International Journal of Medical Informatics 84 (2015) 857867

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International Journal of Medical Informatics

journal homepage: www.ijmijournal.com

Electronic health record usage behaviors in primary care medical

practices: A survey of family physicians in Canada
Guy Par a, , Louis Raymond b , Ana Ortiz de Guinea c , Placide Poba-Nzaou d ,
Marie-Claude Trudel c , Josianne Marsan e , Thomas Micheneau c
a

Chair in Information Technology in Health Care, HEC Montral 3000, Cte-Sainte-Catherine Road, Montral, Qubec H3T 2A7, Canada
Universit du Qubec Trois-Rivires, Canada
c
HEC Montral, Canada
d
Universit du Qubec Montral, Canada
e
Universit Laval, Canada
b

a r t i c l e

i n f o

Article history:
Received 29 December 2014
Received in revised form 13 July 2015
Accepted 14 July 2015
Keywords:
Electronic health record
Usage behaviors
Family physicians
Medical practices
Performance outcomes
Survey research

a b s t r a c t
Objective: The importance and potential value of ofce-based electronic health record (EHR) systems is
being recognized internationally. We thus sought to better understand how EHRs are actually being used
by family physicians and what they perceive to be the main performance outcomes for themselves and
their medical practices.
Methods: We conducted a survey of family physicians practicing in medical practices in Quebec, Canada (n
= 331). Bivariate and multivariate statistical analyses were conducted to characterize EHR usage behaviors
and assess the perceived performance outcomes of these systems.
Results: EHR systems as-used vary substantively from one family physician to another in terms of the
capabilities that are actually mobilized by them. Signicant differences between basic and advanced
users were observed in terms of the EHR systems characteristics and perceived performance outcomes.
Physicians were also clustered under three proles that could be clearly distinguished from one another,
in terms of the extent to which their performance and their practices performance was impacted by their
EHR usage. Physicians that are highly impacted by their EHR system are those who have the longest
usage experience and make the most extended use of their systems capabilities.
Conclusions: Our study indicates that only a minority of family physicians in our sample use most of
the features available in their EHR system. Consequently, few physicians perceive gaining signicant
performance improvements from such systems. Future research must identify the factors that motivate
primary care physicians to assimilate EHR systems in a more extensive manner.
2015 Published by Elsevier Ireland Ltd.

1. Introduction
The importance and potential value of ofce-based electronic
health record (EHR) systems is being recognized internationally
[1]. For instance, as early as 1998, health care authorities in New
Zealand gave many general medical practices a one-time grant of
approximately US$3,600 per family physician to purchase computers. A further catalyst for the EHR movement in that country
was the governments requirement to submit patient disease infor-

Corresponding author. Fax: +1 514 340 6132.

E-mail addresses: guy.pare@hec.ca (G. Par), louis.raymond@uqtr.ca
(L. Raymond), ana.ortiz-de-guinea@hec.ca (A.O.d. Guinea),
poba-nzaou.placide@uqam.ca (P. Poba-Nzaou), marie-claude.trudel@hec.ca
(M.-C. Trudel), josianne.marsan@sio.ulaval.ca (J. Marsan),
thomas.micheneau@hec.ca (T. Micheneau).
http://dx.doi.org/10.1016/j.ijmedinf.2015.07.005
1386-5056/ 2015 Published by Elsevier Ireland Ltd.

mation to registers and to le fee-for-service claims electronically

in order to receive subsidies, combined with nancial incentives
for primary care [2]. Today, virtually all of the countrys family physicians use an EHR system [3]. As another example, the
HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 in the United States supported several
programs including Meaningful EHR use incentives [4]. As a
direct consequence, primary care physicians adoption of EHR systems rose 50% between 2009 and 2012, that is, from 46 to 69%.
Lastly, Canada Health Infoway has recently launched a CDN$380
million investment program to support the use of EHRs to help
clinicians achieve increased clinical value [5] and physician ofce
EHR funding support programs are now in place in most Canadian
provinces [6,7]. As a result of these incentive programs, the adoption rate in Canada has increased from 37% in 2009 to 75% in 2014
[3,8].

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G. Par et al. / International Journal of Medical Informatics 84 (2015) 857867

Contextual
Factors

EHR Usage
Behaviors

Performance
Outcomes of EHR

Family physicians
characteriscs

Use of clinical
funconalies

Medical pracces
characteriscs

Use of
communicaonal
funconalies

Impacts on family
physicians
performance

EHR systems
characteriscs

Use of
administrave
funconalies

Impacts on
medical pracces
performance

Fig. 1. Conceptual framework.

