Our cross-sectional study found that as of January 2020, less than 50% of respondent Swiss chiropractors used an EPR system in clinical practice, while 60% used encrypted email technology. Younger age and larger practices with more clinicians were factors associated with use of these healthcare digitalisation technologies. With respect to the geographic distribution of Swiss chiropractors, the density of chiropractors was estimated at 3.3 per 100,000 inhabitants in Switzerland and ranged from 2.1 to 4.6 per 100,000 inhabitants across the 7 major regions of Switzerland.
Findings within context of existing evidence
In Switzerland, chiropractic is one of five university-based academic health professions, and focuses primarily on the musculoskeletal system [
17]. Swiss chiropractors typically treat the same musculoskeletal pain conditions (e.g., back pain, neck pain) as their international colleagues using manual treatment techniques including spinal manipulation and mobilisation, education and advice, and soft tissue (i.e., myofascial) therapy [
8,
18]. Key differences in clinical practice relative to other settings lie in the expanded scope of practice, increased referrals from medical doctors, and better integration within the healthcare system [
7,
17,
18]. In the United States, use of EPRs in chiropractic practices was estimated by the American Chiropractic Association to be about 33% in 2010 [
19]. Within the Swiss context, primary care physicians showed EPR adoption of roughly 23% in 2010 [
4], and up to 45% in 2013 [
20]. Smaller practices and older physicians were found to use EPR systems less often [
4].
According to the International Organization for Standardization [
21], an EPR can be defined as a repository of patient data in digital form, stored and exchanged securely, aiming to support efficient and quality integrated healthcare [
22]. By supporting the systematic collection and storage of patient and health-related data, the EPR may help improve communication for clinical decision making in healthcare [
23], reduce errors by automated alerts and prompts [
24], and contribute to the development of harmonised health data that could be used to improve clinical practice and research [
25]. The aggregation of nationwide electronic healthcare data may also facilitate population-level healthcare quality monitoring [
11,
26]. A national report highlighted the needs for better availability of information and standardised quality and safety indicators of the Swiss healthcare system [
27].
The use of EPR systems may enable the systematic collection of real-world routine clinical practice information and support the integration of quality measures using the gathered information [
26]. However, some of the reported barriers hindering progress include clinician skepticism of the potential value of EPR systems, complexity and limitations of existing EPR systems, privacy and security concerns, time burden of EPR use, and high costs [
6]. We found similar perceived barriers for EPR and encrypted email use among Swiss chiropractors (qualitative comments collected via our survey), with some raising concerns about (1) EPRs deteriorating the clinician-patient therapeutic alliance and relationship, (2) data privacy and security, and (3) an uncompelling cost-benefit value proposition. This was quite similar to the main barriers for information technology use reported among Swiss ambulatory care physicians in 2008 by Rosemann and colleagues [
4]. Key recommendations for improving and promoting the Swiss eHealth system include fostering the development of an explicit health data strategy to help create the “right” mindset and attitudes, improving the healthcare information technologies infrastructure, harmonising data access procedures, clarifying privacy and consent issues, and aligning incentives with aims and goals [
28].
Regarding the geographic distribution of Swiss chiropractors, to our knowledge, this is the first study to describe the distribution of the chiropractic healthcare workforce in Switzerland. A recently published international study about the chiropractic workforce reported the highest density of chiropractors in the US, estimated at 24 chiropractors per 100,000 inhabitants [
29]. Other European countries were reported to have similar geographic distributions of chiropractors as in Switzerland [
29]. For comparison, the density of general practitioners in Switzerland has been estimated at 106 per 100,000 inhabitants [
30]. This descriptive secondary finding helps to inform the level of musculoskeletal healthcare service capacity in Switzerland with respect to chiropractors—an important health services datapoint given the integration with other Swiss medical professions and high burden from musculoskeletal pain conditions in Switzerland [
7,
31].
