MSc Dissertation Title: An Investigation of the Challenges and Success in the Implementation of Electronic Health Record System in the Gulf Region: A Case Study of Saudi Arabia
ABSTRACT
Hospitals and other health institutions are increasingly adopting new ways to improve service delivery and efficiency in medical processes. EHR system has certainly emerged as a significant tool in how healthcare facilities manage and deliver healthcare services. EHR system helps in storing, sharing, and accessing information about individual patients. As such it enhances helps healthcare professionals to provide care for patient in a timely and convenient manner as well as in more efficient and effective way. Based in this understanding, it is anticipated that the GCC countries which are currently grapping with numerous health challenges can improve delivery of healthcare services by adopting EHR system. However, like in most developing countries across the world, the adoption of EHR system in the GCC countries has been relatively lower and slow despite the spiralling health problems and challenges to healthcare systems in these countries. This study sought to understand the challenges and successes in the adoption of EHR system in Saudi Arabia through the perceptions of healthcare providers in the country. Quantitative research methods were employed in which research data were collected through online questionnaire. The research findings show that the healthcare professionals in Saudi Arabia have positive perceptions and attitudes towards EHR system; something that is attributed to positive attempts to improve adoption of EHR system in the country. Nevertheless, there are a number of challenges that needs to be overcome in order to accelerate uptake of EHR system by the healthcare facilities in the country. The study concludes by offering recommendations on how to overcome the challenges affecting EHR adoption in Saudi Arabia as well as by providing direction for future research based on the limitations of this study.
ACKNOWLEDGEMENT
Table of Contents
ABSTRACT 2
1.1 Overview 9
1.2 Background Information 9
1.2.1 Benefits and Challenges 9
1.2.2 EHR in Saudi Arabia 11
1.3 Statement of the Problem 15
1.4 Research Aims and Objectives 18
1.5 Research Questions 19
1.6 Significance of the Study 19
1.7 Structure of the Dissertation 22
Chapter 2: LITERATURE REVIEW 24
2.1 Overview 24
2.3 Theoretical Framework 24
2.3.1 Technology-Organization-Environment Framework 24
2.3.2 Technology Acceptance Model 29
2.3.3 DeLone & McLean Information System Success Model 32
2.4 Challenges of Implementing EHR Systems 35
2.5 Successes of Implementing EHR Systems 39
2.6 Conceptual Framework 43
Chapter 3: METHODOLOGY 46
3.1 Overview 46
3.2 Research Philosophy 47
3.3 Research Approach 48
3.4 Research Method, Design and Strategy 49
3.5 Data Collection Methods 50
3.5.1 Primary Research 50
3.5.2 Primary Data Collection Procedure 52
3.6 Target Population and Sampling 53
3.7 Data Analysis Methods 54
3.8 Validity and Reliability 55
3.9 Ethical Consideration 56
3.10 Summary 56
Chapter 4: FINDINGS AND ANALYSIS 59
4.1 Overview 59
4.2 Preliminary Findings 59
4.3 Demographic Characteristics 60
4.4 Work/Organizational Environment 64
4.5 Success and Barrier Factors in EHR System Adoption in Saudi Arabia 66
4.6 Perceptions of Healthcare Providers in Saudi Arabia Regarding EHR System 79
4.6.1 Perceptions of healthcare professions in Saudi Arabia Regarding the Quality of EHR System 79
4.6.2 Perceptions of Healthcare Providers Regarding Information Quality of EHR System 83
4.6.3 Healthcare Professionals’ Satisfaction with the EHR System 85
4.6.4 Benefits of the EHR System as Perceived by Healthcare Professionals in Saudi Arabia 87
4.6.5 Perceptions of Healthcare Professionals about Service Quality of the EHR System Service Providers 88
CHAPTER 5: DISCUSSION & CONCLUSIONS 92
5.1 Challenges Affecting Implementation of EHR System in Saudi Arabia 92
5.2 Successes in the Implementation of EHR System in Saudi Arabia 95
5.3 Perceptions of Healthcare Professionals in Saudi Arabia regarding EHR System 98
5.3.1 Perceived Ease of Use 98
5.3.2 Perceived usefulness and benefits of EHR System 101
CHAPTER 6: SUMMARY, RECOMMENDATIOINS AND FUTURE RESEARCH 107
6.1 Summary 107
6.2 Recommendations 111
6.3 Limitations and Future research 113
BIBLIOGRAPHY 116
LIST OF FIGURES
Figure 1: Technology-Organization-Environment Framework 25
Figure 2: Technology Acceptance Model 30
Figure 3: Updated D&M IS Success Model 33
Figure 4: Conceptual Framework 44
Figure 5: Saunders’ et al. (2012) Research Onion 46
Figure 6: Summary of Methodology 57
Figure 7: Gender of the Respondents 60
Figure 8: Title/Designation of the Respondents 61
Figure 9: Primary Clinical Specialty of the Respondents 62
Figure 10: Respondents’ Years in Practice 63
Figure 11: Hours Worked per Week 64
Figure 12: Number of Patients Seen per Hour 66
Figure 13: Awareness of EHR system in Saudi Arabia 67
Figure 14: Healthcare Professionals Using EHR System 68
Figure 15: Barriers to Adoption of EHR System in Saudi Arabia 68
Figure 16: Year EHR System Was Implemented 70
Figure 17: External Support for EHR System Adoption 72
Figure 18: Experience of Healthcare Professionals from Saudi Arabia in Using EHR System 73
Figure 19: Level of Comfort with Computer Technology among Healthcare Professionals in Saudi Arabia 74
Figure 20: Duration of Training in the Use of EHR System for Healthcare Providers in Saudi Arabia 75
Figure 21: Source of Training for Healthcare Providers in the Use of EHR System 76
Figure 22: Time at which Healthcare Providers in Saudi Arabia Document Patients’ Notes 77
Figure 23: How Often Patient Visit Summary Report is Print out from EHR for Patients 78
Figure 24: Perceptions of the Healthcare Providers about EHR System Quality 81
Figure 25: Information quality of EHR system 85
Figure 26: Users’ satisfaction with the EHR system 86
Figure 27: Benefits of the EHR system 88
Figure 28: Timeliness of technical support 89
Figure 29: Reliability of technical support 89
Figure 30: Involvement of Providers in the Implementation of EHR System 90
Figure 31: Would you recommend your current EHR system to others 91
LIST OF TABLES
Table 1: Implementation of EHR in the GCC Countries 40
Table 2: Valid Data 60
Table 3: Descriptive Statistics of Respondents’ Gender 60
Table 4: Title/Designation of the Respondents 61
Table 5: Primary Clinical Specialty of Respondents 62
Table 6: Respondents’ Years in Practice 63
Table 7: Hours Worked per Week 65
Table 8: Number of Patients Seen per Hour 66
Table 9: Awareness of EHR System in Saudi Arabia 67
Table 10: Healthcare Professionals Using EHR System 68
Table 11: Barriers to Adoption of EHR System in Saudi Arabia 69
Table 12: Year EHR System Was Implemented 71
Table 13: External Support for EHR System Adoption 72
Table 14: Experience of Healthcare Professionals from Saudi Arabia in Using EHR System 73
Table 15: Level of Comfort with Computer Technology among Healthcare Professionals in Saudi Arabia 74
Table 16: Duration of Training in the Use of EHR System for Healthcare Providers in Saudi Arabia 75
Table 17: Source for Healthcare Providers in the Use of EHR System 76
Table 18: Time at which Healthcare Providers in Saudi Arabia Document Patients’ Notes 77
Table 19: How Often Patient Visit Summary Report is Print out from EHR for Patients 79
Chapter 1: INTRODUCTION
1.1 Overview
This chapter provides a discussion on the background information on the research topic, the statement of the research problem, the aims and objectives of the research, and the significance and justification of this particular research. It further provides an outline of the dissertation from the introductory chapter to the conclusion.
1.2 Background Information
1.2.1 Benefits and Challenges
Hospitals and other health institutions are increasingly seeking ways of improving service delivery and efficiency in medical processes. Electronic Health Record (EHR) system enables the sharing of individual or group patient(s) information. They assist in the automation of a wide range of health operations (Read 2014). Patients’ data that pertains to medical history, laboratory results, medication taken, allergies, vital signs, weight or even height can be transferred over different medical systems by just a click of a button.
According to OECD (2010), it is sometimes referred to as Electronic Medical Records (EMR) system or Electronic Patient Records (EPR) system; all terms are used by physicians interchangeably. However EMR and EPR relate to specific environments within the healthcare sector including ambulance operations. They both draw from EHR which can be used across hospitals and institutions within the industry. In the health care industry, this software plays a major role of integrating and organizing patients’ information. Globally, governments are increasingly advocating for their adoption in the healthcare sector as opposed to the traditional paper records system (Harman, Flite & Bond 2012). Basically, the EHR system is a tool that assists in capturing, recording and integrating patient information.
EHR systems are highly sophisticated and accessible on portable gadgets like mobile phones; this implies that one does not necessarily have to update patient medical and other health information from designated workstations. Dwight, Paul & Perlin (2006) concur that the benefits associated with the implementation of EHRs include quality improvements in patients’ service delivery. This is due to the fact that anyone within the medical divide would be able to access vital patient information especially during emergency situations or in cases where a patient is required to consult multiple specialists for diagnosis. Another benefit is that it significantly increases efficiency resulting from reduced costs associated with medical misdiagnosis and redundancies in tests. For instance, a central depository EHR for the UK’s National Health Service is expected to lead to close to $100 billion industry-wide saving over a ten year period (Goldman 2009).
It is estimated that EHR systems reduce costs of unwarranted admissions and tests hence increasing overall operational efficiency by at least 6% (OECD 2010). Consequently, hospitals avoid constant insurance and other litigation claims that tend to drain on their resources. Insurance companies are also able to access stored data for purposes of settling medical claims. Read (2014) argues that healthcare providers spend minimal time in paperwork and are able to create even more time to care for more patients. Its use is further supported by the claim that it significantly reduces chances of unauthorized access to patients’ vital records when compared to the paper system. In addition, EHR systems do not contain legibility difficulties normally presented by the paper system (Al-Swad et al. 2013). In the past, such issues would lead to misdiagnosis and other serious medical miscalculations. In Australia, the use of EMR systems was approved for ambulance services. This has since seen general improvement of ambulance services coupled with enhanced training for medical teams as well as creation of future treatment plans.
According to Harman et al. (2012) other benefits that accrue to hospitals that decide to adopt and incorporate the use of EHR systems in routine healthcare operations include less official time spent combing through files to locate patient records. Hospitals are able to issue warnings to relevant patients’ in case of a drug recall or wrongful prescriptions. In addition to this, it becomes easier for hospital staff to upload and update patients’ laboratory tests and results whilst getting rid of the traditional filling system. In cases where patients require transfers or referrals to other institutions, it becomes easier to access copies of records and further make them available at request of subsequent physicians (Dwight et al. 2006).
However, a number of privacy concerns have been raised since the adoption of EHR systems took effect. In the US for example, there were reports of 380 privacy breaches on vital patient records stored by the US Department of Health and Human Services in 2011 alone (Harman et al. 2012). Furthermore, implementation of EHR in many parts of the world has presented many challenges especially when it comes to technology and software usability. Most of the failures can be attributed to inefficiencies caused by usability problems (Harman et al. 2012). There exist other consequences that are not deliberate like omission and data entry errors that complicate adoption measures put in place by governments and physicians. Besides technological, deliberate and unintended difficulties encountered in the implementation of EHRs, there are additional threats to patient data in the health sector that are likely to hinder adoption of the systems. Such threats extend to natural or environmental catastrophes like floods or fires; these are however not unique to EHRs.