In this study, we dene an EHR system as an amalgam of data

acquired and created during a patients course through the health
care system and stored in an electronic medium [[9]:180]. According to Desroches et al. [10], EHR systems include a wide range of
functionalities: patient demographics, patient problem lists, lists of
medications taken by patients, clinical notes, orders for prescriptions, viewing test results, medical history and follow-up notes,
orders for tests, prescriptions and orders sent electronically, warnings of drug interactions, highlighting of out-of-range test levels,
and reminders for guideline-based interventions or screening. But
not all EHR systems acquired by private medical practices provide the same functionalities [10], and once implemented, their
capabilities as-used may also differ substantially from one practice to another, even if the same EHR software has been acquired
[11,12]. Further, there is often a gap between EHR designers expectations and users behaviors and family physicians can also use
EHR systems in ways not anticipated initially [13,14]. Keeping this
in mind, we sought to better characterize how EHR systems are
actually being used by physicians in primary care medical practices and investigate the extent to which these systems contribute
to performance outcomes. More precisely, we attempt to provide
answers to the following research questions: To what extent do
family physicians actually use EHR functionalities? What are the
contextual factors that are related to a more comprehensive use
of EHR systems by these physicians? Most importantly, to what
extent does their EHR system usage have positive impacts in terms
of perceived performance improvements at both the physician and
medical practice levels? The present study complements previous
works in this area which have focused on factors inuencing EHR
acceptance or adoption by physicians [e.g., [1,15]].
In short, given the increasing rate of EHR adoption in several
developed countries, the nature of the usage and impacts of such
systems needs to be evaluated to ensure they are enabling family
physicians and their medical practices to realize expected performance improvements. In this line of thought, this article presents
the results of a survey of Canadian family physicians on their
EHR usage behaviors and their perceptions of the performance
improvements obtained from their EHR system both for themselves
and for their medical practices. It must be noted here that most
Canadian medical practices tend to be privately owned solo/group
practices or interdisciplinary community-based clinics, using standalone EHR systems from small or medium size vendors that are not
well integrated with other health information technologies [16,17].
2. Conceptual framework
In this section we introduce a conceptual framework (see Fig. 1)
to explain family physicians use of EHR systems as well as potential antecedents and performance outcomes of such use. First, we
concur with Orlikowski [18] and with Burton-Jones and Grange

[19] that information systems per se cannot increase individual

and organizational performance, only effective use of these systems can. We thus expect that a full or extended use of EHR
systems will positively affect both physician and medical practice
performance outcomes [16,17] as well as physicians perceptions
of performance improvements gained from such systems.
Following Sykes et al. [20], we consider family physicians use of
EHR systems to be inuenced by both individual and system characteristics. First, prior research in the eld of psychology has used the
demographic characteristics of individuals as predictors of human
behavior [21,22]. Among others, gender and age have been shown
to inuence the use of several technological innovations [20,23].
In addition we explored the idea that physicians prior experience
with EHR systems might also be positively related to their actual
system usage behaviors through a process of experiential learning
[24].
Second, we draw on the information systems and medical
informatics literature to identify two factors that should further
predict physicians EHR usage behaviors, namely, system ease of
use (dened as the extent to which a physician perceives using an
EHR system is free of effort) [25] and functional coverage (dened
as the number of clinical, communicational, and administrative
functionalities perceived to be available in an EHR system) [26].
In addition to individual and system factors, organizational
characteristics have also been associated with IT usage in health
care [27,28]. We identied four distinct organizational characteristics that may lead to higher levels of EHR usage among family
physicians. First, organization size has been one of the most widely
investigated antecedents of IT use in the health care sector [29,30].
According to the resource-based theory [31], larger medical practices are likely to have the capacity to better support physicians
adoption and use of EHR systems by exploiting their internal
resources or by hiring external resources. Second, medical practices located in urban areas usually have greater access to nancial
and human resources than rural clinics by virtue of their greater
proximity to technology vendors, funding agencies, and support
organizations (e.g., EHR system integrators) [27]. We thus expect
to observe higher levels of EHR usage in urban medical practices
than in rural ones. Third, in terms of afliation, we expect physicians working in family medicine group (FMG) practices in close
collaboration with registered nurses and other healthcare professionals to show higher levels of EHR usage than those in solo/small
practices due to greater coordination ability to perform administrative and clinical activities. Indeed, a FMG practice is a group of
family physicians who work in close cooperation with registered
nurses and other healthcare professionals to offer family medicine
services to patients. Family physicians who are members of FMGs
are also able to work closely with other healthcare professionals in
hospitals, community-based centers, and pharmacies to complement the services they offer. Lastly, we posit that medical practices

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859

Fig. 2. Distribution of EMR solutions used by family physicians.

experience with EHR systems will positively inuence physicians

usage behaviors through a process of institutionalization [32].

3. Methods
We conducted a large-scale survey of family physicians practicing in private medical practices in Quebec, Canada. While Quebec
is the second most populous province in this country, with 7.9 million inhabitants, it was ranked last out of 10 provinces in terms of
physician adoption of EHR systems in early 2014, with an overall
adoption rate of 53% [8]. Unlike other nations such as the United
States, salaries of family physicians in Quebec are insulated from
issues related to EHR adoption. Further, the provinces Medicare
fee for service system does not provide incentives for EHR system
use nor does it impose nancial penalties on physicians for lack of
adoption.
The survey questionnaire, prepared in both English and French,
was rst validated by representatives of Canada Health Infoway and
the Quebec Federation of General Practitioners (QFGP). We then
conducted a pre-test with four family physicians and three medical
students. Some minor adjustments were made to the instrument
following these validation steps. This study received approval from
the ethics board committee at HEC Montral.
In April 2013, an invitation to participate in the study was
emailed to 4845 members of the QFGP who had a valid email
address and who were practicing in primary care settings. The invitation letter contained a hyperlink directing the respondents to a
secure Web site that gave them access to the questionnaire. The
Qualtrics platform [33] was used to develop the online questionnaire. A reminder letter was sent to all the intended respondents
one week after the initial invitation. No nancial incentives were
used to maximize response rate.
We collected and analyzed data from 780 family physicians,
representing a response rate of 16%. Low response rates increase
the risk of non-response bias. The potential for such a bias
was rst assessed by comparing the 156 late respondents (i.e.,
those responding after having received the reminder) with the
624 early respondents. Our ndings (not shown here) indicate
no statistically signicant differences between these two sets of
respondents. Next, we compared the demographic characteristics
of our sample with those of the target population, i.e., QFGP members. Our respondents were found to be statistically representative
of the population in terms of physician age, gender, region and

