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ETD-2015-6585.pdf
FACTORS ASSOCIATED WITH THE IMPLEMENTATION AND ADOPTION
OF ELECTRONIC HEALTH RECORDS (EHRs) IN SAUDI ARABIA
By
AHMED SAAD M ALGHAMDI
A Dissertation Submitted to
Rutgers, the State University of New Jersey
Rutgers Biomedical and Health Sciences
School of Health Related Professions
In Partial Fulfillment of the Requirements
For the Degree of
Doctor of Philosophy
Department of Health Informatics
June, 2015
FACTORS ASSOCIATED WITH THE IMPLEMENTATION AND ADOPTION OF
ELECTRONIC HEALTH RECORDS (EHRs) IN SAUDI ARABIA
By
AHMED SAAD M ALGHAMDI
On
June, 2015
Approved by:
Professor Syed S. Haque, Dissertation Advisor & Department Chair Date
Associate Professor Shankar Srinivasan, Dissertation Committee Member Date
Professor Dinesh Mital, Dissertation Committee Member Date
iii
ABSTRACT
FACTORS ASSOCIATED WITH THE IMPLEMENTATION AND ADOPTION OF
ELECTRONIC HEALTH RECORDS (EHRs) IN SAUDI ARABIA
By
AHMED SAAD M ALGHAMDI
The scope of this study was to identify the extent of the relationship between the
factors that associated with delay in the universal implementation of electronic healthcare
records (EHRs) and how to effect on the quality and efficiency of work and acceptance of
implementation EHRs System in Saudi Arabia hospitals. The Proposed research aimed at
pinpointing the precise technological issues that affected on the EHRs system
implementation in the Kingdom of Saudi Arabia, by focusing on those factors which are
recognized to be barriers for such implementations. Using a questionnaire that was
distributed to Ten Hospitals and the Directorate of Health Affairs in Saudi Arabia. These
hospitals are King Fahad Hospital, Baljurashi Hospital, Aqiq Hospital, Psychiatric
Hospital, Mandaq Hospital, Karra Hospital, Rehabilitation Hospital, Mikwah Hospital,
Qilwa Hospital, Hajra Hospital, and General Directorate of Health Affairs. This study
attempted to identify which barriers actually affect the implementation of EHR systems in
Saudi Arabia. For a confidence interval of 5% at the 95% confidence level, 260 surveys
needed to be sent out at the largest hospital, King Fahad Hospital, and the total surveyed
sent out to all hospitals was 1754. Six groups of health care professionals participated in
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this study: physicians, pharmacists, nurses, lab technicians, administration staff, and
medical records staff.
Pearson correlation analysis and a t-test test were used on the collected questionnaire data
to identify the association factors which are significant barriers to EHRs implementations
in Saudi Arabia. Results indicate that there is a relationship between believes that privacy
and security concerns were not a significant obstacle, whenever the facility had enough
employees to ensure that the implemented EHRs was secure and that maintaining and
updating EHRs systems was not too expensive they were more likely to believe that the
implementation EHRs would increase the quality and efficiency of work in hospitals .also
the data show that no statistically significant difference between the belief that EHRs
system maintenance as one of the four most important barriers influencing the success of
EHRs and the belief that the implementation EHRs would increase the quality and
efficiency of work in hospitals, The data also show that Despite that privacy and security
concerns were not a significant obstacle and whenever the facility had enough employees
to ensure that the implemented EHRs was secure will increase the quality and efficiency
of work in hospitals. Also, of the six barriers recognized as being of inhibit to the
implementation of EHRs systems, the four most commonly cited to be significant in Saudi
Arabia by participants were lack of computer skills, adaptation to new technology, costs of
the EHRs system, privacy and security concerns.
v
ACKNOWLEDGEMENT
First and foremost I would like to praise Almighty ALLAH (GOD) for giving me the
strength, and enlightening my life and education to complete this work. “O Lord! Increase
me in knowledge.”
Indeed, this Dissertation would not have been possible without guidance of many
individuals.
I would like to express my thankfulness and appreciation to my advisor Dr. Syed Haque
for his essential, outstanding guidance, support, and encouragement throughout my
studying years. It has been great time to work with you. I’m honored to have been your
student. Thank you Dr. Syed Haque for your support and kindness.
I would like to express my sincere appreciation to all the staff in the Health Informatics
Department and to the committee members Dr. Shankar Srinivasan, Dr. Mittal, Dr. Shibata,
and Dr. Frederik for their kindness, supportive, and advices during the dissertation process.
I would like to express my heartfelt gratitude to my beloved parents Saad Alhoraiti, and
Saleha Alobzah, for their love and taking care of me throughout my life, for their patience,
support , guidance , encouragement , prayers and believing in me during all my studying
levels since I started elementary school until the Ph.D. Level. I love you so much and please
forgive me to be away from you for long time. God Bless you all!
I would like to express all thanks, grateful to my brother. Dr. Mohammed Alhoraiti
Alghamdi (Abu Saad), for his standing behind me all the time and offering me all his
power, money, advices, experiences, guiding me to choose this major to have my Ph.D. in
it, keeping me connected and updating me in knowledge of Biomedical Informatics gap in
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Saudi Arabia and how is it important field to join and work on it. I really love it. Thank
you so much for all your support and help.
I would like to express my genuine gratitude to my darling wife Saedah Aifan, for her love,
encouragement, support, stand behind me, and been so patience through my life and study
period.
Special thanks to my mother-in-law Mother Hassna Daf. Alzharani for her truth love,
praying, generosity, and support. I love you so much and please forgive me to be away
from you for long time!
I would like to express my thanks and appreciation to my brothers and sisters: Sharifah,
Saadiah, Jamman, Abdullah, Saleh, Khaled, Fahad, and Fatimah for their support, love,
offering their time to finish everything quite easy. Thanks for All.
To my gorgeous kids Eyad & Khaled, for filling my life with joy by their love, friendship,
their spontaneous actions, and their attitudes. I love you. May ALLAH (GOD) bless you!
Special thanks and appreciation to Brother. Abdullah Alhoraiti Alghamdi and his wife
Sister. Zahrah Aifan, and his kids Mohammed, Feras, and Waseem, for being so kind, love,
and being generous with me all the time.
Special thanks and appreciation to Eng. Ali A. Aifan for his love, support, and help during
all my studying period.
Special thanks and appreciation to Major. Turkey Alghamdi and his Wife Fatimah for their
love, support and for their hospitality all the time.
Special thanks and appreciation to my sister–in-law Dr. Hanan Aifan and her family
brother Osamah Alghamdi, and their kids Mohammed & Ahmed, for their love, support,
visits, and helping me at all times.
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Special thanks and appreciation to Brothers. Dr. Saleh Aifan, Dr. Saeed Aifan, Eng.
Mohammed Aifan, 1st lieutenant. Faris Aifan, and Abdollhammed Aifan, for their love,
support, and being proud of me all the time.
Special Thanks and appreciation to my nephew Mr. Abdullah Alobzah for his help and
support during the studying period.
My deep thanks and pray to my little nephew who passed away by car accident on 2010:
Mohammed S. Alobza, May Allah forgive him and reward him the highest level of the
paradise, for his encouragement words when I obtained my Master degree
“Congratulations & keep going forward”. Oh Allah give him your Mercy! Ameen!
Finally, I would like to express my thankfulness, gratefulness to King Abdullah Al- Saud,
May Allah forgive him and reward him the paradise. Ameen! By giving me the chance to
study abroad and have great knowledge from one of the most advanced countries in the
world the United States of America.
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Dedication
I wish to dedicate this dissertation to my beloved father & mother who dedicated their
life for me to have the best Knowledge.
Also,
I wish dedicate this dissertation to my darling wife and my sweet kids who dedicated
their love and time for me to finish this research.
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TABLE OF CONTENTS
ABSTRACT OF THE DISSERTATION………………………………………………III
ACNOWLEDGMENTS………………………………………………………………...V
DEDICATION……………………………………………………………………….VIII
TABLE OF CONTENTS……………………………………………………………....IX
LIST OF TABLES…………………………………………………………………....XIII
LIST OF FIGURES……………………………………………………………………XV
CHAPTER I…………………………………………………………………………….1
1.0 INTRODUCTION………………………………………………………………….1
1.1 Background……………………………………………………………………....…..1
1.1.1Differences between the Health Systems of Saudi Arabia and the United States…11
1.1.2 Hospitals in Saudi Arabia………………………………………………………....13
1.2 Objectives and Significance of Research…………………………………………...15
1.3 Statement of Problem……………………………………………………………….17
1.4 Research Hypothesis………………………………………………………………..17
1.5 Definition of Terms ………………………………………………………………...20
CHAPTER II……………………………………………………………………….….21
II. LITERATURE REVIEW………………………………………………….……..21
2.1 Description and History of Electronic Health Record……………………………....21
2.1.1 Description of EHRs……………………………………………………………....21
2.1.2 The History of EHRs……………………………………………………………...22
2.3 The Advantages of Implementing an EHR. ………………………………...…..….25
2.4 Limitations of Traditional Paper Medical Records (PMRs) ……………….……....34
2.5 Errors in the Contents of Paper Medical Records……………………………..…....35
2.5.1 Omission………………………………………………………………………......35
2.5.2 Delays……………………………………………………………………………..35
2.5.3 Misplacement…………………………………………………………………......36
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2.6 Web-Based Access to Electronic Health Records…………………………….….....36
2.6.1 E-Health…………………………………………………………………….……..37
2.6.2 Online Personal Health Record……………………………………………….…...38
2.7 Barriers of the implementation of Electronics Health Records……………..…........39
2.7.1 Lack of Experience with the Use of Computer………………………………........39
2.7.2 Security Concerns Regarding the Use and Access to EHRs Systems…………..…45
2.7.3 High Cost of Adopting EHRs………………………………………………….......53
2.7.4 Resistance to New Technologies of EHRs………………………………..…….....54
2.7.5 Electronic Health Records Systems (EHRs) Maintenance and Downtime……..…54
2.7.6 Adoption of Electronic Health Records (EHRs)…………………………………..56
CHAPTER I I I……………………………………………………….…………..…….58
I I I. METHODOLOGY…………………………………………………………...…..58
3.1 Research Design and Collection Data………………………………………..….......58
3.2 Demographics of Study Population………………………………………..……......62
3.4 Study Population …………………………………………………………..….…....62
2.5 Pilot Study ………………………………………………………………….…........62
2.5.1 Calculation of Sample Size……………………………………………..………....63
2.6 Data Analysis……………………………………………………………………......63
CHAPTER IV……………………………………………………………….………….68
IV. RESULTS………………………………………………………………..………....68
4.1 Descriptive Statistics of the Data …………...…………………………..…………..68
4.1.1 Response Rate per Hospital…………………………………………………….....68
4.1.2 Response Rate per Educational Level………………………………………….....70
4.1.3 Response Rate per Gender………………………………………………….….....72
4.1.4 Response Rate per Health Care Professional……………………...………….…..73
4.1.5 Respondents Choice for the 4 Main Barriers………………….……….................75
4.1.6 Implementation of EHRs……………………………………………..........…......78
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4.1.7 Respondent Rate by Computer Skills……………………………………………....79
4.1.8 Responded Rate of Knowledge about the EHRs Systems……………………….…80
4.1.9 Responded Rate of hours learning of New System…………………………..….…82
4.2 Summary of Statistics of the Data ……………………………………………….…..83
4.2.1 Summary Statistics for All Hospital……………………….……………..…...……83
4.2.2 Summary Statistics For Per Educational Level……………………..…………...…84
4.2.3 Summary Statistics for Gender………………………….…………………..….......85
4.2.4 Summary Statistics for Health Care Professional…………………………….…….85
4.2.5 Summary Statistics for the 4 Main Barriers………………………………………...86
4.2.6 Summary Statistics for Implementation of EHRs…………………………….…….86
4.2.7 Summary Statistics for Computer Skills ……………………………………...…....87
4.2.8 Summary Statistics for Knowledge about EHRs……………………………….......87
4.2.9 Summary Statistics for Training Hours………………..…………………………...88
4.3 Determination the Relationship between Factors Associated with Implementation
of EHRs in Saudi Arabia Hospitals ……………………………………………………...88
4.31 Multiple correlation and T- test Analysis…………………………………………...88
4.3.2 Multiple Regression Analysis……………………………………………..……...100
CHAPTER V…………………………………………………………………………..107
V. DISCUSSION……………………………………………………………………....107
5.1 Status of Current EHRs Implementations…………………………………………..107
5.2 Barriers to EHRs Implementation………………………………………………......108
5.2.1 Security Concerns regarding the Use and Access to EHRs System ……………..108
5.2.2 Concerns about EHRs System Maintenance and Support Programs……………..109
5.2.3 Concerns about Lack of Knowledge of EHRs Systems and Lack of Computer
Literacy Skills…………………………………..……………………………………...110
5.2.4 Concerns about High Cost of Adopting of EHRs………………………….…......110
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5.2.5 Concerns about Security and Reliability………………………………………….111
5.2.6 Concerns about Workflow………………………………………………………...112
CHAPTER VI………………………………………………………………………….112
VI. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS……………….112
6.1 Summary and Conclusion………………………………………………………......112
6.2 Limitations of Study………………………………………………….…………….116
6.3 Recommendations…………………………………………………………………..117
REFERENCES……………………………………………………………..…………..121
APPENDIX A the Questionnaire for the Study………………………………………..148
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LIST OF TABLES
Table 1: Sample and Response Rates by Hospital………………………………….......69
Table 2: Sample by Hospital and Education Level……………………………….….....70
Table 3: Sample by Hospital and Gender……………………………………….…........72
Table 4: Sample by Hospital and Health care Profession………………………………74
Table 5: Ranking of Reported Barriers by Hospital………………………..….…..…...76
Table 6: Reported Implementation of EHRs……………………..………….…….…...78
Table 7: Self-reported Level of Computer Proficiency…………..……………....…….79
Table 8: Self-reported EHRs System Knowledge…………………………...……....…80
Table 9: Self-reported Number of Hours Participants Plan to Spend Learning
the EHRs System…………………………………….……………….………….…….82
Table 10: Summary Statistics for Hospitals……………………………….……….….84
Table 11: Summary Statistics for Education Level………………………………....…84
Table 12: Summary Statistics for Gender…………………………………..…….…...85
Table 13: Summary Statistics for Health Professionals…………………………........85
Table 14: Summary Statistics for Main 4 Barriers of EHRs Implementation…...........86
Table 15: Summary Statistics for Implementation of EHRs………………..........…....87
Table 16: Summary Statistics for Computer Skills …..……………………….….…..87
Table17: Summary Statistics for Knowledge about EHRs……….………………........88
Table 18: Summary Statistics for Training Hours………………...………………..….88
Table 19: Correlations between Acceptance of EHRs and Attitudes about Privacy and
Security Concerns……………………………………………….…….................…….90
Table 20: Independent Sample Test……………………………………………….…...91
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Table 21: Correlations between Acceptance of EHRs and Concerns about Maintenance and
Support ………………………………………………………………………………....93
Table 22: Independent Sample Test………………………………………………...…..94
Table 23: Correlations between Acceptance of EHRs and Concerns about Computer
Literacy Skills and Lack of Knowledge of EHRs……………………………..……......95
Table 24: Correlations between Acceptance of EHRs and Attitudes Cost Concerns..…97
Table 25: Independent Sample Test…………………………………………….…...….98
Table 26: Correlations between Acceptance of EHRs and Attitudes about Privacy and
Security Concerns………………………….…………………………….......................99
Table 27: ANOVA…………………………...…………………………………………104
Table 28: Variables in the Regression Model………………………………...………...106
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LIST OF FIGURES
Figure 1: Bar Graph of Response Rates by Hospital………………………………...…..70
Figure 2: Bar Graph of Sample by Hospital and Education Level…………………......….71
Figure 3: Bar Graph of Sample by Hospital and Gender…………………………….…..73
Figure 4: Bar graph of Sample by Hospital and Healthcare Profession……………....…75
.
Figure 5: Bar graph of Ranking of Reported Barriers by Hospital………………….…...77
Figure 6: Pie Chart of the Number of Respondents by Level of Implementation of an EHR
system ………………………….……………………………………………………..…78
Figure 7: Bar graph of Self-reported Level of Computer Proficiency by Hospital……...80
Figure 8: Bar graph of Self-reported EHRs system knowledge………………………....81
Figure 9: Bar Graph of Self-reported Number of Hours Participants Plan to Spend Learning
the EHRs System………………………………………………………………………..83
Figure 10: Scatterplots of Implementation of EHRs system with quality of work and
efficiency in hospitals…………………………..………………………………………..90
Figure 11: Scatterplots of Implementation of EHRs system and health facility does not
have enough staff to maintain the system. ……………………………………………..93
Figure 12: Scatterplots of Implementation of EHRs system and the cost of
Implementation EHRs system ………………………………………………………….97
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CHAPTER I
I. INTRODUCTION
1.1 Background of the Problem
The Electronic Health Record (EHRs) is a system of managing patient information
in an interoperable, easily accessible, and highly effective manner. It enables easy
retrieval of important health information for patients regardless of their point of
treatment. With EHRs, health physicians can access and evaluate the patients’ history.
With EHRs underpins accurate diagnosis and execution of proper actions to prevent
instances of fatal medical errors. EHR (Ash & Bates, 2005; Podichetty & Penn, 2004).
EHRs technology comes with a number of advantages that include monitoring and
recording of diagnostic information, medical account, and disease symptoms among
others. The EHRs system makes the clinician’s workflow highly streamlined through
automation and increased efficiency since one avoids the difficulty of fumbling through
paper medical records that do not provide consistent information on the patients’ medical
history. The healthcare system monitors, records, and generates precise information
about the progress of patients whilst suggesting feasible solutions to recurring or
sustained symptoms. (Ash & Bates, 2005). Despite the aforementioned benefits that
come with EHRs systems, numerous studies reveal that its implementation in Saudi
Arabia is still in its infancy stages. Empirical research shows that even in the wake of
rapid technological changes and globalization, the country faces major barriers in the
2
implementation of EHRs that either hamper or slow down the process (Ash & Bates,
2005; Podichetty & Penn, 2004).
The contemporary world is characterized by globalization that has been
significantly heightened by enormous shifts and proliferation of technology, especially
in information dissemination through highly interactive communication avenues.
Nevertheless, various health industry players such as hospitals and healthcare centers in
Saudi Arabia have continued to use outmoded paper medical records whilst its
counterparts notably Sweden, the United Kingdom, Netherlands, and Australia have
successfully integrated the EHRs systems in over half of its healthcare systems. However,
the countries have not reached the interoperability objective of the EHRs that seeks to
allow sharing of the patient’s information amongst the various stakeholders in healthcare
systems. Instead, the systems serve local practices. The United States remains at the
forefront of the implementation of EHRs. However, it was not until President Obama’s
government brought in the Affordable Care Act (2010) that the country started embracing
the system and replacing the traditional paper medical records. Numerous studies show
that there was a need for the US to reduce and prevent medical errors that accounted for
significant patient deaths annually systems (Ash & Bates, 2005; Podichetty & Penn,
2004). Many countries now follow suit to improve efficiency and accuracy in their
healthcare systems. Many countries including Saudi Arabia still face challenges in the
implementation of the healthcare electronic system. Substantial evidence suggests that
paper medical records do not provide reliable and updated information on patients.
Health physicians provide medical services based on patient history. In cases where this
information is inaccurate and/or inaccessible, chances of medical errors due to improper
3
prescriptions remain high. This situation can result in adverse patient effects and/or
fatalities (Poon et al., 2004). The EHRs provide real-time access to medical account
concerning the patients; hence, they provide accurate guidance to health physicians in
administering proper medication. Credible evidence from healthcare facilities where the
EHRs was successfully implemented revealed that the system allowed multiple users to
access patient records with ease as data was properly organized, legible, and complete
(Helzner, 2002). In addition, enhanced information access correlated with the improved
quality of patient care services. The players also reported reduced medical injuries
resulting from medical errors (Wager et al., 2000).
The electronic health records systems in Saudi Arabia are a relatively new
concept. The rapid advances in medical technology have created a gap in the ability of
hospitals and patient care facilities to maintain and update their systems. The lack of
centralized healthcare systems with a predetermined list of standard requirements to
protect patient privacy and security issues in addition to the gap in computer literacy
within the medical community has caused a delay in its implementation (Angst &
Agarwal, 2009).
Patient files have historically been stored in paper-based files from which both
patients and doctors have access. The internet and the freedom that it boasts is also
intimidating to those who aren’t familiar with its use. The culture of Saudi Arabia is such
that fear of privacy and the possible unauthorized access to medical records especially
among the female population prevent people from embracing this new technology (Angst
& Agarwal, 2009).
4
The area of EHRs is still an emerging technology that is still not being used by
all hospitals and patient care facilities globally. Though it is used almost universally in
developed countries, countries are still struggling usually lack the financial resources to
fund such a venture. Saudi Arabia features characteristics of both developed and
developing, as parts of Saudi Arabia are indeed developed and prospering, the technology
use of EHRs systems in Saudi Arabia is still in its infancy (Atherley, 2009).
Medical records have always been stored in paper-based files. Complex filing
systems have been implemented in hospitals and doctors’ offices in order to keep up with
the increasing number of patient forms and files. Medical records take up extensive
amounts of space, they also take time to organize and update. Tracking patients’ medical
history with paper-based filing systems is a tedious task. The implementation of
electronic health records is an effective way to manage patient medical records. The
benefits of utilizing electronic health records include the reduction in filing costs and an
increase in the quality of patient care. Managing patient medical records is fast and
efficient using electronic health records (Angst & Agarwal, 2009).