1.2.2 EHR in Saudi Arabia
The proactive efforts of the governments and the health care industry in the Gulf Cooperation Council (GCC) countries have lead to an upswing in the Health Information Technology market. These efforts are aimed at establishing novel hospitals and rolling out initiatives such as WAREED and the national e-health policy (Healthcare Technology Magazine News 2012). WAREED is the largest health information system project set forth by the Ministry of Health in the United Arabs Emirates (UAE). The scope of the WAREED project is “to integrate electronic medical records in all 14 public hospitals and 68 affiliated clinics across Dubai and the Northern Emirates” (U.S.-UAE Business Council, 2014, p. 8).
The alteration in the healthcare data and patient volume is as a consequence of the changing disease profile with reference to the GCC population (Healthcare Technology Magazine News 2012). As a result, the region has increased its total expenditure on healthcare information technology. For instance, in 2011, the GCC spent approximately USD 444.2 million on healthcare IT. According to Healthcare Technology Magazine News (2012) this figure is predicted to have reached USD 550.9 million by the year 2015. UAE and Saudi Arabia popularly use the client-server technology. On the other hand, the other GCC countries take high preference to broadband. The GCC governments are geared toward managing and streamlining healthcare operations through the incorporation of IT. However, they are affected by the market challenges since the countries do not have standards pertaining to data management and storage (Healthcare Technology Magazine News 2012). Moreover, storing data in different formats makes it challenging to integrate data from all hospitals. Furthermore, Alkraiji, El-Hassan & Amin (2014) expect that it will take time and effort for the GCC countries and their workforce to be acquainted with the EHR technology.
There are a number of issues that have compromised the incorporation of IT in healthcare management in Saudi Arabia; thus, the change mechanism has not been adequately practiced. Additionally, there is fear regarding the use of technology and computer literacy among the professionals (Mogli 2011). Most of the health care personnel are old and used to traditional medical practices like filing, they would therefore rather evade usage of any available technology. Mogli (2011) suggests that most of the physicians feel like computerization takes up most of their time; hence most senior staff are not willing to undergo training to nurture their computer skills. In fact, some of them do not like using computers at all.
Regardless of the fact that there are adequate structures and equipment in place, a study carried out by Mogli (2011), established that high capacity servers are not employed in IT usage. There is an inadequate testing and IT maintenance as well as insufficient support for implementation of the system. The study also found out that the backup data and disaster recovery was faulty. Moreover, there are defects in the unique identification number (UIN) for patients. Furthermore, medical errors, reminders, and alerts were not sufficient (Mogli 2011). Alkraiji et al. (2014) add that by explicating that the integration of EHR has been compromised by lack of coordination, the authority of regulation and cooperation.
As it is now, most of the healthcare professionals opt to stick to and use the traditional methods. Healthcare Technology Magazine News (2012) argues that for the GCC countries to improve the adoption of IT in the healthcare sector, they have to increase the number of available technicians. They should do so by escalating the number of technical institutes in the country. Furthermore, they should motivate and train the healthcare professionals so as to pave a way for more usage of IT in healthcare delivery (Mogli 2011). Additionally, government support, the changing disease patterns, escalation in awareness with regard to wellness and health and the increasing volumes of healthcare data are expected to facilitate the growth of IT in the healthcare sector among the GCC countries (Mogli 2011). Healthcare Information Technology in the GCC countries is a component of the Life Sciences Growth Partnership Service Program. This program encompasses Healthcare IT CIO Insights in Southeast Asia, Australia, China and India (Alkraiji et al. 2014).
In Saudi Arabia, the use of EHR systems was introduced in the year 1988 (Hasanain, Vallmuur, & Clark 2014). According to Hasanain et al. (2014), the aim of introducing this system was to enhance the Saudi healthcare system and its service delivery. Additionally, the system was purposed to help in the accomplishment of demands bequeathed on the health organizations (Aldosari 2014). The Saudi Ministry of Health introduced EHRs as one of the priority plans. The Ministry of Health expected the EHRs would enhance the flow of patient information, decrease the patient waiting times and minimize duplication of records and errors (Hasanain et al. 2014). There are successful cases of implementation of EHR system in Saudi Arabia. Accordingly, some of the hospitals have recorded excellent results and have earned awards as a result of their implementation achievements (Aldosari 2014).
As noted by Aldosari (2014) the Saudi Ministry of Health has spent a lot of revenue on the development and improvement of the healthcare system and service delivery. In the context, it has spent millions of dollars on the development and implementation of HIS technologies. Irrespective of the government’s effort and huge investment, success has not been fully achieved (Almuayqil, Atkins & Sharp 2015). This is based on the fact that the implementation of EHRs is executed independently by the Ministry of Health and other government bodies. This independence has made it difficult to intricately integrate patient records (Hasanain et al. 2014). Thus, patients have multiple records in divergent hospitals that are under the management of different government bodies. As a result, there is no standard EHR system employed in the country (Alnuem, El-Masri, Youssef, & Emam 2013). This has complicated the nation-wide implementation of EHR leading to multiple systems. For instance, the bodies such as the Ministry of Defence and Aviation and the National Guard Health Affair, and the private sector have their individual systems (Hasanain et al. 2014).
Moreover, the Saudi Government has invested in programs that should facilitate the EHR implementation like the Master’s program. In 2005, the Saudi Association for Health Informatics (SAHI) was developed with the aim of holding a conference every two years (Alsahafi 2012). The conferences were to focus on health informatics and e-health issues in the country. SAHI has been holding meeting and currently stands as the only association in the country that focuses on e-health (Hasanain et al. 2014). Accordingly, even though the vision regarding the implementation of EHRs in Saudi Arabia is clear, the implementation is still low. This is attributed to challenges that have to be mitigated first.
The implementation of EHR system in Saudi Arabia has been hampered by a number of barriers. Khalifa (2013) categorizes the barriers into six groups. They include human barriers that are concerned with the attitudes, behaviours and beliefs of the healthcare workers and management and professional barriers which are mostly attributable to the management of hospitals. Others include technical barriers that are associated with IT and computers usage by healthcare professionals, and financial barriers concerned with the costs of implementing EHR. In addition, there are also the issues of regulatory and legal barriers which focus on legislation, regulation and laws in Saudi Arabia (Khalifa 2013).
1.3 Statement of the Problem
The health sector in Saudi Arabia has realized tremendous progress in recent years, a factor that has led some of the healthcare facilities in the country to be recognized on the international platform (Altuwaijri 2008). Nevertheless, as pointed out by Altuwaijri (2008) the success in the healthcare sector has not been come with the advancement of the electronic health (e-health) field. This is irrespective of the fact that the hospital requires e-health applications to accomplish some of its goals such as improving the quality of care and minimizing the cost and time of care (Al-Swad et al. 2013).
One of the areas of importance as far as incorporating technology in the health sector is concerned is management of patient data. For a long time, hospital information system (HIS) has been utilized in the management of patient information across the globe (Altuwaijri 2008). Many healthcare facilities in Saudi Arabia are adopting HIS into their practice (Altuwaijri 2008). However, the incorporation and implementation of HIS still faces numerous challenges. With reference to Khalifa (2014) both human and technical challenges complicate the implementation of HIS which in turn compromise the outcome of training health professionals with regard to HIS.
According to Almuayqil, Atkins and Sharp (2015) human barriers are considered the primary impediment to the adoption of EHR in healthcare facilities in Saudi Arabia. Human barriers encompass lack of trust among medical staff with respect to the computer-based medical solutions and medical staffs’ negative beliefs associated with technologies. This is supported by a study executed by Khudair (2008) which sheds more light on the perception of the medical practitioners of EHR. The study established that regardless of the fact that EHRs have been adopted in large and advanced hospital, it is ironical that paper-based medical records still find their usage (Khudair 2008). Almuayqil et al. (2015) attribute this resistance to move from the tradition to the modern technologies to lack of trust in the technologies, negative beliefs among the staff and lack of computer skills and technical expertise.
Khalifa (2014) suggests that this can be accredited to lack of experience, support and knowledge among the health practitioners with reference to the usage of EHR. This is further aggravated by the lack of motivation to train and learn about the utilization of EHR. Furthermore, the awareness in accordance with the benefits and importance of employing the usage of EHR is still low (Khalifa 2014). Regardless of the adoption of EHR, most of the physicians have not integrated their use into their practice even though they bear great comprehension on the importance of EHR and its effect on the healthcare systems (Khudair 2008).
The medical staff in healthcare facilities in Saudi Arabia point out the need for very well structured EHR for every hospital (Khudair 2008). Altuwaijri (2008) agrees with the sentiments made by the staff by arguing that the technical infrastructure is not ready for the implementation process. In general, medical personnel are of the view that the EHR structures need to consider the unique needs of each hospital (Khudair 2008). Furthermore, the structures have to anticipate appropriate and accurate information sharing. Accordingly, an efficient and good networks connection such as an intranet is a necessity (Khudair 2008; Al-Swad et al. 2013).
Some of the health professionals in Saudi hospitals hold that implementation is compromised by the leadership and management in the health sector. As established by Khudair (2008) they attribute poor implementation to exaggeration of financial burden and the underestimation of the EHR benefits by the management. Altuwaijri (2008) adds by postulating that organizational barriers such as poor alignment of e-health with the existing processes and practices and poor change management bar the implementation of EHR.
A study carried out by Khudair (2008) revealed that majority of medical staff fears that their work might be complicated and interrupted by frequent system shutdowns and subsequent failures. The complexity and operation of the system also emerged as a major concern among medics. Based on the results generated by Khudair’s (2008) study, the staff highlighted the probability of the problems pertaining to typos while carrying out the process of data entry due to the fact that the personnel did not have guidelines or manuals with reference that could interpret and subsequently assist in the utilization of EHR (Khalifa 2014). Fears regarding system shutdown can be explicated by the fact that communication networks and the computer terminals are slow, the EHR modules have not been fully incorporated and the interface design of the system is not user friendly (Khalifa 2014). For instance, physicians in Saudi Arabia reportedly had problems with interface design of EHR system (Khudair 2008).
With respect to health staff, the implementation process is impeded by the numerous health policies in place especially with regards to patient privacy. In their opinion, the health authority was charged with the responsibility of facilitating the implementation of EHR if at all its adoption in health facilities was to succeed. Therefore, the health authority has to invest in EHR in order to alleviate the challenges associated with EHR. Moreover, medical practitioners accentuate the need for defined and clear policies that protect the confidentiality of the patients. They believe that a policy that regulates information-sharing has to be ratified so as to boost their confidence in adopting the system as well as patients’ trust that only authorized personnel are allowed to access their medical history and other vital information. Accordingly, they believe that the establishment of a policy will enhance information sharing and cooperation among hospitals in the country (Khudair 2008).
Some of the staff members believe that the policies in place cannot sufficiently deal with critical issues (Khudair 2008). Consequently, some of them have evaded the use of EHR systems. Lack of inter-hospital planning, collaboration and coordination was also cited as one of the impediments to the implementation and adoption of EHRs (Hasanain et al. 2014). The health personnel perceive many challenges that compromise their adaptability and integration of EHR. Even though most of them comprehend the importance and benefits of EHR, they resist adopting it into their practice because of these perceived problems. Therefore, unless these challenges are mitigated, the success of integrating EHR into healthcare sector in Saudi Arabia will be compromised.
