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| ORIGINAL ARTICLE |
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| Year : 2015 | Volume
: 4
| Issue : 1 | Page : 32-41 |
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Electronic health records: Use and barriers among physicians in eastern province of Saudi Arabia
Azza Ali El Mahalli
Department of Health Information Management and Technology, College of Applied Medical Sciences in University of Dammam, Dammam, Saudi Arabia
| Date of Web Publication | 13-Feb-2015 |
Correspondence Address:
Azza Ali El Mahalli
College of Applied Medical Sciences in University of Dammam, Dammam
Saudi Arabia
 Source of Support: This is a budgeted project by Deanship of Scientific Research in University of Dammam- SA (Grant# 2012145), Conflict of Interest: None  | Check |
DOI: 10.4103/2278-0521.151407
Background: Electronic health record (EHR) applications improved quality and diminished health services cost. Aims: Project aimed to determine utilization and barriers of EHR by physicians. Settings: Three governmental hospitals in Eastern Province in Saudi Arabia adopted EHR system with the same software and functionalities. Design: Study was cross-sectional. Materials and Methods: EHR functionalities tool of a previous study was used. Additionally, tool included physicians' data and barriers of utilizing functionalities. Response scale of using functionalities was 'used' or 'not used'. Questionnaires were distributed among physicians working in departments adopting EHR. Overall response rate was 57.5% (319/555). Results: There was under-utilization of almost all functionalities. The least one was 'data back-up and disaster recovery' (18.2%) and the highest was 'enter pharmacy orders' (96.2%). There was no use of communication tools with patients as e-mails, facsimile and short messages. Physicians had no access to charts while they are outside hospital. Patients had no access to records. There was under-utilization of Automatic International Classification of Diseases (ICD) (27.6%). Most common barriers were system hanging up (86.5%), loss of access to records transiently if computer crashes or power fails (85.6%), fastness in utilizing system (84.3%), and system takes additional time for data entry (83.4%). Lack of continuous training/support from IT staff in the hospital (79.3%), lack of customizability of the system according to users' needs (78.1%), complexity of technology (74%), disturbing patient-doctor communication (71.2%, P < 0.05), and lack in belief in EHR adoption (63.6%, P ≤ 0.05) were cited. Conclusions: Under-utilization of most of functionalities. Physicians should be encouraged to use it via overcoming the obstacles. Keywords: Barriers, electronic health records, physicians, Saudi Arabia, use
How to cite this article:
El Mahalli AA. Electronic health records: Use and barriers among physicians in eastern province of Saudi Arabia. Saudi J Health Sci 2015;4:32-41 |
| Introduction | |  |
Sophisticated electronic health record (EHR) improves healthcare. [1],[2],[3] Such system may include reduced time consumed on paperwork, [3] improved patient satisfaction, [4] and diminished cost, [5] improved efficiency, and diminished error. [6] Utilization of EHR functionalities by physicians and other clinicians is essential to prove benefits of such system. [6],[7],[8],[9],[10] In other countries, like the US, practices of physicians are slow. [4],[5] Recent rates of utilization by physicians increased from 18% in 2001 to 72% in the preliminary 2012 estimates. [11],[12] Reluctance of physicians to use EHR is a big hurdle. [7]
Literature review (1998 to 2013), concerning barriers to utilization of EHRs by physicians was conducted. Eight main categories including financial, technical, time, psychological, social, legal, organizational, and change process were reported. Physicians and nurses have preconceived concerns about security and confidentiality, [6],[13],[14],[15] time spent by EHR use, [7] or negative effects on the quality of patient care. [6],[13],[14],[15]
The process of EHR adoption should be treated as a change project, and led by implementers or change managers, in medical practices. The quality of change management plays an important role in the success of EHR adoption. [16]
Saudi Arabia (SA) has prioritized the development of eHealth and, along with it, the transition from paper-based health records to EHRs. The Saudi government adopted the following mission for eHealth: 'A safe quality healthcare system based on patient centric care guided by standards, enabled by eHealth'. [17] The Ministry of Health (MOH) allocated 4 billion Saudi riyal ($1.07 billion in US dollars) towards eHealth programmes for the 4-year period from 2008 to 2011. [18] An eHealth plan has been put together that integrates with the plans of the MOH.