The challenges in implementing electronic health records include the risk
associated with similar central database systems in which security and privacy is always
an issue. Recent breaches in the central databases among large financial institutions has
led to further discussion over the level of security required to adequately ensure that
personal data remains secure (Hoffman & Podgurski, 2012). Also the security of such
databases that contain accurate personal data is the target of hackers and fraudsters who
attempt to access and steal personal data for impersonation for personal ad financial gain
(Atherley, 2009).
5
The centralization of personal data into an information technology database prior
to the confirmation of adequate security protocol increases the risk of security breaches
(Electronic Health Data Breaches Remain Primary Concern despite Increased Use of
Security Technologies and Analytics). The dangers of inadequate security in centralized
databases have been demonstrated in the recent breaches of consumer information within
some major retailers including Target. The relationship between the centralized
databases within financial institutions is evident when researching the plausibility of
using similar systems for patient data (Wang, Zhang, Xu, Yin, & Guo, 2013).
The initial cost associated with transitioning to a fully functional electronic health
records system is very costly to large hospitals and medical practices. Financially, such
upgrades may not seem feasible to some established medical facilities where IT budgets
aimed at security is insufficient. Instead many hospitals and medical facilities are
implementing a partial electronic health records system while maintaining paper-based
filing systems (Morton, 2008).
In the private sector, hospitals and large patient care facilities are searching for
ways in which to lower costs and improve patient care efficiency. The long term cost
benefits of utilizing electronic health records systems results in a reduction in paperwork
and an increase in the quality in patient care. At the same time it raises concerns over
the security of patient data (Angst & Agarwal, 2009).
Each year millions of people all over the world die due to medical errors that could
have been prevented. Medical errors account for billions of dollars a year to hospitals all
over the world as well. These medical errors aren’t only the result of poor medical
training, but as a result of poor communication caused by faulty systems and processes
6
which cause people to make mistakes and fail to the correct the situation in time. The
rising costs that these medical errors have caused are the result of many variables. The
driving forces are that medical profession, doctors and nurses don’t use electronic
healthcare records to their advantage or don’t use them to their full potential. Some
doctors and nurses don’t have access to these systems at all. There has been a lack of
universal EHRs implementation around the world. Cost is an aspect that could be
preventing many hospitals and medical facilities from adopting EHRs systems (Hoffman
& Podgurski, 2012).
Many facilities are still relying on paper-based files. The lacks of information on
paper-based charts don’t allow clinicians to constantly update patient files without
extensive paper-work and constant printing. Often times the information contained in
the charts is outdated. Also the limited amount of transferability of paper files within a
healthcare facility is limited as files can only be in one place at a time and cannot be
shared with multiple healthcare professionals in different locations simultaneously.
Also, it makes it nearly impossible for health professionals to receive the latest updates
in patient files quickly. The ease of mobility with which electronic healthcare files can
be transferred has resulted in an increase in their use and versatility (Morton, 2008).
Electronic healthcare records allows physician to gain real time access to their patients
files. This allows doctors and medical professionals to collaborate and track laboratory
and diagnostic tests easily and efficiently. The slow implementation of electronic
healthcare records has caused a reduction in the quality in patient care and productivity
within hospitals and medical care facilities. Transitioning to electronic healthcare
records is becoming more important than ever as health information in patient files is
7
increasing and the fact that many systems that hospitals use are more administrative than
clinical and most healthcare organizations have been providing healthcare services that
favor the organizational needs rather than that of the patient (Polito, 2011).
For years, patient medical information has been maintained in paper-based
records. These records are usually handwritten and kept in files. Depending on the
legibility of the handwriting of the physicians carrying out the examinations on
patients; the information may not be helpful in the future (Kohn, Corrigan & Donaldson,
2000). Additionally, it is crucial to keep in mind that whenever the patient comes
in for a checkup, the file is retrieved taking a lot of time and the physician scribbles
on the same sheet of paper or adds a new sheet of paper. This further increases the
shortcomings because the history is not consistent. It is extremely hard for one to
make sense of fragmented information besides being ambiguous (Carter, 2008).
Sometimes the file may experience mechanical destruction during retrieval and storage
so that some information is torn off or is no longer legible. This renders the health record
useless to a large extent. It is necessary to understand that even today; the paper records
are the primary mechanism of collecting information from the patients although
now this information is later fed into the computer. Paper-based records are usually
bulky and pose storage problems in the healthcare facility. On the contrary, EHRs require
minimal space for a computer. To sum up on the paper records in healthcare, there are
several issues that are seen as paramount shortcomings of this style of records (Roukema
et al., 2006). These include illegibility, ambiguity and fragmentation. Inaccessibility and
bulk of storage are also disadvantages of this system.
8
Electronic health records (EHRs) provide easy access to patient data that can be
transferred efficiently from one facility to another. Healthcare databases that store vast
amounts of information allow physicians to monitor and record patient data during office
visits and electronically, prescribe medication and tests as well as store and track test
results. The case which patient data can be accessed and recorded makes it both efficient
and once completely implemented cost effective (Wang & Guo, 2013). Hospitals and
medical facilities in Saudi Arabia along with other developing countries have get to fully
implement a universal EHRs database, putting them behind the developing world that
have ceased to rely entirely upon paper based medical files. Paper-based patient files
take up a lot of room and are inefficient as they can be easily filed incorrectly and can
lead to mistakes if files are incomplete. One of the benefits of EHRs systems is the ability
to track who has access to patient files and who has made which changes to each file as
information is entered into data fields (Berg, 2001).
EHRs systems improve healthcare recording process. The ease in which patient
data can be entered and tracked makes it an ideal solution for maintaining patient files.
In addition to being easy to use, it is easy to track who has accessed files and changed
data. The emphasis of the ease with which data can be accessed is a driving force in the
adoption of EHRs worldwide. Patient files can be viewed by any authorized healthcare
professional who has access to the EHRs database that houses patient files (Bergmann &
Haux, 2007).
There is varied information in literature that emphasizes the different strategies of
classification of medical errors within healthcare as a result of mistakes made by doctors
and medical professionals. In the areas of healthcare services, severity of injury from
9
mistakes, legal definitions, typesetting, and type of individual involved in the case along
with the strategies that lack the common framework, there have been increased numbers
of mistakes that are due to poor record keeping. Different organizations and hospitals
have attempted to organize their records and create their own systems for identifying and
solving problems surrounding the lack of EHRs adoption. Feedback controls and the
system controls are needed to track costs associated with EHRs systems (Bleich & Slack,
1992).
Saudi Arabia is the center of the Arab world, and it means different things to so
many people, especially to the millions of followers of Islam. Each year millions of
pilgrims go to Saudi Arabia to perform pilgrimage. To others, Saudi Arabia like the USA
is viewed by many around the world as a land of opportunity, especially for the millions
of people from Asia, Europe and the United States. Large numbers of people from around
the world go to Saudi Arabia in search of work. As a result the Saudi Arabian
government has increased its funding in order to improve healthcare. The extra funding
has allowed both government and private hospitals and patient care facilities to open and
flourish (Iakovidis, 2001).
Saudi Arabian hospitals have been able to offer an increased number to new
treatment options to patients due to the increase in funding and government support
which the healthcare system. Sophisticated treatments such as kidney and liver
transplants open-heart surgery and advanced cancer screening and treatment options have
increased the quality in the recovery of people suffering from the previously mentioned
ailments (Jannadi & Hussain, 2008).
10
The newly sophisticated healthcare system has also improved the quality of
healthcare that expatriates from different countries receive when they visit and/or work
in Saudi Arabia. The majority of medical care is performed at government hospitals and
public patient care facilities, but a growing number of private hospitals are increasingly
offering more services. Many different doctors from different hospitals and patient care
facilities may treat the same patients resulting in information becoming scatter
throughout the healthcare system (Leech, 2004). Due to vast amounts of healthcare
information that is being record for each patient, the storage and retrieval systems of
patient medical files are inefficient. Some of the disadvantages of this health care system
is that the systems that each facility uses are different and there isn’t any integration.
Physicians don’t have access to complete patient files unless in a rare case a patient is
treated at the same facility all the time. In addition, the lack of system integration has
forced many patients to undergo the same diagnostic tests multiple times because the test
results aren’t put into a centralized EHRs system (Koeller, 2002). It is common for
patients to be treated for the same ailment by several physicians. This is not only
inefficient; it is also costly to both people and the government. There are many benefits
to the use of EHRs systems. Many mistakes are made when a physician writes out a
prescription because the pharmacist or other healthcare professional can misinterpret the
handing to mean something else. When physician prescriptions are submitted
electronically, it is less likely to be misinterpreted. Prescriptions can be sent
electronically to the pharmacy and the physician has control over the medications that he
prescribes (Jha & Bates, 2008). The ordering process is streamlined in real-time so that
potential drug interactions or allergies are more easily identified. This also reduces the
11
time that it takes to locate patient charts. EHRs adoptions allows nurses and other medical
care professionals to spend more time treating patients and less time inputting patient
data in the system. Electronic files can be directly input into the system instead of have
to maintain patient data and put it into the system at the end of the day. The reduction of
administrative tasks would allow medical care professionals to increase the time spent
treating their patients rather than performing miscellaneous administrative tasks
(Iakovidis, 2000).
If all goes according to plan, EHRs will be fully functional and exchangeable by
2016. According to the Department of Health and Human Services (HHS) the number of
hospitals adopting EHRs has increased from just 9 percent in 2008 to over 80 percent in
April of 2013. Much of this growth can be attributed to incentives and requirements laid
out in the Recovery Act of 2009 and the Affordable Care Act. The Health Information
Technology for Economic and Clinical Health Act (HITECH Act), enacted under the
Recovery Act of 2009, allocates $24.3 billion to promote and expand the adoption of
health information technology (Murphy, 2011).
However, adoption of EHRs is not as simple as acquiring information technology.
A set of meaningful use stages, developed by HHS, ensures quality and guides EHRs
systems towards the ultimate goal of better patient outcomes. Meaningful use is
determined by attaining certain milestones over time, as defined by HHS, that
demonstrate improved quality, safety and efficiency — and reduce health disparities
while engaging patients and improving care coordination through a secure and private
records system (Walston & Al-Omar, 2008).
12
1.1.1 Differences between the Health Systems of Saudi Arabia and the United States
In the Kingdom of Saudi Arabia, public healthcare facilities provide free
medication to its legitimate citizens. However, the private sector offers care services for
a fee. In contrast, health insurance companies in the United States play a critical role in
the issuance of medical cover to individuals. Hospitals in Saudi Arabia provide free
services to patients based on the sectors within which they belong. As a result, only
members of a particular sector benefit from the free healthcare services that are offered
in the hospitals. For instance, military hospitals provide free services strictly to militants
and their beneficiaries. Others who do not comprise the military can access services from
the private facilities the across country for a fee unless they have been referred to the
military hospitals by other health facilities. Hospital specialization in the Kingdom of
Saudi Arabia is a common practice as the high-level facilities treat specific medical
conditions. Consequently, patient referrals to the specialized hospitals are common in the
country. One of the most prominent referral health facilities in KSA is the King Faisal
Specialist Hospital and Research Center (KFSH&RC). The facility only handles illnesses
that are related to tumors. The hospital deals with tumor-related conditions only. Patients
who are diagnosed with such conditions are referred to the particular facility for
specialized treatment.
In the United States, all the citizens are encouraged to enroll for health insurance
to meet the expensive health services. Open enrollment is done annually. For instance,
programs such as the Medicaid and Medicare facilitate the provision of reasonably priced
medical services for the US population. The programs are aimed at making healthcare
accessible to underprivileged groups in the country. These programs have been
13
operational since 1967. On the other hand, the Saudi Arabia government mandates the
Ministry of Health to control care delivery in both public and private health facilities.
The ministry works in conjunction with several other government agencies the National
Guards hospitals, hospitals of the Ministry of the Interior, Ministry of Defense and
Aviation, and the Royal Commission for Jubail and Yanbu to provide healthcare services
healthcare services to employees and other citizens under special procedures. Recently,
KSA began adopting the concept of health insurance coverage for the working class. The
Saudi Arabian government passed a regulation directing all employed persons in the
private sector to obtain health insurance from the employer companies.
It was not until 2002 that the New Saudi Health System (NSHS) was implemented.
The system sought health insurance for all expatriates and Saudi citizens who worked in
the private sector. The uncovered citizen has a choice of seeking free health services in
public facilities or visiting private sector for paid care. They can also purchase an
insurance plan for private healthcare services. The aforementioned differences between
the healthcare systems of KSA and the US underpin the feasibility of implementing
EHRs in the country.
1.1.2 Hospitals in Saudi Arabia
The Kingdom of Saudi Arabia has an estimated population of more than 26 million
people with an annual growth rate of approximately 2.2% million. The country has over
400 hospitals (249 are MOH, 39 government, and 127 private sector hospitals) that
provide healthcare to the population. These hospitals provide jobs to over 500,000 people
who come from more than 80 countries. The hospitals fall under different managements
14
under the Ministry of Health, Ministry of Defense, National Guard, universities, and/or
private sectors.
A great percentage of KSA hospitals under the Ministry of Health have
implemented the EHRs systems in their facilities such as King Fahad University Hospital
in Riyadh, King Fahd Hospital in Baha, Baljurashi Hospital in Baha, , and Psychiatric
Hospital in Baha. However, the King Faisal Specialist Hospital and Research Center
(KFSH&RC) in Riyadh has full implementation of the EHRs system. The hospital began
its EHRs implementation in1978. The financial and administrative departments were the
first areas within which the system was implemented in the first years. A decade later,
the implementation was taking place in the Laboratory and Pharmacy modules, which
form the primary areas of focus on the electronic health systems. Presently, the hospital
is implemented full Patient Record System (PRS) as part of a larger process of
computerizing the operations of the facility. Various studies have revealed that the
hospital has opted to retain the manual record system despite the enormous steps towards
a complete EHRs system. In addition, many hospitals under the Ministry of Defense have
realized partial and full implementation of the EHRs system in core units such as patient
admission, laboratories, and pharmacies. The Ministry of Defense manages several
hospitals notably the Riyadh Armed Forces Hospital among others. The King Fahad
National Guard Hospital is the largest military hospital under the administration of the
National Guard in the Kingdom of Saudi Arabia. The hospital specializes in advanced
medical conditions. The country has advanced health facilities that deal with trauma and
cardiac cases. However, despite having a basic EHRs system, the hospital replaced it by
advanced CPR technology known as the Misys Healthcare System (MHS). This method
15
has significantly improved the delivery of healthcare in KFNGH because it has facilitated
monitoring and recording to patient information. University hospitals in the country
conduct research on various subjects while also providing healthcare services. However,
they lack functional EHRs systems in their facilities. As a result, they depend on manual
records for their research and patient care.
1.2- Objectives and Significance of Research
The scope of this study was to identify the extent of the relationship between the
factors that associated with delay in the universal implementation of electronic
healthcare records (EHRs) and how to effect on the quality and efficiency of work
and acceptance of implementation EHRs System in Saudi Arabia hospitals. The
major objectives of this research is to The scope of this study was to identify the
extent of the relationship between the factors that associated with delay in the
universal implementation of electronic healthcare records (EHRs) and how to effect
on the quality and efficiency of work and acceptance of implementation EHRs
System in Saudi Arabia hospitals.
The major objectives of this research are to:
1. Identify the technological issues pertaining to patient privacy including access
authorizations to patient data.
2. Identify how education and computer literacy translates to a lack of universal
EHRs implementation.
3. Identify the Security concerns regarding the use and access to EHRs Systems
4. Identify the High Cost of Implementation EHRs.
16
5. Identify the Resistance to New Technologies
6. Identify the EHRs system Maintenance and Down time
7. Identify the Adoption of New Technology
8. Identify the most fundamental barriers that consistently prevent the
implementation of EHRs systems in the Kingdom of Saudi Arabia.
This research will discover the major underlying reasons that there is EHRs
implementation delay and also helped to identify its causes. The implementation of a
universal EHRs system design and compatibility programs will assist in the
comprehensive care that patients receive in Saudi Arabian hospitals and patient care
facilities. This will also allow medical professionals to use the information from this
research to design programs that will assist in establishing policies and training materials
for medical professionals. Furthermore, the expanded research is designed to probe for
quality training issues in the areas of patient privacy concerns in addition to the computer
training.
Whenever there is an issue with the advancement of technology especially in the
medical field there is a need to search for its underlying causes. This research will assist
in identifying the reasons that are preventing complete adoption of EHRs systems and
compatibility issues. Privacy concerns along with the different vendor options and how
it translates into smooth integration within hospitals need further research to measure
their effectiveness.
17
1.3-Statement of Problem
The challenges of implementing electronic health records include security and
privacy concerns along with the issue of cost effectiveness in securing databases. The
privacy concerns affecting the implementation of electronic health records over paper-
based filing systems is the risk of security breaches and identity theft that are not as
common in paper-based filing systems.
The significance of researching the challenges affecting the implementation of
electronic health records systems will allow researchers to evaluate methods of
safeguarding patient privacy. It will also allow federal regulators to develop a uniformed
set of policies and procedures concerning liability in security breaches. The relationship
between the storage of confidential financial data and patient data in illegal activities is
the topic of much recent debate and further research is needed in order to make decisions
in future policies. The question of patient rights to privacy and whether patients should
be able to place limitations on hospitals that are held responsible for the protecting patient
data is also an issue that requires further research.
1.4 Research Hypothesis:
The purpose of this study is to understand the factors associated with delay the
EHRs System implementation in Saudi Arabia. The study will provide valuable
information about current uses and implementation of EHRs systems in Saudi Arabia,
while also, investigating those factors and how to effect on the quality and efficiency of
work and acceptance of implementation EHRs System which enhance such
implementations. The study will include six groups of healthcare professionals:
18
physicians, pharmacists, Nurses, Technicians, Administration Staff, and Medical
Records Staff. The major aim of this research is to examine to what degree a correlation
exists between the acceptance implementation of EHRs systems and the following items:
Lack of computer skills
Cost Of EHRs Systems
Adaption of the new technology
Privacy and security concerns regarding the use and access of EHRs System
EHRS maintenance
Resistance to new technology
The hypotheses that are to be tested are as follows:
Hypothesis 1: Privacy concerns and the lack of authorization controls inhibit the
acceptance of EHRs.
Independent Variables: 30_7, 31_5, 24, 18_4
Dependent Variables: 19
Hypothesis 2: Concerns about EHRs system support and maintenance inhibit the
acceptance of EHRs.
Independent Variables: 18_5, 30_3, 30_4
Dependent Variables: 19
Hypothesis 3: Lack of Knowledge of the EHRs systems and lack of computer literacy
skills inhibit acceptance of the implementation of EHRs systems in Saudi Hospitals.
Independent Variables: 5, 17
19
Dependent Variables: 19
Hypothesis 4: Perception of the costs of implementation of EHRs inhibit the acceptance
of EHRs systems in Saudi Hospitals.
Independent Variables: 30_1, Q22, Q18_2
Dependent Variables: 19
Hypothesis 5: Health care specialists who identify EHRs system as being less secure and
reliable than their paper-based counterparts or as not providing adequate certification and
authorization measures are less probable to accept the adoption of EHRs systems.
Independent Variables: 25, 20, 26
Dependent Variables: 19
Hypothesis 6: Health care specialist who believe that the EHRs System improve current
workflow are more likely to accept the adoption of EHRs systems.
Independent Variables: 16
Dependent Variables: 19
20
1.5 DEFINITION OF TERMS:
EHRs
The Electronic Health Records (EHRs) is a system of managing patients’
information in an interoperable, easily accessible, and highly effective manner.
It is easy to retrieval the health information for patients regardless of their point
of treatment. With The Electronic Health Records (EHRs), healthcare
physicians can access and evaluate the patients’ history. This situation supports
accurate diagnosis and finishing of accurate actions to prevent instances of fatal
medical errors. EHRs technology comes with a number of advantages that
included monitoring and recording of diagnostic information, medical account,
and diseases symptoms among others. (Handler et al., 2003).
(HHS) Department of Health and Human Services
(CPOE) Computerized Physician Order Entry
(PDA) Personal digital assistant
(MHS) Misys Healthcare System
(NSHS) New Saudi Health System
(PRS) Patient Record System
(EMR) Electronic Medical Records
(HIS) Health Information System
(PMRs) Paper Medical Records
(IOM) Institute Of Medicine
(ASP) Application Service Provider
(OPMR) Online Personal Medical Records
(MOH) The Ministry of Health
21
CHAPTER II
II. LITERATURE REVIEW
2.1 Description and History of Electronic Health Record
2.1.1 Description of EHRs
Electronic health records focus on patient data management from capture, storage,
and retrieval whenever such information is needed. The system is designed to enhance
interoperability and interaction between current and past medical history of patients. The
EHRs systems can gather information from a broad range of divergent patient data
sources including visit notes, reports from different physicians, lab and X-ray results, and
information from health facilities. All EHRs systems have similar characteristics that are
listed below (Carter, 2001),
Their primary purpose is to manage patient data
They utilize various methods of data entry including voice recognition, pen, and
optical character recognition
EHRs can network through LAN, internet, and/or wireless systems
They are secured through encryption, passwords, and biometrics
They support instant messaging
EHRs allow flexible storage of clinical information in a way that permits
movement from one system to another.
EHRs systems allow multi-functional capabilities whereby physicians can
perform numerous tasks simultaneously. For instance, they enable physicians to have
22
real-time access to patient problem lists, prescriptions, and related adverse reactions and
test results among other information (Barrett, 2003). The system also enables physicians
to prepare documents and reports regarding the services they offer to patients during their
visits and justification for clinical decisions. In addition, they also identify clinical issues
using red flags that alert and remind physicians. In fact, alerts play a key role in the
clinical practice as they can remind physicians of drug allergies. Furthermore, clinicians
can make guided decisions on clinical issues upon access to comprehensive and steadfast
databases and references that are provided by the EHRs system. The system provides a
basis for standardization of disease management goals for patients with chronic
conditions (Satinsky, 2004).