1.4 Research Aims and Objectives
The main objective of this study was to establish the perception of healthcare providers with regards to the implementation of electronic health record (EHR) system in hospitals in Saudi Arabia particularly Saudi Arabia. This was attained by pursuing the following sub-objectives:
• To find out the different perceptions that exists among healthcare professions on the adoption and implementation of EHR systems in the healthcare facilities in Saudi Arabia.
• To investigate main challenges experienced by hospitals and healthcare providers in EHR systems implementation in Saudi Arabia.
• To determine the successes of EHR adoption and implementation in Saudi Arabia
• To provide recommendations on how to accelerate adoption and implementation of EHR system in Saudi Arabia.
1.5 Research Questions
The following research questions assisted in testing whether there are differences of perception among healthcare professionals with regards to the adoption of EHR systems in Saudi Arabia:
• How do healthcare professionals in Saudi Arabia perceive the adoption and implementation of EHR systems?
• What are the present challenges experienced by hospitals and healthcare providers in Saudi Arabia in their attempts to implement EHR systems?
• What is the success rate of EHR systems implementation across Saudi Arabia?
• How can EHR adoption be accelerated in the healthcare facilities in Saudi Arabia?
1.6 Significance of the Study
As established earlier, adoption of EHR systems in health care improves the quality of care and reduces costs (Khalifa 2014). It promotes evidence-based practice, paves a way for easy accessibility to patient and support information and enables secure, reliable and timely management of patient information (Alsahafi 2012). Through EHR systems, healthcare managers can efficiently manage the workflow and reduce costs (Almuayqil et al. 2015). Additionally, EHR supports inter-hospital sharing of patient information.
For patients, EHR enables them to access easily their personal health records (Alsahafi 2012). Moreover, retrieval of the record is more efficient and time-saving (Alsahafi 2012). Saudi Arabia’s healthcare facilities are missing out on these benefits. This is with the elucidation that in Saudi Arabia, success has been compromised by human, technical and cultural barriers, organizational impediments, and overall financial constraints. Therefore, this study is important because it explored these impediments in depth and produced subsequent results that will go a long way in aiding the establishment of real factors that tend to thwart EHR implementation.
With reference to Alsahafi (2012) the implementation of EHR is Saudi hospitals is low despite the heavy investments that the government has injected into EHR infrastructure. Therefore, the study explored both human barriers and hospital related impediments in order to generate information that will be used to inform hospital-based strategies, system-based strategies and strategies targeting the health practitioners. Accordingly, the results of the study present a broad and in-depth overview of the challenges, factors, and issues affecting the implementation of EHR. They generate a range of solutions targeting all components of the system ensuring adequate coverage of all factors that can potential compromise the system.
It is important to integrate patient health records in a way that they can be distributed and dispersed to different healthcare organizations. Furthermore, it is indispensable for healthcare organizations to share information that can help in the care and treatment of a patient (Alnuem et al. 2013). Countries in Saudi Arabia are moving in the direction of unlimited sharing of patient information through the establishment of EHR system even though the country has not established the system nationwide.
Therefore, this study has proved useful in determining the status of countries in Saudi Arabia as far as EHR implementation is concerned. It has established EHR status in Saudi Arabia, what has been done and what needs to be done with regards to EHRs and offered results that will help in identifying the gaps and impeding factors. The information can be used to inform the policy and subsequent steps and decisions to make certain that the countries move in the desired and right direction.
Furthermore, the study presents an opportunity through which healthcare workers can present their views regarding the challenges they face pertaining to the implementation of EHR system. Therefore, it enables mitigation of perceived challenges that will hopefully increase their levels of satisfaction (Al Alawi et al 2014). As it is now, Al Alawi et al. (2014) elucidates that the level of satisfaction for healthcare providers is compromised by the difficulties in EHR implementation. A higher level of satisfaction will contribute to better performance and an escalated level of productivity and service delivery to patients (Al Alawi et al. 2014). This eventually contributes to patient satisfaction and better outcome in the health care industry.
The study also established the healthcare system and technological challenges affecting the implementation of EHR system. There are different countries that have successfully implemented the EHR system into practice such as the United States, the United Kingdom and Australia (Alsahafi 2012). These countries provide reliable experience and solutions regarding how such problems and challenges can be handled. However, unless the problems and challenges in the Saudi EHR implementation process are identified, it will be hard to locate a possible and reliable solution. Consequently, this study plays a significant role in establishing the challenges to pave way for appropriate solutions.
There emerges best practices and business case for adoption of EHRs as explored in this study. To begin with, they improve quality of information and provide secure patient data. In addition to this, future medical researches can be done using existing patient data and other records that used hospital guidelines on handling patient information. Furthermore, EHRs provides the government with the ability to examine quality measures and assess the performance of health institutions (Al-Swad 2013). Securely stored patient data can be used by medical data networks in their search for health trends, disease outbreaks, and even successful medications. In the case of baby patient registration, records could assist in health care bodies to draw up immunization plans and registrations.
In summary, the study acts as a backbone to the implementation of the EHR system. It outlines challenges encumbering the process. Results can be utilized in the generation of appropriate solutions that will facilitate the smooth implementation and adoption of the EHR system by future medical practitioners and institutions. This information is usable by healthcare managers who are seeking to create an environment for the implementation process. In general, all the above benefits of recorded data by use of EHRs enable the improvement of quality of service delivery to patients’ as well as provision of better working standards for physicians and other hospital staff within the healthcare sector. Most importantly the government of Saudi Arabia can adopt some of the recommendations from this study to ensure that the investments made for EHR systems are worthwhile.
1.7 Structure of the Dissertation
The structure of this dissertation follows the standard approach and steps commonly employed in writing dissertation/thesis paper. That is, the dissertation has six chapters which are organised as follows:
Chapter 1: Introduction
The chapter introduces the research subject – “Factors Determining Success and Challenges of EHR System Adoption in Saudi Arabia.” It provides background information on the research, statement of the research problem, aims and objectives, research questions, significance of the research, and an outline of the dissertation.
Chapter 2: Literature Review
This chapter provides a discussion on relevant theories and models as well as on existing literature related to the research subject. The materials reviewed in this section were obtained from peer-reviewed journal articles, books, and other reliable publications. The literature review section is divided into four main areas: theoretical framework, challenges of EHR implementation, success of EHR implementation, and conceptual framework.
Chapter 3: Methodology
Chapter three outlines and discusses the methodological approaches used to collect and synthesise research data. It provides a comprehensive discussion on the research philosophy, approaches, design, strategies, and methods of data collection and analysis including sampling techniques and data collection instruments.
Chapter 4: Findings
This section presents the research findings of the online self-administered questionnaire. The chapter focuses on the healthcare professionals in Saudi Arabia and their opinions and perceptions regarding implementation of EHR in Saudi Arabia. The findings are presented in figures and tables.
Chapter 5: Discussion of Research Finding
This chapter presents a detailed discussion of the research findings by relating and comparing them with the existing knowledge on the research topic. In addition, critical and analytical discussion is present in relation to the specific objectives of this study.
Chapter 6: Conclusion, Recommendations and Future Studies
In this final chapter, specific conclusions are drawn based on the specific objectives of the research. It further assesses whether the study has met its objectives and the implications of the research to key stakeholders in the EHR implementation and use in Saudi Arabia. Recommendations are made to enhance adoption and usage of EHR system in the healthcare facilities in Saudi Arabia, and how future research can be improved based on the scope and limitations of this study.
Chapter 2: LITERATURE REVIEW
2.1 Overview
This chapter provides a discussion on relevant theories and models as well as on existing literature related to the research subject. The materials reviewed in this section were obtained from peer-reviewed journal articles, books, and other reliable publications. The literature review section is divided into four main areas: theoretical framework, challenges of EHR implementation, success of EHR implementation, and conceptual framework.
2.2 Theoretical Framework
Following the review of literature on the perception of healthcare providers with regards to the implementation of electronic health record (EHR) system in hospitals in Saudi Arabia three models are examined: Technology-Organization-Environment Framework, the Technology Accepted Model and DeLone and McLean Information System Success Model. The three theories/models were considered important for this study because they depict acceptance of an IT infrastructure as dependent on the users’ evaluation of the specific influencing constructs or variables.
2.3.1 Technology-Organization-Environment Framework
Technology-Organization-Environment (TOE) framework was founded by Tornatzky and Fleischer in 1990 in their study of innovations in technology and their subsequent adoption. It is a theory developed at an organizational-level that is based on three facets that work together in determining how the organization perceive and implements new systems into its information management program (as illustrated in Figure 1 below) (Lee & Shim 2007).
Figure 1: Technology-Organization-Environment Framework
Source: Baker (2012)
The model can be summarized as follows:
• Technological context include both the external and internal equipment and procedures in an organization.
• Organizational context explain organizational factors like size, resources available, human resources, extent to which it is consolidated and how management conducts its responsibilities.
• Environmental context is concerned with the industrial composition in which the organization operates its competitors and the regulatory framework in which it operates on.
2.3.1.1 Technological context
This part of the TOE theory comprises of all procedures and equipment available to the organization. It is a combination of technology employed and already adopted by the facility in its routine operations as well as those that are yet to be acquired but available in the market. On one hand technologies that already exist within the firm dictate the speed and extent to which the further technological overhaul the organization can bear (Collins et al. 1988). On the other hand, those that are available in the market also set limits on the adoption pace and extent. They also provide guidance to firms on the equipment and processes that can be employed in the process of implementation.
External technologies can further be divided into three groups: incremental, synthetic and discontinuous. Incremental posses the lowest level of risk associated with adoption; for instance, advancement from lower versions of ERP to more sophisticated versions but of a similar system (Tornatzky and Fleischer 1990). The second group is of those that bring about synthetic alterations which involve moderate level of change like patients being able to access prescriptions and other health information over the hospitals website. Discontinuous technologies are known to be drastic and involve major changes in processes or equipment. It is advisable that organizations adopting radical changes make speedy decisions and fast implementation cycles if they are to maintain competitive advantage in the industry. According to Thong (1999) management ought to adopt ERP system changes that will improve the facility’s competency of service delivery to patients through gradual and well calculated implementation strategy. Although the adoption of newer technology may assist in speeding up routine procedures in a facility, they vary in their level of impact. Hence healthcare managers must practice caution and carefully evaluate the facility’s needs in relation to industry’s implementation pace.
2.3.1.2 Organizational context
This relates to the organizational traits, resources available both human and structural, communication protocol and procedures and the relationship between employees. Organizational factors hold a number of influences on the adoption and implementation processes of systems. Tushman and Nadler (1986) were of the view that mechanical processes that connect subunits within the facility enhance innovation. They further add that the availability of product defenders, border spanners, and guardians including employees that act as casual mediators also eases the adoption process.
Organic and decentralization structures that encourage teamwork amongst employees and other stakeholders encourage open communication and accountability within an organization; an important determinant in the reporting framework (Burns & Stalker 1978). In the adoption phase, it is best practice to utilize organic and decentralized structures while the mechanistic ones are more applicable in the implementation phase. This stems from the argument that the innovation processes requires clear definition of employee responsibilities with formal reporting channels and unified decision-making procedures. Open communication within a facility can either enhance or hinder innovation. Management’s creation of a working environment that is open to new ideas and opinions of employees encourages innovation. It is the role of management to notify its employees of the significance of innovation through an appropriate management strategy.
