IT in General Practice: A 10-country comparison
It is commonplace, if not universal, for general practitioners (GPs) in 10 countries around the world to use computers for clinical purposes. However, this is not yet the case in Canada, despite growing efforts to introduce information technology (IT) into our health care system. Why have GPs in other countries adopted IT to a significantly greater degree than their Canadian counterparts?

In 2005 Canada Health Infoway undertook a study to identify the contributing factors behind the high rate of IT adoption and use among GPs in 10 countries: England, Scotland, Denmark, Sweden, Norway, the Netherlands, Austria, Germany, New Zealand and Australia. Findings were based on data collected from scientific studies; reports from governments, professional associations and the Organization of Economic Cooperation and Development (OECD); and interviews with physicians and government representatives.

The study identified a number of contributing factors and reasons why GPs in these countries have more readily welcomed IT in their medical practices. These include:

• financial support from government, ranging from a one-time grant to ongoing funding tied to use of the technology for predetermined purposes
• "pay for performance" incentives or quality targets that can only be reached easily with automated records
• support by medical associations or licensing authorities
• leadership by peers
• the existence of a national IT health strategy and a unifying body
• certification of vendor systems by governments or medical associations
• change management or other support
• No single variable explains why GPs in other countries have adopted IT to such a significant degree. Clinical applications vary widely by country, and there is no single overwhelming benefit to prompt physicians to use computers for clinical care. However, electronic transmission of prescription orders and laboratory results was almost universally available.

Specific findings

Prevalence of IT in physician offices

Survey data indicate that more than 95% of GPs in nine countries have office computers that are used for clinical purposes; the exception is Germany, where an estimated 90% of GPs have such office equipment but only 40% of physicians use the computers themselves. These percentages are far higher than in Canada, where the number of physicians who report having electronic medical records or who use technology in clinical care is about 20%.

Diversity of health care funding and delivery

The 10 countries studied have diverse health care funding and delivery systems. A degree of publicly funded health care or health insurance is common, but the mix of public/private funding varies, as does the degree to which the system administration is centralized or mandated to regional authorities. The majority of GPs in these countries are private practitioners operating on a fee-for-service basis, but this is not universal. The number of physicians working alone or in group practices also varies from country to country. Accordingly, there is no single system variable that can account for why such a high percentage of physicians have adopted technology.

Predisposing factors

In some countries the innovative work of a select group of pioneering physicians is a significant factor, and in others external forces appear to have driven the adoption of IT for clinical care. Yet despite the heterogeneity of the health care systems, common factors appear repeatedly. Perhaps the most important is the involvement of the GPs themselves, either as individuals or through the organizations that represent them.

One predisposing factor that appears across most of the spectrum is the use of technology for billing and administration. In virtually all countries studied governments required GPs to install computers to bill for care provided. Once the office technology infrastructure was in place, use of the computer for clinical care applications generally followed. Even though governments have required physicians to use computers for billing, no country has required GPs to use technology for clinical care - although this is changing in some jurisdictions.

Paper-light, not paperless

Despite the widespread use of IT for at least one clinical application, physicians in all countries except Denmark and Norway continue to practice in offices where paper is predominant. And despite the proven benefits of using IT in clinical care, the transition to IT-based practices in these countries has rarely been smooth or well-planned.

Prescriptions and laboratory results

While there is wide variation in the clinical applications for which computers are used, the percentage of GPs with some automated system to requisition medications and prescriptions exceeds 90% in all 10 countries. There are many differences in how this application is used, ranging from an electronic exchange of prescribing information between the doctor's office and pharmacy, to systems in which a prescription is written electronically but printed in paper form and given to the patient. Such technology is seen as being particularly beneficial for repeat prescriptions, and addresses one of the key patient safety issues associated with prescriptions: illegible handwriting and the potential for error.

The study found that transmission of laboratory results is by far the most common electronic communication application. In all countries except Germany and Norway, at least half of all laboratory results are transmitted electronically to GP offices. Electronic communication or messaging for other purposes is still not widespread.

Other applications

Other clinical applications or benefits seen for physicians adopting IT include:

• electronic medical records (EMRs)
• communication with hospitals and other health care providers
• access to clinical information on the Internet
• quicker access to patient information such as laboratory results and hospital discharge summaries

No country studied has a full, national health care network for the electronic exchange of patient information; in Norway a national network exists, but so far it is used only to transmit accounting data. Many of the countries have local or regional electronic networks for health data, and all plan to introduce a national network in the near future.