Physicians and barriers affecting such utilization have published studies for adoption of EHR functionalities. [19],[20] Results showed under-utilization and physicians do not benefit from all the services provided by the system. [21]
To date, there have been no definitive national studies in SA that provide reliable estimates of the adoption of different functionalities of the new EHR software version by physicians. This research is a follow-up research for another one conducted in 2010. [22] Study tool of the previous study was used in this research. However, target population in this project was physicians instead of heads of IT departments. MOH intends to apply this new software for all governmental hospitals. Therefore, measuring its adoption rate and barriers is crucial to decision makers at the central level.
The project aimed to assess utilization and barriers of EHR system by physicians at three governmental hospitals adopting the same EHR software version in Eastern Province, SA.
| Materials and methods | | |
Three governmental hospitals adopted a new EHR system in Eastern Province, SA. These are general hospitals affiliate to MOH. Two hospitals have more than 300 beds. Third hospital has 150 beds and lies in a town at the border between SA and Kuwait.
The departments participated in the study were as follows: Surgery/anaesthesia (general, plastic and orthopaedics), medical (internal medicine, nephrology, cardiology, diabetes mellitus and endocrinology, chest diseases, paediatric and neurology and psychiatry), emergency departments (ED) (emergency room and intensive care unit), ancillary services (physiotherapy, laboratory and radiology) and others (dentistry, dermatology, ophthalmology and ear, nose and throat). These were the departments adopting EHR at time of data collection.
Study design was cross-sectional paper-based questionnaire study.
Data collection tool was self-administered paper-based questionnaire. Response scale for using functionalities was 'used' or 'not used'. The questionnaire was distributed among physicians in February 2012. It collected the following data:
I Demographics of physicians (age, gender, nationality, years in medical practice); work position and department; computer literacy (computer availability at the workplace, ever attending a computer course, self- rated computer skills) and duration of EHR practicing
II Different functionalities of the EHR system [22] including:
a. Chart review:
- Obtain and review lab results
- Obtain and review radiology results
- Obtain and review other test results
- Create and review scanned documents
- Review progress notes
- Monitor current and past medications and medication refills.
b. Decision support:
- Receive drug interaction alerts when writing prescriptions
- Receive drug allergy alerts when writing prescriptions
- Highlight test results that are out of normal range
- Clinical guidelines.
c. Order entry:
- Enter lab orders
- Enter radiology orders
- Enter pharmacy orders
d. Documentation:
- Create and maintain patient-related medical problem list
- Create and maintain common medication list
- Identify patient-specific allergies
- Document patient discharge instructions.
e. Communication with patients: Email, fax and mobile phone SMS system
f. Additional tool:
- Managing patient referrals
- Allowing physicians, when out of the hospital, to use the Internet to access patient health records
- Allowing patients to use the Internet to access parts of their health records
- ICD codes
- Generating health statistics
- Data backup and disaster recovery.
III Barriers of utilization of EHR system: Literature review was used for extracting different barriers [6],[7],[13],[16],[20],[23],[24],[25] as:
- Confidentiality, security and data privacy (e. g., place of computer)
- loss of access to medical records transiently if computer crashes or power fails
- Fastness in utilizing EHR system
- Additional time for data entry affect utilizing the EHR system
- Complexity of technology affect utilizing EHR system
- Disturbing patient-doctor communication
- Lack of belief in EHRs adoption
- Lack of customizability of the system according to users' needs
- Lack of continuous training/support from information technology staff in hospital
- Lack of drug alert system (e. g., drug interactions, drug allergy, etc.)
- Lack of pregnancy alert system
- System hanging up problem
- Others.
Barriers were determined as yes and no.
All physicians using the EHR system were included. Questionnaires were distributed as follows:
- Hospital A: Questionnaires were distributed among 225 participants. However, only 133 participated. The response rate was 59.1%
- Hospital B: Questionnaires were distributed among 250 participants. However, only 144 participated. The response rate was 57.6%
- Hospital C: Questionnaires were distributed among 80 participants. However, only 42 participated. The response rate was 52.5%.
Physicians working at the departments using the EHR system and willing to participate were included.
Formal approval was taken before conducting the research. Confidentiality of the data collected from physicians was considered.
Pilot study was conducted at hospital A. Paper-based questionnaire was distributed among 20 physicians and 12 ones were recollected (response rate = 60.0%). Two barriers hindering EHR adoption were added titled: System hanging up problem and problem with pregnancy alert system as mentioned by physicians.