Size as an organizational factor does not influence the adoption process much; however, some researches argue that more developed and mature organizations are better placed to adopt new innovations. This has come under criticism from researchers that believe in other organizational factors to be of greater influence than size. Another factor is slack; it may not directly promote innovation even though most organizations include it as an important factor. An emerging fact in this theory with regards to the organizational context is that the right mix of structures by a facility’s management has the capacity to enhance ERP adoption and implementation in the Healthcare sector.
2.3.1.3 Environmental context
This section of the TOE framework comprises of an industry’s structure, availability of skilled service providers as well as the regulations set by the government. With regards to competition it is believed that organizations within an industry tend to adopt innovation faster when facing increased competition. Kamath and Liker (1994) added that smaller organizations within an industry are more likely to be guided by the steps taken by major firms in implementing and adopting innovations.
Tornatzky and Fleischer (1990) further agree that an industry’s maturity level also determines speed of adoption; for instance, in a rapidly growing industry, firms are likely to adopt innovations faster compared to a developed or declining industry. In an industry that is declining, firms may opt to save on costs by minimizing their investment in innovation while others may decide to incorporate innovation that is streamlined with enhancement of efficiency. Levin and others (1987) contributed to this context by stating that labour intensive organizations will tend to adopt innovations that save on the cost of labour. He therefore concludes that innovation is encouraged by the availability of experts and other individuals with extensive knowledge in technology.
Regulations set forth by the government for a particular industry could either foster or deter adoption efforts by firms. In instances where regulations are imposed on an industry to adopt certain technology with the aim of sustaining the environment, organizations have no choice but to implement. Conversely, the existence of bureaucracies and extensive requirements within the process of adoption hinder implementation efforts. In hospitals for example, the safety equipment and machinery on patients and healthcare providers has to be ascertained by the government and other medical committees before its adoption and implementation.
According to Tornatzky and Fleischer (1990), the summation of all these contexts may constrain or encourage adoption and implementation of innovation technologies. Various researchers in varied fields including Ramdani and others (2009) have used TOE to explain adoption and implementation of different technological systems.
2.3.2 Technology Acceptance Model
The other theory that examines adoption and implementation of technological innovation is Technology Acceptance Model (TAM). This model however, is directly linked to the use of IT and specifically concerned with the acceptance of new technology in an industry. TAM originates from Reasoned Action Theory which examines the behaviour and acceptance factors of the users of new technology particularly information systems. The theory holds that the behaviour and acceptance level of individuals are dependent on perception towards its usefulness and ease of use as shown in Figure 2 below.
Davis (1989) defines the concept of perceived usefulness and perceived ease of use as “the degree to which an individual believes that using a particular system would enhance his or her productivity” and “the degree an individual believes that using a particular system would be free of effort” respectively. The model attempts to foresee whether or not a system will be acceptable by various stakeholders. It further recognizes necessary changes that have to be made in order for a system to be accepted by targeted users. According to the theory of reasoned action, behavioural intention plays a role in influencing use of information systems. This intent is itself influenced by perception as well as individual attitudes and feelings towards a new system as expressed in the figure below:
Figure 2: Technology Acceptance Model
Source: Davis (1989)
Davis (1989) further states that apart from attitude, the expected impact that an information system will have on an individual’s performance significantly determines whether or not its use will be accepted. This implies that if an employee perceives that an information system will enhance his performance, there are high chances that he will incorporate it into his routine even if he did not accept it from the introduction phase. Saga and Zmud (1994) added to this argument by stating that whether or not an individual enjoys using a new system, he or she may agree to accept it if it seems opportune, practical and socially advantageous. Given two alternatives, an employ will choose that which he perceives is easier to use.
Davis (1989) uses two traits to explain the link between perceived ease of use and a person’s attitude: instrumentality and self-efficiency. Bandura (1982) theorizes that self-efficiency implies the increased efficiency perception an individual gets with increasing ease of use. Individuals that are able to manoeuvre the use of an information system with ease take more in charge with regards to handling the system equipment. In summary, the ease of handling information systems motivates and encourages their adoption by employees. In his theory, Davis (1989) argues that there is a higher connection between the individual’s intention to adopt a system and his perception regarding its role in performance improvement than there is with perception on ease of use.
Therefore based on this model, perceived usefulness of a tool takes precedence over perceived ease of use. Numerous researchers over the years have found fault with the models inability to adequately address all the factors leading to the actual usage of a system. Consequently, the model has been modified countless times to provide a clear link between the factors influencing perceived and ease of use. According to Venkatesh & Davis (2000) other factors include image and voluntarity which are grouped under collective influence processes. To this regard it is important to understand the role played by social factors in influencing information system commitment in order to examine and predict the acceptance and usage of technology. They also cited cognitive instrumental processes which relate to quality of production, the significance of a job and certainty of outcomes. Both processes arguably influence an individual’s intention to use and the perception of usefulness.
Venkatesh & Davis (2000) further add that the attitude aspect did not quite influence intention and perception of usefulness hence it could be disqualified as a factor given the empirical evidence available to exclude it. Generally, behavioural intention factors can be categorized into four different groups: individual context, organizational context, social context and system context. Organizational context relates to the influence an organization has in enhancing an individual’s technological use.
According to Thong, Hong & Tam (2002) variables in the organizational context include accessibility, relevance and visibility of a system; all work together to influence perceived ease of use and perceived usefulness of an information system. Even though the IT acceptance study has yielded numerous positive outcomes, the question of the influence of factors in the acceptance model are arguable. For instance, Petter, DeLone & McLean (2008) noted that TAM is ineffective in understanding and measuring the success of IT systems since the model focuses much on acceptance which does not correspond with success. Nevertheless, it must be noted that acceptance of IT system is an important factor in the success of IT system since acceptance is a significant and necessary antecedent to success of information system (Petter et al. 2008).
2.3.3 DeLone & McLean Information System Success Model
DeLone & McLean Information System (IS) Success Model is an integrated theory that seeks to explain the concept of information system success. As noted by Hellsten & Markova (2006), the main aim of DeLone & McLean IS success model is to provide a framework for measuring and understand various dependent variables or factors in the information technology research. The original D&M IS Success Model features six dimensions: Information Quality, System Quality, System Use, User satisfaction, Individual impact, and Organizational Impact. According to DeLone & McLean (1992), the six variables are interdependent success measures and not independent variables (cited in Hellsten & Markova 2006). However, following ten years of research and attempts to validate the D&M IS Success Model, DeLone & McLean (2003) agreed to revise the original model based on the proposed modifications made by empirical studies that had used the model since 1992.
As shown in Figure 3 below, the updated model include service quality as an interdependent variable in the measure of IS success. According to Petter et al. (2008), the updated model also sought to address the criticism that IT system can impact levels other than organizational and individual levels as conceptualized in the original model. As such, the updated model replaced with impacts on individual and organization levels with net benefits since IS success was found to have an impact on not only individuals and organizations, but also industries, workgroups, and societies at large (DeLone & McLean 2003; Petter et al. 2008). The authors also made modifications to the use construct. DeLone & McLean (2003) explained that ‘use’ must also come before user satisfaction in terms of a process, but in a causal sense, positive experience with ‘use’ will result in greater ‘user satisfaction.’ The key variables or constructs can be summarized as follows:
Figure 3: Updated D&M IS Success Model
Source: DeLone & McLean (2003, p. 24).
• “System quality” in the context of information technology, measures the desired attributes of IT system such as ease of use, system reliability, response time, availability, system flexibility, adaptability and ease of learning.
• “Information quality” measures the IS content issues. It captures the desirable characteristics of the system outputs (i.e. management reports and Web page). The content of IT system should be personalized, secure, easy to understand, relevant, complete, accurate, concise, and timely in order to enable help users enhance their tasks completion.
• “Service quality” measures the overall quality of the support that users of the system receive from the Information Technology department and support personnel. According to DeLone & McLean (2003), whether the support is provided internally by the IT department, or outsourced to an IS system provider, the quality of such support is important as users of IS system are now consumers and poor user support will lead to lost sales and lost customers (and low adoption of IS system). It concerns accuracy, reliability, responsiveness, technical competence, and empathy of the personnel staff.
• “System use” measures how users of the IS system utilize the capabilities of the system. It relates to everything concerning the visit to a page on the system, navigation within the page, information retrieval, and completion of a task. Petter et al. (2008) note that this construct can be measured in terms of extent of use, frequency of use, Nature of use, amount of use, appropriateness of use, and purpose of use.
• “User satisfaction” measures the degree to which a user of an IT system feels satisfied with the system. This is an important construct of measuring users’ opinions and perceptions of IT system and covers the entire user experience cycle from access to the system to information retrieval to task completion (DeLone & McLean 2003).
• “Net benefits” is the extent to which an IS system can be considered to enhance success of individuals, workgroups, organization, group of people, economies, industries, and even societies. They are an important IS success construct as they measure the balance of negative and positive effects of the IT system on individuals, organizations, workgroups, industries, and societies (DeLone & McLean 2003). Success of IS system can be measured in terms of job creation, improved profits, improved efficiency, improved welfare, improved adoption, and cost reductions (Petter et al. 2008).
The updated D&M IS Success Model has since been widely used by IS researchers to understand and measure factors influencing the success of IS system (Petter et al. 2008; Wang 2008). Therefore, the constructs of the updated model were considered relevant in understanding and measuring the factors influencing adoption and implementation of EHR system in the healthcare facilities in Saudi Arabia.
2.4 Challenges of Implementing EHR Systems
It is noted that while many industries improve on efficiency through adoption of information during IT ‘revolution’ of the late twentieth century, healthcare sector has generally been slow to adopt IT, despite many governments’ efforts to stimulate adoption (Mattke et al. 2015). For instance, even after studies conducted in the United States in 2005 illustrated that adoption of IT in healthcare practice could save the US government more than $80 billion annually (Hillestad et al. 2005), latest studies have shown that the adoption of IT by healthcare facilities in the US has been slow as just 27 percent of hospitals and 40 percent of physician practices achieving the standards for basic EHR (Kellermann & Jones 2013).
Mattke et al. (2015) attribute lack of adoption of EHR system in many countries to limited investment in IT in the health sector relative to other industries. This problem is starker in GCC countries whose investment in healthcare is relatively low as compared to the OECD countries (Mattke et al. 2015). For instance, the proportion of GDP in each of the GCC countries allocated to healthcare is approximately a quarter that of the OECD countries (Mattke et al. 2015). Therefore, economic growth and development could also be an issue in the adoption of EHR system in Saudi Arabia considering the fact that GCC governments (including that of Saudi Arabia) fund and provide most healthcare needs for their nationals.
A large body of research has identified the challenges affecting the implementation of EHR systems in health facilities. However, it is worth noting that there is little research on the challenges of implementing EHR in Saudi Arabia. In fact, most studies on this subject have been conducted in the West. For instance, a study conducted in Alabama, United States to investigate the perceptions regarding EHR implementation among health information management professionals revealed that lack of adequate funding for EHR implementation, lack of interoperability, concern about physician, and lack of national standards and code sets to guide use of EHR systems were the major barriers to the implementation of EHR (Houser & Johnson 2008).
