Active use by healthcare providers
Digital Health Evidence Review: This section provides information on active user of EHRs in other countries.
What is active use?
Active use is distinct from adoption because it measures regular or ongoing engagement with a system. In contrast, adoption is a measure of the growth in registration or acceptance of a new system over time. Canada is an international leader in the reporting of active EHR use by their healthcare providers. In Canada, EHR implementation is led by the states who each report on the number of active users of their EHRs. The definition of an ‘active user’ is different between states but all require at least one EHR system access per month. Driving active EHR use is incentivised in Canada.
How does active use change over time?
At a national level, Canada estimates that there will be 500,000 users when the EHR system has reached maturity. This number of users represents 80% of all physicians, nurses and pharmacists as well as 50% of other clinicians and administrators. Active use is closely related to system maturity with the highest level of access by users seen in systems that have been in operation the longest.  Figure 1 below shows how national levels of active use have increased over time.  
Figure 1 Percentage of estimated monthly active users in Canada, 2015 - 2016
At a local level, active use can vary considerably. For example, a summary of active users in the Greater Toronto Area between Jan 2015 and May 2016 showed that the level of active use ranged from 18% to 100% within healthcare organisations. The highest proportion of active users (>50%) was seen in community-based hospitals and community care access centres. 
What is the relationship between active use and adoption?
The Canadian example also demonstrates the lag between adoption and active use. For example, throughout 2015 and 2016 in South West Ontario there was a focus on adoption and connecting clinicians across the full continuum of care to their local EHR.
In April 2016 :
Internationally, active use is an underexplored area. However, as outlined in the international overview section, many countries are early in their EHR journeys. It is likely that active use will be explored further as we move into the next decade of EHRs and these systems mature.
1 eHealth Ontario. Benefits Realization Update 2016. 2016.
Available from: https://www.ehealthontario.on.ca/images/uploads/pages/documents/2016_Benefits_Realization_Update_EN.pdf [Accessed 18th Oct 2017].
2 Gheorghiu B, Hagens S. Measuring interoperable EHR adoption and maturity: a Canadian example. BMC Medical Informatics and Decision Making. 2016;16(8).
3 Canada Health Infoway. A Conversation about Digital Health: Annual Report 2015 - 2016. 2016.
Available from: https://www.infoway-inforoute.ca/en/component/edocman/resources/i-infoway-i-corporate/annual-reports/3098-annual-report-2015-2016 [Accessed 18th Oct 2017]