by June Kaminski, RN MSN PhD(c)
Editor in Chief

CJNI was initiated by June Kaminski in 2006 when she was President-Elect of CNIA. She is currently Faculty and Curriculum Coordinator of a BSN Advanced Entry nursing program at Kwantlen Polytechnic University; Communications Officer, Webmaster, and former President of the Canadian Association of Nurses for the Environment and Editor in Chief of the Online Journal of Nursing Informatics. In 2012, June was honoured to receive the CASN and Canada Health Infoway’s inaugural Nursing Faculty E-Health Award 2012 in Ottawa Canada. She also won the Distinguished Teaching Award from Kwantlen Polytechnic University in 2016. She offers the Nursing Informatics Learning Centre with accredited CEU informatics courses.

Citation: Kaminski, J. (2024). Editorial. How does Informatics support Primary Health Care? Canadian Journal of Nursing Informatics, 19(1).  https://cjni.net/journal/?p=12727

The Promise

It has been close to a quarter century since the federal government declared that all Canadians should have access to robust primary health care (PHC) that has been tailored to meet their holistic needs. PHC puts the individual client at the centre of care, with resources and support aimed at promoting physical, mental, emotional, and spiritual well-being through community-driven, diverse ‘close to home’ collaborative team services. An optimistic goal was to ensure that at least 50% of Canadians would have access to primary health care teams by 2011 (Health Canada, 2012). We are not there yet for many reasons, but it is worth looking at how informatics can support the growth of primary health care in Canada.

Although envisioned as a positive step forward to meeting the gaps in care and the strain on the healthcare system that all nurses are acutely aware of, PHC is still not where we targeted it would be by now. “PHC is the most inclusive, equitable, cost-effective and efficient approach to enhance people’s physical and mental health, as well as social well-being´ (World Health Organization, 2023, pgh. 9). Client-centered care and strong healthcare provider-client partnerships are the heart of the evolving Canadian primary health care system. Presently, relatively few Canadians access primary health care services in this way.

“The essential principles of PHC, as set out in the World Health Organization’s Declaration of Alma-Ata, are:

• accessibility
• active public participation
• health promotion and chronic disease prevention and management
• the use of appropriate technology and innovation
• intersectoral cooperation and collaboration” (Canadian Nurses Association, 2015, p. 1).

Eight years ago, attendance at the Canadian Nurses’ Association Biennium Convention in Saint John, New Brunswick that focused on the theme, Nurses: Driving the Shift to Primary Health Care sparked ongoing enthusiasm for the promise of primary health care and how PHC could be promoted through the use of electronic health records (EHR), telehealth and mHealth. “Informatics plays a fundamental role in the promotion of primary health care, through a variety of technologies and processes including electronic health records (EHR), telehealth, eHealth, Mobile health and applications (mHealth), and personal health records (PHR). Nurses are just beginning to become involved in using these methods of providing client-centred care to Canadians. There is plenty of room for improvement.

Telehealth and mHealth are two areas that are beginning to develop across Canada and provide access and convenient ways for people to connect with health professionals especially in rural, remote but also congested urban areas. Canada Health Infoway and COACH –the Canadian Health Informatics Association encourage all health care professionals to become knowledgeable and competent in the use of all technologies in practice, including EHR, mHealth and telehealth” (Kaminski, 2016, pgh. 5). “Other technologies can support information-sharing among providers so that Canadians need not repeat their health histories or undergo the same tests for every health care professional they see. In these ways, all aspects of personal care are brought together in a coordinated way” (Health Canada, 2012, p. 1).

Of course, telehealth came to the forefront during the COVID-19 pandemic lockdown and service demand surge for acute and community-based care across the nation. “The onset of the COVID-19 pandemic upended primary health care delivery across the country, with the rapid deployment and expansion of virtual care services. By April 2020, approximately two-thirds of patient visits with primary care providers were done virtually. This pivot highlighted the potential for better patient access in a connected world, but it also uncovered gaps in technology and inconsistencies in how primary health care information is collected and used. Data in primary health care is widely captured in various forms through digital health technologies. The use of this data, however, is currently constrained due to a lack of data standardization and access” (Canada Health Infoway, 2022, p. 6).