2.1.2 The History of EHRs:
With the emergence of computers in the 1960s, many industries welcomed and
began integrating technology in their business activities. However, a substantial amount
of literature reveals that the health care industry has been slow in the adoption of
computer technology despite the innovation capabilities enhanced by information
technology (IT). Service industries such as banking finance and telecommunications are
some of the sectors that welcomed and embraced computer technology (Neil, 2000).
Larry Weed, who introduced the conception Problem Oriented Medical Record into
healthcare, first speculated the idea of recording patient information (Berner et al., 2005)
.The idea sought to replace paperwork based recording of patient data as he envisioned a
recording system that was to allow third party individuals to verify patient information
independently. Nevertheless, despite the many benefits of EMR, its take-off were
significantly slow. The idea of EHRs aimed at enhancing the reliability of information
23
and protection from data loss. The EHRs technology increases the storage space virtually
while relieving physicians from paper charts. Due to proficient organization of patient
data, the system has resulted in improved care delivery that has been characterized by
reduced mortality rates in healthcare facilities that have realized its implementation.
Efficient is also realized since medical errors are pointedly reduced due to proper
management of health information. Today, the idea of EMR has been promoted through
the proposal of healthcare systems to adopt EHRs. Healthcare leaders are encouraged to
envision apt strategies that endorse note documentation, information coding, and
interactive decision-making (McDonald, 1976). Notable forms of EHRs systems in
different health facilities include the HELP system at the LDS Hospital in Utah, the
COSTAR system at Massachusetts General Hospital, and the TMR system at Duke. Most
of the systems date back to the 1970s and utilized techniques in workflow, exhibition,
and user interface that formed the standardized basis of modern technology of the 21st
Century (McDounal, 1976: Warner et al., 1972: Barnett et al., 1979). Despite these
systems being a landmark discovery that can revolutionize healthcare systems,
administrators failed to support them as some considered them as unbeneficial. Other
managers were reluctant to spend enormous amounts of capital and labor in systems
whose feasibility was skeptical. These arguments have been the active barriers to the
successful implementation of EHRs up-to-date. In the 1970s, two approaches to health
information system (HIS) applications emerged. The first approach was a concept of
immense design whereby single, large time-shared computer were used to support a
collection of applications (Shortliffe et al., 1990). The other one used a multi-machine
model. However, these approaches were deemed impractical. Many systems at the time
24
lacked interoperability as they functioned from a stand-alone perspective. EHRs were
meant for interactivity within healthcare settings. Physicians often preferred relying on
their acquaintance and experience rather than the systems. The systems were incapable
of providing fine-grained and comprehensive data on patients. In the1980s, there were
notable technological advancements that supported the EHRs systems. This set of
circumstances led to the development of affordable networking systems that underpinned
the implementation of EHRs (Morris et al., 1995). Data interchange was amplified as the
first version of the HL7 standard was developed. Massive research also intensified as
attempts were made to apply the expert system methodologies in developing more
suitable decision support systems for clinical needs. Research on various systems such
as QMR, DXPLAIN, and ILIAD among others proved that integrating reminders and
alerts into the EHRs systems lowered healthcare costs. Technology improved
significantly from the 1980s onwards. There was continued the development of standards
in the HL7 that focused on recording electronic data, which was easily shared and
accessible (Santinsky, 2004). By the late 1980’s, most healthcare institutions had realized
the enormous achievements in the implementation of the EHRs systems.
Interconnectivity was ensured by the installation of single terminal PCs that were located
either in the office or hospital ward where health care workers retrieved essential patient
test results including blood chemistry, microbiology, radiology, and biopsy reports. It
included three major facets that included uses and users, technology, and policy and
implementation. There was an increased need to revolutionize the EHRs systems with a
view of promoting healthcare delivery (Santinsky, 2004).
25
2.1.3 The Advantages of Implementing a EHRs
The benefit of implementing a EHRs system would be the streamlining patient
care through the ease of access to necessary patient information by primary care takers.
The benefit of electronic information systems is that is allows vast amounts of
information to be maintained and accessed by doctors and medical support staff in order
to communicate patient care information quickly and accurately (Shamilyan,2008).
There are many types of information systems that hold vast amounts of patient data from
radiology reports, lab reports from blood tests and other medical tests to physical exam
results and prescription medications (Young, 2000).
Patient data that is collected and stored electronically within general practitioner
offices during routine visits can be used in conjunction with data collected from patient
visits to specialists to improve communication between doctors who are treating the same
patients(Swartz,2004).This information serves as valuable resources to supporting
diagnosis and tracking patient care. Also patient laboratory and medical test results that
from test prescribed from these doctors should not only be stored in the local databases,
but also the hospital and medical care facility databases where these test were performed.
The benefit of this the recoding process is that patient care data is automatically updated
and kept track of to maintain updated records (Oriz & Clancy, 2003). Any diagnosis and
patient symptoms should be recorded electronically including a doctor’s notes that would
complement any possible condition that the patient is experiencing as this could possibly
assist in the diagnosis of rare conditions and could also be used to track possible
symptoms that could have otherwise been overlooked (Leech,2004).
26
According to the 2003 IOM report, many healthcare providers were reluctant to
implement electronic records, despite the above-mentioned limitations associated with
PMR (Wang et al. 397). This reluctance can be attributed to the non-supportive
management who, for varying reasons, prevent the implementation of EHRs in most
healthcare facilities. Some of the reasons that managers lean on for non-implementation
include lack of funds to facilitate the acquisition of the facilities and training in the use
of the technology. Numerous studies have revealed that the lack of awareness of the
merits that come with EHRs implementation prevents healthcare facilities from
embracing the system. Empirical evidence shows that a great proportion of the healthcare
providers do not see the benefits of EHRs since not all physicians are tech-savvy. Others
are unwilling to undergo electronic training. However, the respondents failed to
acknowledge that paper-based medical records hamper quality, accuracy, consistency,
accessibility, interoperability, instant availability, and portability of patient information.
For an effective campaign on the potential benefits that accrue due to the implementation
of EHRs, there is a need to integrate the system into medical schools. New health
physicians who will leave schools in the next few years should be competent in the use
of the electronic system (Coffey et al. 55).
Saudi Arabia has a distinctive location in the Islamic world, where the two holiest
places of Islam, Mecca and Medina, are located. Annually, around two million pilgrims
throughout the world perform the hajj. For instance, there were 2.3 million pilgrims,
69.8% of whom came from overseas countries during the 2009 hajj season (Ministry of
Health, 2009). The annual host of such an event is a significant challenge that needs an
intended and structured effort across many organizations and departments to ensure
27
sufficient services, including healthcare services (Jannadi et al., 2008). During the hajj
season, the healthcare services provide both preventive and medicinal care for all
pilgrims, regardless of their nationality. For instance, in 2009, there were twenty-one
hospitals, seven of which were seasonal. In addition, there were 157 PHC centers, of
which 119 were seasonal. Annually, the Saudi government represented by the MOH, tries
to improve and enhance the delivery of healthcare services to pilgrims (Jannadi et al.,
2008). Nevertheless, it should be noted that all healthcare services provided during
this season are free of charge for all pilgrims. This creates significant demand on the
healthcare budget in particular, and therefore it has become necessary to look for new
approaches to deliver better healthcare at a lower cost. Overwhelmingly, the finance for
healthcare in Saudi Arabia is mainly provided from government revenue. The MOH is
the main government financer of healthcare services in Saudi Arabia. The Saudi
government expenditure on the MOH rose from 2.8% in 1970 to 6.2% in 200 (Ministry
of Health, 2009). According to the World Bank, the total expenditure on public health
during 2010 was 4.3% GDP (The World Bank, 2012).
The recording of patient data that is collected at specialized medical facilities that
conduct laboratory tests, CT scans, MRIs and other specialized services can easily be
forwarded electronically to any medical care professionals that are treating a specific
patient. The easy transfer of such data would allow healthcare professionals to care for
and quickly treat patients. The ability to pass information quickly allows healthcare
professionals to collaborate and develop treatment programs for patients and track patient
progress accurately by comparing notes on the same databased. The ability of doctors to
access patient data through the use of authorization codes from an external network
28
allows EHRs systems to track who has accessed patient files and can alert database
managers in the event of a security breach.
It is commonly known among healthcare professionals that patients often neglect
to inform all of their doctors of the medications that they are taking. Many patients are
being treated by not only their primary care physician, but also other specialists as well
for different medical problems. Keeping track of all the medications that various doctors
are prescribing them may not always be possible for patients to remember, let alone
inform each doctor of any changes in their medications. Most patients will visit a single
pharmacy to have prescriptions filled. The implementation of EHRs systems to track
medications that are given to patients within doctors’ offices, hospitals and pharmacies
is essential to monitoring patient medication and any problems that could occur when
combining different types of drugs. The dangers that come with the lack of patient
knowledge could potentially lead to higher fatalities among patients that don’t report all
their medication. Hence the added benefit of implementing EHRs systems that are user
friendly in order to ward off resistance. Patient safety is dependent upon doctors
accessing patient data quickly and being able to effectively track treatment plans that are
prescribed by all treating physicians.
The development of healthcare services in Saudi Arabia, in association with other
factors such as improvement in the access of public education and more health awareness
among the community, have contributed to the considerable enhancements in health
pointers. However, it has been pointed out that, in spite of the variety of healthcare
services providers, there are no apparent communication channels between them. This
leads to duplication of efforts and a waste of resources in the healthcare sector (Alhusaini,
29
2006). For instance, there are significant opportunities for the healthcare domain to
benefit from laboratories, equipment, training aids and well-qualified personnel from
diverse countries. Nevertheless, the benefit of such opportunities is narrow within each
domain, as a result of weak integration and coordination among these sectors. In order
to address this issue of poor coordination among healthcare providers in Saudi Arabia
and to provide the residents with well-updated, organized, affordable and comprehensive
healthcare system, in 2002, a royal decree led to the establishment of the Council of
Health Services. It was directed by the Minister of Health and included representatives
of other government and private healthcare domains (Almalki, Fitzgerald & Clark, 2011).
Although the Council aimed at enhancing the coordination and integration among
all healthcare sectors in the country, there has not been significant progress in this
regard. Today with the increasing realization of the major positive impact that technology
can have on the quality of healthcare, many healthcare providers in Saudi Arabia have
been increasingly relying on information and communication technology by
implementing advanced information systems. However, this effort has not been
accompanied by integration and coordination between these implemented systems.
Therefore, this leads to diversity in the systems used among healthcare providers, which
makes it difficult to create a standard national network and repositories for the health
records.
Unfortunately this computerizing health care record for patients across Saudi
Arabia has been challenging as only 30% of hospitals have computerized patient data
files. It is only estimated that about 15 to 20% of physician offices have computerized
patient data. Only a relative few hospitals have made the investment into EHRs systems
30
and still very few plans to implement new EHRs systems in the coming years according
to several studies.
Accurate information regarding family health history is one of the criteria for the
practice guidelines. Any medical information should be recorded accurately. Illnesses
that do not seem important even to patients should be documented and in which case may
ultimately allow physicians to make more accurate diagnosis or to begin screening for
possible conditions as early as possible. A little documentation can go a long way and
securing access for all treating physicians can assist in treating patients and increases the
likelihood that any serious illnesses will be detected early.
Clinicians are the medical workers directly involved with the patients, be
they nurses, physicians, psychiatrists or psychologists. They might be operating in
private practice or they may be in the public health sector. All medical facilities keep
records on the patients they attend. The following are the benefits that EHRs may have
for them in the course of their practice. Availability of a system of information that is
easy to access and which is detailed pertaining to a patient will assist the clinician to
make solid decisions about the patient’s needs based on the past data like drugs
administered, allergies found, reactions to certain drugs or procedures and effectiveness
of initial treatments (Health & Medicine, 2006). Combining information technology,
wireless networking technology and mobile computing technology in the form of a
personal digital assistant (PDA) has been recently known to retrieve patient information
quickly as physician orders, test results and lab tests can be ordered from anywhere. This
reduces the time and costs associated with paper-work and could ultimately improve the
quality of care. Personal digital assistants can also allow nurses and doctors to spend
31
more hands on time with patients instead of spending extra time completing redundant
paperwork that must be entered manually into EHRs system. PDA has the ability to
streamline the data recording process through the implementation of preset screen
options and automatic patient data fillers. The latest technology offers PDAs in the form
of tablet computers that can be used to handwrite notes that use handwriting recognition
in order to fill in information fields which are stored in electronic patient files that be
accessed by all treating physicians and nurses. For instance, if a patient had been treated
in a certain healthcare facility for a particular disease and then he returns with the same
complaint, the clinician, after referring to past medication given to the client, may choose
to change the medication. They will find it easier to locate the patient’s health records
from the EHRs than from physical documents such as files, which can easily be
misplaced or be concealed in huge volumes of files (Milewski, 2009). There have been
recent technological advances that offer physicians and hospitals software interfaces that
are designed to easily manage patient data through the use of computer, and PDAs. Much
of the software can be used via the web and through local connections to access patient
data in order to track patient care. Web based applications such as those used to by
pharmacies and doctors’ offices to order prescriptions and test for patients and to keep
records of test results can be accessed from just about anywhere, allowing doctors to
share information easily and design appropriate treatment plans for patients. Several
types of software programs are available for use by doctors and hospitals with different
advanced features. Software providers that offer options which include the ability to
shares medical information virtually by recording patient logs that can be used to connect
a group of care providers and organizations without data centralization or replacement of
32
existing information systems. Other information systems have the ability to record and
track patient data that by allowing physicians to conduct exams in a point and click format
that has preset options. The software then has the ability to use the assessment to produce
a comprehensive evaluation history of a patient’s medical conditions while minimizing
the workload for treating physicians and increasing efficiency. Software advances have
led to the ability of several programs to be able to store photos or pictures of scans
electronically and keep track of patient vital signs such as blood test results, blood
pressure, EKG results and temperature. Several privacy and integrity issues have been
raised especially with the security issues that have surfaced within the financial sector.
The increased amount of security breaches within the financial sector has been increased.
The shortage of local healthcare professionals including physicians, nurses and
pharmacists also stands as an obstacle for healthcare system reform in Saudi Arabia. Most
of healthcare professionals are expatriates which leads to instability in the health
workforce. It was pointed out by the MOH that the total health workforce in Saudi Arabia
is about 248,000, where 125, 000 of them work in the MOH. Therefore, attracting more
Saudis into the health professions, nursing in particular, is set as a priority in the health
system reform. Another challenging factor faced by the MOH is funding healthcare
service. As the total spending on public health provided by the government and
health services are free, this lead to significant demands on the healthcare budget in
particular. The high demands on the healthcare budget can be attributed to different
factors including the rapid increase in the population of Saudi Arabia and the increasing
cost of new technologies. To meet these challenges, the MOH has established a national
strategy for improving the healthcare services in the country. In April 2009, this strategy
33
was permitted by the Council of Ministers. The strategy aimed to diversity fund sources,
develop information systems, develop the human workforce, activate the
administration and monitoring the MOH role over medical services, encourage the
private sector to provide health services and distribute healthcare services equitably to
all regions. The implementation of this strategy is to be done by the MOH in cooperation
with other healthcare sectors, and the Council of Health Services will be responsible for
supervising this implementation. Saudi government has achieved a great development
over the last few decades despite facing significant challenges such as the increasing
number of population and the hosting of around two million pilgrims annually in the
Hajj season which requires great efforts to provide effective healthcare services. In
order to improve the quality of healthcare provided, a great effort has been made to
connect MOH hospitals, but lack of communication infrastructures and sufficient fund
are the main barriers faced. A budget of SR 4 billion was allocated by MOH to
establish a four year development programmed (2008-11) to develop e-health in
public hospitals. Furthermore, a number of conferences have been held to emphasize
the importance of health informatics. Nevertheless, there are good implementation of
EHRs among healthcare sectors such as King Faisal Specialist Hospital & Research
Centre (KFSH & RC). Another successful implementation of EHRs has been achieved
at the National Guard Health Affairs (SANG-HA), one of the leading healthcare
providers. There are different challenges that MOH need to overcome in order to increase
the effectiveness of the healthcare services. Some of these major challenges are a lack of
a unified system, the shortage of health workforce and doctors’ attitudes to EHRs
implementation. A national strategy has been established to meet these challenges which
34
to be implemented by MOH and under the supervision of the Council of Health
Services.
2.1.4 Limitations of Traditional Paper Medical Records (PMRs)
The emergence of the Electronic Health Record (EHRs) systems rendered the
traditional Paper Medical Records (PMRs) obsolete. In the twenty-first century,
streamlined flow and sharing of patient information is vital for disease diagnosis,
monitoring, control, and treatment. The use of traditional paper records is an impediment
to the attainment of the above objective due to various limitations. At the outset, PMRs
hinder availability and sharing of patient information amongst the health physicians since
only one person can access it at a time. Therefore, a lot of time is wasted as the records
move from one health facility to the other for the evaluation, particularly in the event of
referrals. Manual documents are subject to misplacement due to poor handling habits by
either the patients or physicians. In addition, delayed access to patient’s data affects
coding, billing, and reimbursement processes. Secondly, the quality of PMRs is not
guaranteed since paper is fragile and subject to staining, tearing, and fading.
Consequently, patient information in PMRs can be distorted or lost. This set of
circumstances can lead to loss of vital patient data. In addition, due to multiple
circumstances that are posed to the healthcare providers, fragmentation of information
increases because there is little or no sharing of patients’ historical records. Furthermore,
handling of PMRs is tedious and costly. Such costs result from activities such as
duplication, filing, retrieval, and supply of papers for copies, staffing for records
management, distribution, and storage among others. The costs escalate in case of lost
data. As a result, patients can be requested to undergo duplicate tests to obtain the lost
35
results. Additionally, PMRs limit productivity because a lot of time is lost during the
search for paper charts and missing files. Delivering the paper records to different
locations within the facilities also leads to time wastage.
2.1.5 Errors in the Contents of Paper Medical Records
PMRs often result in fatal errors that pose adverse effects on patient’s’ healthcare
provision. As aforementioned, paper records are subject to loss and mishandling among
other factors that lead to errors. There have been reports of medical errors that result in
clinical injuries or fatalities. Medical faults can be attributed to the non-reliability of
PMRs. Many researchers have revealed that paper medical records are prone to numerous
errors that include omission, delays, and misplacement among others (Farshi, Jebreili,
and Abdinia 367)
2.1.5.1 Omission
Sometimes, PMRs fail to provide complete patient information. Healthcare
providers can forget or ignore to include some details due to the tedious process of
recording medical information manually. Omission can have substantial effects later,
when a different health care provider requires the data (Farshi, Jebreili, and Abdinia 367).
2.1.5.2 Delays
Delivery of paper records to different departments or facility locales can be
delayed due to numerous factors such as distance, unavailability of papers for
duplication, and/or busy photocopiers. However, electronic medical systems minimize
delays since data can be shared instantly regardless of the distances involved.
36
2.1.5.3 Misplacement
According to Farshi, Jebreili, and Abdinia, PMRs can be misplaced or lost.
Sometimes the patients are charged with the handling of the paper records (367). Sick
people can misplace or lose them in case of unconsciousness or worsening conditions.
For instance, in a study that was conducted by the Institute of Medicine (IOM) on a
sample of 1000 patient visits to five outpatient US Army facilities in 1997, the following
data was obtained:
11.5% of the patients did not have any historical data available.
Between 5% and 20% of the charts available had missing patients’ information.
For instance, 75% did not indicate consistent laboratory results and 25% of the
handwritten data was incomplete and incomprehensible due to illegibility.
14% - 78% of laboratory results were sketchily indicated in the PMR, and some
missing elaboration was noted.
12% - 51% of the patient visits did not have clear referral documents. As a result,
diagnosis information was difficult to retrieve.
24% - 35% of the patients’ records presented incomplete information despite the
patients having gone through different facilities prior to visiting the army referral
facility (Coffey et al. 54).
2.6 Web-Based Access to Electronic Health Records
In the wake of technological advancement, particularly in the IT sector, no one
wishes to be left behind in the traditional way of doing things. The internet has sparked
a revolution in the way humans share day-to-day experiences (Ilie, Courtesy, and Van
37
Slyke 8). The medical sector stands to benefit significantly if the technology is embraced
in every activity that touches on the management of illnesses. The EHRs comes with a
high level of interactivity amongst the patients and healthcare providers. The systems
cheaply and easily avail vital medical information to all health stakeholders.
2.6.1 E-Health
Health e-commerce is a component of modern health practice in the 21st Century.
Online presence is becoming an important development in the sector. For instance, e-
health portals such as http://www.onhealth.com and http://www.medscape.com are open
to all health stakeholders. The portals facilitate free and unlimited medical information
and innovations in health practice for a better future. Health e-commerce connectivity
initiatives include internet-accessible EMR systems and assessment of provider quality
based on clinical outcomes (Wang et al. 400). The modern e-commerce healthcare
services do not target consumers only but are also accessible to patients among other
parties. In fact, the IOM report indicated that more than 60 million people access the web
in search of medical information yearly. For instance, Hi-Ethics is a set of 14 principles
that were developed by a group of internet healthcare companies that direct websites to
adhere to several guidelines such as providing credible and up-to-date information
besides ensuring high privacy and security of health data. The concept of the Online
Personal Medical Records (OPMR) is based on an online software application that allows
individuals to manage their health information and/or other peoples’ health data under
their authority. Patient information can be entered into the OPMR systems in two ways.