length of professional experience. In short, these two steps reveal

that sampling error is unlikely, and thus give condence that our
sample approximates the characteristics of the target population
[34].
While the original survey targeted two different types of physicians, those working in medical practices with and without EHR
systems, only responses from those actually using EHR systems
(n = 331; 42%) are of interest in this article. The results from the
survey of family physicians working in medical practices without
an EHR system can be found elsewhere [35].
Using an initial list of 24 EHR system functionalities (e.g., electronic prescribing of medication), we asked our respondents to
indicate whether each functionality was available or not in their
EHR system, and if available, whether they actually used it or not.
The list of functionalities was determined from previous empirical studies of the actual use of EHR systems within the clinical,
communicational and administrative processes of family physician practices [10,3644]. Furthermore, using a set of 26 potential
individual and organizational impacts of EHR systems, culled from
the previously reviewed literature [16,4558], we asked respondents to what extent they agreed (where 1 = strongly disagree and
5 = strongly agree) with statements about the impact of EHR usage
on their individual performance (e.g., has facilitated my application of clinical care guidelines for my patients) and on their
practices performance (e.g., has improved teamwork and continuity of care provided to patients). It took our respondents an average
of 24 min to complete the online survey. All items comprised in
our questionnaire instrument can be found in the Appendix (online
supplement). As shown next, several statistical analyzes including
exploratory and conrmatory factor analyses, cluster analyses, and
analyses of variance and covariance were performed. Data were
analyzed using the IBM SPSS Statistics software (version 20).

4. Results
Of the 331 respondents, 48% were women. As for their age, 38%
were in their 50s, 28% in their 40s, and 19% in their 30s. They had 22
years experience in the medical profession on average, with a minimum of 2 and a maximum of 45. They also had an average of 4 years
experience in using their clinics EHR system, with 56% of the sampled physicians having 3 years of experience or less. Importantly,
we asked our respondents to indicate which specic EHR solutions
they used. Fig. 2 shows that they use three main solutions: Kinlogix,

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G. Par et al. / International Journal of Medical Informatics 84 (2015) 857867

Table 1
Exploratory factor analysis of EHR system functionalities.
EHR functionalities

EHR capability
Clinical

Past medical history

Clinical notes
Family diseases/family history
Patient demographics
Electronic prescribing of medication
Alerts about a potential problem with drug use dose or drug interaction
Monitoring patients with chronic diseases
Planning and coordination of patient care
Reminder for guideline-based interventions and/or screening tests
Viewing laboratory tests results
Out-of-range test levels highlighted
Viewing imaging results
All lab tests ordered are tracked until results reach clinicians
Electronic ordering of laboratory tests
Access medical records from other clinics/hospitals
Electronic referrals to specialists
Communication and follow-up with gov. agencies
Electronic transfer of tests prescription to lab
Electronic transfer of prescription to pharmacy
Patients appointment scheduling
Remote access to EHR system (from home)
Accessibility of EHR on travel (train/airport/mobile)
Billing management
Secure transmissions protecting patients health privacy
% of variance
Cumulated % of variance
Mean functional use scoreb
a
b

Communicational

Admin.

FC1

FC2

FC3

FC4

FC5

FC6

FC7

FC8

.89
.74
.86

22.4
22.4
.79

.73
.55
.51

4.2
26.6
.74

.77
.74
.79

12.1
38.7
.46

.81
.79
.50
.63

7.6
46.3
.59

.64
.50
.73
.49

5.2
51.5
.28

.57
.72

4.4
55.9
.25

.87
.86
5.7
66.3
.49

.62
.77
.75

4.7
60.6
.61

Dash indicates a loading inferior to 0.49.

Number of EHR functionalities used/total number of EHR functionalities available (range from 0 to 1).

by Telus Health (50%); Virtual Medical Clinic (VMC), by Omni-Med

(19%); and Purkinje Dossier, by Purkinje (14%). The remaining 17%
consisted of other EHR systems such as Toubib, Suite MobileMed
and OscarQc.
An exploratory factor analysis (EFA) using the principal components method was rst performed to empirically regroup the
24 EHR functionalities, as used by the surveyed physicians, into
8 functional categories (FC). EFA is used when researchers make
no a priori assumptions as to the factor structure of the data [59].
As shown in Table 1, each of these categories was in turn determined to be part of an EHR systems clinical, communicational or
administrative capability. For instance, the Patient care management FC regroups three EHR functionalities of a clinical nature
that were signicantly interrelated when used by the surveyed
family physicians, namely, monitoring patients with chronic diseases, planning and coordination of patient care and reminder
for guideline-based interventions/tests.
Interestingly, we found that our respondents perceived a number of clinical and communicational functionalities of an EHR
system to be unavailable to them (see Table 2 ). For instance,
the reminder for guideline-based interventions/tests functionality was available in 43% of the systems, and electronic transfer of
prescription to pharmacy in only 15%. Thus, it appears that not all
EHR systems are created equal in the eyes of their users. Moreover,
we found that family physicians did not use all of the functionalities available in their EHR system. For instance, the reminder
for guideline-based interventions/tests functionality was actually
used by 29% of the surveyed physicians, and electronic transfer
of prescription to pharmacy by only 10%. The extent to which a
physician uses the EHR system was also ascertained for each FC, a
functional use score being calculated as the ratio of the number
of functionalities used over the total number of available functionalities in the category. For instance, the respondents use, on
average, 28% of the EHR functionalities in the Communication with