Similarly, other studies conducted in the US by Hersh (2004) and Bates (2005) established that the major challenge facing the implementation of the EHR systems were a misalignment of benefits and costs. In other words, most physicians are concerned about the reimbursement as they have to pay for the electronic health records while most of the benefits accrue to purchasers and payers (Bates 2005). However, these studies also added that lack of interoperability is a significant factor affecting the implementation of EHR systems in health facilities. Bates (2005) added that fears about privacy of data, resistance by physicians due to time concerns, maintenance of the system, the number of EHR vendors in the marketplace, and the vendors’ transience nature are also of great concern for hospitals and healthcare professionals when considering to implement EHR systems in their organizations.
Lorenzi & Riley (2004) investigated the selection and implementation of EHR systems in small ambulatory practice setting and established that the implementation of EHR systems is influenced by a number of factors including the individual factors within each ambulatory practice setting, the change management issues, leadership, training, and the technology itself. In addition, the researchers found that the lack of prevalence of EHR systems in most physicians’ offices was due to the perception of physicians that the EHR systems are costly and would require major investment; they are cumbersome as compared to paper-based records; they offer benefits to other stakeholders (such as payers and society) and not healthcare providers; their implementation disrupts workflow and practice productivity; and that they are not standardised hence difficult to use. Although such findings made in the US offer significant insights into the challenges facing implementation of EHR systems, the challenges might not be similar be similar to those experienced in Saudi Arabia due to differences in economic, social, and political issues between the West and the Gulf region.
However, some obstacles and challenges found in the West are more or less the same with those cited in Saudi Arabia based on the limited research findings available. For instance, in a study conducted in Saudi Arabia by Khalifa (2013), it was established that the implementation of EHR system is hampered by technical factors (i.e. computers and information technology); human factors (i.e. socio-cultural issues such as values, norms, beliefs, attitudes, and behaviours); organizational factors (i.e. hospital management); professional factors (i.e. the uniqueness of healthcare practice); legal and regulatory factors (i.e. local laws and legislations on healthcare practices); and financial factors (i.e. costs of adoption and lack of funding). Khalifa (2013) asserted that the costs of adopting and implementing EHR system and the beliefs of healthcare practitioners in Saudi Arabia were the major hindrance to the adoption and implementation of EHR system in country.
Similarly, Hasanian et al. (2014) found that the main challenges facing implementation of EHR system in Saudi Arabia were related to the resources barriers – most hospitals experience staff shortages especially IT staff, and shortages of computers and other technical resources; social barriers – most health professionals resist adoption of EHR system, have too much workload, lack IT competence, and experience language barrier considering the fact that most software come in English language and not the widely used Arabic language; and technical barriers – those associated with lack of standardised EHR systems in the market, security concerns, and complexity of EHR systems. Similarly, Alshamari & Seliaman (2014) attributed the challenges to implementation of EHR systems in Saudi Arabia to lack of competence and training on how to use these technological applications.
Such findings are consistent with those made in Almuayqil et al. (2015). Almuayqil et al. (2015) reported that while the Saudi Arabian government has made tremendous efforts to improve its electronic health services, the implementation of the initiatives has been hampered by a number of challenges and problems. These challenges and problems include: non-connectivity of information systems to build up a national healthcare system; lack of computer skills and technical expertise among healthcare professionals and staff; failure of adoption of Health Information Services (HIS); human barriers (i.e. lack of trust in technology-based medical solutions by medical staff and negatives beliefs of healthcare practitioners towards technologies); cultural barriers (i.e. preferences of physical interaction to virtual contact in the Saudi Arabian culture); medical safety (i.e. due to communication gaps and limited adoption of technology); financial barriers (i.e. costs associated with transferring traditional paper health records to EHR system); and security and privacy (i.e. easy access to EHR of patients).
Al-Harbi (2011) also found that most healthcare professions in Saudi Arabia consider EHR system as a hindrance to their work as they have busy schedule and increased workload. Additionally, he noted that most hospitals experience systems and technical breakdown and have insufficient computers that cannot support successful implementation. Despite these negatives and challenges, the existing literature indicates that the healthcare professionals are aware of the benefits and the need to implement EHR system in their health facilities (Alkraiji, et al. 2014; Al-Harbi 2011; Khalifa 2013). For Aldosari (2014), the challenges and difficulties facing implementation of EHR system relate to the legacy of paper data systems (i.e. hospitals experience problems of scanning documents and converting data. In the maintenance phase, healthcare facilities encounter problems associated with software updating and maintenance, and in the improvement phase, the main challenges encountered by users of EHR system relate to the communication and exchange of health information (Aldosari 2014).
In a study conducted by Al Alawi et al. (2014) to examine physician satisfaction with an electronic medical records (EMR) system and to establish the main limitations of the EMR system in United Arabs Emirates, it was found that while physicians were generally satisfied with the EMR system, they experienced significant difficulties during implementation of the system. In addition, the researchers noted that physicians found the long time needed to perform the documentation had negative impact on their practice and communication with patients (Al Alawi et al. 2014). The study did not seek the perceptions and opinions of other healthcare professionals and staff with regards to the challenges affecting adoption and usage of EHR system in their healthcare facilities.
Similarly, Alkraiji et al. (2014) who attempted to investigate the challenges and opportunities for health informatics in the GCC countries, failed to provide an empirical study with a genaralisable research data. Nevertheless, their study revealed that that the GCC countries faced a number of challenges relating to adoption of health informatics in healthcare practice in the region. These include: shortage of professionals, interoperability issues, ethical and privacy concerns, issues regarding management of health data, lack of clinicians’ engagement, lack of procedures and policies (inadequate regulatory framework), and complexity of the health ecosystem (Alkraiji et al. 2014). Although the researchers made significant contributions to the understanding of challenges affecting health informatics implementation in Saudi Arabia, their use of secondary research methods made their findings less generalisable.
2.5 Successes of Implementing EHR Systems
Some positives have been noted in the literature with regards to the implementation of EHR systems in Saudi Arabia. However, the existing literature on the adoption of EHR system has provided limited empirical evidence on the success of EHR adoption (especially by not focusing on the perceptions and attitudes of healthcare professionals) in Saudi Arabia. For instance, Parry’s (2014) report which appeared on Arab Health Magazine, noted that there were significant developments in Saudi Arabia with regards to adoption of EHR system. While noting that Saudi Arabia is affected by numerous health problems including increased incidences and prevalence of non-communicable diseases, Parry (2014) noted that GCC governments have made attempts at improving adoption of EHR system in their healthcare facilities. For instance, the GCC countries had started an initiative in 2012 to formulate a regional strategy that would address health issues in the region. Most important, the governments of the six GCC countries had sent representatives to UK to learn and experience the success story of adoption of EHR system in the UK with an aim of developing and implementing a world-class EHR system across the Gulf region (Parry 2014). Moreover, some studies have documented initial progress in the adoption of EHR system in the Gulf region. As summarised in Table 1, the region is showing some progress in terms of implementation of EHR systems.
Table 1: Implementation of EHR in the GCC Countries
Country MRD* well-equipped staff (untrained) MRD* lack policies & procedures, poor management EHR vendor developed EHR in-house developed
Kuwait Yes Yes Yes Partially
S. Arabia No Yes Yes –
Bahrain Yes Yes Partially Yes
Qatar Yes Yes Yes Partially
UAE – Abu Dhabi Yes Yes Yes –
Sultanate of Oman No Yes Partially Yes
*MRD is Medical Records Department
Source: Mogli (2011, p. 68)
Mogli (2011) established that the GCC countries experienced mixed progress in terms of EHR implementation. While a few health facilities (5-10 percent) had implemented and maintained high standards of health record management using EHR systems, majority of the health facilities in the region lacked health record management “at the fundamental planning and budgeting levels of health services” (Mogli 2011, p. 69). However, Mogli (2011) noted that the implementation of EHR in the Gulf region had brought about significant success as 70-80 percent of the hospitals that had implemented EHR systems experienced improved functioning, saved time of nursing, medical and medical records staff, controlled diagnoses and drug prescriptions, and regularised patient flow.
The findings by Mogli (2011) are consistent with those made by other researchers. For instance, while Al-Harbi (2011) noted that many barriers and challenges are facing the implementation of health information technology at King Abdul-Aziz Medical City, Saudi Arabia, healthcare providers at the hospitals reported that the health information applications were beneficial and valuable in their work. Additionally, the researcher reported that majority of the healthcare providers were in fact using the health information applications adopted by the hospital. Alkraiji et al. (2014) also noted positive development in some GCC countries (i.e. Saudi Arabia, Bahrain, and UAE) where there are government initiatives to improve adoption of EHR systems in their health facilities. However, the study by Alkraiji et al. (2014) does not illustrate the perceptions or views of healthcare providers in respect to these positive initiatives by their governments.
On the other hand, Khalifa (2013) reported that there is generally great awareness of the benefits of EHRs among healthcare providers in the region. The researchers found that most healthcare providers were aware that the EHR systems were capable of reducing medical errors and healthcare costs; enhancing access to information; improving accuracy and efficiency of clinical management as well as healthcare quality; and increasing productivity of healthcare providers. However, the study by Khalifa (2013) like many other reviewed here was conducted in Saudi Arabia.
Similarly, Aldosari (2014) conducted a study to investigate the rates, level, and determinants of EHR system implementation among 22 private and non-profit healthcare facilities in Riyadh, Saudi Arabia. Based on the researcher’s findings, the rates of adoption of EHR system were relatively better as compared to those reported from other districts in Saudi Arabia and other countries. Of the 22 healthcare facilities, 11 were found to have implemented fully functioning electronic health record systems, eight were in the process of implementation, and three were yet to adopt EHR system. However, there were significant variations in the levels of adoption of EHR system among healthcare facilities as 16 different types of EHR system were being employed across the 19 healthcare facilities that had adopted EHR systems.
A study conducted in primary healthcare centres in Al Ain, UAE by Al Alawi et al. (2014) established that many physicians were satisfied with the EMR system. According to the researches, most physicians were satisfied with the orders and results of the radiology and laboratory functions and stressed that this was the greatest advantage of electronic medical reports system. Moreover, the researcher found that physicians in the UAE were satisfied with the EMR system’s prescription function since it saved time and reduced errors (Al Alawi et al. 2014). Although Al Alawi et al. (2014) made significant conclusions by noting that physicians are generally satisfied with EHR system and have positive perception about the benefits of the application of the system, they also suggested that future studies need to focus on the other healthcare practitioners and patients to investigate their perception and attitudes towards the EHR system. Moreover, Al Alawi’s et al. (2014) study employed qualitative research methods and collected data through focus group interviews and therefore the results of the study could not be generalized.
Another positive in the integration of IT into healthcare practice is the introduction of the innovative SGH We Care app. This app has been introduced by the Saudi German Hospital (SGH) Group, a leading international healthcare provider which operates mainly in the Gulf region (SGH Group 2015). As illustrated on Google play, the SGH We Care app enables patients to submit questions to SGH specialists, book appointment online, and access all the last posts by SGH Group, including promotions and timings (Google 2015). In addition, the app also allows patients to access medical news feed, a complete medical encyclopaedia, information about common health problems and preventive measures, and a large database of FAQs on health and healthcare. Although the app is yet to be linked with patient medical data base such as EHR system to facilitate access of x-ray, laboratories, and reports, it is a positive step towards enhancing convenient delivery of healthcare through paperless working environment in Saudi Arabia and the Gulf region.
In summary, as illustrated in this review, there are significant improvements in Saudi Arabia in respect to the adoption and implementation of EHR systems. However, limited research has been conducted in the region to investigate the challenges and successes of implementing EHR systems in the local health facilities and organizations as perceived by healthcare providers who are the primary users of these new innovations in healthcare practice. Besides, of the limited studies done so far, majority have been done in Saudi Arabia and have made no effort at generalising their research findings to other five countries in the region. This research therefore sought to fill this gap in the literature on implementation of EHR systems in Saudi Arabia.