At the outset, patients can enter the data individually. Secondly, data can be entered
through a link to a third party’s computer system such as a laboratory system or
38
physician's EMR system (Wang et al. 401). Most of the OPMR systems can only handle
one problem at a time. Others can take up multiple data on various health issues
concurrently. OPMRs that link up with EHRs systems deal with multiple problems. They
can also be updated automatically through the EMR system to maintain a constant
relevance. However, sometimes compatibility of various OPMR with EMR systems fails,
especially in the event that patients’ change their personal data handlers such as switching
between health physicians. To increase compatibility modes, some technologies
solutions have been put forward (Wang et al. 402).
2.6.2 Online Personal Health Records
Numerous studies have revealed that some technological such as the integration of
speech recognition features in an attempt to make the usefulness of the EHRs a reality
failed. However, the system focuses on the enterprise regardless of whether it is a solo
practice or multi-specialty clinic, provided it can use the internet to retrieve data from
different providers and data repositories such as laboratory and radiology reports.
Confidentiality is among the most important concerns that patients raise regarding the e-
health sites (Shah et al. 112). Although the EHRs systems aims at achieving interactivity
and interoperability of healthcare practices for the benefit of patients, physicians, and
service providers among others, the system can be intrusive in a way that a particular
group of patients with peculiar diseases can feel targeted by some stakeholders as a way
of promoting their products. Therefore, patients ought to be careful when uploading their
confidential information on websites that are insecure. Security features should be
flexible and configurable with respect to the preferences of the end users. There is a need
for the health facilities to provide crucial information on the legal patient data handlers
39
to avoid losses in the event that the providers leave the business due factors such as
insolvency, mergers, or change of business among others. The government should also
play a part in the regulation of the operations of OPMRs to foster certainty and security
of patient data (Shah et al. 114).
The continued use of traditional manual paper records is an impediment to the
many benefits that come with the implementation of EHRs systems. Health stakeholders
need to identify the existing obstacles to full application of EHRs with a view of
addressing them accordingly. The aforementioned limitations of PMRs are undesirable.
The government needs to increase subsidies even for the small healthcare facilities. It can
also offer incentives to the private stakeholders. If the electronic health record systems
are introduced in the Schools of Medicine, they will increase awareness and development
of competent health professionals to safeguard the future of the medical services.
2.7 Barriers of the implementation of Electronics Health Records
The implementations of EHRs systems have faced many challenges in Saudi
Arabia such as:
2.7.1 Lack of experience with the use of computer
The lack of computer proficiency among physicians, and healthcare staff, aging
hardware in addition to the lack of software usability in EHRs software systems have
contributed to the delay in the adoption of effective EHRs systems. There have been
many studies documenting the causes behind the delay in the successful implementation
of EHRs systems that have identified various reasons for the delay (Walston &Al-Omar,
2008).
40
Physicians and medical staff in Saudi Arabia don’t all possess the computer skills
necessary to operate EHRs systems. Furthermore the training needed to provide the
computer skills that are needed to operate the software is quite time consuming due to
the initial level of those who are to receive training. Also, complete implementation of
these systems is time consuming even for hospitals that have staff with adequate
computer skills. Hospitals and medical facilities also incur substantial costs when
integrating new healthcare system software. These costs are important barriers to
consider prior to integrating any new systems because additional costs in training and
system customization must also be factored into the total costs. These issues are unique
to the adoption of healthcare systems in developing countries (Mufti, 2000).
Identifying areas of training that are needed prior to the implementation of EHRs
system would help to cut costs that are associated with unneeded training. Also hospitals
that have more IT-support would experience an easier transition to the software
integration. The initial time costs that are experienced coupled with the increased burden
placed on physicians to learn new systems will decrease their use of hospitals information
systems and lowers the potential for achieving quality improvements to healthcare.
Hospitals and medical facilities that order their software systems from large
experienced vendors have a better chance of initial success of software implementation
due to the increased IT-support systems that the vendors possess. Larger vendors have
more resources at their disposal and they also have more hands on experience with
assisting hospitals with software customization. Smaller vendors lack the support and
resources that are needed to effectively aid hospitals in a complete introduction of EHRs
system through customization (Hoffman &podgurski, 2012).
41
Solving software integration issues by making software designs more user
friendly to healthcare professionals would increase the ease of transition. Challenges
affecting the exchange of information between healthcare information systems between
different hospitals and medical facilities raise another barrier for integration of healthcare
information systems. The lack of integration makes it difficult to access clinical data
such as lab reports, radiology and referral systems. The slow process of integration also
increases the time that it takes to give patient care. Working between paper-based and
electronic healthcare systems requires more time to enter data from external systems and
also increases workflow (Benson, 2002).
EHRs systems require technological support structures from vendors, software
creators and manufacturers. Smaller vendors are unable to provide all the services that
larger hospitals and system integrations will need. Therefore conducting business with
larger vendors that have the financial resources and supportive staff is more advisable to
larger hospitals installing new EHRs systems. The complex support systems that are
designed to assist in the EHRs implementation process. The final tuning and
customization of hardware and software has to be performed in stages and not all as once
in order to test the effectiveness of the system. The EHRs system has to be user friendly
for physicians and staff to increase its effectiveness. Moreover as is the case with most
developing countries, hospitals and medical facilities are known to have older computer
system hardware due in part to limited funds available. The issue with interface usability
is a major problem that has to be solved in order for any real progress to be made in
seeing a universal EHRs system in place in Saudi Arabia. The difficulties that cause poor
system execution include the both basic and advanced technology that physicians and
42
staff are unable to operate due in part to their limited computer knowledge. More
advanced support software such as voice-recognition, touch screen and mobile devices
that have sought to simplify the process, has only made it more difficult for users that are
accustomed to using older forms of computer technology because there more to learn in
the way of inputting data. Furthermore it is the staff and nursing who are usually
responsible for inputting patient data into technology information systems. Hospital
support staff and nurses haven’t received the specialized computer software training that
is required to operate advanced patient machinery. As is the case with most developing
countries, due to limited funds and access to technology, not many professionals other
than IT professionals have undergone training to work with advanced medical software
as is usually provided on the job (Tian, 2011).
Healthcare professionals including doctors and staff are being forced to dedicate
more time to training and system customization. The increased time that is being used
for miscellaneous tasks could instead be used to focus on the quality of patient care and
workflow design. Several previous studies have indicated that during the time of EHRs
implementation, Saudi physicians have been burdened with extra work because of the
need to learn new skills and also learn how to operate new software programs. The
increased workload resulted in longer work days and reduced productivity for physicians
(Mandle & Kohance, 2001). Also fewer patients were being seen each day while
experiencing longer wait times at the same time.
In addition to the extra workload that physicians would be required to perform,
hospital staff and nurses would be the ones who would manually transfer patient data into
the EHRs system databases in the absence of dedicated IT professionals. The process of
43
transferring all patient files into EHRs systems would prove to be the most time
consuming as hospitals have gone years accumulating paper-based patient data (Chassin
&Donldson,1998) .Unless hospitals intended to use both EHRs and paper-based patient
file systems, the manpower required to conduct such a task would be extensive.
Physician patient communication had been impaired during EHRs
implementation as well. The increased time that physicians spend learning to use new
EHRs software systems effectively has been shown to negatively affect physician-
patient communication. Communication issues have also negatively affected patient
satisfaction (Mcalister &Rhodes, 2010).
The lack of communication can contribute to a resistance in changing over to EHRs
system. The possible negative effect on productivity could result in physicians and staff
resisting the implementation of EHRs system. This resistance could make it nearly
impossible to guarantee a successful implementation (Sheikh, 2011).
As with any corporate change, management will serve a critical role in whether
or not the implementation is effective. Larger hospitals with more experienced managers
will be more successful in transitioning from paper-based records to electronic records
because they have the corporate leadership needed to guide their staff successfully
through the transition (Breg, 2001).
According to this research study that was conducted in hospitals in Baha region
in southern province of Saudi Arabia, to measure physicians’ computer literacy skills,
there was a lack of computer literacy among those who participated in the study. Those
surveyed within the different hospitals in the region responded that they lack adequate
44
computer skills. This study was conducted as a result of the obvious lack of computer
literacy among physicians in Saudi Arabia. The survey questioned the need for medical
schools to require their students to use computer during their studies and also for Saudi
Medical schools to find way to incorporate EHRs systems into their curriculum. This is
seen as a major barrier to implementing a nationwide EHRs system as the professionals
that would be leading the transition away from paper-based files don’t have the computer
literacy skills to lead the transition. Access to EHRs systems while in medical school is
crucial to learning the ins and outs of EHRs systems.
Computerized Physician Order Entry (CPOE) refers to electronically entering
medication orders or other physician instructions in place of paper charts. CPOE
is one of the most important components of any EHRs as it can assist in reducing errors
related to illegibility of handwriting or transcription of medication orders. Some of the
most common errors that can be reduced through CPOE are prescribing errors, including
wrong drugs, form, dosage or frequency; incorrect route; and contraindicated drug
use and interaction (Fontan et al., 2003). In the CPOE system, orders are incorporated
with patient information such as laboratory and prescription data and further they
are automatically checked for potential errors or patient harm. In this respect,
healthcare professionals should be able to digitally record all the information about the
health of patients into their EHRs. This means that healthcare professionals should be
able to access patients’ EHRs and make changes in the records in respect to any change
in the condition of the patient (Dolin, 2010).
Medical doctors have shown little interest in computerization. Many of the
healthcare specialists who have been interviewed held that they were comfortable with
45
PMR systems since they were simple to use. They affirmed that an individual required
no training to use papers. However, it is true that most of the healthcare providers have
little or no computer skills that are paramount to the handling of electronic devices that
are connected to the EHRs systems (Berger et al., 1999). Some of the medical physicians
are aged. For this reason, they do not intend to undergo any training in computer
technology despite the fact they are competent professionals in medicine. In facilities
where EHRs systems were being implemented, issues such as the lack of knowledge to
handle the advanced technology were common among the clinicians, even the middle
aged anxiety (Igbarria & Parasuraman, 1989). Insufficient software knowledge together
with minimal computer skills can lead to failure of the entire system. This set of
circumstances can result in slow workflow and low productivity. Such occurrences can
have adverse effects on the situations of the patient. The lasting solution to knowledge-
related barriers is thorough training of entrant doctors to replace the aging and retiring
traditional doctors. In this manner, the implementation will not discriminate the
physicians based on age (Ilie, Courtesy, and Van Slyke 9).
2.7.2 Security concerns regarding the use and access to EHRs Systems
Other factors that are considered barriers to nationwide adoption of the EHRs
systems in Saudi Arabia would be the concept of patient privacy. The security among
software systems is a major problem in developing countries because their systems are
not advanced enough to monitor hackers. Hospitals in Saudi Arabia don’t always have
the funds available to employ large number of IT professionals to monitor EHRs security
systems. The increase in hackers and unauthorized access to patient information globally
has raised issues all over the world whether or not all EHRs systems are safe to use
46
(Madsen, 2008). The ability for hackers and thieves to gain access to patient files is a
very real issue that affects both developed and developing countries alike. The benefits
and risks of implementing EHRs system must be carefully weighed, however it is
becoming more common place to incorporate such technology that all those who don’t
are viewed as being outdated (Mandle &Kohane,2001).
EHRs are centrally managed where different personnel may have access to them.
Thus, a patient’s medical record may be easily accessed by different departments within
a facility and even externally by other healthcare units. This means malicious usage of
patient information can result. There is also the issue of manipulation of data, where a
patient’s information may be wrongly entered, leading to a wrong diagnosis and/or
prescription of medication (Smaltz and Eta, 2007). Because EHRs usage is a relatively
recent development in medical practice, there are insufficient rules governing the use and
disclosure of personal information. This is a major challenge in the use of EHRs systems.
For the EHRs system to succeed there needs to be an accountability and integrity in
carrying out the different roles in medical practice. This will include accountability on
the parts of the patient, clinician, other hospital staff, health management and
insurance companies. While healthcare key players and governments may try to
implement such measures, there are concerns that the number of personnel with access
to EHRs would be so great and the patient base so huge that there would be mass breach
of confidentiality and patient privacy (Bourne, 2009).
EHRs systems are diverse and the people in hospitals and medical facilities with
access to patient data are overwhelming, therefore it is imperative for technology to be
secured prior to execution. Basic computer security systems are insufficient to
47
safeguarding such personal data. As with financial institutions that provide information
to customers electronically, the medical information that is stored in hospital databases
must be available to all applicable parties. Not only will hospital physicians have access
to patient data, primary care doctors, nurses and pharmacists must be granted access as
needed as well. Placing safeguards including multiple authorization checks in place for
different categories of patient data is important to maintaining patient privacy rights.
Over the past several decades, the digital era has increased the mobility of information
and its ease of access. Databases of information have allowed both the public and private
sector to store data over the internet and cloud connections, making paper-based files
obsolete. In an age of digital files, there are yet an increasing number of barriers that are
preventing many medical facilities from adopting a fully functional electronic health
records system. Patient privacy rights and issues over security requirements have
prevented the universal digitization of patient data. Also patients’ right to control access
to their personal information and the lack of checks and balances has many people
concerned over its long-term viability (Polito, 2011).
The decision over the safety and security of electronic health records is to be
evaluated on a system wide basis which is dependent upon the level of security protocols
that are put in place (Wang, Zhang, Xu, Yin, & Guo, 2013). Security software and the
use of checks and balances within health organizations prevent the unauthorized access
of confidential information. Organizational security methods that are employed through
each hospital and/or medical facility including private doctors’ offices protect patient
data. Federal compliance through the Health Insurance Portability and Accountability
Act (HIPAA) requires hospitals and medical professionals to safeguard patient data and
48
limit access. The continuous issues surrounding internal fraud and identity theft among
those with access to confidential information has led to numerous studies across various
disciplines over the requirements for internal security measures (Polito, 2011).
There are no clear set rules and regulations governing the creation, retention and
sharing of patient information. First, there needs to be a harmonized way of creating a
patient’s file. This involves having a unique patient identifier that will apply across all
healthcare providers. Secondly, there is a need for a standard layout for patient
information collection across the healthcare profession (Menachemi, 2006). Thirdly,
there must be a standard method of information sharing between the various hospitals or
healthcare units when the need arises. Such circumstances include referrals, change
of preference by the patient or even cases where certain healthcare units close down
and patient information needs to be retained. There have been two approaches suggested
to enhance health data sharing between hospitals. These were the centralized data server
model and the peer-to-peer model of file synchronization. While both are viable, they
are still rendered unusable because there is no standardized method or format of
record creation (Waegemann, 2003). This means that even if the records would
be passed to different units, the usability of these records would be limited.
The latest advances in information technology have made it possible for patient
data to be centralized into large databases that have improved the efficiency of healthcare.
The benefits of implementing electronic health records are extensive, but the associated
risks raise concerns over privacy rights and security. In hospitals, centralized databases
are increasingly becoming more efficient in identifying patients and limiting errors in
patient treatment (Morton, 2008). Patients are able to receive fast and efficient care
49
through the application of electronic health records from the ease of accessing patient
medical records to electronically sending prescriptions to pharmacies. Though there are
many benefits to using electronic health records, there must be a balance.
Centralized databases allow hospitals and healthcare facilities to quickly access
patient data in order to provide fast and high quality care to patients. The reduction in
paper work allows doctors and medical professionals to improve the quality and
efficiency of patient care. Concerns over the security of centralized electronic health
records and the risk of security breaches of confidential information have been raised as
a result of recent breaches of information among financial institutions (Wang, Zhang,
Xu, Yin, & Guo, 2013). Databases that contain confidential personal data are the ideal
target for hackers and fraudsters that target vulnerable databases for loopholes in security
systems. Identity theft and the safety of inputting personal data into electronic systems
have raised questions over how such practices should be regulated (Polito, 2011).
Adoption of electronic health records has long been debated, and minus the long
term cost savings benefits of installing such a system would require patients to sacrifice
their privacy and personal security. The misuse and management of personal information
among the private sector IT security systems has become apparent with the security
breaches among financial institutions including Citibank in 2011, and major retailers
including Target in 2013, that suffered security breaches of confidential personal data
that belonged to millions of customers (Electronic Health Data Breaches Remain Primary
Concern Despite Increased Use of Security Technologies and Analytics).
The Ministry of Health (MOH) in Saudi Arabia holds responsibility for planning,
managing and providing health policies and the supervision of health programs. It is also
50
responsible for monitoring health services in the private sector, as well as directing other
government and private organizations on approaches to achieving the objectives of
the government’s health (Altuwaijri, 2008). In spite of these achievements, the healthcare
system in Saudi Arabia faces various challenges that call for new approaches and
polices by the MOH as well as effective collaboration with other sector.
The last official survey in 2010 placed Saudi Arabia’s population at 27.1 million,
compared with 22.6 million in 2004. It was estimated that the population growth rate
was 3.2% per annum annually, for the period between 2004 to2010 (Central Department
of Statistics and Information). Saudi citizens represent approximately 68.9% of the total
population. It is estimated that 67.1% of the population is under the age of 30 years,
while about 37.2% are under 15 years and an estimated 5.2% comprises the population
over 60 years (as cited in Almalki, Fitzgerald & Clark, 2011). Estimated that, by 2025
Saudi Arabia’s population will reach 39.8 million (United Nations, 2003). Therefore,
there will be an increasing demand on the necessary services and facilities including
healthcare services as a result of this unprecedented growth in the population, while
simultaneously creating economic opportunities.
According to the 2013 HIMSS Security Survey, there is more work that is needed
in order to safeguard patient data from inappropriate access by unauthorized individuals
including hospital employees. According to the survey, despite improvements in
database security, 19% of respondents had reported security breaches and 12% of
organizations that responded had at least one reported case of identity theft. The survey
also brought to light several barriers that are preventing the secure installation of
electronic health records which include budgeting issues, and lack of leadership that is
51
dedicated to ensuring patient privacy. Hospitals and medical facilities aren’t spending
enough to finance adequate security programs in their IT departments. Only 52% of
respondents reported a full-time leader that manages patient data security. Also 92% of
respondents admitted to conducting a formal risk analysis annually compared to only
54% of organizations that have a tested data breach response plan (Electronic Health
Data Breaches Remain Primary Concern despite Increased Use of Security Technologies
and Analytics).
Anti-virus and anti-hacker security programs in addition to incorporating the
latest security barriers and password use throughout all healthcare organizations should
reduce the risk of both internal and external security breaches. Data integrity,
accountability, access control and confidentiality are requirements of an effective
security system. Electronic health records are at an increased risk of manipulation and
abuse. The storage of patient data is also at risk of being illegally modified or lost as a
result of lapses in security programs and database glitches (Wang, Zhang, Xu, Yin, &
Guo, 2013).
The latest medical equipment and patient monitors allow hospitals to wirelessly
monitor and track patient data and transmit information through networks. These
wireless networks can be easily hacked into when security software isn’t up to date. The
increase in patient care providers who have access to patient data increases the risk of
unauthorized access to confidential data. Patient monitors and wireless equipment are
more prone to security problems resulting from framework design and negligence in
managing network errors. The illegal hacking and downloading of data from a
compromised system can be conducted through the use of operator commands that
52
include macro and Java Script to break through the computer network (Wang, Zhang,
Xu, Yin, & Guo, 2013).
The electronic storage of patient data across different databases with the ability
to link data in order to determine patient identity should be separated into different files
in which authorized access is required for each file prior to viewing. There is an increased
security risk within databases that neglect to employ multiple access barriers as
unauthorized attempts to access information are not routinely activated (Wang, Zhang,
Xu, Yin, & Guo, 2013).
Through the use of electronic health records public health officials are able to
monitor public health threats and the spread of disease. Without the technology, the
public would receive notices of disease outbreaks. The technology increases the speed
in which health professionals can alert the government to possible threats to both locally
and internationally (Hoffman & Podgurski, 2012).
The obvious benefits of using electronic health records, however the challenge
with implementing it requires more research and development. Prior to deciding what
kind of database programs should be used, patient privacy and security needs to be
reviewed and addressed. The proposed research study is to identify and evaluate the
challenges affecting the implementation of electronic health records over paper-based
patient filing systems. The variables affecting the risk including lack of security and
patient privacy issues will also be researched.
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2.7.3 High Cost of Adopting EHRs
Most of the facilities where EHRs implementation has been accomplished have revealed
that the system is capital intensive. In fact, the approximate minimum implementation
cost ranged from $255,000 per facility for third party hosted solution to $260,000 for
vendor hosted ‘Software as a Service’ (SaaS) in 2011. Given this high cost, most of the
facilities management opts to maintain the PMRs since they are cheaper in the end. The
initial cost of setting up the infrastructure, training, and maintenance are deemed the
greatest obstacle to the adoption of EHRs systems in many health institutions in the US.
The stakeholders claim that they are unaware of the benefits that come with the electronic
systems, especially in the private sector. They also perceive that the overall driving force
towards implementation of the systems is profitability of the healthcare facilities (Coffey
et al. 56). EHRs have other additional costs due to software licensing, support, hardware
maintenance, and internet connectivity among others. The EHRs connectivity costs vary
depending on whether a facility acquires its server or subscribes to an Application
Service Provider (ASP). Ownership attracts high up-front capital costs while the ASP
approach costs are deemed minimal at both the installation stage and maintenance. Those
who choose the contracted or (SaaS) pay a monthly fee for the services. EHRs-related
costs include transition costs, system upgrading, management configuration costs,
reviews, audits, IT policies, privacy, and data integrity. Others encompass
telecommunications costs for added bandwidth (wireless services), software, and
additional computing devices (both stationary and mobile) that are necessary for other
users who form part of the health care service provision, technical, and clinical-technical
support staff (Coffey et al. 54).
