The Canadian health care system is characterized by two trends: the emergence of e-health [1, 38] and a shift from paternalistic-type medicine to a consumer-based approach [11, 39]. Today's patients can be well versed in their disease, seek information from numerous and varying sources including the Internet and have the desire to be active participants in making health care decisions . Patients are now more commonly regarded as partners in their care [41–44]. They are often eager to retrieve quality health related information on the Internet. There is a growing interest in developing innovative ways of providing access to one's personal health and medical record [6, 9, 13, 16, 19, 45, 46].
The results of this research suggest that Canadian acute care and public hospitals are moving in the direction of adopting EHRs as is indicated in Tables 2 and 3. The results suggest this is especially true in the province of Ontario from which a majority of respondents came. The high percentage of respondents from Ontario reflects a system of less centralization in Ontario than in others provinces across the country. Over half of the respondents to this study had some sort of EHR in place for between 1 – 5 years, but the EHR was not the only mechanism for recording patient data, as shown in Table 2.
A significant number of our respondents thought that their institution was on track with the rest of the country in terms of adoption of EHR. This finding supports the general trend towards adoption of this technology; however, with the national agenda of having a fully interoperable pan-Canada EHR by 2010 , it is somewhat discouraging that over 30% of institutions self-identified as being behind on adoption and implementation of EHRs. Respondents identified financial barriers as the major obstacle to implementation of EHRs. This result reflects the perception of respondents; not necessarily the percentage of the institutional budget spent on information technologies (IT); information that was not solicited in this survey.
Organizations seem to be responding even more slowly to the consumerist trend in health care, and people's desire for access to their health information. Less than 25% of participants responded that patients would like access to their full electronic health record and only 16% thought that patients would like access to their lab results. This perception is in contrast to other Canadian studies that suggest that the majority of patients and the public would like access to components of their health record . Although less than 10% of respondents thought that health care professionals would want patients accessing their full EHR, 25% did indicate that they thought patients should have access to some records such as laboratory test results
For successful wide scale adoption of new technologies like EHR, this survey highlights the need for a culture shift in the health care environment to one that better supports embracing new technologies. There were a small number of respondents who self-identified as leaders in Canada in the field of EHR. These early adopters play an important role in influencing and encouraging others in the change process. Early adopters of PHR technologies in the United States and United Kingdom, for example, have reported that the majority of participants found that accessing their health record was easy and that their medical record was complete and accurate [13, 14]. The majority of participants in that study found the information in their PHR to be understandable. Only a few respondents were concerned about confidentiality or about the possibility of learning of negative test results . These results suggest that providing people with access to their EHR is potentially less of a problem than is feared by many health care providers. It also suggests that our respondents' perceptions about patient attitudes regarding access to their PHR may not reflect what patients really want.
Our results suggest that administrators of Canadian Healthcare institutions and health care providers are still anxious about providing access to their EHR. When asked about providers' willingness to provide patient access to the EHR only very few respondents thought that providers would be eager and willing to open the record. On the other hand, when asked about patient desire to access the EHR many more respondents thought that patients would be willing and eager. Similarly, in the opinion of the health care administrators and providers, clinicians were less likely to be willing to open up the full EHR, despite the belief that patients would want access to the full record. These results are representative of the disconnect that exists between consumer desire and provider willingness. These results most likely reflect unwillingness on the part of the providers to give up "ownership" (a legal concept) of the medical record. Providers traditionally have seen the record as existing in their domain and have not fully embraced the role of custodian of the record (Wiljer D, Urowitz S, Carter A, Leonard K, Catton P. Guardians and Gatekeepers: Whose Record is it Anyways? Submitted). Recognizing this, systems can be implemented that would reduce provider/intuitional hesitation for providing patient access to the EHR. Firstly, having a mechanism in place to deal with patient anxieties that may result from viewing their record is necessary, and secondly there needs to be a refocusing of attitudes related to the understanding of EHR ownership. Traditionally, the perception has been that ownership of the record has resided with the provider or the institution , when in fact certain jurisdictions have described the provider/institution more as the custodian of information (PHIPA 54.1). A landmark ruling from the Supreme Court of Canada in 1992 (McInerney vs MacDonald) specified that patients have a right to access their personal health information. Embracing these types of changes would advance the system towards wider adoption of a ubiquitous EHR, which would in turn support readily accessible PHRs.
Due to the complex methodology for distributing the questionnaire to the broadest pool of respondents, the reported response rate may not be completely accurate. Two hundred thirteen emails were sent to CEOs of Canadian general and acute care hospitals who were asked to forward the questionnaire to others in their institutions. CEOs who were responsible for more than one hospital within a health care system only received one link to the questionnaire. There was no method for tracking the number of questionnaires that were forwarded to multiple recipients within each institution, and therefore it was not possible to calculate the actual number of surveys distributed. There were at least 3 hospitals that had multiple respondents and one respondent who completed a single questionnaire for 13 separate hospitals. Although it is possible that more than the original 213 questionnaires were distributed, we can only report an approximate response rate of 39% (83/213) calculated based on the number of surveys originally distributed and the number of unique responses returned.
As a result of the low response rate, the results from this cross sectional survey may not be representative of all Canadian acute care and general hospitals. The low number of respondents to the survey limited the authors to a descriptive analysis without making statistical inferences on the reliability of the comparisons.