2.6 Conceptual Framework
Figure 4: Conceptual Framework
Source: Developed by the Researcher (based on Updated D&M IS Success Model, TAM, TOE Model, and Literature Review)
Based on the key arguments in the literature review and the theoretical frameworks discussed above, the conceptual framework illustrated in Figure 4 above was developed and used to facilitate understanding of the research subject and meeting the research objectives. In summary, the conceptual framework consists of six constructs or variables that are interdependent. The first construct is external environment which encompasses the nature of support provided by EHR system vendors, cultural factors influencing adoption of EHR system, and healthcare system in a country. The second construct is the technological factors which relates to quality of the EHR system and quality of information and contents of EHR system. The third variable is the organizational environment (or internal factors) which measures how organizational culture of individual healthcare facilities and organizational resources that influence adoption and implementation of EHR system.
The fourth variable is the system use (or intention to use) which is influenced by the external environment, technological factors, and organizational factors as well as user satisfaction with EHR system. Similarly, the fifth construct (‘user satisfaction’) is influenced by external environment, technological factors and organizational factors as well as system use. Finally, the ‘successes or challenges’ associated with EHR system are influenced by the system use and use satisfaction and measures the perceptions of healthcare professionals regarding the challenges and successes of EHR system adoption in Saudi Arabia. This framework was used to develop questionnaires and direct data collection process as illustrated in the next chapter.
Chapter 3: METHODOLOGY
3.1 Overview
This chapter provides a discussion and illustration on the methodological approaches and procedures used in obtaining data that could answer the research questions and meet the research objectives. The discussion focuses on the wider aspects of methodology such as research philosophy, approach, and strategies as well as on specific areas such as data collection procedures and methods, and methods of data analysis. The chapter also attempts to offer justification and rationale for specific methods and approaches employed in obtaining the research data. As shown in Figure 5 below, Saunders, Lewis and Thornhill’s (2012) research onion was employed as a reference guide for the discussion on the different areas of methodological approaches and procedure adopted in the study.
Figure 5: Saunders’ et al. (2012) Research Onion
Source: Saunders et al. (2012)
3.2 Research Philosophy
The use of a research philosophy is vital in uncovering the underlying presumptions of any method of study. It steers all the methodology procedures including data collection, analysis and interpretation so as to provide explanations about the phenomenon under investigation. There are two primary types of research paradigms available to a researcher: positivism and interpretivism (Creswell 2009). According to Yin (2009) interpretivist approach ensures accuracy through studying a situation and resulting human behaviour in its natural environment. Interpretive philosophy is driven by the need to offer recommendations for possible solutions to the phenomenon under study (Creswell 2009). Interpretivism is majorly concerned with attaining objectivity whilst the positivist philosophy of research is based on the argument that human behaviour can only be truly understood through experiencing actual situations; this experience is achieved through observation and experimentation (Saunders et al. 2012).
To this end, the study employed positivism philosophy of research in its attempt to attain the set objectives. Macionis (2012) suggests that the paradigm of positivism examines social realities through observation and use of logic. The objective of this study was to establish the perception of healthcare providers with regards to the implementation of EHR system in hospitals in Saudi Arabia. Thus, the use of positivism was appropriate in understanding the true perceptions that healthcare professions hold with regards to the adoption and implementation of EHR systems in the health facilities in Saudi Arabia
The determinism assumption held by positivism states that events are as a result of certain occurrences (Creswell & Plano Clark 2007). This assumption assisted in examining the challenges faced by healthcare practitioners as a determinant to the adoption of EHR systems. Through positivism paradigm, causal effects were examined so as to enable prediction of potential challenges and manage their effects (Macionis 2012). Another assumption held by positivism is empiricism that requires evidence to support theories. Data collected in this study was analysed to answer research questions posted by the researcher.
Dash (1993) argues that an advantage of using positivism is the ability of a researcher to generalize findings from one case to an entire population within similar situations. The main objective of this research philosophy is to organize and arrange research finding in such a way that they support arguments made in a study making it appropriate for this study since any past theories can be debated based on the evidence gathered from this research. Quality of precision attached to positivism further appealed to the topic under study given that the study needed to accurately predict outcomes in healthcare facilities in Saudi Arabia.
3.3 Research Approach
Inductive and deductive research approaches can both be used in a scientific research depending on the goals of the study. Inductive research approach entails a detailed assessment of a phenomenon which is likely to provide appropriate explanation to support claims posted by a researcher. This approach relies on the evidence available to the researcher (Copi et al. 2007). On the other hand, deductive approach entails the formulation of a research strategy after the premise of the theory under investigation has been developed. It therefore draws conclusions from existing propositions (Cohen & Maldonado 2007). Deductive approach in research is different from inductive reasoning in that inductive studies do not deal with present premises instead they involve starting from a general phenomenon and narrowing it down to a particular environment (Cozby 2001).
Deductive approach was used in this study due to its effectiveness in providing the researcher with abundant sources used as reference documents. Deductive approach assisted in relating the pattern created by other EHR implementation researches to the results of obtained from the study. Another factor that justified the use of deductive reasoning for this study is that it contains a lower level of risk compared to induction. This is due to the fact that deductive approach draws from already established facts hence lower risk of making wrong conclusions or judgements during research.
3.4 Research Method, Design and Strategy
This study chose quantitative over qualitative research method to examine the set objective and consequently answer study questions. Qualitative approach to research is mainly concerned with shedding light on opinions of subjects and capturing views of respondents; hence it has the advantage of providing comprehensive information in an attempt to achieve study objectives (Creswell 2009). Qualitative method thus ensures perceptions of individuals are fully captured in order to give an in-depth exploration of issues under investigation. However, qualitative method is less effective in theory testing studies and in generating generalizable data (as was the case in this study).
Thus quantitative method was deemed suitable since it enabled the researcher to study the reality of the human phenomenon and factors affecting certain behaviour in individuals in the healthcare sector. Christensen, Johnson and Turner (2010) state that quantitative methods enhance objectivity of a research and as such prevent the researcher from imposing his/her personal views and opinions on the study. This method was effective in this regard as it restricted the presentation of finding to their true nature free from personal perception and bias (Creswell 2014). Furthermore, quantitative methods provided an opportunity for generalization of results which implies that situations in other health institution within Saudi Arabia could be understood based on the research findings.
Quantitative approach was appropriate cause and effect of challenges experienced during EHR implementation. Its nature limits the finding of a study to that particular case. Descriptive design was employed using case study strategy. Unlike explorative design whose data cannot be generalised and causal design which is mainly concerned with explaining the causal relationship between factors or variables, descriptive design was considered appropriate for this study as it allowed for portrayal of individuals under study in the most accurate way by providing a description of the participants and the perceptions they have towards EHR adoption. In essence, the use of descriptive design enabled the researcher to answer the “what is” question with regards to how healthcare professionals perceive implementation of EHR system in Saudi Arabia (Creswell 2009).
According to Cohen and Maldonado (2007) descriptive design uses three strategies to achieve its goal of accuracy: observation which involves viewing and recording activities and actions of participants; survey which is regarded as a short interview of participants; and case studies. Yin (2009) suggests that case studies do not give a general outlook of a survey rather they provide a critical analysis of the phenomenon under study. They are important in the examination of the validity of models and test their applicability in the natural world (SageDul & Hak 2008). A case study was carried out in hospitals in Saudi Arabia to provide in-depth description of the information gathered regarding the perceptions of physicians, nurses, and other healthcare professionals about the successes and challenges affecting implementation of EHR systems in Saudi Arabia.
3.5 Data Collection Methods
3.5.1 Primary Research
According to Gulati (2009) there are two methods of data collection – primary and secondary – which can be used to gather the necessary information for a study. Secondary data includes information obtained from publications such as reports, newspaper, journals, and magazine reviews. Yin (2009) stated that secondary data is that which has been reported by previous researchers hence can be used to support the finding of new studies. It therefore avails to a researcher a rich pool of reference material that further increase the accuracy and reliability of a study.
Primary data for this study was collected by the researcher using questionnaires after the researcher had reviewed sufficient secondary research carried in the past within the healthcare industry. Primary data was preferred since it allowed the researcher to collect information that was unique to hospitals in Saudi Arabia and to concentrate on the specific concerns in the study (Hancké 2009). The use of this type of data was useful in answering the question of ‘what health and technological challenges are considered unique to Saudi Arabia particularly in Saudi Arabia’. Primary data collection was further justified by the researcher’s need to be able to manage the source of data that was suitable taking into account time constraints and objective of the study.
Structured online questionnaires (illustrated in Appendix B) were used to obtain data from the healthcare providers. Questionnaires are an inexpensive, speedy and convenient method of obtaining standardized information about individuals participating in a study. They also assisted in obtaining information on knowledge, experiences, and perceptions of research participants (Groves et al. 2009). Survey method provided the researcher with vital public information from healthcare practitioners in Saudi Arabian hospitals. All except one of the 28 questions asked were closed and provided the respondents with multiple choices to relay their responses (see Appendix B). The final question which was open ended sought the participants’ view of what they would change in the current EHR system given the chance.
The questions were structured based on the conceptual framework (illustrated in Figure 4 above) which considered external environment, technological factors, and organizational factors as key variables influencing users’ perception of challenges and successes of EHR system adoption in healthcare facilities in Saudi Arabia. As such, the theme of questions on the questionnaires was focused on understanding how healthcare providers perceive EHR in the practice. This was important in obtaining accurate data that were in line with the research objectives. Most importantly, the same set of questions (as shown in Appendix B) was administered to the healthcare providers and staff regardless of their professions. This was important in ensuring that the questionnaire generated accurate measure of the behaviours, perceptions, opinions and experiences of healthcare providers regarding EHR adoption in Saudi Arabia.
The mode of survey used by the researcher was online. This entailed the distribution of questionnaires through online survey company, called Survs (survs.com) to each individual participant who was given a unique password to access the questionnaires. Online surveys were especially convenient as they incurred very low cost associated with internet use. Moreover, it allowed the researcher to a survey a significant sample from various healthcare facilities in Saudi Arabia. The aspect of time saving prompted participants’ willingness to participate in the study considering the fact that healthcare professionals usually have busy schedules and would not participate in lengthy surveys.
3.5.2 Primary Data Collection Procedure
To gain access to the healthcare facilities in Saudi Arabia, the researcher relied on both personal network and official application to communicate the request for this research to be conducted at the healthcare facilities and to have the healthcare providers of the hospitals participate in the research. Thus, permission to carry out this research was sought in two phases. First, six letters (see Appendix C for a copy of the letter) and copies of the research proposal were sent to six hospitals within Saudi Arabia to the Human Resources Managers of each facility through e-mail. The letter detailed the purpose of the research and its significance to the healthcare sector. It further stated the objective of the study and the targeted population.
Following the notification, e-mails were sent to different health facilities requesting volunteers who wished to participate to send feedback to the researcher (see Appendix A for the copy of email sent to the respondents). Volunteers were required to provide the researcher with their e-mail addresses to facilitate timely distribution of log-ins to the online firm hosting the survey questionnaires. The survey was conducted over a period of one month between April 10, 2015 and May 17, 2015. The completed questionnaires were automatically saved online on survs.com.