54
2.7.4 Resistance to New Technologies of (EHRs)
The greatest obstacle to EHRs implementation is resistance from health physicians.
Most of them expressed a feeling of contentment with the use of PMRs. They affirmed
that the use of the electronic system had a negative impact on the physicians’ workflow
(Ilie, Courtesy, and Van Slyke 2). For instance, one hospital reported a 20% loss in
efficiency. Others claimed that the system was 30% slower than the PMRs. As a result,
the healthcare providers had become dependent on traditional paper-based ordering. Any
change was perceived as a source of inefficiency in the practice. In addition, some
organizations claimed that it was uneconomical to pay for the training of community-
based physicians who worked based on part-time arrangements besides their
unwillingness to undertake the training. In some cases, the resistance of physicians to
change turned into rebellion, which derailed the entire implementation process. The
negative publicity resulted in failure of the management to adopt the EHRs. Some
patients also expressed the fear of their confidential information falling into wrong hands.
In fact, 22% of those interviewed were reluctant to accept uploading their confidential
information regarding past medical history unless watertight security for their
information was guaranteed (Ilie, Courtesy, and Van Slyke 7).
2.7.5 Electronic Health Record System EHRs System Maintenance and Downtime
The Maintenance and Downtime is factor that can influence the adoption of
Electronic Health Records Systems (EHRs System) in Saudi Arabia. The government of
this country has invested significant capital into its healthcare system, and much attention
is paid to information technologies (Almalki, Fitzgerald, and Clark 784). In turn, EHRs
System are critical for improving the time-efficiency of many hospitals.
55
These tools can significantly improve the performance of various medical
institutions. For instance, they can be vital for improving internal audit within hospitals
(Alsosari 496). Currently, these technologies have already been adopted by some Saudi
hospitals (Alsanea 117). Nevertheless, the rate of adoption is not very high (Bah 1).
Overall, the degree of adoption depends on various factors. For instance, one can speak
about perceived ease of use and the skills of various medical workers who will rely on
EHRs System (Shaker, Farooq and Dhafar 1). The problem is that in many cases, nurses
or physicians may lack necessary competencies to apply EHRs System effectively. As a
result, they cannot fully benefit from adopting such technologies (Shaker and Farooq
173). This is one of the challenges that should be taken into account. Additionally, the
degree of implementation depends on the security of these technologies. At present, the
risk of security breaches has not been completely eliminated, and the confidential data of
patients can be transferred to unauthorized third-parties (Ozair 74). This is one of the
risks that one should not overlook. Apart from that, it is important to provide clear
evidence indicating that these tools can be effective. Hospital administrators in Saudi
Arabia should see the improvements that these technologies can bring (Moja, Bertizzolo
and Bonovas 12). In some cases, they may see the advantages of these tools, especially
if the usability of this system is rather poor. Furthermore, it is critical to remove such a
problem as downtime. This term is used to describe the period during which the system
is not available to the users. This technical problem can significantly undermine the work
of many medical institutions (Oral 100). In turn, the adoption of EHRs System is more
likely to intensify provided that there are well-developed procedures for coping with such
difficulties. If these procedures are absent, medical workers may not get access to vital
56
information as soon as possible. Among other important barriers, one should certainly
distinguish lack of proper maintenance. In particular, hospital administrators may believe
that they will not be able to address problems related to these technologies effectively.
This is why they are unwilling to adopt them. This difficulty is relevant to Saudi Arabia
and many other countries. Thus, one can argue that much depends on the ability of
developers to support hospitals. In this context, maintenance also includes training which
can be of great benefit to many medical workers.
Furthermore, the implementation of these technologies depends on the availability
of software (Aminpour, Sadoughi, and Ahamdi 57). For instance, open-source software
can be useful for modifying technologies, especially at the time when some technical
problems have to be resolved (Aminpour, Sadoughi, and Ahamdi 57). On the whole, this
discussion shows that the adoption of EHRs System can be influenced by different
factors. In particular, one should speak about computer literacy skills of medical workers
who will be the main users of these technologies. Additionally, it is critical to consider
the ability of developers to reduce the downtime and provide support to medical
institutions. If these issues are effectively addressed, the rate of adoption will increase
significantly.
2.7.6 Adaptation of Electronic Healthcare Records (EHRs)
As a result of technological innovations in the past decades, many healthcare
professionals are recognizing the need to improve the health information technology
division of healthcare. According to Xierali et al. (14), incorporation of information
technology in medical record promotes the quality of care and efficiency of the workflow.
Lee, Kuo, and Goodwin (1) indicate that Electronic Health Records (EHRs) have
57
enhanced the collection, storage, and reporting of information regarding the patients.
Moreover, the systems are useful in safeguarding policy compliance and decision-
making within the healthcare institutions. Past research studies have reported that EHRs
are efficient as they minimize errors during the entry of data in comparison to the
conventional forms of record keeping. Although the use of EHRs is projected to
transform the health information management systems within hospitals, Jones and
Furukawa (1254) state that they are characterized by low rates of adoption. Particularly,
smaller healthcare facilities have failed to recognize the significance of these systems in
the health sector. As a result, federal governments in the developed world are faced with
challenges in solving the digital divide associated with EHRs. Additionally, Abramson
et al. (1156) report that governments are increasing the amount of funding to promote the
implementation and adaptation of the EHRs. Such interventions are beneficial as they
ensure that the benefits of the systems are felt across the healthcare sector (Granlien and
Hertzum 198). In reference to Menachemi, Powers, and Brooks (184), another major
barrier to the adoption of the systems is the characteristics of the healthcare providers.
Specifically, the adoption and acceptance is dependent of the technological abilities,
specialty, and age of the nurses and physicians.
According to King, Furukawa, and Buntin (2038), there is need to ensure that the
adoption of the EHRs benefits all individuals across the population. The limitations
concerning access to new technologies in some healthcare institutions hinder the
adoption of the systems. Moreover, financial constraint is likely to affect the adoption of
the system in such regions. Similarly, McAlearney et al. (463) note that the
implementation phases of EHRs are costly and many facilities may require federal
58
support. In a research undertaken by these authors, the health professionals reported that
they were worried about the transition from “old to new” recording systems (463). In this
view, it is important to offer comprehensive training to the healthcare providers on the
importance of incorporating the systems in the workflow (King, et al., 2038).
Furthermore, Ginn, Shen, and Moseley (338) report that the perceptions of the
management may limit the adoption of the systems. Such perceptions are determined by
the financial implications of EHRs implementation. Thus, awareness campaigns by the
ministry of health are crucial in educating the entire health sector on the importance of
the EHRs. Angst and Agarwal (340) argue that issues relating to the privacy of the
patient’s records have been identified as obstacles to the implementation of EHRs.
Therefore, ethical issues relating to privacy and confidentiality of the records should be
incorporated into the training phases. All the aforementioned barriers have slowed the
implementation and adoption of the Electronic Health Records systems throughout the
healthcare sector. Therefore, policy makers and institutional managements have a vital
role to play in determining how the barriers can be eliminated. Furthermore, all the
personnel in the health sector should cooperate in enhancing the adoption of the EHRs.
CHAPTER III
III. METHODLOGY
3.1 Research Design and Collection Data:
Quantitative research method was conducted. Research articles and cases studies
will be gathered from academic journals and university studies along with financial
records from healthcare facilities will be analyzed for relevant data. Also relevant
59
academic articles, journals and reports from financial institutions utilizing central
databases to store confidential information will be reviewed for security practices.
Further evaluation over the need for the implementation of security practices and
precautions that institutions have in place will be reviewed using relevant data that will
be obtained either directly from the institution or through information databases.
There are two types of methods that are used to conduct quantitative research,
primary and secondary research methods. The primary research method is used when
there is not data from which to conduct research. The researcher obtains primary data by
conducting interviews, sending out questionnaires and surveys and also collecting data
samples from other scholars. There the data collected from primary sources can be
customized to answer target research questions. The data is usually new and dissimilar
from other sources. It has to be processed and analyzed before the researcher can make
any sense of it. It also has to be strategically applied to the questions at hand. Secondary
sources of data are those that have been obtained from outside sources. Secondary data
is usually used as supportive data and May not related directly to the researcher’s primary
research topic, but can serve as a guide. When comparing the use of these two types of
data, one has to identify the advantages and disadvantages of using either one. The
collection and use of primary data usually takes more time to collect because
questionnaires and surveys have to be created and then send out. Also participants have
to be sourced and selected to ensure that the data obtained is relevant to the hypothesis.
It is also more expensive to do because of the materials and software that are needed to
collect and analyze the data. The secondary data research method is less time consuming
and more cost efficient as the data has already been collected and analyzed.
60
Information gathered from scholarly articles and case studies on EHRs usage will
be used to identify key factors supporting or in opposition to the research questions and
hypothesis of this study. Key factors that are being questioned are the nature of concerns
over patient privacy, computer skills and general communication. Results from research
provide preliminary answers to research questions.
A survey is being conducted measuring barriers affecting the implementation of
EHRs systems in Saudi Arabia. 11 health facilities in the Baha province of Saudi Arabia
were sent a survey that is supposed of measure the level of EHRs implementation at their
hospital and/or patient care facility, and potential barrier for is implementation. The
major potential barriers to the successful implementation of EHRs implementation that
the survey is testing for is educational level, computer knowledge, level of training given
to employees, security and privacy issue concerns, Lack of EHRs awareness, Cost of
EHRs systems, Resistance to new technologies, Confidentiality and privacy concerns,
Security concerns regarding the use and access to EHRs Systems, and the EHRs system
maintenance. An evaluation over the need for the implementation of security practices
and precautions that institutions have in place will be reviewed using relevant data that
will be obtained either directly from the institution or through information databases.
This study will be conducted using quantitative research method. Quantitative
research methods including data mining, the collection and analysis of empirical data,
and the modeling and analysis of data from case studies and other relevant documents.
The proposed research method for this study is to analyze historical data and literature
reviews including corporate hospital financial records in the search for budgeting
practices. This research will also analyze case studies and possible data mining for
61
security breaches. However, In order to make the survey anonymous and respect the
participants rights to privacy. The survey questions doesn’t includes any personally
identifiable questions. A survey was distributed to 11 Health facilities in Baha Province
of Saudi Arabia in order to collect data by a survey on targeted research questions that
measure, security concerns, technological skills among hospital employees and other
relevant questions. The data will be evaluated for each Hospital/health facility to draw
conclusions to research questions. The data that is collected from the surveys of the
different hospitals/health facilities will be used to support or oppose the research
hypothesis. The survey questions target to 3 categories as follow: 1- Demographics, 2-
EHRs System Existence and availability, 3- Factors associated with implementation and
adoption of EHRs System. A survey has been compiled as seen in the sample copy
provided in Appendix A.
All computation were performed with SAS® released 9.2 running on IPM PC with
windows/ XP operating system. The following SAS procedure were used to explore,
manipulate, format and analyze the data: DATA STEPS, FORMAT procedure, CHART
producer, FREQ procedure, and T-Test procedure. For continuous variables the method
were used appropriate to analyze the data:
Mean, SD for descriptive analysis.
Correlation Analysis : Pearson correlation
Correlation Analysis : Spearman correlation
T-test
62
3.2 Demographics of Study Population:
In order to have a good sample analysis, this study focused on 11 different
facilities in Baha province, which followed one administrative body and they are a clear
representation of all hospitals in Saudi Arabia. These hospitals are King Fahad Hospital,
Baljurashi Hospital, Aqiq Hospital, Psychiatric Hospital, Mandaq Hospital, Karra
Hospital, Rehabiltaion Hospital, Mikwah Hospital, Qilwa Hospital, Hajra Hospital, and
General Directorate of Health Affairs
3.3 Study Population:
The Survey was formulated in such a way as to collect information regarding to
the hypotheses described in section 1.4. The survey questions used to give an acceptable
answer to the questions related to the Factors Associated with Implementation and
Adoption of EHRs. Therefore, the survey targeted to all the group belong to the health
field, and deal with a different parts of a EHRs System. Hence, each group gets to work
at least with one specific part of an EHRs System, statistics were derive individually for
each individual group which helped to get more understand which group are more rise
to resisting the adoption of EHRs System.
3.4 Pilot Study:
The survey shown in Appendix A was first evaluated by advisor to ascertain its
structure and validity. The pilot study consisted of 1754 surveys which were distributed
among the six group of health care staff, for 3 weeks to collect the data from the 6 groups
(Physicians, Nurses, Lab Technician, Pharmacists, Medical records, and administrative
staff.
63
3.4.1 Calculation of Sample Size (Power Analysis)
A power analysis was performed to ensure that a power of .8 was obtained as is
standard in clinical psychology research (Cohen, 1992). At least 256 participants were
necessary to achieve statistical significance of effects at small to medium effect size.
3.5 Data Analysis
All statistical tests were conducted at the 95% confidence level (α = .05). Data
analysis was performed in several steps. First, descriptive statistics were calculated.
Tables and graphs were created for responses to each question in the questionnaire.
Second the study hypotheses were investigated. The following is a description of the
analysis performed for each study hypothesis:
Hypothesis 1: Security concerns and the lack of authorization controls inhibit the
acceptance of EHRs by medical professionals.
Hypothesis 1 was analyzed using Pearson correlation analysis and a t-test test. The
dependent variable for Hypothesis 1 was acceptance of EHRs, as measured by Question
19. Question 19 stated, “Implementing of EHRs system will increase the quality of work
and efficiency in hospitals, together with providing better patient care, and safety”. This
was a Likert style question coded into a continuous variable. Two continuous and one
categorical independent variable were used in the analysis. The two continuous variables
were coded from responses to Question 27 and Question 32. Question 27 asked
respondents to rank the obstacles the organization will face in implementing EHR. The
rank of “Meeting Privacy and Security Standards” was coded into a continuous variable.
For Question 32, respondents were asked to rate on a scale between strongly agree and
64
strongly disagree whether they believe “Our facility does not have enough employees to
ensure that the EHR is secure.” This was also coded into a continuous variable. The
relationships between these two continuous independent variables and the dependent
variable were analyzed using Spearman correlation. There was also a categorical
independent variable that was coded from responses to Question 12. Question 12 asked
respondents to choose the four most important barriers that affect successful
implementation of EHRs. The response option of “Privacy and security concerns
regarding the use and access of EHRs System” was coded as a dichotomous variable. A
t-test was conducted to examine the relationship between this variable and the dependent
variable.
Hypothesis 2: Concerns about EHRs system maintenance and support programs
would inhibit the acceptance of EHRs by medical professionals.
Hypothesis 2 was analyzed using Pearson correlation analysis and a t-test. Hypothesis 2
stated that concerns about EHRs system maintenance and support programs would inhibit
the acceptance of EHRs by medical professionals. The dependent variable for Hypothesis
2 was acceptance of EHRs, as measured by Question 19. Question 19 stated
“Implementing of EHRs system will increase the quality of work and efficiency in
hospitals, together with providing better patient care, and safety”. This was a Likert style
question coded into a continuous variable. Two continuous and one categorical
independent variables were used in the analysis. The two continuous variables were
coded from responses to Question 32. For Question 32, respondents were asked to rate
on a scale between strongly agree and strongly disagree whether they believe
“Maintaining and updating EHRs systems is too expensive” and “Our facility does not
65
have enough staff to maintain the system.” This was also coded into a continuous
variable. The relationships between these two continuous independent variables and the
dependent variable were analyzed using Spearman correlation. There was also a
categorical independent variable that was coded from responses to Question 12. Question
12 asked respondents to choose the four most important barriers that affect successful
implementation of EHRs. The response option of “EHRs system maintenance” was
coded as a dichotomous variable. A t-test was conducted to examine the relationship
between this variable and the dependent variable.
Hypothesis 3: Concerns about lack of knowledge of the EHRs systems and lack
of computer literacy skills would inhibit the acceptance of EHRs by medical
professionals.
The dependent variable for Hypothesis 3 was acceptance of EHRs, as measured by
Question 19. Question 19 stated “Implementing of EHRs system will increase the quality
of work and efficiency in hospitals, together with providing better patient care, and
safety”. This was a Likert style question coded into a continuous variable. The two
continuous independent variables were coded from responses to Question 4 and Question
5. For Question 4, respondents were asked to report on a Likert style scale between very
little and a great deal to the question “How much do you know about Electronic Health
Records?” These responses were coded into a continuous variable. For Question 5,
respondents were asked to respond on a Likert style scale between strongly agree and
strongly disagree to “My computer skills are weak and I would ask someone to help me
to do the computer-related work” These responses were coded into a continuous variable.
66
Hypothesis 4: Concerns about cost would inhibit the acceptance of EHRs by medical
professionals.
The dependent variable for Hypothesis 4 was acceptance of EHRs, as measured
by Question 19. Question 19 stated “Implementing of EHRs system will increase the
quality of work and efficiency in hospitals, together with providing better patient care,
and safety”. This was a Likert style question coded into a continuous variable. The two
continuous independent variables were coded from responses to Question 22 and
Question 32. For Question 22, respondents were asked to report on a Likert style scale
between strongly agree and strongly disagree with the statement “I think the EHRs
system to be more useful in the health facility, but I think that the costs for a full
implementation are too high” The response to this question was coded as a continuous
variable. For Question 32, respondents were asked to rate on a scale between strongly
agree and strongly disagree whether they believe “The cost of implementing an EHR
system is too high.” The response to this question was also coded as a continuous
variable. There was also a categorical independent variable that was coded from
responses to Question 12. Question 12 asked respondents to choose the four most
important barriers that affect successful implementation of EHRs. The response option
of “Cost of EHR system” was coded as a dichotomous variable. A t-test was conducted
to examine the relationship between this variable and the dependent variable.
Hypothesis 5: Concerns about EHRs systems being less secure and reliable than their
paper-based counterparts would inhibit the acceptance of EHRs by medical
professionals.
67
The dependent variable for Hypothesis 5 was acceptance of EHRs, as measured by
Question 20. For Question 20, respondents were asked to respond to a Likert scale style
question with responses between strongly agree and strongly disagree with the statement
“In my opinion, I think that EHRs system will protect the privacy of our patients’ more
than paper-based medical records.” The response to this question was coded into a
continuous variable. For Question 25, respondents were asked to respond to a Likert scale
style question with responses between strongly agree and strongly disagree with the
statement “I think the EHRs system is secured and trusted more than paper-based medical
records” The response to this question was coded into a continuous variable.
Hypothesis 6: Those medical professional that believe that EHRs systems improve
current workflow are more likely to accept the adoption of EHRs systems.
Question 19 stated, “Implementing of EHRs system will increase the quality of work and
efficiency in hospitals, together with providing better patient care, and safety.” This was
a Likert style question coded into a continuous dependent variable. For Question 23,
respondents were asked to respond to a Likert scale style question with responses
between strongly agree and strongly disagree with the statement “I prefer adopting new
technologies with they are proven to increase quality and efficiency of workflow.” The
response to this question was coded into a continuous variable. This was the independent
variable in the analysis.
68
CHAPTER IV
IV. RESULTS
4.1 DESCRIPTIVE STATISTICS OF THE DATA
4.1.1 RESPONSE RATE PER HOSPITAL
Hospital employees were surveyed from 10 hospitals in Saudi Arabia and the
General Directorate of Health Affairs. Sample size calculation was performed at the 95%
confidence level. We wanted a confidence interval of 5% at most for each hospital, so a
sample size calculation was performed for Baljurashi Hospital, with the highest
population.
In order to perform the sample size calculation, the calculator at
http://www.surveysystem.com/sscalc.htm#one was used. The following formula was
used to compute the number of surveys needed for each hospital:
𝑁 =
𝑍 𝑝(1 − 𝑝) 𝑐2
1 +
𝑍 𝑝(1 − 𝑝) 𝑐2 𝑄
In this formula N is the sample size.
P is the proportion, largest possible number for this is 0.5
c = confidence interval entered as a decimal. So, for 5% it is 0.05
Q is the total population, so for King Fahad Hospital Q would be 800 and for
Aqiq Hospital it would be 220.
Z = is the Z value. For 95% confidence, it would be 1.68
For a confidence interval of 5% at the 95% confidence level, 260 surveys needed
to be sent out at the largest hospital, King Fahad Hospital. Below is the number of
69
surveys sent out: the response rate, the total number of people employed at the facility,
and the confidence interval for each hospital. Note, that each confidence interval is 5%
or smaller. (See Table 1 and Figure 1).
Table 1
Sample and Response Rates by Hospital
Health Facility Name Total
Number
Employed
at Facility
Number
of
Surveys
Needed
Sample
Response
Response
Rate
King Fahad Hospital 750-800 260 48 18.46%
Baljurashi Hospital 800-850 265 56 21.13%
Aqiq Hospital 200-220 140 76 54.29%
Psychiatric Hospital 200-240 148 26 17.57%
Mandaq Hospital 200-250 152 42 27.63%
Karra Hospital 100-150 108 37 34.26%
Rehabilitation Hospital 200-230 144 34 23.61%
Mikwah Hospital 250-280 162 31 19.14%
Qilwa Hospital 200-220 140 66 47.14%
Hajra Hospital 100-150 108 32 29.63%
General Directorate of
Health Affairs
150-190 127 21
16.54%
Total 1754 469 26.74%
70
Figure 1.
Bar Graph of Response Rates by Hospital
4.1.2 RESPONSE RATE PER EDUCATIONAL LEVEL
Participants in the survey were asked to self-report their highest level of education
obtained. Participants reported the following levels of completed education: (a) High
School or below; (B) Two Year Diploma or Certificate; (c) Bachelor’s Degree; and (d)
Master’s or Higher Education. Below are the number of participants and percentages of
the sample by level of completed education for each hospital (see Table 2 and see Figure
2).
