provides support and education to healthcare providers to ensure a high level of Australian healthcare organisations are connected to the My Health Record system, uploading information and educated about the benefits and clinical use of My Health Record in delivering safer and more efficient patient care.
As of August 2018, the majority of Australian general practices, pharmacies and public hospitals were connected to the system. Providers who are recognised under the Healthcare Identifiers Act are able to apply for access to the system and connect via secure conformant clinical software.
There is a range of education materials and other supporting information available to assist healthcare providers in understanding how to connect, view and use the My Health Record system.
What factors impact adoption?
The adoption of electronic health record systems is complex with many factors that either limit or support adoption of these systems. In Australia, the following factors have been highlighted as key to impacting the adoption of national shared health.
|General practitioners  reported that the factors that support adoption include whether they were offered assistance to adopt, whether the EHR will save them time in the long run and if the system allowed for better communication with the care team.|
|Specialists reported that factors that support adoption include whether EHR systems are endorsed by professional bodies as well as financial incentives.|
|Allied Health practitioners report that the key factors supporting adoption include demand from other practitioners and patients, whether they have been advised by professional bodies as well as financial incentives.|
|Individuals report that key factors that support adoption are whether they are asked by their GP to sign up, and if the EHR enables individuals to share medical information with chosen health professionals.|
For individuals, the key supporting factors for adoption related to engagement with healthcare providers, while the key limiting factor related to privacy concerns.  For healthcare providers, the key supporting factors for adoption were better communication and financial incentives, while the key limiting factors related to concerns regarding the technology and the reliability of health information. 
How have EHRs been adopted?
There is limited data available internationally on the adoption of digital health systems at a national level. In this section, some international EHR adoption examples are provided to demonstrate the variation in implementation approaches.
Hong Kong SAR has had a staged approach to implementing EHRs where the initial focus was sharing between public health systems and more recently sharing between public and private systems. The Hospital Authority (HA) began implementing their clinical management system in 1994, by the year 2000 a single electronic record existed for all patients in the HA across the 42 public hospitals and associated clinics. Hong Kong SAR’s Electronic Health Record Sharing System (eHRSS) was launched in March 2016 and is the two-way EHR sharing among public and private healthcare providers. The eHRSS requires an individual's consent to create the record. Individuals will have access to their health information via a portal in Stage 2 (currently under development) but can today complete a form to request data  Over the first 10 months of the eHRSS, more than 100,000 members of public had registered (approx. 1.4% of total population).  As of July 2018, nearly 800,000 members of public had registered (approx. 10.8% of total population). 
Singapore’s experience with EHR, which was introduced in 2012, saw significant growth in GP adoption. In the period between March 2014 and February 2015, there was a 24% rise in GP clinic adoption from 13% to 37%.  Overall, three years after launch, it was estimated that 40% of GP clinics had access to their EHR. 
At July 2015, there were 43 tertiary teaching hospitals and 292 general hospitals in South Korea. In 2015, 11.6% of South Korean tertiary teaching and general hospitals had a comprehensive EHR, and 46.5% had a basic EHR. 
In the US, adoption is reported based on the type of clinical information system that clinicians have in their practice. Certified EHRs are those that meet criteria for meaningful use which included a focus on ease of information exchange in its second stage of implementation.
In 2015, certified EHR adoption was at :
- 81% for primary care
- 74% for medical specialists
- 77% for surgical specialists
How have portals been adopted?
In this section, case studies describing national portal adoption are provided to demonstrate the variation in international implementation approaches.
General practices in New Zealand are currently implementing patient portals, with support provided by their Primary Health Organisations (PHOs). Individuals who wish to gain electronic access to their health information register via their GPs. Access to portals is generally provided at no cost to the patient however fees can be charged for the use of the functions. 
Portals can provide a summary view of the health information held in the general practice’s patient management system, including laboratory results, clinical notes and hospital discharge summaries. Over the past four years (March 2014 to March 2018) over 600,000 people, 13% of the NZ population enrolled in general practices, have registered to access a patient portal. 
There is wide variation in the size of the 34 PHOs in NZ, and all of them are supporting the uptake of portals. The number of practices within a PHO ranged from 2 to 175 and more than 58% of general practices have implemented patient portals (March 2014 to March 2018).
In Canada, evidence shows that the annual adoption rate of portals connected to EHRs is not impacted by the size of the target population.  Within the first 18 months after portal launch, the annual adoption rate was between 5 and 10% of the target population.  This rate of adoption was observed for systems within primary care organisations, whole hospitals and whole states.
The Health Information National Trends Survey (HINTS) is a US population-based health care use survey. HINTS data indicate that in 2017 over half of individuals, 52%, reported that they had been offered online access to their medical record by a healthcare provider or insurer.  Of the 52% that were offered access, over half viewed their record at least once within the past year. Nationally, this represents 28% of individuals. In addition, approximately one-quarter nationally did not view their record online in the past year. 
Analyses of the 2014 HINTS data showed the association between patient demographics and patient interest in, access to, and engagement with online patient health information or portals.  The results showed that:
- 92% of individuals felt access to their patient health information online was very or somewhat important
- 34% reported being offered electronic access to their patient health information from their healthcare provider
- 28% reported accessing their own patient health information through a secure website or mobile app and 17% accessed their information more than 3 times in the last year
Opennotes allows individuals access to their clinical notes through an online, secure patient portal and has been in operation since 2010.  From the initial study of Opennotes, patients reported an increased sense of control, greater understanding of their medical issues and better preparation for future visits.  As of June 2018, more than 25 million people had access to their notes.  It is anticipated that by the end of 2018, almost 40 million patients will have access to their notes. 
How have PHRs been adopted?
There is limited data available on the adoption of PHRs internationally. Case studies of implementation in Australia, Austria, Estonia and Sweden can be found on the international overview page, and more information about methods of participation for citizens and clinicians, and rights of individuals to control access and the content of their records can be found in the use by individual page.
Initially called the ‘dossier médical personnel’ (DMP), the PHR in France has been designed for individuals who have government health insurance in their own name (i.e. no DMP for children or non-working spouses), equating to approximately 38 million or 57% of the total population. From 2010, healthcare professionals and especially GPs were encouraged to create a DMP in order to improve the continuity of care for patients. It was projected that by the end of the third year, 9 million or 23% of the target population would have a DMP.  Five years after launch of the DMP, there were an estimated 570,000 DMPs equating to 1.5% of the target population (as of December 2015). 
On the recommendations of a national working group piloted by the French Ministry of Health, a new French Health Act was published in 2016 including a special article to support the relaunch of the DMP.  The DMP became ‘dossier medical partagé’ (with ‘partagé’ for shared) and was presented as the medical record for the coordination of care.
Following the publication of the 2016 French Health Act, the DMP project was piloted by the government health insurance. New functionalities have been developed, including the creation of DMPs by patients or at national insurance offices, as well as the creation of DMPs for all individuals covered by the government health insurance (including children and non-working spouses, increasing the target population to more than 66 million), the release of a moble app for patients to access their DMP, and the automatic population of DMPs with data from insurance claims to avoid empty DMPs.  In addition, incentives have been implemented at a national level to encourage hospitals and biology laboratories to push discharge summaries, resp. biological test results into DMPs. However, the opt-in model requested by patient associations remains in operation.
The new DMP has been tested in nine French counties where in one year, more than 500,000 DMPs have been created. In July 2018, there were 1 275 000 DMPs and the national deployment of the new DMP is planned for October 2018.
The international adoption of EHRs, PHRs and portals varies globally, and represents a significant benefit for consumers and clinicians, as well as a change in healthcare delivery processes for a range of healthcare providers.
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