Quebec’s Digital Health Record Faces Issues: Costs, Translation & System Fit

Implementation of Quebec’s new digital health record system is facing challenges, including translation issues, cost overruns, and software usability concerns, as the rollout approaches in May. The $402 million project, spearheaded by Epic Systems, is initially being piloted in the Mauricie-et-du-Centre-du-Québec and North Montreal regions.

Internal communications from Santé Québec reportedly restrict employees working on the Dossier santé numérique (DSN) from speaking to the media. “We see forbidden for employees to speak negatively about the Digital Health Record,” stated Isabelle Roy, president of the North Montreal Nursing Professionals Union.

The government of Quebec selected Epic Systems in 2023 to deploy the DSN, but concerns already existed regarding the company’s track record in other countries, with several nations previously experiencing difficulties with the Epic model. The project’s scale and complexity have prompted some healthcare workers to voice their concerns.

Four employees, wishing to remain anonymous to avoid professional repercussions, have shared their experiences with Radio-Canada.

American Software for Quebec’s Healthcare System

Epic Systems initially designed its software for the U.S. Healthcare system, which differs fundamentally from the Quebec model.

“In the United States, the system is highly hospital-focused, so prevention and social services are not part of their healthcare system. It is also very hierarchical, with hospitals having owners and managers,” explained Myriam Lavoie-Moore, a research associate at the IRIS (Institut de recherche et d’informations socio-économiques) and a specialist in digital technologies and health.

The Epic software recognizes hospital centers but doesn’t automatically recognize Quebec healthcare facilities, such as long-term care facilities (CHSLD), community service centers (CLSC), youth centers, perinatal centers, or addiction centers.

Sources indicate that “everything has to be created” from scratch, requiring significant effort from healthcare staff. This adaptation is described as an “aberration” by those who spoke with Radio-Canada, who believe Quebec underestimated the labor costs associated with programming and training related to the DSN.

This oversight has already contributed to cost overruns of $136 million.

Radio-Canada attempted to contact Epic Systems for an interview but was directed to Santé Québec. Santé Québec declined to provide an interview regarding the DSN but offered a brief written statement.

Difficult French Translation for the American Software

Radio-Canada has also learned that the translation of the software from English to French is often inaccurate, with errors, Anglicisms, and medical terms not properly classified or named.

Sources cited several examples:

• The term “ordonnance” (prescription) is used to schedule a home visit for a new mother;
• “Prescription” is used to designate an interprofessional referral to consult, for example, an occupational therapist, physiotherapist, or nutritionist;
• And to refer to a stretcher? The word “brancard” is used.

Sources fear that these translation errors could create confusion, errors, and slowdowns in daily practices.

Regarding the translation issues, Santé Québec stated in writing that “the translation is progressing as planned and there are very few elements left to complete in the user interfaces. Work is progressing daily, both internally and in collaboration with the publisher.”

To Avoid Paperwork, Standardized Online Forms

The goal of the DSN is to digitize all practices. To avoid using paper, employees report they will now work with online digital forms, meaning they will have to answer pre-defined questions to track patients.

For example, “to administer each medication, there will be a series of small questions or assessments to complete. In long-term care facilities, it will seize 20 to 30 minutes per patient to distribute medication, and that’s just for the morning medication. This doesn’t include medication at 10 a.m., 12 p.m., 2 p.m.… When you calculate that an auxiliary nurse has 32 patients, clearly, there won’t be enough hours in the day,” explained Roy. Administering medication normally takes only 5 to 10 minutes, she added.

It’s a huge number of clicks to do the same tasks we used to do.

Sources fear that the Epic Systems software is poorly suited to the community sector of the Quebec healthcare network. Follow-up in nursing or laboratory care is different from follow-up in addiction or homelessness, and human experiences sometimes struggle to fit into a rigid digital form.

“If social services and prevention services work less well in the computer system and create glitches and bugs and turn into less efficient, will we blame the IT department or the services themselves? There is a real risk of replicating the American model rather than strengthening our own,” warned Lavoie-Moore.

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And, Not Everything Will Be in the DSN

The goal of the DSN is to have everything in one place. “But the further we get into the project, the more we realize that we will continue to apply other programs outside of the DSN,” noted the union president.

She explained, for example, that the list of medication profiles will not be accessible in the DSN, as originally planned. “It will rather be available via a paper portfolio to facilitate scanning.”

Roy also questioned the fate of portable tablets purchased to scan medications onto the online platform, which she says no longer appear to be useful.

The union president also reported that Sainte-Justine Hospital never approved the integration of a digital form specific to its practices into the Digital Health Record.

Regarding the development of a baby, she reported, for example, that “nurses will have to continue using the paper form, scanning it, and then trying to transfer it into the Digital Health Record.” In this specific situation, Roy believes the DSN will be unhelpful.

All sources who spoke with Radio-Canada fear that the increased workload associated with learning the new platform, resolving technical issues, and using both the old (paper) and new method (DSN) will be overwhelming. They fear negative consequences for services offered to patients in an already strained healthcare system.

Was Another Option Possible?

Frédéric Cuppens, director of the Multidisciplinary Institute in Cybersecurity and Cyber Resilience at Polytechnique Montréal, wonders if Quebec could have considered another option for digitizing the medical data of Quebecers.

He cites the example of France, which opted for a federated rather than centralized system—as is the case in Quebec—to deploy the Personalized Medical Record.

“The federated system relies on an existing system. There is already software deployed in hospitals, and to federate it means introducing interfaces [so that these different softwares can communicate with each other],” explained Cuppens.

He points out that this method is a less ambitious project than the DSN and responds to needs with a lesser impact on health services and employee training, as they are already familiar with the software they use.

In the long term, he still believes that the DSN option remains interesting, as it could reduce operating costs (maintenance, updates, etc.) through the deployment of a single solution in the province.

However, Cuppens insists: “It is normal that there are a number of problems in the initial deployment phase. … It is a very, very ambitious project.”