A call for standardization of clinical content for EMRs in primary care across Canada
The Covid-19 pandemic has exposed shortcomings within the Canadian healthcare system, particularly in relation to sustainable access to high quality primary care.1 Over 50% of physicians have reported burnout double that of pre-pandemic levels and are highly likely to reduce clinical hours over the next 24 months.2 While there are many possible contributing factors and corresponding solutions, we propose that providing primary care providers with high quality, up-to-date clinical content within their electronic medical records (EMRs) is a relatively low cost and rapidly achievable goal that can improve both clinician experience and patient outcomes. Though many vendors have their own collection of EMR resources available and users often create their own templates and tools,3-5 a national, standardized library of such resources does not exist that is consumable by and available to all EMR platforms. We urgently put forward a call to address this gap and the concurrent advancement of research exploring the impact of quality clinical content in EMRs.
The use of EMRs has become widespread in Canada over the last two decades, with up to 85% of primary care physicians using an EMR as of 2017.6 Much focus has historically gone to certifying EMR products in the market to ensure core functional needs are met, such as being able to document clinical visits, viewing laboratory results, or schedule appointments. Comparatively, little attention has been given to ensuring there is equal access to high-quality clinical content within these platforms, regardless of the vendor.
Clinical content can include a broad array of configurable components within an EMR that are directly used in clinical care delivery, such as encounter templates, clinical forms, patient handouts, standardized patient questionnaires, medical calculators, or even links to reference libraries of clinical knowledge.7 We particularly call out encounter templates and patient handouts for various reasons: 1) they can introduce efficiency in clinical practice by streamlining documentation and supporting patient education efforts, 2) they offer the optimal way to incorporate clinical guidelines and to help enable clinical decision support, and 3) they are most likely to have common pathways amongst different EMRs, or in the case of patient handouts, may or may not require EMR involvement at all.
A 2021 systematic review investigated the impact of diabetes management guideline integration into EMRs on patient outcomes and found that implementation of such practices improved documentation of cardiovascular risk factors, microvascular complication screening, and vaccinations.8 With this, it has been found that an amalgamation of EMR intervention strategies can lead to improvements in achieving guideline and screening targets, thus better quality of care.8
Most EMR vendors maintain a generic database of such tools that clinics draw from, thereafter allowing users to configure these tools as required or build new ones. The responsibility is however left on individual clinics and groups to find and maintain such clinical content within the EMRs. While clinicians must be able to maintain the capability to individualize these resources as appropriate for their practice and population, the absence of a high quality database providing this service across the country remains a gap. A single organization, either an existing entity with the appropriate reach or a new one representing membership across relevant stakeholders, could maintain such a database that would be available to all EMR vendors and thus the clinical community. Such an effort would not require standardization of EMR platform functioning or any software changes; rather simply the configuration of clinical content for consistency in practice in whichever format is native to a given EMR. EMR vendors are incentivized as this offloads the liability of creating and maintaining such clinical content databases without any software modifications on their end. Furthermore, leveraging a large national body to authorize the adoption of this requirement (such as Canada Health Infoway or Digital Health Canada) will assist in compliance. In addition, looking upstream, authors producing clinical guidelines could also support knowledge translation by producing clinical content that incorporates their evidence directly to this database, as shown in Figure 1.
We propose five guiding principles for such an effort. It must 1) reflect the best evidence available 2) be pragmatic to real clinical practice 3) be scalable to all EMRs 4) be iterative and 5) be non-profit.
EVIDENCE-BASED: Such a database would require collaboration of subject matter experts across the country, which would likely be organizations that currently produce specific resources and content, or that may be working on similar efforts at a regional or provincial level. SCALABLE: The resources would need to be made available in a generic format (e.g. text documents) such that they could be easily converted into corresponding tools within the various EMRs. It is important that the effort does not mandate new software development or complex implementation criteria, but rather allow the mechanisms that different EMRs already have in place to incorporate the content organically. This will reduce friction in deployment as well as cost. PRAGMATIC: It is important that the content reflects real-life clinical practice. This may not immediately be accomplished. However, systems could be put in place, such as providing a rating system for tools and incorporating feedback as it is received. ITERATIVE: It would also need to be updated routinely to ensure the content incorporates evolving guidelines and clinical knowledge. NON-PROFIT: Lastly, such an effort should be led by a public or non-profit entity. It is imperative that the subject matter experts involved in the process do not have any conflicts of interest with other industries (for example, the pharmaceutical industry) that may influence clinical content recommendations.

Clinicians of course have the autonomy and capability of searching for and selecting the right tools that they feel are necessary to deliver the best possible care to their patients. However, making a high quality clinical content database available to all primary care providers as a baseline, regardless of their EMR, is a practical way to support care delivery at the frontlines and hopefully improve patient outcomes in return. The time is now, to act nationally in a coordinated fashion to make such a resource available and to shed further light on how clinical content within EMR systems impacts quality of care and provider experience.

Figure 1: Proposed Process Flow for Establishing a Library of EMR Resources based on our Guiding Principles
Amama Khairzad
BSc, McMaster University
MSc. eHealth, McMaster University
Ishan Aditya
BHSc, McMaster University
MD, University of Toronto
Resident Physician - Family Medicine, McMaster University
Puneet Seth
BSc, University of Ottawa
MD, McMaster University
Part-Time Assistant Clinical Professor (Adjunct)
Department of Family Medicine, McMaster University
References
1. A struggling system - Understanding the health care impacts of the pandemic [Internet]. Canadian Medical Association; 2021 [cited 2022Sep17]. Available from: https://www.cma.ca/sites/default/files/pdf/health-advocacy/Deloitte-report-nov2021-EN.pdf
2. Wright T. 'we are absolutely destroyed': Health workers facing burnout, even as COVID levels ease - national [Internet]. Global News. Global News; 2022 [cited 2022Sep17]. Available from: https://globalnews.ca/news/8889103/covid-burnout-destroyed-health-workers/
3. Digital Patient Forms: Telus Health [Internet]. TELUS Health. Telus; 2022 [cited 2022Sep17]. Available from: https://www.telus.com/en/health/health-professionals/clinics/emr-add-ons/digital-patient-forms
4. Download report by Template (RBT) - world oscar [Internet]. World OSCAR - Open Source Clinical Application Resource. 2022 [cited 2022Sep17]. Available from: https://worldoscar.org/downloads/report-by-template-rbt/
5. Medical forms software: E forms [Internet]. Accuro EMR. Accuro EMR; 2020 [cited 2022Sep17]. Available from: https://accuroemr.com/emr-software/medical-forms/
6. Canada Health Infoway. Use of Electronic Medical Records among Canadian Physicians, 2017 Update. Toronto, ON: Canada Health Infoway; 2017.
7. Wiebe N, Xu Y, Shaheen AA, Eastwood C, Boussat B, Quan H. Indicators of missing Electronic Medical Record (EMR) discharge summaries: A retrospective study on Canadian data. International Journal of Population Data Science. 2020;5(1).
8. Shah S, Yeheskel A, Hossain A, Kerr J, Young K, Shakik S, Nichols J, Yu C. The impact of guideline integration into electronic medical records on outcomes for patients with diabetes: a systematic review. The American Journal of Medicine. 2021 Aug 1;134(8):952-62.