3.6 Target Population and Sampling
The population targeted for this research was all healthcare professionals currently practicing in Saudi Arabia. Initially, it was expected that 100 respondents would participate in the study. To increase the chances of reaching this target, many prospective respondents were supplied with log-ins into survs.com since there were chances that the target population would visit the website without completing the questionnaire as is the case in most online surveys. Consequently, 370 visited the site hosting the questionnaire for this study. Nevertheless, 56 responded to the questions leading to a response rate of 56 percent as 44 percent did not respond. The choice of Saudi Arabia as a case assisted in addressing the challenges such as costs, time, and other research logistics which are normally encountered while using wider surveys (Yin 2009). This therefore narrowed down the research to only include healthcare practitioners currently practicing in Saudi Arabia which generated findings that could be generalized to the entire healthcare providers in the Gulf region. Cohen and Maldonado (2007) concur that sampling criteria in survey are divided into two major groups: probabilistic and non-probabilistic methods of selection. Sampling is significant for any research as it allows for the selection of a fraction of subject from an entire population of items which saves both time and money that would otherwise be injected into a research (Kothari 2008).
The researcher used a non-probabilistic selection method known as convenience sampling to select a sample of 56 healthcare practitioners. Convenience sampling is the most basic of sampling techniques and involves selection of subjects; in this case, healthcare providers in Saudi Arabian hospitals from the larger population of health practitioners in the country by focusing on those who have the capability and are willing to provide the necessary information. Although probabilistic sampling techniques such as simple random and stratified random sampling would have been ideal in this study, convenience sampling was considered appropriate because of language barrier. In other words, it was understood most healthcare professionals would not answer the research question appropriately as the questionnaires (see Appendix B) were designed in English while healthcare professionals in Saudi Arabia are more proficient in Arabic than in English language. This method of selection was preferred because of time and resources constraints and it would have been tedious to conduct a random sampling of close to 170,000 healthcare professionals (see Khaliq 2012) in Saudi Arabia alone. Nevertheless, a sample size of 56 healthcare practitioners was large enough to reduce the margin for error and statistical bias even after some participants failed to respond to the sent questionnaires.
3.7 Data Analysis Methods
In line with the research approach chosen, quantitative testing of the information gathered was done in response to the main objective of establishing the perception of healthcare providers with regards to the implementation of EHR system in hospitals in Saudi Arabia. Quantitative method of analysis was vital in analyzing all numerical data or data that was measurable by scale (Hancké 2009). The researcher carried out a descriptive analysis of the collected data using the computer package Social Packages for the Social Science (SPSS). SPSS is an effective statistical analysis program that is able to handle quantitative data.
Data collected through questionnaires was coded and analysed using descriptive statistics such as frequencies and measures of central tendency. Coding was done to quantify qualitative responses and further facilitate analysis using numerals rather than statements or themes as in the case of qualitative analysis. Coding transformed each question into a variable that can be analysed independently from other questions in the questionnaire while each respondent was coded as a unique case from others. Test for correlation was also performed to establish the relationship between variables and the degree to which the challenges faced by healthcare providers in Saudi Arabian hospitals influenced the perceptions held by those individuals.
3.8 Validity and Reliability
According to Cozby (2001) validity implies the truth behind the conclusions of a research. It is measured by the accuracy of the research which is attained by carrying out extensive and detailed study. It is a foundation of supporting a researcher’s results as a true reflection of the event under study. According to Christensen et al. (2010), the use of positivism as a research philosophy means that the findings of the study are a true reflection of the phenomenon. The use of case study as a research strategy and descriptive design by the researcher increased the accuracy of findings since all existing theories and literature behind the implementation and adoption of EHR systems in the healthcare sector were analysed before embarking on this research (George & Bennett 2005). To this end, the researcher can confidently claim accuracy of results. This study was also validated by the use of convenience sampling which ensured that only those capable of answering the research questions participated, and by giving potential participants unique passwords to access the survey questionnaires online which ensured that only those recruited to participate in the study actually participated.
Reliability is the ability of a study to be consistent in findings. This implies that under similar circumstances, even if the researcher uses a different approach and evaluation strategies the results should be the same as earlier studies carried out (Creswell 2014). This study is deemed reliable, because the researcher has managed to maintain consistency with past studies conducted about EHR implementation in the healthcare sector. Reports, journals and other scholarly and non-scholarly articles further prove that the findings from this study are reliable. Due to the in-depth and extensive nature of analysis of theories prior to an actual research, case studies tend to provide reliable findings (Dornyei 2007). Hence the study of EHR implementation in Saudi Arabian hospitals as a case study further enhanced reliability of this research.
3.9 Ethical Consideration
Ethical issues that were raised during the study were mainly anonymity, confidentiality, volunteerism and informed consent. Since anonymity is an ethical issue associated with online surveys, the researcher made certain to uphold respondents’ anonymity where participating individuals wished to remain anonymous. This ensured the safeguarding of participants’ identity in the course of carrying out the study. Moreover, the respondents were asked to make informed consent through e-mail communication that contained the link to the survey. They were further told to exit the survey at any time or point since their participation was voluntary. In order to protect the confidentiality of the data and respondents’ identity, the researcher ensured that only those supplied with the password could access the survey and data. In addition, the research data were solely used for the specific objectives of the study and this was duly communicated to the respondents.
3.10 Summary
In summary, to understand the perception of healthcare professionals in Saudi Arabia regarding the challenges and successes of EHR implementation, positivist research paradigm/philosophy was chosen for the reason that it provided a way of testing the hypotheses and theories in the literature. For that reason, deductive approach was used to generate data that could be used to make specific observations and conclusions about the research phenomenon. Being an empirical study using deductive approach, quantitative research methods were used to meet the research objectives.
The study used descriptive research design to provide a clear description of the research participants and their perception. This was achieved through a case study of Saudi Arabia in which data were collected using online questionnaires. The questionnaire had 28 questions concentrated on the challenges and successes of EHR system implementation in Saudi Arabia, with a particular focus on how healthcare professionals in Saudi Arabia perceived the quality of EHR system, information, and services. The research data were analysed using SPSS. Ethically, the researcher ensured that privacy and confidentiality of the research respondents were protected during data collection and by using the data for the purposes of this research only. Figure 6 below provides a simple procedure used in conducting this study in relation to collection and analysis of data.
Figure 6: Summary of Methodology
Chapter 4: FINDINGS AND ANALYSIS
4.1 Overview
This chapter presents the findings of the study based on the research objectives and methodology employed. The findings are broadly categorised into demographic characteristics of respondents, perceptions of healthcare professions on adoption and implementation of EHR system in Saudi Arabia; and EHR implementation challenges experienced by hospitals and healthcare providers in Saudi Arabia. The main objective of conducting this study was to investigate the perceptions of healthcare providers regarding the implementation of electronic health record (EHR) system in health facilities in Saudi Arabia. To address this objective, the researcher sought to understand the demographic characteristics of the healthcare providers in Saudi Arabia.
4.2 Preliminary Findings
The study was hosted by an online survey company, survs.com on which respondents were directed to complete the survey questions. Each respondent was given a password to gain access to the survey. This was important in ensuring that only individuals requested to participate in the survey could answer the research questions, guaranteeing the accuracy and validity of data. Significantly, the survey targeted a sample of 100 respondents from a group of healthcare professionals in Saudi Arabia from the potential 170,000 (i.e. the population size of healthcare professionals in Saudi Arabia). 56 respondents responded to the questions; resulting in a response rate of 56 percent taking into account the fact that the sample size of the study was 100 respondents. However, the completion rate was 100 percent as all the respondents who completed the online questionnaires.
4.3 Demographic Characteristics
The demographic data of the respondents captured by the survey were the name, place of work (i.e. country), gender, title (designation), primary clinical speciality, and years of practice. Other common demographic data such as age, level of education, and income were considered less important to the objectives of this study which focused on the perception of healthcare professionals about the implementation of electronic health records systems in Saudi Arabia. As illustrated in Figure 7, analysis of the research data indicated that majority of the respondents were male who accounted for 53 percent (29) of the total respondents while female respondents accounted for 47 percent (26) of the total respondents. One respondent did not answer this question (see details in Table 2 & 3).
Table 2: Valid Data
N Valid
Missing 55
1
Figure 7: Gender of the Respondents
Table 3: Descriptive Statistics of Respondents’ Gender
Gender Frequency Percent Valid Percent Cumulative Percent
Valid Male 29 53 53 53
Female 26 47 47 100
Total 55 100 100
The respondents surveyed in this study had different titles or designation in their health facilities. That is, 20 percent (11 respondents) were Managing Directors, 21 percent (12 respondents) were Nurse Practitioners, 2 percent (1 respondent) was Physician Assistant, and 57 percent (32 respondents) had different titles including, Specialist Dental Assistant, Dentist, General Dentist, Dental Intern, Administrator, Physiotherapist, Cardio Vascular Invasive Specialist, Laboratory Technician, Pharmacist, Consultant, and General Physician, among others (see Figure 8 and Table 4 for illustrations).
Figure 8: Title/Designation of the Respondents
Table 4: Title/Designation of the Respondents
Title/Designation Frequency Percent Valid Percent Cumulative Percent
Valid Managing Director 11 20 20 20
Nurse Practitioner 12 21 21 41
Physician Assistant 1 2 2 43
Others 32 57 57 100
Total 56 100 100
The respondents were also asked about their primary clinical specialty in their current practice. As shown in Figure 9 and Table 5, the data can be summarised as follows: General Practice 37 percent (21 respondents); Family Practice 2 percent (1 respondent); Internal Medicine 4 percent (2 respondents); Obstetrics/Gynaecology 4 percent (2 respondents); Paediatrics 0 percent (0 respondents); Behavioural Specialist 0 percent (0 respondents); and Others (e.g. Dentistry, Cardiology, ENT, Pharmacotherapy, Surgery, Midwifery, Laboratory, and Dental Nursing, among others) 53 percent (30 respondents).
Figure 9: Primary Clinical Specialty of the Respondents
Table 5: Primary Clinical Specialty of Respondents
Primary Clinical Specialty Frequency Percent Valid Percent Cumulative Percent
Valid General Practice 21 38 38 37
Family Practice 1 2 2 39
Internal Medicine 2 4 4 43
Ob/Gyn 2 4 4 47
Paediatrics 0 0 0 47
Behavioural Specialist 0 0 0 47
Others 30 53 53 100
Total 56 100 100
The healthcare professionals were also asked about their years of experience in their areas of clinical specialty. Figure 10 and Table 6 illustrate that majority of the respondents were found to have been in practice for less than 5 years (52 percent). Those who had been in practice for 5-10 years were 20 percent (11 respondents); 10-15 years were 5 percent (3 respondents); 15-20 years were 13 percent (7 respondents); and more than 20 years were 11 percent (6 respondents).
Figure 10: Respondents’ Years in Practice
Table 6: Respondents’ Years in Practice
Years in Practice Frequency Percent Valid Percent Cumulative Percent
Valid Less than 5 years 29 52 52 52
5-10 years 11 20 20 72
10-15 years 3 5 5 77
15-20 years 7 12 12 89
More than 20 years 6 11 11 100
Total 56 100 100
4.4 Work/Organizational Environment
The respondents were asked to provide details about working conditions their current practice facilities. The findings indicate most healthcare professionals in Saudi Arabia work long hours in order to provide the necessary healthcare services for patients in the country. This was supported that the fact that majority of respondents reported that they were working for at least 45 hours per week at their practice facility. As shown in Figure 11 and Table 7 below, 60 percent of the respondents reported that they worked for or more than 45 hours every week; 16 percent reported that they worked for 35-44 hours per week; and 24 percent reported that they worked for less than 34 hours per week. One respondent did not answer this questions (i.e. “On average, how many hours a week do you work in this practice facility? (Hours per week)”).