Table 2
Sample by Hospital and Education Level
Education Level
Health Facility
Name High School or
Below
Two Year
Diploma or
Certificate
Bachelor’s
Degree
Masters or Higher
Education
N % N % N % N %
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Response Rates by Hospital
71
King Fahad
Hospital 1 2.1% 8 17.0% 23 48.9% 15 31.9%
Baljurashi
Hospital 3 5.4% 18 32.1% 16 28.6% 19 33.9%
Aqiq Hospital 13 54.2% 19 32.1% 33 28.6% 9 33.9%
Psychiatric
Hospital 1 3.8% 5 19.2% 16 61.5% 4 15.4%
Mandaq
Hospital 0 0.0% 9 21.4% 23 54.8% 10 23.8%
Karra
Hospital 2 5.6% 11 30.6% 19 52.8% 4 11.1%
Rehabilitation
Hospital 0 0.0% 9 27.3% 16 48.5% 8 24.2%
Mikwah
Hospital 0 0.0% 5 17.2% 18 62.1% 6 20.7%
Qilwa
Hospital 2 3.2% 8 12.7% 35 55.6% 18 28.6%
Hajra Hospital 2 6.5% 3 9.7% 21 67.7% 5 16.1%
General
Directorate of
Health Affairs
0 0.0% 4 19.0% 10 47.6% 7 33.3%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Education Level of Respondants by Hospital
High School or Below Two Year Diploma or Certificate
Bachelor’s Degree Masters or Higher Education
Figure 2: Bar Graph of Sample by Hospital and Education Level
72
4.1.3 RESPONSE RATE PER GENDER
Both male and female respondents were surveyed. A total of 292 male
respondents and 157 female respondents participated in the survey. Below are the number
of participants and percentages of the sample by gender for each hospital (see Table 3
and see Figure 3).
Table 3
Sample by Hospital and Gender
Gender
Health
Facility Name Male Female
N % N %
King Fahad
Hospital 33 70.2% 14 29.8%
Baljurashi
Hospital 42 79.2% 11 20.8%
Aqiq Hospital 40 62.5% 24 37.5%
Psychiatric
Hospital 20 76.9% 6 23.1%
Mandaq
Hospital 14 33.3% 28 66.7%
Karra Hospital 24 66.7% 12 33.3%
Rehabilitation
Hospital 22 66.7% 11 33.3%
Mikwah
Hospital 21 66.7% 10 36.9%
Qilwa
Hospital 41 63.1% 24 12.7%
Hajra Hospital 20 64.5% 11 35.5%
General
Directorate of
Health Affairs
15 71.4% 6 28.6%
73
FIGURE 3: Bar Graph of Sample by Hospital and Gender
4.1.4 RESPONSE RATE PER HEALTH CARE PROFESSIONAL
Participants in the survey were asked to self-report their healthcare profession.
Participants reported the following healthcare professions: (a) Physician; (B) Nurse; (C)
Pharmacist; And (D) Lab Technician; (E) Administration Staff; And (F) Medical
Records. Below are the number of participants and percentages of the sample by level of
completed education for each hospital (see Table 4 and see Figure 4).
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Respondants by Gender
Male Female
74
Table 4
Sample by Hospital and Healthcare Profession
Healthcare Profession
Health
Facility
Name Physicians Nurses
Pharmac
ists
Lab
Technici
an
Adminis
tration
Staff
Medic
al
Record
s
N % N % N % N % N % N %
King Fahad
Hospital 14 29.2% 4 8.3
% 4
8.3
% 4
8.3
% 8
16
.7
%
1
4
29.2
%
Baljurashi
Hospital 21 38.2% 8
14.
5% 9
16.4
% 6
10.9
% 5
9.
1
%
6 10.9
%
Aqiq
Hospital 18 23.7% 22 28.
9%
1
0
13.2
% 6
7.9
% 15
19
.7
%
5 6.6
%
Psychiatric
Hospital 8 30.8% 4 15.
4% 4
15.4
% 4
15.4
% 3
11
.5
%
3 11.5
%
Mandaq
Hospital 9 21.4% 25 59.
5% 2
4.8
% 0
0.0
% 3
7.
1
%
3 7.1
%
Karra
Hospital 5 13.9% 10 27.
8% 5
13.9
% 6
16.7
% 5
13
.9
%
5 13.9
%
Rehabilitati
on Hospital 11 33,3% 6 18.
2% 2
6.1
% 0
0.0
% 7
21
.2
%
7 21.2
%
Mikwah
Hospital 5 16.7% 6 20.
0% 3
10.0
% 4
13.3
% 4
13
.3
%
8 26.7
%
Qilwa
Hospital 21 31.8% 17 25.
8% 2
3.0
% 6
9.1
% 8
12
.1
%
1
2
18.2
%
75
Hajra
Hospital 4 12.9% 4 12.
9% 3
9.7
% 3
9.7
% 5
16
.1
%
1
2
38.7
%
General
Directorate
of Health
Affairs
4 20.0% 4 20.
0% 1
5.0
% 2
10.0
% 7
35
.0
%
2 10%
Figure 4
Bar graph of Sample by Hospital and Healthcare Profession
4.1.5 RESPONDENTS CHOICE FOR THE 4 MAIN BARRIERS
Participants were asked to report the four most important barriers to EHR systems
implementation. Participants were given a list of the following six barriers. The list of barriers
presented to participants were the following:
Lack of computer skills
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Respondants by Job Type
Physicians Nurses Pharmacists
Lab Technicians Administration Staff Medical Records
76
Cost of EHRs system
Adaptation to new technology
Privacy and security concerns regarding the use and access of EHRs System
EHRs maintenance
Resistance to new technology
The four most commonly cited barriers by participants were lack of computer skills,
adaptation to new technology, costs of the EHRs system, and privacy and security concerns.
Table 5 displays the participants’ choices by hospital.
Table 5
Ranking of Reported Barriers by Hospital
Barriers
Lack of
Computer
Skills
Adaptation to
New
Technology
Cost
of
EHR
Syste
m
Privacy
and
Security
Concern
s
EHR
System
Mainten
ance
Resista
nce to
New
Technol
ogy
King
Fahad
Hospital
35
(72.9%) 37 (77.1%)
38
(79.2
%)
36 (75%) 18
(37.5%)
20
(41.7%)
Baljurashi
Hospital
38
(67.9%) 30 (53.6%)
20
(35.7
%)
25
(44.6%)
23
(41.4%)
18
(32.1%)
Aqiq
Hospital
64
(84.2%) 53 (69.7%)
34
(44.7
%)
33
(43.3%)
38(50.0%
)
40
(52.6%)
Psychiatri
c Hospital
20
(76.9%) 19 (73.3%)
17
(65.4
%)
17
(65.4%) 8 (30.8%)
11
(42.3%)
Mandaq
Hospital
29
(69.0%) 19 (45.2%)
19
(45.2
%)
20
(47.6%)
10
(23.8%)
9
(21.4%)
Karra
Hospital
20
(54.1%) 21(56.8%)
20
(54.1
%)
18
(48.6%)
16
(43.2%)
14
(37.8%)
Rehabilita
tion
Hospital
27
(79.4%) 24 (70.6%)
25
(73.5
%)
24
(70.6%)
12
(35.3%)
11
(32.4%)
77
Mikwah
Hospital
23
(74.2%) 21 (67.7%)
18
(58.1
%)
26
(83.9%)
15
(48.4%)
13
(41.9%)
Qilwa
Hospital
18
(72.7%) 22 (33.3%)
17
(25.8
%)
36
(54.5%)
42
(63.6%)
25
(37.9%)
Hajra
Hospital
26
(81.3%) 18 (56.3%)
27
(84.4
%)
19
(59.4%)
7 (21.9%) 13
(40.6%)
General
Directorat
e of Health
Affairs
12
(57.1%) 14 (66.7%)
13
(61.9
%)
12
(57.1%)
9 (42.9%) 8
(38.1%)
Total 349
(66.6%) 300 (57.3%)
289
(55.2
%)
173
(52.1%)
200
(38.2%)
185
(35.3%)
Figure 5.
Bar graph of Ranking of Reported Barriers by Hospital
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Lack of Computer Skills Adaptation to New Technology Cost of EHR System
Privacy and Security Concerns EHR System Maintenance Resistance to New Technology
78
4.1.6 IMPLEMENTATION OF EHRs
Participants were asked to report whether the EHRs system was implemented at
their organization. There were 262 participants (57.5%) who reported that EHRs system
was fully implemented at their organization, 93 participants (20.4%) who reported that
an EHR system was partially implemented at their organization, and 101 participants
(22.1%) who reported that that EHRs system was not implemented at all at their
organization (see Table 6 and Figure 6).
Table 6
Reported Implementation of EHRs
N %
Fully implemented ( Yes) 262 57.5%
Partial implemented (Maybe) 93 20.4%
Not implemented at all ( No) 101 22.1%
Total 524 100.0%
Figure 6: Pie Chart of the Number of Respondents by Level of Implementation of an
EHR system
57.5 20%
22%
Level of Implementation
Fully implemented ( Yes) Partial implemented (Maybe)
Not implemented at all ( No)
79
4.1.7 Respondent Rate by Computer Skills
Participants were asked to report their level of computer skills. Participants were
presented with three choices, excellent, adequate and poor. Table 7 and Figure 7 summarize the
participant responses by hospital.
Table 7
Self-reported Level of Computer Proficiency
Excellent Adequate Poor
King Fahad Hospital 7 (14.9%) 33 (70.2%) 7 (14.9%)
Baljurashi Hospital 16 (29.6%) 32 (59.3%) 6 (11.1%)
Aqiq Hospital 12 (16.0%) 50 (66.7%) 13 (17.3%)
Psychiatric Hospital 2 (7.7%) 18 (69.2%) 6 (23.1%)
Mandaq Hospital 4 (9.8%) 34 (82.9%) 3 (7.3%)
Karra Hospital 6 (17.1%) 26 (74.3%) 3 (8.6%)
Rehabilitation
Hospital 4 (12.1%) 16 (48.5%) 13 (39.4%)
Mikwah Hospital 3 (10.7%) 18 (64.3%) 7 (25.0%)
Qilwa Hospital 20 (30.3%) 35 (53.0%) 11 (16.7%)
Hajra Hospital 6 (21.9%) 19 (59.4%) 7 (21.9%)
General Directorate
of Health Affairs 8 (40%) 12 (60.0%) 0 (0.0%)
Total 91 (19.6%) 298 (64.2%) 75 (16.2%)
80
Figure 7: Bar Graph of Self-reported Level of Computer Proficiency by Hospital
4.1.8 Responded Rate of Knowledge about the EHR Systems
Participants were asked to report their level of knowledge of EHRs systems. Participants
were presented with four choices, a great deal, a few things, a little, and very little. Table 8 and
Figure 8 summarize the participant responses by hospital.
Table 8
Self-reported EHRs system knowledge
A Great Deal A Few
Things A Little Very Little
King Fahad
Hospital 8 (17.0%) 16 (34.0%) 9 (19.1%) 14 (29.8)
Baljurashi
Hospital 11 (20.4%) 23 (42.6%) 7 (13.0%) 13 (24.1%)
Aqiq Hospital 14 (18.4%) 20 (26.3%) 33 (43.4%) 9 (11.8%)
Psychiatric
Hospital 0 (0.0%) 8 (32.0%) 9 (36.0%) 8 (32.0%)
Mandaq
Hospital 4 (9.8%) 15 (36.6%) 15 (36.6%) 7 (17.1%)
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Excellent Adequate Poor
81
Karra
Hospital 6 (16.7%) 12 (33.3%) 10 (27.8%) 8 (22.2%)
Rehabilitation
Hospital 3 (9.1%) 10 (30.3%) 8 (24.2%) 12 (36.6%)
Mikwah
Hospital 3 (10.7%) 15 (53.6%) 8 (28.6%) 2 (7.1%)
Qilwa
Hospital 7 (10.6%) 25 (37.9%) 24 (36.4%) 10 (15.2%)
Hajra Hospital 5 (15.6%) 18 (56.3%) 4 (12.5%) 5 (15.6%)
General
Directorate of
Health Affairs
4 (19.0%) 10 (47.6%) 4 (19.0%) 3 (14.3%)
Total 66 (14.2%) 175
(37.6%)
134
(28.8%) 91 (19.5%)
Figure 8: Bar graph of Self-reported EHRs system knowledge
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
A Great Deal A Few Things A Little Very Little
82
4.1.9 Responded Rate of hours learning of new System
Participants were asked to report the number of hours they plan on spending to learn the
new EHRs system. Participants were presented with four choices, four hours, 8 hours, 12 hours,
or more than 16 hours. Table 9 and Figure 9 summarize the participant responses by hospital.
Table9
Self-reported Number of Hours Participants Plan to Spend Learning the EHRs System
4 hours 8 hours 12 hours 16 or more
hours
King Fahad Hospital 8 (18.6%) 8 (37.2%) 12 (30.2%) 6 (14.0%)
Baljurashi Hospital 29 (52.7%) 11 (20.0%) 10 (18.2%) 5 (9.1%)
Aqiq Hospital 16 (21.1%) 35 (46.1%) 21 (27.6%) 4 (5.3%)
Psychiatric Hospital 3 (11.5%) 8 (30.8%) 10 (38.5%) 5 (19.2%)
Mandaq Hospital 4 (35.0%) 8 (27.5%) 8 (27.5%) 4 (10.0%)
Karra Hospital 14 (38.9%) 8 (22.2%) 6 (16.7%) 8 (22.2%)
Rehabilitation
Hospital 9 (26.5%) 15 (44.1%) 7 (20.6%) 3 (8.8%)
Mikwah Hospital 3 (9.7%) 9 (29.0%) 11 (35.5%) 8 (25.5%)
Qilwa Hospital 19 (28.8%) 14 (21.2%) 15 (22.7%) 18 (27.3%)
Hajra Hospital 2 (6.5%) 2 (6.5%) 12 (38.7%) 15 (48.4%)
General Directorate
of Health Affairs 4 (20.0%) 4 (20.0%) 5 (25.0%) 7 (35.0%)
Total 85 (18.3%) 124 (26.7%) 133 (28.6%) 123 (26.5%)
83
Figure 9
Bar Graph of Self-reported Number of Hours Participants Plan to Spend Learning the
EHRs System
4.2 SUMMARY OF STATISTICS OF THE DATA
4.2.1 Summary Statistics for All Hospital
Based on the result of the sample frequencies, there were 469 participants in this
study. For Hospital employees were surveyed from 10 hospitals in Saudi Arabia and the
General Directorate of Health Affairs. All these hospitals participants average was = 9.77
with Standard Deviation SD = 3.13(see table10)
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
4 hours 8 hours 12 hours 16 or more hours
84
Min Value 1
Max Value 11
Mean 5.45
Variance 9.77
Standard Deviation 3.13
Total Responses 469
Table 10: Summary Statistics for Hospitals
4.2.2 Summary Statistics For Per Educational Level
Based on the result of the participants in the survey were asked to self-report their
highest level of education obtained. Participants reported the following levels of
completed education: (a) High School or below; (B) Two Year Diploma or Certificate;
(c) Bachelor’s Degree; and (d) Master’s or Higher Education. All educational level
participants average was =2.92 with Standard Deviation SD = 0.80 (see table 11)
Min Value 1
Max Value 4
Mean 2.92
Variance 0.64
Standard Deviation 0.80
Total Responses 467
Table 11: Summary Statistics for Education Level
85
4.2.3 Summary Statistics for Gender
Based on the result of the both male and female respondents were surveyed. A total
of 292 male respondents and 157 female respondents participated in the survey. The
participants average was = 2.92 with Standard Deviation SD = 0.80 (see table 12)
Min Value 1
Max Value 4
Mean 2.92
Variance 0.64
Standard Deviation 0.80
Total Responses 467
Table 12: Summary Statistics for Gender
4.2.4 Summary Statistics for Health Care Professional
Based on the result of Participants in the survey were asked to self-report their
healthcare profession. Participants reported the following healthcare professions: (a)
Physician; (B) Nurse; (C) Pharmacist; And (D) Lab Technician; (E) Administration Staff;
And (F) Medical Records. Below are the number of participants average was = 3.14 and
standard deviation SD=1.86 (see Table 13)
Min Value 1
Max Value 6
Mean 3.14
Variance 3.48
Standard Deviation 1.86
Total Responses 472
Table 13: Summary Statistics for Health professionals
86
4.2.5 Summary Statistics for the 4 Main Barriers
Participants were asked to report the four most important barriers to EHR systems
implementation. Participants were given a list of the following six barriers. The list of
barriers presented to participants were the following: Lack of computer skills, Cost of
EHRs System, Adaptation to new technology, Privacy and security concerns regarding
the use and access of EHRs System, EHRs maintenance and Resistance to new
technology .the average four most commonly cited barriers by participants were lack of
computer skills, adaptation to new technology, costs of the EHRs system, and privacy
and security concerns’ = M =.52 with SD = .50 (see Table 14)
Min Value 1
Max Value 6
Mean 0.52
Variance 0.85
Standard Deviation 0.50
Total Responses 462
Table 14: Summary Statistics for main 4 barriers of EHRs implementation
4.2.6 Summary Statistics for Implementation of EHRs
Based on the result of participants were asked to report whether the EHRs system was
implemented at their organization. The mean was = 1.65and SD= 0.82 (see Table 15)
87
Min Value 1
Max Value 3
Mean 1.65
Variance 0.67
Standard Deviation 0.82
Total Responses 456
Table 15: Summary Statistics for Implementation of EHRs Implementation
4.2.7 Summary Statistics for Computer Skills
Based on the result of the Participants were asked to report their level of
computer skills. Participants were presented with three choices, excellent, adequate
and poor. The average was= 2.03 and standard deviation was = 0.60 (see Table 16)
Min Value 1
Max Value 3
Mean 2.03
Variance 0.36
Standard Deviation 0.60
Total Responses 464
Table 16: Summary Statistics for computer Skills
4.2.8 Summary Statistics for Knowledge about EHRs
Based on the result of the Participants were asked to report their level of knowledge of
EHRs systems. Participants were presented with four choices, a great deal, a few things,
a little, and very little. The average was= 2.46 and standard deviation was = 0.96 (see
Table 17)
88
Min Value 1
Max Value 4
Mean 2.46
Variance 0.92
Standard Deviation 0.96
Total Responses 466
Table17: Summary Statistics for Knowledge about EHRs
4.2.9 Summary Statistics for Training Hours
Based on the result of the Participants were asked to report the number of hours they
plan on spending to learn the new EHRs system. Participants were presented with four
choices, four hours, 8 hours, 12 hours, or more than 16 hours. Table 18 summarize the
participant Statistics for Training Hours.
Min Value 1
Max Value 4
Mean 2.37
Variance 1.13
Standard Deviation 1.06
Total Responses 465
Table 18: Summary Statistics for Training Hours
4.3 Determination the Relationship between Factors Associated With
Implementation of EHRs in Saudi Arabia Hospitals.
4.3.1 Multiple correlation and T- test Analysis
Hypothesis 1:
Hypothesis 1 stated that security concerns and the lack of authorization controls inhibit
the acceptance of EHRs by medical professionals. Hypothesis 1 was analyzed using
Pearson correlation analysis and a t-test test. The dependent variable for Hypothesis 1
89
was acceptance of EHRs, as measured by Question 19. Question 19 stated,
“Implementing of EHRs system will increase the quality of work and efficiency in
hospitals, together with providing better patient care, and safety”. This was a Likert style
question coded into a continuous variable. Two continuous and one categorical
independent variable were used in the analysis. The two continuous variables were coded
from responses to Question 27 and Question 32. Question 27 asked respondents to rank
the obstacles the organization will face in implementing EHR. The rank of “Meeting
Privacy and Security Standards” was coded into a continuous variable. For Question 32,
respondents were asked to rate on a scale between strongly agree and strongly disagree
whether they believe “Our facility does not have enough employees to ensure that the EHR is
secure.” This was also coded into a continuous variable. The relationships between these two
continuous independent variables and the dependent variable were analyzed using Spearman
correlation. There was also a categorical independent variable that was coded from responses to
Question 12. Question 12 asked respondents to choose the four most important barriers that affect
successful implementation of EHRs. The response option of “Privacy and security concerns
regarding the use and access of EHRs System” was coded as a dichotomous variable. A t-test
was conducted to examine the relationship between this variable and the dependent variable.
Since, multiple Correlation tests were conducted, Bonferroni adjustment was
used to analyze this hypothesis and all tests were conducted at the 97.5% confidence level
(α = .025). The data revealed that those participants who believed that privacy and
security concerns were not a significant obstacle were more likely to believe that the
implementation EHRs would increase the quality and efficiency of work in hospitals,
r(412)=.13, p<006. The data also revealed that those participants who believed that their
facility had enough employees to ensure that the implemented EHR was secure were
90
more likely to believe that the implementation EHRs would increase the quality and
efficiency of work in hospitals r(425)=.13, p<.006 (see Table 19 and Figure 10).
Table 19
Correlations between Acceptance of EHRs and Attitudes about Privacy and Security Concerns
1. 2. 3.
1. Acceptance of EHRs Implementation (Question
19)
2. Privacy and Security Concerns are not Obstacle
(Question 27_5)
.134**
3. Facility Does has Enough Employees to Ensure
that EHR is Secure (Question 32_6)
.133** .605***
Note.*p<.05, **p<.01, ***p<.05
91
Figure 10: Scatterplots of Implementation of EHRs system with quality of work
and efficiency in hospitals.