other institutions category, that is, approximately one out of four

potentially available functionalities. With an average high of 79%
for the Patient history and clinical notes functional category to
an average low of 25% for Electronic transfers, this broad range of
functional use scores conrms that EHR systems as-implemented
and as-used vary substantively from one family physician to
another in terms of the clinical, communicational and administrative capabilities that are actually available to them and are actually
used by them. All in all, surveyed physicians only use, on average,
65% of the functionalities available in the EHR systems deployed in
their medical practice.
We then sought to determine our respondents EHR user prole
on the basis of their use of the eight basic functionalities that constitute their EHR system. Through a cluster analysis, we grouped the
family physicians into clusters such that each clusters membership
is homogeneous with respect to their use of EHR systems. The SPSS
Two-Step clustering algorithm was chosen as it can handle a large
number of cases and automatically determines the optimal number
of clusters [60]. A two-cluster solution was found to be optimal in
identifying groups of physicians that could be clearly distinguished
from one another. Indeed, results in Table 3 reveal the existence of
two EHR user proles.
Drawing upon the previously mentioned notion of full or
extended use of EHR systems, the 149 family physicians (45% of
the sample) that compose the rst EHR user prole were called
Advanced users, as they were found to make broad use of most
of the EHR functionalities available in each of the 8 FCs (88% of
the functionalities on average), with the exception of the Communication with other institutions (46%) and Electronic transfers
(39%) categories. Overall, these physicians used on average 21 out
of the 24 functionalities potentially found in an EHR system. In contrast to the rst prole, the 182 physicians (55% of the sample)
composing the second EHR user prole were named Basic users as
their use of EHRs is much narrower on all system functionalities

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861

Table 2
Characterization of EHR functionalities as used by family physicians.
Availability
Use
Functional usea
(% of EHR systems) (% of physicians) (Mean)

EHR
Capability

EHR functional category

EHR functionality

Clinical capability

Patient history and clinical notes

Past medical history
Clinical notes
Family diseases/family history
Patient demographics and prescription management
Patient demographics
Electronic prescribing of
medication
Electronic alerts or prompts about a potential problem
With drug use dose or drug interaction
Patient care management
Monitoring patients with chronic diseases
Planning and coordination of patient care
Reminder for guideline-based interventions and/or
Screening tests
Visualization of results
Viewing laboratory tests results
Out-of-range test levels highlighted
Viewing imaging results
All lab tests ordered are tracked until results reach
Clinicians
Communication with other institutions
Electronic ordering of laboratory tests
Access to medical records from other clinics/hospitals
Electronic referrals to specialists
Communication and follow-up with government agencies (e.g., public health agency)
Electronic transfers
Electronic transfer of tests prescription to laboratory
Electronic transfer of prescription to pharmacy
Appointment scheduling and distance access
Patients appointment scheduling
Accessibility of EHR remotely (from home or outside the clinic)
Accessibility of EHR on travel (train, airport, mobile)
Billing and data security
Billing management
Secure transmissions protecting patients health privacy
0.65

Communication
capability

Administrative
capability

All EHR functionalities

a

0.79
90%
89%
86%

79%
83%
75%

89%
89%
79%

82%
80%
59%

68%
64%
43%

53%
55%
29%

88%
65%
54%
46%

82%
60%
51%
39%

49%
36%
31%
22%

34%
34%
27%
18%

44%
15%

39%
10%

92%
89%
66%

79%
68%
35%

78%
69%

42%
61%

0.74

0.46

0.59

0.28

0.25

0.61

0.49

Number of EHR functionalities used/total number of EHR functionalities (range of 01).

(46% on average), with the possible exception of two clinical functions, namely Patient history and clinical notes (64%) and Patient
demographics and prescription management (61%). Overall, family physicians showing this prole used only 11 out of 24 possible
EHR functionalities on average, noting that their most signicant
difference with the other prole was in their much lower use of
the Patient care management functionalities (23% vs. 73%). Basic
users would thus tend to view EHRs solely as a tool for achieving
the vision of a paperless medical practice, that is, purely for its
automational effects.
In order to identify individual, technological and organizational
antecedents to EHR usage by family physicians, we sought to contextualize the two user proles that emerged from our analyses, as

shown in Table 4. In this regard, one rst notes that Advanced users
did not differ signicantly from Basic users in terms of their age,
their medical experience and their EHR usage experience. However,
a signicantly greater proportion of female physicians were typied as Advanced users. Basic users were also distinguished from
Advanced users by characterizing the EHR systems used by each
group. Indeed, Advanced users perceived their EHR system to be
signicantly easier to use, and especially with respect to their interactions with patients, when compared to Basic users. The former
group also indicated that their EHR systems functional coverage,
that is, the number of clinical, communicational and administrative functionalities available to them, was signicantly greater on
average than the latter.