Statistical package of social sciences (SPSS) version 20 was used for data entry and analysis. Descriptive statistics was used. Differences between groups were measured using Chi square and Monte Carlo tests. The statistical significance was determined when the P value was ≤ 0.05.
| Results | | |
Results [see [Table 1]] revealed that mean age of physicians was (35.4 ± 9.7). They were mostly men (63.3%) and Saudis (52.4%). Difference between hospitals regarding age and nationality was statistically significant (P < 0.05). Mean of medical practice years was X ± SD = 10.5 ± 8.9 and EHR practice years was X ± SD = 2.5 ± 2.0. Regarding computer literacy, most of respondents had a computer at work place (97.2%). The highest percent of respondents had 'average' self-rating of computer skills (72.1%). | Table 1: Profile of physicians at governmental hospitals adopting electronic health record in Eastern Province, SA
Click here to view |
There was under-utilization of almost all functionalities [Table 2] and [Figure 1]. 'Obtain and review lab results' represented the highest frequency functionality used in chart review (94.4%, P < 0.05). However, 'Review progress notes' represented the lowest frequency of utilization (45.1%, P < 0.05). Concerning 'decision support', 'Highlight test results that are out of normal range' showed the highest frequency of utilization (87.5%, P < 0.05). However, 'clinical guidelines' reported the lowest one (50.5%, P < 0.05). For order entry, 'Enter pharmacy orders' represented the highest frequency of utilization (96.2%, P < 0.05). On the other hand, 'Enter lab orders' was the lowest (86.5%, P < 0.05). With respect to documentation, 'Create and maintain common medication list' was the highest functionality utilized (81.2%, P > 0.05). However, 'Create and maintain patient-related medical problem list' was the least functionality utilized (69.6, P < 0.05). There was no utilization of any communication tools with patients [e-mails, facsimile (fax), and short messages service (SMS)]. For additional tools, 'Managing patient referrals' as the highest functionality used (28.8, P < 0.05) [Figure 1]. However, there was no utilization of 'Allowing physicians, when out of the hospital, to use the internet to access patient health records' nor 'Allowing patients to use the internet to access parts of their health records' functionalities. | Figure 1: Extent of utilization of electronic health record (EHR) functionalities at governmental hospitals in Eastern Province, SA (2012)
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 | Table 2: Extent of utilization of electronic health record functionalities at governmental hospitals in Eastern Province, SA
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Difference between work positions of physicians (intern/resident, specialist and consultant) [Table 3] was significant for utilization of obtain and review lab results. Consultant represented the highest utilization (98.5%), followed by intern/resident (96.3%). For enter lab orders, intern/resident represented the highest utilization (91.9%), then consultant (89.6%). Additionally for enter pharmacy orders; consultant represented the highest utilization (100%), followed by intern/resident (98.1%). Differences between departments were statistically significant for adopting most of functionalities. Physicians practicing EHR > 0 years were the highest users of 'Receive drug interaction alerts when prescribing' functionality (100%, P < 0.05). Physicians practiced medicine >20 years were highest users of 'Receive drug allergy alerts' when prescribing (95.3%, P < 0.05). | Table 3: Utilization of electronic health record functionalities by demographics and computer literacy of physicians at governmental hospitals in Eastern Province, SA
Click here to view |
The most frequently cited barriers among all hospitals [Table 4] were 'system hanging up problem' (86.5%), followed by 'loss of access to medical records transiently if computer crashes or power fails' (85.6%), then 'fastness in utilizing EHR system, i. e., minimal wait between screens, minimal boot-up time, etc.' (84.3%). 'Lack of belief in EHRs adoption' was the least reported barrier (63.6%, P < 0.05). On the other hand, 'disturbing patient-doctor communication' representing (71.2%, P < 0.05) [Figure 2]. | Figure 2: Barriers preventing utilization of the electronic health record system at governmental hospitals in Eastern Province, SA (2012)
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 | Table 4: Barriers of physicians with the electronic health record system at governmental hospitals in Eastern Province, SA
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| Discussion | | |
EHR practices have many benefits such as improvements in storage and retrieval of patient information as well as improving quality of services offered to patient and reducing errors. However, only few of EHR system functionalities are used due to some potential barriers preventing their fully utilization. Therefore, the delivery of healthcare services could be enhanced if advanced functionalities of the software are consistently and effectively adopted. [23]
Results of the present study demonstrated low adoption of most chart review functionalities. This goes hand in hand with a frequently cited barrier in this study; system hanging up problem (86.5%) and/or additional time for data entry affects utilizing the EHR system in all hospitals (83.4%).
E-prescribing is substantial to improve the quality of patient care, diminish medication errors and build awareness to improving patient safety. [26] The present study showed relatively low utilization of monitor current and past medications and medication refills (87.5%). The difference between hospitals was statistically significant (P < 0.05).