A t-test revealed that those participants who were more likely to select privacy
and security concerns as one of the four most important barriers influencing the success
of EHRs (Question 12_4) were less likely to believe that the implementation EHRs would
increase the quality and efficiency of work in hospitals, t (313.74) = -3.67, p<.001 (see
table 20) Hypothesis 1 was supported.
t df Std.
Dev
Sig(2tailed Mean
Difference
Implementing
of EHRs
system will
increase the
quality of
work and
efficiency in
hospitals.
Equal
Variance
assumed
-3.907 460 1.151 0.000 -0.352
Equal
variances
not
assumed
-3.672 313.743 0.785 0.000 -00.352
Table 20: Independent Sample Test
Hypothesis 2:
Hypothesis 2 was analyzed using Pearson correlation analysis and a t-test.
Hypothesis 2 stated that concerns about EHR system maintenance and support programs
would inhibit the acceptance of EHRs by medical professionals. The dependent variable
for Hypothesis 2 was acceptance of EHRs, as measured by Question 19. Question 19
stated “Implementing of EHRs system will increase the quality of work and efficiency in
hospitals, together with providing better patient care, and safety”. This was a Likert style
question coded into a continuous variable. Two continuous and one categorical
92
independent variables were used in the analysis. The two continuous variables were
coded from responses to Question 32. For Question 32, respondents were asked to rate
on a scale between strongly agree and strongly disagree whether they believe
“Maintaining and updating EHRs systems is too expensive” and “Our facility does not have
enough staff to maintain the system.” This was also coded into a continuous variable. The
relationships between these two continuous independent variables and the dependent variable
were analyzed using Spearman correlation. There was also a categorical independent variable
that was coded from responses to Question 12. Question 12 asked respondents to choose the four
most important barriers that affect successful implementation of EHRs. The response option of
“EHRs system maintenance” was coded as a dichotomous variable. A t-test was conducted to
examine the relationship between this variable and the dependent variable.
Since, multiple Correlation tests were conducted, Bonferroni adjustment was
used to analyze this hypothesis and all tests were conducted at the 97.5% confidence level
(α = .025). The data revealed that those participants who believed that maintaining and
updating EHRs systems was not too expensive were more likely to believe that the
implementation EHRs would increase the quality and efficiency of work in hospitals,
r(427)=.143, p<.003. The data also revealed that those participants who believed that
their facility had enough employees to the EHRs system was properly maintained were
more likely to believe that the implementation EHRs would increase the quality and
efficiency of work in hospitals r(425)=.191, p<0.006 (see Table 21 and figure 11).
93
Table 21
Correlations between Acceptance of EHRs and Concerns about System Maintenance and Support
1. 2. 3.
1. Acceptance of EHRs Implementation
2. Belief that maintaining and updating EHR
systems is not too Expensive (Question 32_3)
0.143**
3. Belief that their facility does have enough staff
to maintain the EHR system (Question 32_4)
0.191*** 0.737***
Note.*p<.05, **p<.01, ***p<.05
Figure 11: Scatterplots of Implementation of EHRs system and health facility
does not have enough staff to maintain the system.
A t-test revealed that there was no statistically significant difference between the
belief that EHR system maintenance as one of the four most important barriers
94
influencing the success of EHRs (Question 12_5) and the belief that the implementation
EHRs would increase the quality and efficiency of work in hospitals, t(450) = -0.30,
p=.76 (see Table 22). Hypothesis 2 was partially supported.
t df Std.
Dev
Sig(2tailed Mean
Difference
Implementing
of EHRs
system will
increase the
quality of
work and
efficiency in
hospitals.
Equal
Variance
assumed
-0.299 460 1.017 0.765 -0.027
Equal
variances
not
assumed
-0.304 441.892 0.899 0.771 -0.027
Table 22: Independent Sample Test
Hypothesis 3:
Hypothesis 3 was analyzed using Pearson correlation analysis. Hypothesis 3
stated that concerns about lack of knowledge of the EHRs systems and lack of computer
literacy skills would inhibit the acceptance of EHRs by medical professionals. The
dependent variable for Hypothesis 3 was acceptance of EHRs, as measured by Question
19. Question 19 stated “Implementing of EHRs system will increase the quality of work
and efficiency in hospitals, together with providing better patient care, and safety”. This
was a Likert style question coded into a continuous variable. The two continuous
independent variables were coded from responses to Question 4 and Question 5. For
Question 4, respondents were asked to report on a Likert style scale between very little
and a great deal to the question “How much do you know about Electronic Health
Records?” These responses were coded into a continuous variable. For Question 5,
respondents were asked to respond on a Likert style scale between strongly agree and
95
strongly disagree to “My computer skills are weak and I would ask someone to help me
to do the computer-related work” These responses were coded into a continuous variable.
Since, multiple Correlation tests were conducted, Bonferroni adjustment was
used to analyze this hypothesis and all tests were conducted at the 97.5% confidence level
(α = 0.025). The data revealed that those participants who reported greater knowledge
about EHRs were more likely to believe that the implementation EHRs would increase
the quality and efficiency of work in hospitals, r(455)=.10, p<.023. The data also
revealed that those participants who reported better levels of computer skills were more
likely to believe that the implementation EHRs would increase the quality and efficiency
of work in hospitals r(456)=0.21, p<.001 (See Table 23). Hypothesis 3 was supported.
Table 23
Correlations between Acceptance of EHRs and Concerns about Computer Literacy Skills and
Lack of Knowledge of EHRs
1. 2. 3.
1. Acceptance of EHRs Implementation
2. Self-report Knowledge of EHRs (Question 4) 0.106**
3. Self-report Computer Skills (Question 5) 0.212*** 0.302***
Note.*p<.05, **p<.01, ***p<.05
Hypothesis 4:
Hypothesis 4 was analyzed using Pearson correlation analysis and a t-test.
Hypothesis 4 stated that concerns about cost would inhibit the acceptance of EHRs by
medical professionals. The dependent variable for Hypothesis 4 was acceptance of EHRs,
as measured by Question 19. Question 19 stated “Implementing of EHRs system
will increase the quality of work and efficiency in hospitals, together with providing
96
better patient care, and safety”. This was a Likert style question coded into a continuous
variable. The two continuous independent variables were coded from responses to
Question 22 and Question 32. For Question 22, respondents were asked to report on a
Likert style scale between strongly agree and strongly disagree with the statement “I
think the EHRs system to be more useful in the health facility, but I think that the costs
for a full implementation are too high” The response to this question was coded as a
continuous variable. For Question 32, respondents were asked to rate on a scale between
strongly agree and strongly disagree whether they believe “The cost of implementing an
EHR system is too high.” The response to this question was also coded as a continuous variable.
There was also a categorical independent variable that was coded from responses to Question 12.
Question 12 asked respondents to choose the four most important barriers that affect successful
implementation of EHRs. The response option of “Cost of EHR system” was coded as a
dichotomous variable. A t-test was conducted to examine the relationship between this variable
and the dependent variable.
Since, multiple Correlation tests were conducted, Bonferroni adjustment was
used to analyze this hypothesis and all tests were conducted at the 97.5% confidence level
(α = .025). The data revealed that those participants who reported they believed that
although EHRs systems are useful in a healthcare facility, the costs of implementation
were too high were less likely to believe that the implementation EHRs would increase
the quality and efficiency of work in hospitals, r(453)=.30, p<.001. The data also
revealed that those participants who believed that the costs of implementing an EHRs
were too high were less likely to believe that the implementation EHRs would increase
the quality and efficiency of work in hospitals r(433)=.16, p<.001. (See Table 24 and
Figure 12). Hypothesis 4 was supported.
97
Table 24
Correlations between Acceptance of EHRs and Attitudes Cost Concerns
1. 2. 3.
1. Acceptance of EHRs Implementation
2. Belief that Although EHR System is Useful in a
Health Facility, the Costs of Implementation are
Too High (Question 22)
0.30***
3. Belief that the Cost of Implementing an EHR
system is too high (Question 32_1)
0.16** 0.65***
Note.*p<.05, **p<.01, ***p<.05
Figure 12: Scatterplots of Implementation of EHRs system and the cost of
Implementation EHRs system.
98
A t-test revealed that there was no statistically significant difference between the
belief that EHR system maintenance as one of the four most important barriers
influencing the success of EHRs (Question 12_2) and the belief that the implementation
EHRs would increase the quality and efficiency of work in hospitals, t(460) = -3.44, p =
0.001. (See table 25). Hypothesis 4 was supported.
t df Std.
Dev
Sig(2tailed Mean
Difference
Implementing
of EHRs
system will
increase the
quality of
work and
efficiency in
hospitals.
Equal
Variance
assumed
-3.438 460 1.072 0.001 -0.314
Equal
variances
not
assumed
-3.287 323.718 0.877 0.001 -0.314
Table 25: Independent Sample Test
Hypothesis 5:
Hypothesis 5 was analyzed using Pearson correlation analysis. Hypothesis 5
stated that concerns about EHR systems being less secure and reliable than their paper-
based counterparts would inhibit the acceptance of EHRs by medical professionals. The
dependent variable for Hypothesis 5 was acceptance of EHRs, as measured by Question
20. For Question 20, respondents were asked to respond to a Likert scale style question
with responses between strongly agree and strongly disagree with the statement “In my
opinion, I think that EHRs system will protect the privacy of our patients’ more than
paper-based medical records.” The response to this question was coded into a continuous
variable. For Question 25, respondents were asked to respond to a Likert scale style
question with responses between strongly agree and strongly disagree with the statement
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“I think the EHRs system is secured and trusted more than paper-based medical records”
The response to this question was coded into a continuous variable.
Since, multiple Correlation tests were conducted, Bonferroni adjustment was
used to analyze this hypothesis and all tests were conducted at the 97.5% confidence level
(α = .025). The data revealed that those participants who reported they believed that
EHRs would protect patient privacy better than paper records (Question 20) were more
likely to believe that the implementation EHRs would increase the quality and efficiency
of work in hospitals, r(459)=0.61, p<0.001 (see Table 26). The data also revealed that
those participants who reported they believed that EHRs are more secure than paper-
based medical records (Question 25) were more likely to believe that the implementation
EHRs would increase the quality and efficiency of work in hospitals, r(459)=.61, p<.001.
Hypothesis 5 was supported.
Table 26
Correlations between Acceptance of EHRs and Attitudes about Privacy and Security Concerns
1. 2. 3.
1. Acceptance of EHRs Implementation
2. Belief that EHRs protect privacy better than paper
records (Question 20)
0.614***
3.Belief that EHRs are more secure than paper-
based medical records (Question 25)
0.488*** 0.617***
Note.*p<.05, **p<.01, ***p<.05
Hypothesis 6:
Hypothesis 6 was analyzed using Pearson correlation analysis. Hypothesis 6 stated
that those medical professional that believed that EHR systems improve current
workflow are more likely to accept the adoption of EHR systems. Question 19 stated,
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“Implementing of EHRs system will increase the quality of work and efficiency in
hospitals, together with providing better patient care, and safety.” This was a Likert style
question coded into a continuous dependent variable. For Question 23, respondents were
asked to respond to a Likert scale style question with responses between strongly agree
and strongly disagree with the statement “I prefer adopting new technologies with they
are proven to increase quality and efficiency of workflow.” The response to this question
was coded into a continuous variable. This was the independent variable in the analysis.
4.3.2 Multiple Regression Analysis.
The following dependent and independent variables were included in the regression
model:
1. Dependent Variable
a. Acceptance of EHRS. This is the degree to which the respondent believes
that their institution should implement an EHR system. The question
stated: “Implementing of EHRs system will increase the quality of work
and efficiency in hospitals, together with providing better patient care,
and safety”. This was a Likert style question coded into a continuous
variable, with values from 1(strongly disagree) to 5(strongly agree).
2. Independent Variables
a. Self-reported Computer Skills. For Question 5, respondents were asked
to respond to a Likert style scale between strongly agree and strongly
disagree to “My computer skills are weak and I would ask someone to
help me to do the computer-related work” These responses were coded
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into a continuous variable, with values from 1(strongly disagree) to
5(strongly agree).
b. Meeting Privacy and Security Standards is a Hurdle to
Implementation. The belief that meeting privacy and security standards
is a hurdle to implementation. Question 27 asked respondents to rank the
obstacles the organization will face in implementing EHR. The rank of
“Meeting Privacy and Security Standards” was coded into a continuous
variable.
c. Self-report Knowledge of EHRs. This question assessed the knowledge
of EHRs of the respondent. Question 4, respondents were asked to report
on a Likert style scale between very little and a great deal to the question
“How much do you know about Electronic Health Records?” These
responses were coded into a continuous variable, with values from
1(strongly disagree) to 5(strongly agree).
d. Resistance to New Technology is a Barrier. The belief that resistance to
new technology is a barrier for implementation of EHRS systems.
Question 12 asked respondents to choose the four most important barriers
that affect successful implementation of EHRs. The response option of
“Resistance to New Technology” was coded as a dichotomous variable, 1
for a yes response and 0 for a no response.
e. EHR System Maintenance is a Barrier. The belief that EHR system
maintenance is a barrier. Question 12 asked respondents to choose the
four most important barriers that affect successful implementation of
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EHRs. The response option of “EHR system maintenance” was coded as
a dichotomous variable, 1 for a yes response and 0 for a no response.
f. Adaptation of New Technology is a Barrier. The belief that reluctance
to adopt new technology is a barrier. Question 12 asked respondents to
choose the four most important barriers that affect successful
implementation of EHRs. The response option of “Adaptation of New
Technology” was coded as a dichotomous variable, 1 for a yes response
and 0 for a no response.
g. Cost of EHR system is a Barrier. The belief that the cost of the EHR
system is a barrier Question 12 asked respondents to choose the four most
important barriers that affect successful implementation of EHRs. The
response option of “Cost of EHR system” was coded as a dichotomous
variable, 1 for a yes response and 0 for a no response.
h. EHR is Useful, but Costs are Too High. The belief that EHR is useful,
but that costs are too high. For Question 22, respondents were asked to
report on a Likert style scale between strongly agree and strongly disagree
with the statement “I think the EHRs system to be more useful in the
health facility, but I think that the costs for a full implementation are too
high” The response to this question was coded as a continuous variable.
The response to this question was coded into a continuous variable, with
values from 1(strongly disagree) to 5(strongly agree).
i. Fear of New Technology is a Factor. The belief that few of new
technology is a factor. For Question 24, respondents were asked to
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respond on a Likert scale between strongly agree and strongly disagree
with the statement “Do you think the unsecured (fearing) of using
technology to be the main barrier in implementing EHR system?” The
response to this question was coded into a continuous variable, with
values from 1(strongly disagree) to 5(strongly agree).
j. EHRs protect privacy better than paper records. This the belief that
EHRs will protect privacy of patients better than paper records. For
Question 20, respondents were asked to respond to a Likert scale style
question with responses between strongly agree and strongly disagree
with the statement “In my opinion, I think that EHRs system will protect
the privacy of our patients’ more than paper-based medical records.” The
response to this question was coded into a continuous variable, with
values from 1(strongly disagree) to 5(strongly agree).
k. EHRs are more trusted than paper records. The belief that EHRs are
more trusted than paper records. For Question 20, respondents were asked
to respond to a Likert scale style question with responses between strongly
agree and strongly disagree with the statement “In my opinion, I think that
EHRs system will protect the privacy of our patients’ more than paper-
based medical records.” The response to this question was coded into a
continuous variable, with values from 1(strongly disagree) to 5(strongly
agree).
i. Preference to Adapt New Technology, when Proven to Increase
Quality. The belief that it is best to adapt to new technology when it is
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proven to increase quality. For Question 19, respondents were asked to
respond to a Likert scale style question with responses between strongly
agree and strongly disagree with the statement “Implementing of EHRs
system will increase the quality of work and efficiency in hospitals,
together with providing better patient care and safety.” The response to
this question was coded into a continuous variable, with values from
1(strongly disagree) to 5(strongly agree).
Multiple regression analysis was performed to determine the relationship between
these independent variables and the acceptance of EHRs. The model was statistically
significant F (10,375) = 26.37, p <0.001 (see figure 27). The model accounted for 41.3
percent of the variation in the data. (See table 27).
Table 27: ANOVA.
Model Sum of Squares df
Mean
Square F-statistic p-value
Regression 152.41 10 15.24 26.37 <0.001
Residual 216.71 375 0.58
Total 369.12 385
Each regression variable was analyzed for statistical significance. There was no
statistically significant relationship between self-reported computer skills and acceptance
of EHRs, β = 0.05, t (363) = 0.82, p =0.42. There was also no statistically significant
relationship between the belief that cost of EHR system is a barrier and acceptance of
EHRs, β = 0.08, t (363) = .83, p =.41. There was also no statistically significant
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relationship between the belief that adaptation of new technology is a barrier and
acceptance of EHRs, β = 0.14, t (363) = 1.93, p =0.05. There was also no statistically
significant relationship between the belief that EHR system maintenance is a barrier is a
barrier and acceptance of EHRs, β = -0.07, t (363) = -0.90, p =0.37. There was also no
statistically significant relationship between the belief that resistance to new technology
is a barrier and acceptance of EHRs, β = 0.12, t (363) = 1.54, p =0.13. There was also no
statistically significant relationship between the belief that EHR is useful, but costs are
too high is a barrier and acceptance of EHRs, β = 0.02, t (363) = 0.47, p =0.64. However,
there was a statistically significant relationship between the belief that they prefer to
adapt new technology, when proven to increase quality is a barrier and acceptance of
EHRs, β = 0.34, t (363) = 7.15, p < .001. Those who believed that prefer to adapt new
technology, when proven to increase quality is a barrier, were more likely to accept EHRs
(increasing relationship, direct relationship).
There was also no statistically significant relationship between the belief that fear of new
technology is a factor and acceptance of EHRs, β = -0.02, t (363) = -0.48, p =.63.
However, there was a statistically significant relationship between the belief meeting
privacy and security standards is a hurdle to implementation and acceptance of EHRs, β
= -0.05, t (363) = -3.12, p = .002. Those who believed that meeting privacy and security
standards is a hurdle to implementation were more likely to accept EHRs (inverse
relationship, negative relationship). There was also no statistically significant
relationship between self-report knowledge of EHRs and acceptance of EHRs, β = 0.07,
t (363) = 1.80, p =0.07. However, there was a statistically significant relationship
between the belief that EHRs protect privacy and acceptance of EHRs, β = .44, t (363) =
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8.75, p < 0.001. Those who believed that EHRs protect privacy were more likely to accept
EHRs (direct relationship, positive relationship). There was also no statistically
significant relationship between the belief that EHRs are more trusted than paper records
and acceptance of EHRs, β = 0.06, t (363) = 1.80, p =0.07 (see Table 28).
Table 28
Variables in the Regression Model
Variable
Symbo
l β t
p-
value
(Constant) A 0.50 2.18 0.03
Self-reported Computer Skills A1 0.05 0.82 0.42
Cost of EHR system is a Barrier A2 0.08 0.83 0.41
Adaptation of New Technology is a Barrier A3 0.14 1.93 0.05
EHR System Maintenance is a Barrier A4 -0.07 -0.90 0.37
Resistance to New Technology is a Barrier A5 0.12 1.54 0.13
EHR is Useful, but Costs are Too High A6 0.02 0.47 0.64
Preference to Adapt New Technology, when
Proven to Increase Quality
A7
0.34 7.15 0.001
Fear of New Technology is a Factor A8 -0.02 -0.48 0.63
Meeting Privacy and Security Standards is a
Hurdle to Implementation
A9
-0.05 -3.12 0.002
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Self-report Knowledge of EHRs A10 0.07 1.80 0.07
EHRs protect privacy A11 0.44 8.75 0.001
EHRs are more trusted than paper records. A12 0.06 1.21 0.23
- Equation with all the variables:
Acceptance of EHRs = 0.50 + 0.05*A1 + 0.08*A2 + 0.14*A3 -0.07*A4 + 0.12*A5 +
0.02*A6 + 0.34*A7 - 0.02* A8 -0.05*A9+ 0.07* A10 + 0.44* A11 + 0.06* A12
- Equation with only significant variables:
Acceptance of EHRs = 0.50 + 0.34*Preference to Adapt New Technology, when Proven
to Increase Quality Factor -0.05* Meeting Privacy and Security Standards is a Hurdle
to Implementation + 0.44* EHRs protect privacy.
CHAPTER V
V. DISCUSSION
5.1 Status of Current EHRs Implementations
Before addressing the barriers to EHRs implementation, analysis of the results
regarding the current level of EHRs implementation are discussed. The results are
displayed in Table 5 and Figure 5. There were 262 participants (57.5%) who reported
that an EHR system was fully implemented at their organization, 93 participants (20.4%)
who reported that EHRs system was partially implemented at their organization, and 101
participants (22.1%) who reported that that an EHR system was not implemented at all
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at their organization. A majority of respondents reported that EHRs was fully
implemented and only 22.1% of respondents reported that EHRs systems were not
implemented at all at their hospital. Since there were more than 265 respondents in this
study the sample size was large enough to conclude that these percentages accurately
represent the percentages of the population.
5.2 Barriers to EHR implementation
5.2.1 Security Concerns Regarding the Use and Access to EHRs Systems
“Security concerns and the lack of authorization controls inhibit the acceptance of EHRs
by medical professionals.”