Table 3
EHR user proles resulting from cluster analysis.
EHR user prolesEHR capabilityEHR functional category

Advanced users(n = 149)Mean

Basic users(n = 182)Mean

ANOVA F

Clinical capability
Clinical notes and history
Patient care management
Prescription management and patient demographics

0.97
0.73
0.89

0.64
0.23
0.61

83.7***
84.5***
88.0***

Communicational capability
Visualization of results
Communication with other institutions
Electronic transfers

0.75
0.46
0.39

0.45
0.14
0.13

75.7***
14.1***
64.7***

Administrative capability
Billing and data security
Distance access and appointment scheduling

0.70
0.79

0.32
0.46

81.9***
04.0***

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G. Par et al. / International Journal of Medical Informatics 84 (2015) 857867

Table 4
Inuence of contextual factors on family physicians EHR usage behaviors.
EHR user prolesContextual factors

Advanced users(n = 149)Mean

Basic users(n = 182)Mean

ANOVA F

Family physicians characteristics

Age of the family physician a
Gender (1: female, 0: male)
Medical experience (no. of years)
EHR usage experience (no. of years)

3.5
0.5
22.1
4.3

3.4
0.4
21.7
3.9

1.1
4.8 **
0.1
0.9

14.6
11.8
0.8
0.9

15.8
11.8
0.8
0.8

7.2 **
0.0
0.0
4.1*

2.0
3.1

1.7
2.5

9.9 **
27.3 ***

8.0
6.0
4.5

5.5
3.8
3.5

125.7 ***
126.6 ***
54.2 ***

Medical practices characteristics

Experience with EHRs (no. of years)
Size (no. of family physicians)
Localization (1 = urban, 0 = rural)
Afliation b
EHR systems characteristics
EHR ease of use c
with respect to care providers
with respect to patients
Functional coverage d
Clinical functionalities
Communicational functionalities
Administrative functionalities
*
**
***
a
b
c
d

p < 0.05.
p < 0.01.
p < 0.001.
1 = 29 years or less, 2 = 3039, 3 = 4049, 4 = 5059, 5 = 6069, 6 = 70 years or more.
1 = member of a FMG (Family Medicine Group), 0 = non-member.
As perceived by the user on a scale of 1 (unusable) to 5 (very easy to use).
Number of functionalities used/total number of functionalities available.

Table 5
Conrmatory factor analysis of the perceived performance outcomes of EHR.
Perceived performance outcomes of EHR

Individual impact categories

Organizational impact categories

IC1

IC2

IC3

IC4

IC5

IC6

Impacts on the family physicians performance

Has improved the quality of preventive care given to my patients

.87

Has improved the monitoring of my patients with chronic diseases

Has improved the safety of care for my patients
Has facilitated my application of clinical care guidelines for my patients
Has facilitated my clinical decision making

.83
.69
.85
.80

Has improved the quality of prescriptions to my patients

.61

Has improved the quality of my documentation and my clinical notes

Has improved my communication with health care providers
Has allowed me to use clinical resources more wisely
Has reduced the average duration of the encounter with my patients
Has allowed me to be more efcient
Has improved the communication and interaction with my patients
Has reduced my time spent on medical documentation and ordering
Has increased my job satisfaction
Impacts on the medical practices performance
Has improved the efciency of the clinics staff
Has improved teamwork and continuity of care provided by the clinic
Has decreased the clinics operating costs
Has reduced the number of no shows
Has increased the clinics revenues
Has improved the quality of services delivered to the clinics patients
Has decreased the number of patients visits to the clinic
Has improved collaboration with other clinical care providers
Has improved prescriptions management at the clinic
Has increased access to care for the community served by the clinic
Has increased immunization rates in the community
Has improved satisfaction of the clinics staff and physicians
Cronbachs alpha coefcient
Composite reliability coefcient
Average variance extracted
Mean [Likert scales of 1 (strongly disagree) to 5 (strongly agree)]
Standard Deviation
MinimumMaximum

.70
.73
.77
.77
.79
.81
.73

1.0

.91
.90
.61
2.9
1.0
15

.91
.92
.60
2.9
1.0
15

1.0
1.0
1.0
3.6
1.2
15

.64
.66

.69

.81
.73
.72
.67

.68
.90
.89
.49
3.1
0.9
15

.71

.82

.73
.74
.59
2.7
1.0
15

.89
.77

.82
.82
.69
2.5
1.0
15

Model t indices: 2 = 971.5 (df = 275) 2 /df = 3.5 CFI = .90 GFI = .79 RMR = .08 RMSEA = .09.
IC1: Quality of care provided by the physician; IC2: Efciency of the physician; IC3: Work satisfaction of the physician; IC4: Impacts on the clinics workow (operational);
IC5: Impacts on the clinics nancial position (economic); IC6: Impacts on the clinics community (social).