Among the most serious healthcare problems are medication errors and adverse drug reactions. EHR adoption can reduce this error as the system checks the medication against all the other medications in the patient's chart and also against patient's allergies. [27] The present study revealed low adoption rate of receive drug interaction alerts when writing prescriptions (81.8%) and receive drug allergy alerts when writing prescriptions (82.8%). This goes parallel with a frequently cited barrier; problem with drug alert system (58.9%). With respect to order entry functionality, results showed that utilization rate of lab order entry was 86.5% (P < 0.05). For radiology order entry, utilization was 93.4%. Utilization of pharmacy order entry was 96.2% (P < 0.05). This was higher than findings of a study conducted in India where adoption rate of pharmacy order entry was 78%, and radiology order entry was 75%. [28]
EHR system has many communication tools that enable exchange of information between physicians and between them and patients. [23],[29] E-mail tool is the commonest communication tool used for exchange of information [29] by physicians (88.6%). [6] Fax tool is used for transforming the important forms in and/or outside the hospital, and SMS tool is used to remind patients of their appointments. [29] The present study revealed that there was no use of any of these communication tools at all at any hospital. Lack of use of e-mail could be attributed to lack of access to the internet in these hospitals. This was parallel to a frequently cited barrier in the present study, disturbing patient-doctor communication (71.2%, P < 0.05).
Utilization of ICD coding was low (27.6%). Here, hospitals affiliate to MOH and patients do not pay for services.
Physicians frequently cited loss of access to medical records transiently if computer crashes or power fails as a barrier (85.6%). Current EHR users in Florida experienced the same barrier (20.4%). [23]
Adoption of EHR necessitates proper training for the users to facilitate this shift. Ineffective training of users was one of the most frequent barriers of EHR adoption. [30] Training could be in the form of orientation for new users and emphasizing the basic computer skills and continuous training for current users even the system is up and running. However, lack of IT technical support is impacting negatively on EHR adoption. [24] Lack of continuous training and support from IT staff was frequently cited barrier in the present study (79.3%). A study of minority practices reported that lack of computer technical support was a barrier for (63.1%), and lack of system training was a barrier for (78.3%) of users. [25] Another study showed that 65% of the users reported that poor training is a barrier in utilizing EHR system. [31]
Complexity of EHR system leads to diminished user satisfaction. Complexity and usability problems associated with EHRs results in physicians having to devote time and effort to master them. [16] One study illustrated that (7.4%) of current EHR system users experienced complexity of the system. [23] In Massachusetts, majority of physicians pointed to technical factors including lack of computer skills, lack of technical support and technical limitations as important barriers. [32] The present study pointed that complexity of technology affects utilizing EHR system was a frequently cited barrier (74.0%).
Advantage of EMR software customization is one of the most important benefits of EHR as it helps reduce the errors and users disappointment and improve the EHR quality. [33] Research proved that 15.3% of current EHR users experienced the same barrier as they cannot find a system that meets their special needs/requirements. [23] The present study demonstrated that lack of customizability of the system according to users' needs was a frequently cited barrier (78.1%).
The present study noted that confidentiality, security and privacy were a barrier (68.3%). This goes hand in hand with findings in Massachusetts, where 55% of physicians noted concerns about privacy or security as a barrier to EHR adoption. [32]
| Conclusions and recommendations | | |
There was under-utilization of almost all EHR functionalities. There was no use of any communication tool with patients such as e-mails, fax and SMS. Physicians have no access to the medical records while they are outside the hospital. Patients have no access to their medical records. There was low utilization of ICD-coding. Most common barriers were system hanging up, loss of access to records transiently if computer crashes or power fails, fastness in utilizing system and system takes additional time for data entry. Additionally, physicians cited lack of continuous training/support from IT staff in the hospital, lack of customizability of the system according to users' needs, complexity of technology, disturbing patient-doctor communication and lack in belief in EHR adoption as barriers.
Based on findings, the following is recommended:
- Periodic assessment should be conducted to assess extent of utilization of different functionalities of the system and do improvements accordingly
- Orientation training should be done for the new physicians and continuous training for the current users. In addition, coordination should be done between the hospital and the EHR system vendor to conduct initial and follow up training
- 24-hour availability of technical support in the hospitals
- The option should be given to physicians to customize the output according to users' need
- Improvement of different communication tools with patients such as SMS and fax by the IT staff
- A high attention should be drawn to the use of the emails between physicians themselves and with their patients. This could be done via providing internet access to the hospital.
Limitation of study
Low response rate of physicians. Lack of validity and reliability of the data collection tool.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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