Relevance and implications
Since EPRs form the basis of any eHealth system, a comprehensive implementation of a well-structured, interoperable, and meaningfully useful EPR system is crucial for achieving health information exchange and healthcare practice supported by electronic processes [
32]. This is reflected by the Swiss national eHealth strategy, which aims to encourage and promote digitalization within the health system [
33].
A new law as of 1 January 2022, which requires newly licensed outpatient healthcare providers to join an EPR community, is yet another top-down policy nudge to encourage healthcare digitalization adoption in Swiss primary care, with more experienced outpatient service providers being exempt for now [
5]. Most Swiss chiropractors have not been required to switch to an EPR system due to this new law—our survey reveals an experienced workforce with a mean 22 years (SD, 10 years) of clinical experience. As new chiropractors are licensed and enter the healthcare workforce over time, the prevalence of digitalization among Swiss chiropractors will increase, not only because of this new law requiring EPR use among newly licensed clinicians, but also because EPR and encrypted email use among Swiss chiropractors are associated with younger age, as our study found.
It may be helpful for clinicians looking to adopt digital healthcare technologies to select products with consideration of the Swiss eHealth strategy [
33]. Currently, many products used by Swiss chiropractors have no integration to an interoperable national EPR system and no patient access portal features, which may hinder the full promise of a digitalized Swiss primary care community. To increase the use of EPRs and digital health technologies both in Switzerland and within other primary care health systems around the world [
34,
35], several approaches could be helpful. First, the benefit of EPRs in daily routine care must be increased—for example, by decision support systems, reminder systems to enable proactive treatment of patients with chronic diseases, and tools to support healthcare quality improvement and monitoring of patient reported outcome and experience measures. In addition, adequate approaches to offer fair and reasonable reimbursement for practice-level time and financial investments related to digitalization have to be considered, such as additional payment for electronically generated, evidence-based quality indicators.
Strengths and limitations
A key strength of our study was the high participation rate of 76% of the full population of Swiss chiropractors, suggesting excellent representativeness of our findings. Notable limitations are that we collected data via an electronic survey, which may have led to selective participation of chiropractors more comfortable with technology. We also limited our data collection to a brief and focused survey. This pragmatic decision was made to maximize clinician participation, although it limits the breadth of our findings.
Due to the limitations of our collected data, we cannot be certain why German-speaking clinicians were more likely to use encrypted email compared with French- or Italian-speaking clinicians (86% versus 14%). However, one explanation may be a greater uptake of the Swiss German-based HIN encrypted email technology among German-speaking chiropractors (94% market share). Encrypted email by HIN—a solution for sending sensitive data by email in compliance with Swiss data protection regulations—was founded in 1996, in Steinhausen, Canton Zug, and has developed its services primarily within the German-speaking region of Switzerland. Only as recently as 2020, did HIN establish a branch in Yverdon-les-Bains, Canton Vaud, to better serve the needs of French-speaking Switzerland (la Romandie) [
36].
Our cross-sectional survey was conducted between December 2019 and January 2020, so we do not believe our findings to be seriously affected by the COVID-19 pandemic. The first positive case of COVID-19 in Switzerland was confirmed on 25 February 2020, and a State of Extraordinary Situation under the Federal Law of Epidemics was declared on 16 March 2020. Our study was conducted before the COVID-19 pandemic. Nonetheless, a more recent survey of 152 Swiss chiropractors conducted through the Swiss chiropractic practice-based research network (PBRN) between September 2021 and December 2021 [
37], suggested increased adoption of EPR and encrypted email technologies among Swiss chiropractors, with 56% (95%CI, 48–64%) of participants reporting use of an EPR system, and 85% (95%CI, 78–90%) use of encrypted email communication. These findings, although promising, should be cautiously interpreted as the participation proportion in the 2021 PBRN survey [
37] was lower than in the currently reported 2019 EPR survey (47% versus 76%), and may represent a different study population.