G. Par et al. / International Journal of Medical Informatics 84 (2015) 857867

Regarding the organizational context of EHR use, it was found

that Advanced users did not differ signicantly from Basic users in
terms of their clinics size and localization (urban vs. rural). However, a signicantly greater proportion of Advanced users practiced
in clinics afliated to a FMG. Surprisingly, it was also found that
Advanced users work in primary care clinics that have a little less
EHR system experience (14.6 years on average) than those of Basic
users (15.8 years on average).
Next, a conrmatory factor analysis, using the EQS structural equation modeling technique, was performed to empirically
validate the hexa-dimensional structure posited for the EHR performance outcomes construct. As indicated in Table 5, the six
dimensions were found to have adequate unidimensionality, internal consistency and convergent validity [61]. Looking at the mean
EHR impacts score for each of the dimensions conrms that up to
now, family physicians consider their use of EHR systems to have
had little impact, on average, on their medical practice. While they
perceive such usage to have increased their job satisfaction somewhat (mean of 3.6 on a scale of 15; where 1 = no increase and
5 = signicant increase), they are unsure as to its positive impact
on their clinics workow (3.1), whereas they indicate no improvements with regard to the quality of care services provided to their
patients (2.9) and to their efciency as physicians (2.9). Moreover,
the absence on EHR impacts on average is even more conrmed
by our respondents with regard to their clinics nancial situation
(2.7) and to the community served by their clinic (2.5).
We then sought to determine the respondents prole on the
basis of the individual and organizational impacts (IC1IC6) perceived to result from their use of an EHR system. Through a cluster
analysis similar to the previous one, the respondents were clustered
anew under three proles that could be clearly distinguished from
one another and were respectively named Highly Impacted (n = 54),
Slightly Impacted (n = 126) and Non-Impacted (n = 151) physicians.
As shown in Table 6, the rst and smallest group (16%) is constituted
of physicians who view EHR usage as having a positive inuence
overall on both their individual performance and their clinics performance. Those in the second group (38%) perceive benets to have
been accrued mainly in terms of their increased job satisfaction
and somewhat in terms of their clinics improved workow. The
physicians in the third and largest group (46%) perceive neither
individual nor organizational performance improvements to have
been obtained from their use of an EHR system.

863

Next, we tested our conceptual framework by ascertaining to what extent physicians in the three groups differed in
terms of their use of the eight categories of clinical, communication and administrative functionalities available in EHR
systems. As shown in Table 7, analyses of variance and covariance conrm that using an EHR system can signicantly improve
the performance of family physicians and primary care practices.
The preceding results show unequivocally that the physicians
proled as being Highly Impacted are those that make the most
wide-ranging use of their clinics EHR system capabilities. Conversely, physicians proled as being Non Impacted are those that
make the least use of their system. For instance, the latter group
uses on average only 32% of clinical functionalities pertaining to
the patient care management category (e.g., monitoring patients
with chronic diseases), as opposed to 73% for the former group.
The same can be said for the EHR functionalities that pertain to the
communication with other institutions category (e.g. electronic
ordering of lab tests), with 20% for the second group vs. 44% for
the rst group. For their part, physicians proled as being Slightly
Impacted seem closer to those in the last group, differing from
the Non Impacted physicians in their greater use of clinical functionalities mostly, whereas they differ from the Highly Impacted
physicians in their narrower use of their EHR system across all eight
categories of functionalities. Moreover these differences in EHR
system usage between the three groups remain signicant when
controlling for the physicians and the clinics length of experience
with their system.
To further investigate the antecedents of EHR performance outcomes, the individual, system and organizational characteristics
that characterize the context of EHR usage were broken down by
the three EHR impacts proles. As shown in Table 8, one rst nds
that the clinics experience with EHRs, size, localization and afliation have no real bearing upon their attainment of performance
improvements from an EHR system. With regard to the family
physicians characteristics, neither their age nor gender nor their
medical experience seems to bear upon the performance outcomes
of EHR usage. The physicians personal EHR usage experience does
seem to matter however, as the Highly Impacted physicians are
found to be signicantly more experienced in this regard (6.0 years
on average) than the Slightly Impacted and Non Impacted physicians (3.7 years on average). This result supports recent ndings

Table 6
EHR impacts proles resulting from cluster analysis.
EHR performance outcomes
EHR impacts*

Impacts on the family physicians

performance
Quality of care provided by the
physician
Physicians efciency
Physicians work satisfaction
Impacts on the primary care
clinics performance
Impacts on the clinics workow
Impacts on the clinics nancial
position
Impacts on the clinics community

EHR impacts proles

ANOVA F

Highly impacted physicians

(n = 54)
Mean

Slightly impacted physicians

(n = 126)
Mean

Non impacted physicians

(n = 151)
Mean

4.21

3.22

2.13

227.5**

4.41
4.91

3.22
3.92

2.03
2.83

365.0**
123.7**

4.31
4.01

3.42
2.92

2.43
2.03

282.6**
147.7**

3.81

2.92

1.63

307.0**

*
As perceived by the family physician on Likert scales of 1 (strongly disagree) to 5 (strongly agree) Nota. Within rows, different subscripts indicate signicant (p < 0.05)
pair-wise differences between means on Tamhanes T2 (post hoc) test.
**
p < 0.001.