Since, multiple Correlation tests were conducted, Bonferroni adjustment was used
to analyze this hypothesis and all tests were conducted at the 97.5% confidence level (α
= .025). The data revealed that those participants who believed that privacy and security
concerns were not a significant obstacle were more likely to believe that the
implementation EHRs would increase the quality and efficiency of work in hospitals,
r(412)=.13, p=.006. The data also revealed that those participants who believed that their
facility had enough employees to ensure that the implemented EHRs was secure were
more likely to believe that the implementation EHRs would increase the quality and
efficiency of work in hospitals r(425)=.13, p=.006. A t-test revealed that those
participants who were more likely to select privacy and security concerns as one of the
four most important barriers influencing the success of EHRs (Question 12_4) were less
likely to believe that the implementation EHRs would increase the quality and efficiency
of work in hospitals, t(313.74) = -3.67, p<.001. Hypothesis 1 was supported by the data.
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There was enough evidence to conclude that security concerns and the lack of
authorization controls inhibit the acceptance of EHRs by medical professionals.
5.2.2 Concerns about EHRs System Maintenance and Support Programs
“Concerns about EHRs system maintenance and support programs would inhibit the
acceptance of EHRs by medical professionals.”
Since, multiple Correlation tests were conducted, Bonferroni adjustment was used
to analyze this hypothesis and all tests were conducted at the 97.5% confidence level (α
= .025). The data revealed that those participants who believed that maintaining and
updating EHRs systems was not too expensive were more likely to believe that the
implementation EHRs would increase the quality and efficiency of work in hospitals,
r(427)=.143, p=.003. The data also revealed that those participants who believed that
their facility had enough employees to the EHRs system was properly maintained were
more likely to believe that the implementation EHRs would increase the quality and
efficiency of work in hospitals r(425)=.191, p=.006 . A t-test revealed that there was no
statistically significant difference between the belief that EHRs system maintenance as
one of the four most important barriers influencing the success of EHRs (Question 12_5)
and the belief that the implementation EHRs would increase the quality and efficiency of
work in hospitals, t(450) = -.30, p=.76. Hypothesis 2 was partially supported. There was
some evidence that concerns about EHRs system maintenance and support programs
would inhibit the acceptance of EHRs by medical professionals.
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5.2.3 Concerns about Lack of Knowledge of EHRs systems and Lack of Computer
Literacy Skills
“Concerns about lack of knowledge of the EHRs systems and lack of computer literacy
skills would inhibit the acceptance of EHRs by medical professionals.”
Since, multiple Correlation tests were conducted, Bonferroni adjustment was
used to analyze this hypothesis and all tests were conducted at the 97.5% confidence level
(α = .025). The data revealed that those participants who reported greater knowledge
about EHRs were more likely to believe that the implementation EHRs would increase
the quality and efficiency of work in hospitals, r(455)=.10, p=.023. The data also revealed
that those participants who reported better levels of computer skills were more likely to
believe that the implementation EHRs would increase the quality and efficiency of work
in hospitals r(456)=.21, p<.001. Hypothesis 3 was supported. There was enough
evidence to conclude that concerns about lack of knowledge of the EHRs systems and
lack of computer literacy skills would inhibit the acceptance of EHRs by medical
professionals.
5.2.4 Concerns about High cost of adopting of EHRs
“Concerns about cost would inhibit the acceptance of EHRs by medical professionals.”
Since, multiple Correlation tests were conducted, Bonferroni adjustment was used
to analyze this hypothesis and all tests were conducted at the 97.5% confidence level (α
= .025). The data revealed that those participants who reported they believed that
although EHRs systems are useful in a healthcare facility, the costs of implementation
were too high were less likely to believe that the implementation EHRs would increase
the quality and efficiency of work in hospitals, r(453)=.30, p<.001. The data also revealed
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that those participants who believed that the costs of implementing EHRs were too high
were less likely to believe that the implementation EHRs would increase the quality and
efficiency of work in hospitals r(433)=.16, p<.001. Hypothesis 4 was supported. There
was enough evidence to conclude that concerns about cost would inhibit the acceptance
of EHRs by medical professionals
5.2.5 Concerns about Security and Reliability
“Concerns about EHRs systems being less secure and reliable than their paper-based
counterparts would inhibit the acceptance of EHRs by medical professionals”
Since, multiple Correlation tests were conducted, Bonferroni adjustment was
used to analyze this hypothesis and all tests were conducted at the 97.5% confidence level
(α = .025). The data revealed that those participants who reported they believed that
EHRs would protect patient privacy better than paper records (Question 20) were more
likely to believe that the implementation EHRs would increase the quality and efficiency
of work in hospitals, r(459)=.61, p<.001. The data also revealed that those participants
who reported they believed that EHRs are more secure than paper-based medical records
(Question 25) were more likely to believe that the implementation EHRs would increase
the quality and efficiency of work in hospitals, r(459)=.61, p<.001. Hypothesis 5 was
supported. There was enough evidence to conclude that concerns about EHRs systems
being less secure and reliable than their paper-based counterparts would inhibit the
acceptance of EHRs by medical professionals.
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5.2.6 Concerns about Workflow
“Those medical professional that believe that EHRs systems improve current workflow
are more likely to accept the adoption of EHRs systems.”
Since, multiple Correlation tests were conducted, Bonferroni adjustment was
used to analyze this hypothesis and all tests were conducted at the 97.5% confidence level
(α = .025). The data revealed that those participants who reported they believed that
EHRs would protect patient privacy better than paper records (Question 20) were more
likely to believe that the implementation EHRs would increase the quality and efficiency
of work in hospitals, r(459)=.61, p<.001. The data also revealed that those participants
who reported they believed that EHRs are more secure than paper-based medical records
(Question 25) were more likely to believe that the implementation EHRs would increase
the quality and efficiency of work in hospitals, r(459)=.61, p<.001. Hypothesis 5 was
supported. There was enough evidence to conclude that those medical professional that
believe that EHRs systems improve current workflow are more likely to accept the
adoption of EHRs systems.”
CHAPTER VI
VI. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
6.1 SUMMARY AND CONCLUSION:
The health care system of KSA stands to improve substantially upon successful
implementation of the electronic health records system. EHRs help in data management,
interoperability, information sharing, and decision making by health physicians. The
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system also cuts data storage costs, minimizes information loss, and prevents medical
errors that result in fatal injuries and deaths. The rapidly burgeoning population of the
KSA requires a modern health care system to ensure efficient and effective disease
control and monitoring.
The goal of this study was to explore the implementation and adoption of
Electronic Health Records system (EHRs) in Kingdom of Saudi Arabia, together with
the factors associated with the implementations and adoption. This study attempted to
find EHRs system in Saudi hospitals and health facilities and the factors which affect or
delay this implementation and adoption. Therefore, this research aimed examined the
following major points relating to EHRs system in Saudi Arabia:
• What is the present status of implementing and adopting of EHRs system in the
health facilities of Kingdom of Saudi Arabia?
• What are the factors associated with the implementation and adoption of EHRs
system in the health facilities of Kingdom of Saudi Arabia?
• There were six groups of healthcare specialists who participated in this study:
Physicians, Nurses, Pharmacists, Lab Technicians, Administration Staff, and Medical
Records. All of these groups are working in 11 health facilities at Baha Province in Saudi
Arabia: These health facilities are King Fahad Hospital, Baljurashi Hospital, Aqiq
Hospital, Psychiatric Hospital, Mandaq Hospital, Karra Hospital, Rehabiltaion Hospital,
Mikwah Hospital, Qilwa Hospital, Hajra Hospital, and General Directorate of Health
Affairs.
• The research findings are as follows:
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• There were 262 participants (57.5%) who reported that an EHR system was fully
implemented at their organization.
• 93 participants (20.4%) who reported that an EHR system was partially
implemented at their organization.
• 101 participants (22.1%) who reported that that an EHR system was not
implemented at all at their organization.
• The study shows that health specialists in Saudi Arabia consider Resistance to
New Technology EHR systems is not a significant obstacle.
• The study shows that health specialists in Saudi Arabia were believed that EHR
systems improve current workflow are more likely to accept the adoption of EHR
systems.
• The study shows that health specialists in Saudi Arabia participants who believed
that privacy and security concerns were not a significant obstacle were more likely to
believe that the implementation EHRs would increase the quality and efficiency of work
in hospitals.
• The study shows that health specialists in Saudi Arabia were believed that
maintaining and updating EHRs system was not too expensive were more likely to
believe that the implementation EHRs would increase the quality and efficiency of work
in hospitals.
• The study shows that health specialists in Saudi Arabia were believed that their
facility had enough employees to the EHRs system was properly maintained were more
115
likely to believe that the implementation EHRs would increase the quality and efficiency
of work in hospitals.
• The study shows that health specialists in Saudi Arabia were reported greater
knowledge about EHRs were more likely to believe that the implementation EHRs would
increase the quality and efficiency of work in hospitals.
• The study shows that health specialists in Saudi Arabia were reported better levels
of computer skills were more likely to believe that the implementation EHRs would
increase the quality and efficiency of work in hospitals.
• The study shows that health specialists in Saudi Arabia were reported they
believed that although EHRs system are useful in a healthcare facility, the costs of
implementation were too high were less likely to believe that the implementation EHRs
would increase the quality and efficiency of work in hospitals.
• The study shows that health specialists in Saudi Arabia were believed that the
costs of implementing EHRs were too high were less likely to believe that the
implementation EHRs would increase the quality and efficiency of work in hospitals.
• The study shows that health specialists in Saudi Arabia were reported they
believed that EHRs would protect patient privacy better than paper records more likely
to believe that the implementation EHRs would increase the quality and efficiency of
work in hospitals.
• The study shows that health specialists in Saudi Arabia were reported they
believed that EHRs are more secure than paper-based medical records were more likely
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to believe that the implementation EHRs would increase the quality and efficiency of
work in hospitals.
This research study was showed that implementation levels of EHRs systems vary
significantly between hospitals. Also, there were different among the health care
professionals who participated in the study have a different opinion, view, and perception
of the level about EHRs system implemented in their health care facility. However,
there’s general agreement among all participants of this study to the factors that delay the
implementation of EHRs system in Saudi Arabia Hospitals. These obstacles factors seem
to be the same trends existed in other countries. Participants identified Lack of experience
with the use of computer, Security concerns regarding the use and access to EHR
Systems, High Cost of Adopting EHRs, Resistance to New Technologies, EHRs system
Maintenance and down time, and Adoption of New Technology to be significant barriers
when it comes to EHRs implementation and adoption.
6.2 LIMITATIONS OF STUDY
The study is limited to the implementation and adoption of EHRs systems as
affected by those factors associated to the implementation and adoption which act as
major barriers to such implementations. Future research can study the effects of EHRs
System implementation and adoption on the total quality of care as perceived by the
patients. The study is also limited to Saudi Arabia healthcare Hospitals. The study can be
extended to other countries which have implemented similar healthcare system.
The study is limited to 11 major health facilities, 10 hospitals and the General
Directorate of Health Affairs in Baha Province in Saudi Arabia. Further research can be
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done with small health centers or any health facilities, to study the impact of the
implementation of EHRs system on different health institutions. Future research can
investigate the quality of work, efficiency, properties, advantages, and any problems
related to/and affect to EHRs System software.
6.3 Recommendations:
Various recommendations can be considered to support the implementation of EHRs in
the Kingdom of Saudi Arabia.
1. Electronic Health Records are vital for hospital administration to improve patient
outcomes by eradicating medical errors. Therefore, the KSA government needs
to increase budgetary allocations for the public hospitals to support EHRs
implementation. In addition, the government should support and create an ample
environment to allow private hospitals to thrive in the implementation of the
system.
2. The government needs to promote training and avail support forums through
provision of appropriate literature on EHRs. The Ministry of Health can offer
suck kind of literature by using the government health portal, as in the case of
the US, where the public can access it easily. Additionally, the EHRs system
should allow multilevel confidentiality such that health providers from the
diverse health institutions gain access to patient information that is relevant to
their responsibilities while preventing access to confidential data that other
stakeholders are not supposed to view.
3. There should be a well-documented contingency plan that prevents frustrating
scenarios in cases where the systems fail. Therefore, the government should
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invest in thorough training for both IT professionals and physicians to allow
successful integration of the systems and healthcare. This situation will ensure
credibility, reliability, and accuracy of the EHRs systems. Consequently, regular
system check, servicing, upgrading, and testing are recommended. Finally yet
importantly, governments around the world should support the implementation
of electronic health records to improve care delivery and patient safety in health
institutions.
4. EHRs can only be successful if all the health providers understand how to use
them. In this view, it is crucial to involve the healthcare providers from their
creation to their implementation. This is likely to promote thorough
understanding of the EHRs and enhance their application in the healthcare
setting. Moreover, the system developers should incorporate the requirements of
the health providers during EHRs development, as this would guarantee that they
support and appreciate the systems.
5. EHRs departments should ensure that the healthcare professionals are well
trained in using the EHRs. This can be done through the integration of
motivational packages that include bonuses, incentives, and payment for time
spent in training. Additionally, they should establish interdepartmental
competitions that reward the departments that implement the systems effectively.
6. Similar to any other new systems in the workplace, there is the need to increase
the level of awareness on EHRs. This guarantees that the workers fully
understand the benefits of using the systems. Moreover, the awareness should be
done through the application of a multi-stage approach that involves training on
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the use of EHRs in the different levels of medical school. Integrating such
training in the medical school curriculum would ensure that all the healthcare
professionals are well educated on the systems when they join the workforce.
7. The incorporation of EHRs training in the medical school curriculum would
ensure that the healthcare providers are conversant about their use in different
departments. It is also likely to decrease the amount of resources and time that
institutions spend on training the workers on the use of EHRs
8. The ministry of health should create teaching programs that focus on health
information management. Such programs should be compulsory and introduced
in medical schools and healthcare organizations. Furthermore, EHRs systems
should be included in the curriculum. Such programs would ensure that the
healthcare professionals are well educated on the use of EHRs systems. The
incorporation of computer and information technology training in the programs
would also be beneficial to the healthcare providers.
9. The presence of health informatics technicians in the health sector is crucial to
the success of the EHRs. This is only possible through the incorporation of health
informatics and other related courses in the different university levels.
Consequently, there would be sufficient trained health informatics professionals
who would assist in the development and implementations of the EHRs. The
availability of the trained employees would also be crucial in troubleshooting
challenges associated with the systems.
10. The implementation and management of EHRs is expensive. Thus, it is vital for
healthcare organizations to have sufficient funding to safeguard the operation of
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the systems. The ministry of health should also participate in the provision of
funding to healthcare institutions and assist in paying the initial cost of
implementation.
11. The hospital management should take into account the cost of developing and
maintaining the EHRs when discussing and developing their annual budgets.
Planning for the maintenance of the programs would be easier and reduce the
financial burden on healthcare institutions.
12. Healthcare records should be confidential, and the users of the EHRs systems
should be well educated on the ethical issues relating to the patient’s information.
The repercussions of abusing the information should be well outlined when
training the healthcare professionals on the use of EHRs.
13. The healthcare institutions should be well prepared to reform their medical and
managerial processes to incorporate the needs of the EHRs as this guarantees the
survival and success of the systems.
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References
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Appendix A
THE QUESTIONNAIRE FOR THE STUDY
Q1
What is your gender?
Male
Female
Q2
What is your educational level?
High School or below
Two Years Diploma or Certificate
Bachelor Degree
Masters and higher Education
Q3
What is your job title?
Physicians
Nurses
Pharmacists
Lab Technicians
Administration Staff
Medical Records
Q4
From the following list, which hospital (or Health Facility) do you work in?
King Fahad Hospital
Baljurashi Hospital
Aqiq Hospital
Psychiatric Hospital
Mandaq Hospital
149
Karra Hospital
Rehabilitation Hospital
Mikwah Hospital
Qilwa Hospital
Hajra Hospital
General Directorate of Health Affairs
Q5
How much do you know about Electronic Health Records (EHRs) system?
Very Little
A little
A few things
A great deal
Q6
My computer skills are weak and I would ask someone to help me to do the
Computer-related work
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Q7
How many hours would you be willing to dedicate to learning this new system?
4
8
12
16 or more
Q8
As a health employee, I am planning to improve my computer skills through proper
training to be more positive in my work.
150
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
Q9
Does Electronic Health Records (EHRs) System implemented in your facility?
Yes
Maybe
No
Q10
Are there problems regarding the management of patients’ health records at this time?
Yes
Maybe
No
Q11
During implementation, to what degree patient volume be reduced during the initial
weeks using the new Electronic Health Records (EHRs) System?
up to 5 %
5% to 10 %
10% to 15 %
15% to 20%
Q12
In your facility, is the use of EHRs System?
Optional
Required
I don't know
Q13
151
If you exchange or share patient care and or billing information with others locations or
service providers, how do you transfer the information?
Through EHRs System
Manually
Others
Q14
When a patient visit the emergency room, do you usually notify the patent's primary care
physician?
Yes
I don't know
No
Q15
If you notify the primary care physician when patients visit the emergency room, do
the physicians have access to Electronic notifications and information?
Yes
I don't know
No
Q16
What are your expectations of the new EHRs system?
The EHRs system will improve productivity and office efficiency starting on day one
The EHRs system will improve productivity and office efficiency over time
The EHRs system is just a replacement for traditional paper-based patient folders
The EHRs system is unlikely to improve productivity and office efficiency
Q17
Please rate your computer skills.
Poor
Adequate
Excellent
152
Q18
From the following list, choose the most 4 barriers that affect the successful of
EHRs implementation
Lack of computer skills
Cost of EHRs System
Adoption to new technology
Privacy and security concerns regarding the use and access of EHRs System
EHRs System maintenance
Resistance to new technology
Q19
Implementing of EHRs system will increase the quality of work and efficiency in
hospitals, together with providing better patient care, and safety
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Q20
In my opinion, I think that EHRs system will protecting the privacy of our patients more
than
Paper-based medical records.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Q21
EHRs system give patients easier control on who has the authorization to access to the
information.
Strongly Disagree
Disagree
153
Neither Agree nor Disagree
Agree
Strongly Agree
Q22
I think the EHRs system to be more useful in the health facility, but I think that the costs
for a full
Implementation too high.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Q23
I prefer to adopting new technologies when it proven to increase the quality and efficiency
of workflow.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Q24
Do you think the unsecured (fearing) of the using technology to be
main barrier in implementing EHRs System among health care staff?
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Q25
154
I think the EHRs system is secured and trusted more than the paper-based
medical records
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Q26
I think EHRs System will be more useful to transferring the patients information and
contact with other hospitals
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Q27
Does your hospital or patient care facility currently have a computerized system which
allows for?
Fully
Implemente
d Across
ALL Units
Fully
Implemente
d in at least
one Unit
Beginnin
g to
Impleme
nt in at
least one
Unit
Have
Resource
s to
Impleme
nt in the
next year
Do Not have
Resources
but
Considering
Implementin
g
Not in Place
and Not
Considering
Implementin
g
Patient
Demographi
cs
Nurses Note
Physician
Note
Problem
Lists
155
Fully
Implemente
d Across
ALL Units
Fully
Implemente
d in at least
one Unit
Beginnin
g to
Impleme
nt in at
least one
Unit
Have
Resource
s to
Impleme
nt in the
next year
Do Not have
Resources
but
Considering
Implementin
g
Not in Place
and Not
Considering
Implementin
g
Medication
Lists
Discharge
Summaries
Advanced
Directives
Q28
Does your hospital or patient care facility currently have a computerized system which
allows for?
Fully
Implemente
d Across
ALL Units
Fully
Implemente
d in at least
one Unit
Beginning
to
Implemen
t in at
least one
Unit
Have
Resources
to
Implemen
t in the
next year
Do Not have
Resources
but
Considering
Implementin
g
Not in Place
and Not
Considering
Implementin
g
Laborator
y reports
Radiology
reports
Radiology
images
Diagnosti
c test
results
Diagnosti
c test
images
Q29
Does your hospital or patient care facility currently have a computerized system which
allows for?
156
Fully
Implemente
d
Mostly
Implemente
d
Partially
Implemente
d
Implementatio
n is in progress
Plan to
implemen
t when
resources
become
available
Do not
plan to
implemen
t
Clinical
guidelines
Clinical
reminders
Drug
allergy
alerts
Drug-
drug
interactio
n alerts
Drug-lab
interactio
n alerts
Drug
dosing
support
Q30
Please rate each of the following concerns over the implementation of an EHR system:
Strongly
Disagree Disagree
Neither
Agree nor
Disagree Agree
Strongly
Agree
The cost of
implementing an EHR
system is too high.
Our facility does not
have the resources
available to fund a new
program.
Maintaining and
updating EHR systems is
too expensive.
Our facility does not
have enough staff to
maintain the system.
157
Strongly
Disagree Disagree
Neither
Agree nor
Disagree Agree
Strongly
Agree
Training our employees
to use an EHR system is
too expensive.
Our facility does not
have enough employees
to ensure that the EHR is
secure
The security of patient
medical information is a
major concern.
Q31
What is the biggest hurdle your organization will face in meeting in implementing an
effective and meaningful use EHRs system? Please rate items in order of concern from 1
to 9, with "1" being the biggest concern, "2" the second biggest concern, and so on
1 2 3 4 5 6 7 8 9
Implementing/upgrading
to a certified EHR
system
Capturing /submitting
Quality Measures
Maintain and up‐to‐ date Problem List
Providing Medication
reconciliation
Meeting Privacy and
Security Standards
Producing Summary
Records (Paper or
CCD/CCR)
Provide patients with
access to data, and the
tools to make informed
health decisions
Exchange meaningful
clinical information
among professional
healthcare team
Others
158
Q32
Please rate each of the following perceived benefits that you believe will occur as a result
of implementing of EHRs system
Strongly
Disagree Disagree
Neither
Agree nor
Disagree Agree
Strongly
Agree
Improve workflow.
Reduce medical errors.
Reduce costs
Reduce treatment time/
length of stay
Increase revenue
Minimize malpractice
claims