Where Canada stands

The good news for Canada is that the factors identified in other countries as supporting the implementation and adoption of IT for clinical purposes are present in at least some provinces. And while the clinical applications used elsewhere have not been widely adopted in Canada because of the lack of the necessary infrastructure or connectivity, the benefits from having such applications are just as clear.

Current data on Canadian physicians and their attitudes toward technology comes from a survey of 1990 GPs and specialists that was conducted last year (2005) by the Canadian Medical Association and Canada Health Infoway.

In Canada electronic billing is mandatory in all provinces, with the exception of Manitoba where it will be mandated in 2007. This means that computers are already in place in most GP offices, except where physicians have outsourced this (e.g., Quebec). In addition, Canadian physicians are already aware of the benefits of using technology for administrative purposes to improve office efficiency. This makes more widespread use of clinical applications a natural next step, as has been the experience in other countries.

Most GPs in other countries are not operating paperless offices, so the Canadian experience is not so different. Even Canadian physicians who have already implemented an EMR still maintain and use paper files to communicate with other providers.

Each of the factors identified as supporting the move to an electronic environment exists in at least one province.

• The governments of Alberta, Ontario, Quebec, Nova Scotia and British Columbia have programs in place to directly compensate at least some physicians for purchasing and operating a computer system.
• Ontario and British Columbia have implemented disease management and primary care programs that pay bonuses to physicians who meet certain targets, as is the case in the United Kingdom. Realistically such targets can only be met if patient records are automated, so this serves as a significant incentive.
• Vendor accreditation systems exist in Alberta and Ontario, and work is underway to make such a system nationwide.
• National and provincial medical associations have supported the move to IT and the Canadian Medical Association has had an e-strategy in place for more than five years.
• Canada has a well-established national IT health strategy and a federally-funded body - Canada Health Infoway - with a mandate to implement that strategy.

Survey findings for Canadian physicians

The CMA/Infoway survey of Canadian physicians shows that many factors that have led GPs in other countries to adopt technology are equally important for Canadian physicians. Physicians say that improving quality and efficiency of their practices and saving time are the top two reasons why they would adopt an EMR in their practices. These are followed by many factors seen as important in other countries, such as the need for compensation and proper support.
While the ability to write electronic prescriptions exists (at least theoretically) in Canada, such applications are not widely used because of the absence of both legislation allowing electronic signatures and a network linking physicians and pharmacists. Our GPs also do not have a network that allows the electronic transmission of laboratory results to physicians working in the community - another reason why a clinical application prevalent elsewhere is not common in Canada.

However, some clinical applications - such as the use of the Internet to gather relevant clinical information for patient management - are being used by Canadian physicians, and a number of EMR systems are available and in use in Canada. Most community-based Canadian physicians who responded to the recent survey said they had access to high-speed Internet in their offices, and more than one-third of respondents said they are already communicating with colleagues by e-mail, evaluating treatment options online, and sending referral letters electronically.

Many countries are moving to implement a national health IT infrastructure, and the same is true here. Canada Health Infoway is focusing on investing in projects that will help establish national patient and provider databases as well as the laboratory and pharmacy systems that have been key to adoption in other countries. Infoway has been working closely with the provinces and territories and a number of them now have plans and timelines for the roll out of an electronic health record. Yet, at present clinical care networks are uncommon and rudimentary, existing to a greater degree only in Alberta which is further ahead with its provincial electronic health record framework. Canada also faces unique challenges, as the vast majority of community-based physicians are unable to communicate with hospital IT systems; this means they do not have access to the same rapid transmission of patient data that is available to their hospital-based colleagues.

Integration of computers and IT into physician practices is far less advanced in Canada, compared with countries where clinical computer use is a fact of life for GPs. But with more than 90% of Canadian doctors saying they have some degree of computer skill, and with some already working with an EMR and others planning to invest in such systems in the near future, the climate is ripe for Canada to rapidly catch up to other countries. The key point remains that GPs and the organizations that represent them must be intimately involved in the transition.

The move to get technology into GP offices in Canada may appear to be a slow and laborious process. However, incremental gains are being made. A close look at countries that appear to be far ahead of Canada shows that their experiences often involved mis-steps and shifts in direction, but that they have achieved the goal of having most GPs use technology for clinical purposes. Based on those experiences and the steps already taken in Canada, it seems clear that with involvement of the GP community Canada can move closer to matching the gains made in other countries.