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G. Par et al. / International Journal of Medical Informatics 84 (2015) 857867

Table 7
Breakdown of family physicians EHR usage behaviors by EHR impacts prole.
Family physicians EHR usage behaviorsa

EHR impacts proles

Highly impacted physicians
(n = 54)
Mean

Use of clinical functionalities

Patient history and clinical notes
0.961
Past medical history
Clinical notes
Family diseases/family history
Prescription management and patient
0.871
demographics
Patient demographics
Electronic prescribing of medication
Electronic alerts or prompts about a potential
problem with drug use dose or drug interaction
Patient care management
0.731
Monitoring patients with chronic diseases
Planning and coordination of patient care
Reminder for guideline-based
interventions/screening tests
Use of communication functionalities
Visualization of results
0.731
Viewing laboratory tests results
Out-of-range test levels highlighted
Viewing imaging results
All lab tests are tracked until results reach
clinicians
Communication with other institutions
0.441
Electronic ordering of laboratory tests
Access to medical records from other clinics
hospitals
Electronic referrals to specialists
Communication and follow-up with
government agencies
Electronic transfers
0.401
Electronic transfer of tests prescription to
laboratory
Electronic transfer of prescription to pharmacy
Use of administrative functionalities
Appointment scheduling and distance access 0.851
Patients appointment scheduling
Accessibility of EHR remotely (from home or
outside)
Accessibility of EHR on travel (train, airport,
mobile)
Billing and data security
0.791
Billing management
Secure transmissions protecting patients
health privacy

Slightly impacted physicians

(n = 126)
Mean

Non impacted physicians

(n = 151)
Mean

ANOVA F

ANCOVA F

0.832

0.693

13.3***

13.2***

0.782

0.663

12.2***

10.2***

0.512

0.323

24.0***

24.9***

0.582

0.543

6.0**

3.9**

0.312

0.203

14.4***

14.0***

0.232

0.213

8.2***

6.6**

0.562

0.573

16.9***

13.3***

0.522

0.363

22.1***

17.6***

p < 0.05.
a
No. of EHR functionalities used by the physician/total no. of EHR functionalities (range of 01).

With covariates: Clinics EHR experience, Physicians EHR experience Nota. Within rows, different subscripts indicate signicant (p < 0.05) pair-wise differences between
means on Tamhanes T2 (post hoc) test.
**
p < 0.01.
***
p < 0.001.

which indicate that physicians in the United States can successfully adjust to EHR and are able over time to make fuller use of
their EHR system [62].
Lastly, the EHR characteristic found to be most relevant is the
systems ease of use. Here the Highly Impacted physicians differ
from the other two groups in that they perceive their system to be
signicantly easier to use, both with respect to patients and to other
care providers. Furthermore, the systems functional coverage, i.e.,
the number of different clinical, communicational and administrative functionalities available in the EHR software product, is a
measure of EHR capability. The mean coverage score is signicantly
inferior for the Slightly Impacted and Non Impacted proles with
regard to clinical functionalities specically, when compared to the
Highly Impacted prole. In other words, the performance improvements to be obtained from an EHR system are dependent above all
upon the clinical capability that is provided by the system through

functionalities such as patient care management, prescription management, patient history and clinical notes.
5. Discussion
The results of this study represent yet another justication to
pursue research on the performance outcomes, determinants and
process of assimilation of EHR systems by physicians [63]. In the
case of the private medical practices studied here, nding that
most family physicians (and their practices) are not signicantly
impacted by their use of an EHR system poses a challenge to medical
informatics researchers and practitioners. Indeed, if EHR systems
are to make a difference in the face of the increasing complexity
of private medical practices, rising health costs and an aging population, these systems must be shown to improve the quality of care
services as well as the efciency of medical practices workows

G. Par et al. / International Journal of Medical Informatics 84 (2015) 857867

865

Table 8
Breakdown of contextual factors by EHR impacts prole.
Contextual factors

Family physicians characteristics

Age of the family physician a
Gender (1: female, 0: male)
Medical experience (no. of years)
EHR experience (no. of years)
Medical practices characteristics
Size of the clinic (no. of family
physicians)
Localization (1: urban, 0: rural)
Afliation b
Clinics EHR experience (no. of years)
EHR systems characteristics
Ease of use c
With respect to patients
With respect to other care providers
Functional coveraged
Clinical functionalities
Communicational functionalities
Administrative functionalities

EHR impacts proles

Highly impacted physicians
(n = 54)
Mean

Slightly impacted physicians

(n = 126)
Mean

Non impacted physicians

(n = 151)
Mean

ANOVA F

3.7
0.61
22.9
6.01

3.4
0.45
21.0
4.02

3.4
0.45
22.3
3.52

1.7
2.3
0.7
8.8***

11.6

11.6

0.78
0.87
13.02

0.75
0.89
15.41

0.80
0.84
15.91

0.6
0.3
10.3***

3.61
2.51

2.82
1.92

2.43
1.53

25.6***
27.7***

0.81
0.61
0.9

0.72
0.51,2
0.9

0.63
0.42
0.9

18.9***
8.7***
1.8

1.6

Nota. Within rows, different subscripts indicate signicant (p < 0.05) pair-wise differences between means on Tamhanes T2 (post hoc) test.
a
1 = 29 years or less, 2 = 3039, 3 = 4049, 4 = 5059, 5 = 6069, 6 = 70 years or more.
b
1 = member of a FMG (Family Medicine group), 0 = non-member.
c
As perceived by physicians on a Likert scale of 1 (unusable) to 5 (very easy to use).
d
Number of functionalities used/total number of available functionalities.
***
p < 0.001.