Data Standardization

This lack of data standardization has been partially addressed by the Canadian Institute for Health Information (CIHI) through the development of the revised Primary health care EMR minimum data set (2022). CIHI have been working on this data set for years, but the recent pandemic and the high stress experienced by all who work in healthcare has sparked a new resolve to put this data set into practice. “This update brings us closer to the ideal vision for primary care data — standardized data that can be shared, accessed, and updated by providers across the spectrum of care to ensure safe and quality care for patients. Working together to improve primary care data in Canada will provide a real benefit to patients, clinicians, researchers, and the broader health system” (CIHI, 2022, p. 7).

A key aspect of high quality PHC is well-integrated and diverse teams or networks. Nurses can play a key role in these teams, especially nurse practitioners and community-based nurses. “Building capacity by enhancing PHC competencies throughout the nursing community is an important way to strengthen Canada’s health-care system” (Canadian Nurses Association, 2015, p. 3). These teams can be pivotal in ensuring continuity of care across the spectrum of life from birth to death.

PHC provides the perfect model for delivering three types of continuity:

“Informational continuity refers to information on prior events that is used to give care that is appropriate to the patient’s current circumstance.

Relational continuity recognizes the importance of knowledge of the patient as a person; an ongoing relationship between patients and providers is the underpinning that connects care over time and bridges events.

Management continuity ensures that care received from different providers is connected in a coherent way. Management continuity is usually focused on specific, often chronic, health problems” (Enhancing Interdisciplinary Collaboration in Primary Health Care (EICP) Initiative, 2003, p. 23).

PHC also reinforces the move toward person-centred, individualized care. “Strengthening primary health care represents a fundamental shift from health care delivery focused on treating disease toward health systems that address the specific health needs of patients and communities, with a predominant focus on generalism, comprehensiveness and continuity of care” (van Weel & Kidd, 2018, p. e464).

New Technologies

The PHC landscape is a perfect arena for informatics and technology integration. Classic requirements such as access, interoperability, user-friendly interfaces, and inclusion of artificial intelligence (AI) and machine learning (ML) via computers, mobile devices, wearable devices, remote monitoring equipment, and other forms of technology can improve the way we apply informatics to PHC.  However, we have a long way to go to make this a reality. “Few current PHC systems take advantage of data and digital technology—worldwide, very few primary health care systems are taking full advantage of the increased quantity and quality of data, information, and evidence to improve PHC. As governments continue to invest in harmonized digital tools and health information systems, they must also invest in the human resources needed to turn this information into better clinical and management decisions” (PATH, 2019, pgh. 9).

AI is one area that is just beginning to be explored within healthcare but holds some promise for PHC. “Indeed, integration of AI into CBPHC could help in a variety of ways, including identifying patterns, optimizing operations, and gaining insights from clinical big data and community-level data that are beyond the capabilities of humans. Over time, using AI in CBPHC could lessen the excessive workload for health care providers by integrating large quantities of data and knowledge into clinical practice and analyzing these data in ways humans cannot, thus yielding insights that could not otherwise be obtained. This will allow health care providers to devote their time and energy to the more human aspects of health care” (Abbasgholizadeh Rahimi, 2021, p. 29839). AI also provides superb predictive modeling capabilities, that can help with planning of PHC services and programs (Liyanage, 2019).

Of course, AI also poses some challenges, such as the need for expert programming and validation of AI systems as well as access to high-quality, relevant robust data (Abbasgholizadeh Rahimi, 2021). Datasets need to be representative of the populations served by PHC. There is also the issue of trust: can health providers trust AI-mediated decisions? (Liyanage, 2019). Often, health providers are skeptical of using AI for clinical decision-making but welcome the ability of AI to assist with documentation and management tasks. Terry et al. (2022) found that “participants identified the importance of applications of AI in primary health care practice (including decision support, routine task completion, patient self-management, analyzing practice data, and analysis of existing evidence), while recognizing the current reality posed by a lack of available tools” (p. 4).

It is important that health providers and decision-makers continue to explore ways to include technology and informatics in emerging PHC initiatives to improve access, communication, monitoring, education, and data/information access (Jain, 2023, p. 1). This incorporation can support PHC in many ways such as supporting self-care, diagnostics, and ongoing management, as well as improving digital literacy and access to personalized information (WHO, 2018). “To make digital health a reality in primary health care, countries must address its key components. These include: building the physical infrastructure; deploying appropriate services and applications; developing a capable health workforce; ensuring a sound legal and regulatory environment; and improving governance, policy, standardization and interoperability” (WHO, 2018, p.6).