and operations. This studys characterization of the perceived outcomes of EHRs thus beg the question as to why family physicians
use these systems if most perceive no performance improvements
to be obtained for themselves and their medical practice in doing
so.
In seeking a solution to the preceding problem, we rst looked
at the extent to which family physicians actually use the EHR systems made available to them. We found that physicians used, on
average, 65% of all the functionalities available in the EHR systems
deployed in their medical practices. Additional analyses of physicians EHR usage behaviors allowed us to separate them into two
distinct groups, namely, basic and advanced users. Physicians in
the former group used on average 11 out of the 24 functionalities potentially available in an EHR system compared to 21 for
advanced users. Basic users thus seem to view EHRs solely as a
tool for achieving the vision of a paperless medical practice, that
is, purely for its automational effects. Ultimately, we found that
those physicians who did obtain high performance improvements
(for themselves and their practice) were the ones whose EHR usage
could be qualied as advanced [64], that is, who got the most out
of their EHRs capability by using signicantly more of its clinical
and, to a lesser extent, communicational functionalities. This nding supports prior works conducted in the United States, wherein
the purported benets of EHR systems are deemed to be truly
obtained only insofar as their use by physicians is meaningful
[6568].
Yet our ndings clearly indicate that highly impacted physicians
remain a minority (16%) of EHR users. There is thus a need, emerging from this study, to investigate the individual, technological,
organizational and legal factors that motivate or persuade family
physicians to proactively explore their EHR systems functionalities and subsequently use a broader range of functionalities to
better support their clinical, communicational and administrative
activities or tasks [69]. For one thing, our ndings reveal that fuller
usage by family physicians requires EHR software products to be
easier to use or more physician-friendly. And added indications

were found that the alignment and scope of these software products (system coverage/integration) as well as their IT sophistication
(system access/interface) could lead to a more extensive usage of
EHRs in primary care contexts.
There is also empirical evidence here that physicians can learn,
as those who perceived being highly impacted by their EHR system
were the most experienced users. This calls for greater insight on
how family physicians can be encouraged to innovate with information technology in their medical practice, and in particular how
an appropriate learning environment and climate can be established [70]. Lastly, recent empirical evidence shows positive results
on EHR usage among physicians in the United States since the introduction of the meaningful use regulation [71]. Future research
efforts should thus investigate the inuence of similar coercive
mechanisms on physicians EHR usage behaviors in other countries
such as the United Kingdom, Australia, and Canada.
5.1. Study limitations
Our results must be considered in light of the studys low
response rate and the common limitations associated with survey
research, as there may yet be biases related to the perceptual nature
of the EHR performance data. Relying on more than a single respondent per medical practice, including non-physician members such
as registered nurses and secretaries would have provided a truer
picture of the perceived performance improvements obtained by
the practice from its assimilation of EHR technology. The variability observed in the performance outcomes of EHR systems could be
further explained by better understanding the full clinical environment of EHR utilization. In-depth case studies should thus complete
the picture provided here by improving our comprehension of
the process of using an EHR system effectively, to improve the
performance of family physicians and their medical practices. For
instance, the process model proposed by Carayon et al. [72] would
be of great help to deepen our understanding of how EHR usage in
medical practices affects work processes (clinical and administra-

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G. Par et al. / International Journal of Medical Informatics 84 (2015) 857867

References
Summary table
What was known on the topic
Ofce-based electronic health record (EHR) systems are
rapidly diffusing in most developed countries.
The potential benets of using EHR systems in primary care
settings are numerous, including better quality and continuity of care, greater productivity, and positive nancial
returns.
But as there is often a gap between software designers
expectations and users behaviors, family physicians can use
EHR systems in ways not anticipated initially.
What this study added to prior knowledge
EHR systems as-used vary substantively from one family physician to another in terms of the capabilities that are
actually mobilized by them.
Based on our taxonomy of EHR usage behaviors, family
physicians can be categorized as either basic or advanced
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Physicians who perceive to be highly and positively impacted
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However, only a minority of family physicians seem to use
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tive) and the consequent individual and organizational outcomes.

Finally, in addition to functional coverage and ease of use it would
seem important to consider perceived usefulness as another key
antecedent in future models; as is usually done in information systems and medical informatics acceptance research.
6. Conclusion
In facing contemporary healthcare challenges, governments
and other key stakeholders such as medical associations are continuously searching for ways and means to improve both the
effectiveness and efciency with which primary care services are
provided to their population. This study has conrmed that the
advanced use of EHR systems by family physicians constitute a
signicant part of the solution in this regard. Prior research in this
area has been greatly benecial in helping us learn how to get users
to accept and adopt EHR systems [e.g.,1], but EHR system usage
alone is not sufcient to obtain signicant performance improvements as this study has showed. In short, EHR system use must be
advanced or extended in order to reach signicant performance
gains in primary care, both at the individual and the organizational
levels. Thus, medical informatics researchers must identify the individual and organizational levers that motivate family physicians to
assimilate EHR systems in a more extensive and intensive manner.

Acknowledgements
The nancial support of Canada Health Infoway for this study is
acknowledged.
Appendix A. Supplementary data
Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.ijmedinf.2015.
07.005.

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