References

Abbasgholizadeh Rahimi, S., Légaré, F., Sharma, G., Archambault, P., Zomahoun, H. T. V., Chandavong, S., Rheault, N., T Wong, S., Langlois, L., Couturier, Y., Salmeron, J. L., Gagnon, M. P., & Légaré, J. (2021). Application of Artificial Intelligence in Community-Based Primary Health Care: Systematic Scoping Review and Critical Appraisal. Journal of medical Internet research, 23(9), e29839. https://doi.org/10.2196/29839

Breton, M., Deville-Stoetzel, N., Gaboury, I., Smithman, M. A., Kaczorowski, J., Lussier, M. T., Haggerty, J., Motulsky, A., Nugus, P., Layani, G., Paré, G., Evoy, G., Arsenault, M., Paquette, J. S., Quinty, J., Authier, M., Mokraoui, N., Luc, M., & Lavoie, M. E. (2021). Telehealth in primary healthcare: A portrait of its rapid implementation during the COVID-19 pandemic. Healthcare policy = Politiques de sante, 17(1), 73–90. https://doi.org/10.12927/hcpol.2021.26576

Canadian Institute for Health Information (CIHI). (2022). Primary health care EMR minimum data set. https://secure.cihi.ca/free_products/phc-emr-mds-v1.1-en.pdf

Canadian Nurses Association. (2015). Primary health care: Position statement. https://hl-prod-ca-oc-download.s3-ca-central-1.amazonaws.com/CNA/2f975e7e-4a40-45ca-863c-5ebf0a138d5e/UploadedImages/documents/Primary_health_care_position_statement.pdf

Enhancing Interdisciplinary Collaboration in Primary Health Care Initiative. (2005). Barriers and facilitators to enhancing interdisciplinary collaboration in primary health care. https://www.eicp-acis.ca/pdf/pdfs/Barriers-and-Facilitators-to-Enhancing-Interdisciplinary-Collaboration-in-Primary-Health-Care.pdf

Health Canada. (2012). About primary health care. Government of Canada. https://www.canada.ca/en/health-canada/services/primary-health-care/about-primary-health-care.html

Jain, N. (2023). Leveraging technology innovations to improve primary healthcare access. LinkedIn. https://www.linkedin.com/pulse/leveraging-technology-innovations-improve-primary-healthcare-jain/

Kaminski, J. (2016). Editorial. Informatics and Primary Health Care: Reflections on the Biennium. Canadian Journal of Nursing Informatics, 11(12).  https://cjni.net/journal/?p=4758

Liyanage, H., Liaw, S. T., Jonnagaddala, J., Schreiber, R., Kuziemsky, C., Terry, A. L., & de Lusignan, S. (2019). Artificial Intelligence in Primary Health Care: Perceptions, Issues, and Challenges. Yearbook of medical informatics, 28(1), 41–46. https://doi.org/10.1055/s-0039-1677901

Primary Health Care, Nova Scotia Health. (2023). Strengthening the Primary Health Care System in Nova Scotia. Evidence synthesis and guiding document for primary care delivery: Collaborative family practice team-based care and health homes. Nova Scotia: Primary Health Care, Nova Scotia Health. https://www.nshealth.ca/sites/default/files/documents/Strengthening%20Primary%20Healthcare.pdf

PATH. (2019). What is “PHC” and why is everyone talking about it? https://www.path.org/our-impact/articles/what-is-primary-health-care/

Terry, A. L., Kueper, J. K., Beleno, R., Brown, J. B., Cejic, S., Dang, J., Leger, D., McKay, S., Meredith, L., Pinto, A. D., Ryan, B. L., Stewart, M., Zwarenstein, M., & Lizotte, D. J. (2022). Is primary health care ready for artificial intelligence? What do primary health care stakeholders say?. BMC medical informatics and decision making, 22(1), 237. https://doi.org/10.1186/s12911-022-01984-6

Van Weel, C. & Kidd, M.R. (2018). Why strengthening primary health care is essential to achieving universal health coverage. Canadian Medical Association Journal, 190(15), e463-e466. https://doi.org/10.1503/cmaj.170784

World Health Organization. (2023). Primary health care: Factsheet. https://www.who.int/news-room/fact-sheets/detail/primary-health-care

World Health Organization. (2018). Digital technologies: shaping the future of primary health care. https://www.who.int/docs/default-source/primary-health-care-conference/digital-technologies.pdf

World Health Organization. (1978). Declaration of Alma-Ata. https://www.who.int/teams/social-determinants-of-health/declaration-of-alma-ata