Figure 11: Hours Worked per Week
Table 7: Hours Worked per Week
Hours worked per week Frequency Percent Valid Percent Cumulative Percent
Valid More than 45 hours 33 60 60 60
35-44 hours 9 16 16 76
Less than 34 hours 13 24 24 100
Total 55 100 100
The survey also revealed that the healthcare providers in Saudi Arabia have relatively busy scheduling considering the number of patients that they see per hour in their practice facilities. Majority of the respondents stated that they usually have at least three patients per hour. However, some reported that they normally see as many as 10 patients per hour at their health facilities, a pointer of the workload in the health facilities in Saudi Arabia considering the fact that those who reported to have seen three or more patients per hour constituted 65 percent of the total number of the respondents. In particular, 40 percent of the respondents stated that they had 3-5 patients per hour; 35 percent had 1-2 patients per hour; and 25 percent attended to at least 6 patients at their health facilities (see Figure 12 and Table 8 below). Five respondents did not answer this question appropriately and therefore 51 were used as the valid ones.
Figure 12: Number of Patients Seen per Hour
Table 8: Number of Patients Seen per Hour
Number of Patient/Hour Frequency Percent Valid Percent Cumulative Percent
Valid 1-2 patients 18 35 35 35
3-5 patients 20 40 40 75
6 or more patients 13 25 25 100
Total 51 100 100
4.5 Success and Barrier Factors in EHR System Adoption in Saudi Arabia
There is a high level of awareness about electronic health records systems among healthcare professionals in Saudi Arabia. As illustrated in Table 9 and Figure 13 below, 43 respondents (78 percent) reported that they were aware of EHR systems while 12 respondents (22 percent) stated that they were not aware of the EHR system. One respondent skipped this question, and therefore 55 responses were found valid for the purposes of this analysis. Although the level of awareness about EHR system is high among the healthcare professionals in Saudi Arabia, the fact that 22 percent of the respondents do not know about EHR system should be a cause for alarm since healthcare professionals are the primary users and beneficiaries of EHR system. Nevertheless, these findings provided a preview of challenges and successes in the implementation of EHR system in Saudi Arabia.
Figure 13: Awareness of EHR system in Saudi Arabia
Table 9: Awareness of EHR System in Saudi Arabia
Are You Awareness of EHR System? Frequency Percent Valid Percent Cumulative Percent
Valid Yes 43 78 78 78
No 12 22 22 100
Total 55 100 100
Significantly, the rate of adoption of EHR system in Saudi Arabia is generally low which could be a pointer to the significant number of healthcare providers lacking knowledge of EHR system. The survey data revealed that close to half of healthcare professionals in Saudi Arabia (42 percent) do not currently use EHR system. 32 of the respondent (58 percent) surveyed in this study reported that they were currently using EHR system in their practice (as illustrated in Table 10 and Figure 14 below). In addition to the indication that the research data illustrate low level of adoption of EHR system in Saudi Arabia, the findings further illustrate the significantly high number of healthcare professionals who are not aware of the EHR system.
Figure 14: Healthcare Professionals Using EHR System
Table 10: Healthcare Professionals Using EHR System
Usage of EHR System Frequency Percent Valid Percent Cumulative Percent
Valid Yes 32 58 58 58
No 23 42 42 100
Total 55 100 100
A number of factors were identified by healthcare professionals as contributing to the low level of adoption of EHR system in their practice. As shown in Table 11 and Figure 15 below, the respondents identified limited funds as a major factor (40 percent). Other factors include information technology problems (28 percent), administrative barriers (36 percent), and lack of knowledge of EHR system (16 percent). Significantly, legal/regulatory barriers were found to have no effect on the adoption of EHR system in Saudi Arabia. These findings demonstrate that the major challenges facing implementation of EHR system in Saudi Arabia are internal and not external to the healthcare facilities in this country.
Figure 15: Barriers to Adoption of EHR System in Saudi Arabia
Table 11: Barriers to Adoption of EHR System in Saudi Arabia
Barriers to Adoption of EHR System Frequency Percent Valid Percent Cumulative Percent
No. of Respondents who answered this question were 25* Limited funds 10 40 34 34
IT problems 7 28 23 57
Administrative barriers 9 36 30 87
Legal/regulatory barriers 0 0 0 87
Others 4 16 13 120***
Total 30** 120*** 120***
*was the number of respondents who validly responded to the question: “If your answer to Q10 is No, what are the factors preventing you from implementing EHR system?” This figure was used to calculate the percentages.
**was the total of the frequencies. It differs from the total number of respondents because the question allowed the respondents to choose more than one answer.
***the total percentages were more than 100 percent because respondents were allowed to choose more than one answer for this particular question.
Despite the numerous challenges and barriers facing the implementation of EHR system in Saudi Arabia, it is worth noting that the healthcare facilities in the country have started adopting EHR system in their operations. However, the findings show that the most of the implementations have been undertaken in the last five years as 86 percent of the respondents indicated that EHR system was implemented in their healthcare facilities not earlier than 2010. Conversely, 14 percent of the respondents reported that they started seeing EHR system in their practice facilities earlier than 2010 (see illustrations in Figure 16 and Table 12 below).
Figure 16: Year EHR System Was Implemented
Table 12: Year EHR System Was Implemented
Year of Implementation Frequency Percent Valid Percent Cumulative Percent
Valid Before 2010 3 14 14 14
2010 3 14 14 28
2011 3 14 14 42
2012 5 24 14 66
2013 1 5 5 71
2014 5 24 24 95
2015 1 5 5 100
Total 21 100 100
The respondents were also asked if their healthcare facilities had access to loans, grants or government aid to support their EHR system adoption attempts. Significantly, government aid was mentioned 25 times by the respondents accounting to 81 percent; it was followed by grants which were mentioned 12 times (39 percent); and finally loans which was mentioned 8 times (26 percent) (as shown in Table 13 and Figure 17). Interestingly, as noted earlier, limited funding was reported by the respondents as leading contributor to low level of adoption of EHR system in their healthcare facilities. Thus, it can be deduced that the loans, grants, and government aid offered to healthcare facilities in Saudi Arabia are not adequate.
Figure 17: External Support for EHR System Adoption
Table 13: External Support for EHR System Adoption
External Support for EHR System Frequency Percent Valid Percent Cumulative Percent
No. of Respondents who answered this question were 31* Loans 8 26 26 26
Grants 12 39 39 65
Government Aid 25 81 81 146***
Total 35** 146*** 146***
*was the number of respondents who validly responded to the question: “Does your practice have access to any of the following towards implementation of the EHR system?” This figure was used to calculate the percentages.
**was the total of the frequencies. It differs from the total number of respondents because the question allowed the respondents to choose more than one answer.
***the total percentages were more than 100 percent because respondents were allowed to choose more than one answer for this particular question.
For the respondents who have been using EHR systems in their professional practice, the research findings indicate that most of them have little experience in using EHR system. As indicated in Figure 18 and Table 14 below, analysis of the data revealed that majority of healthcare professionals (76 percent) who are currently using EHR systems have less than four years experience while a few (6 percent) have been using EHR systems for more than ten years in their professional practice. Six respondents (18 percent) reported that they had been using EHR systems in their practice for 5-9 years. These findings are consistent with the fact that the most of the adoptions of the EHR systems in healthcare facilities in Saudi Arabia have been undertaken in the last five years, and the fact that there is generally low level of adoption of EHR systems in this country.
Figure 18: Experience of Healthcare Professionals from Saudi Arabia in Using EHR System
Table 14: Experience of Healthcare Professionals from Saudi Arabia in Using EHR System
Experience in EHR systems Frequency Percent Valid Percent Cumulative Percent
Valid 1-4 years 25 76 76 76
5-9 years 6 18 18 94
10 or More years 2 6 6 100
Total 33 100 100
Although a small percentage of the healthcare professionals (2 percent) reported that they were not comfortable with computer technology, it nonetheless confirmed that the earlier findings that the implementation of EHR systems in Saudi Arabia is hampered by IT problems. Majority of the healthcare professionals (55 percent) reported that they were very comfortable with computer technology while 43 percent stated that their level of comfort with computer technology was satisfactory (see Figure 19 and Table 15 for illustrations). In general, the healthcare professionals in Saudi Arabia are computer literate and therefore, could efficiently and effectively use the EHR system in their practice.
Figure 19: Level of Comfort with Computer Technology among Healthcare Professionals in Saudi Arabia
Table 15: Level of Comfort with Computer Technology among Healthcare Professionals in Saudi Arabia
Level of Comfort with Computer Technology Frequency Percent Valid Percent Cumulative Percent
Valid Very Satisfactory 29 55 55 55
Satisfactory 23 43 43 98
Not Comfortable 1 2 2 100
Total 53 100 100
However, the ability of the healthcare professionals to use the EHR systems effectively and efficiently could be hampered by the fact that a significant number of them have no training in the use of the EHR system. As indicated in Table 16 and Figure 20 below, the findings established that 40 percent (21 respondents) had received no training in the use of EHR system while majority of the healthcare providers (27 respondents which accounted for 51 percent) had received less than 10 hours of training in the use of EHR system. Four respondents (8 percent) reported that they had received a more than 10 hours training in the use of EHR system while 1 respondent (2 percent) noted that he had undertaken training in the use of EHR system through voice recognition session which lasted for 1-2 hours.
Figure 20: Duration of Training in the Use of EHR System for Healthcare Providers in Saudi Arabia
Table 16: Duration of Training in the Use of EHR System for Healthcare Providers in Saudi Arabia
Period of Training in EHR System Frequency Percent Valid Percent Cumulative Percent
Valid More than 10 hours 4 7 7 7
Less than 10 hours 27 51 51 58
No training 21 40 40 98
Other 1 2 2 100
Total 53 100 100
It is also interesting to understand the source of training for healthcare providers in Saudi Arabia. Majority of the healthcare providers (22 respondents accounting for 45 percent) in this country were noted to be receiving their training in the use of EHR systems from other practice staff who already have knowledge and experience in EHR systems. Training by vendors of EHR systems or from practice trainers accounted for 22 percent while 33 percent did not receive any training (see illustrations in Figure 21 and Table 17 below). These figures are consistent with the fact that a significant number of healthcare facilities in Saudi Arabia (as earlier shown in Figure 8 and Table 9) are not using EHR systems due to many factors such as IT problems.
Figure 21: Source of Training for Healthcare Providers in the Use of EHR System
Table 17: Source for Healthcare Providers in the Use of EHR System
Source of Training in EHR System Frequency Percent Valid Percent Cumulative Percent
Valid Training by Vendor or Practice Trainers 11 22 22 22
Training from Other Practice Staff 22 45 45 67
No Training 16 33 33 100
Other 0 0 0 100
Total 49 100 100
The respondents were also asked described how they typically documented patients’ notes in their practice facilities. As shown in Figure 22 and Table 18 below, most of the respondents (63 percent) noted that they documented patients’ notes during their encounter with the patients while a significant number (37 percent) reported that they documented patients’ notes after the encounter with the patients.
Figure 22: Time at which Healthcare Providers in Saudi Arabia Document Patients’ Notes
Table 18: Time at which Healthcare Providers in Saudi Arabia Document Patients’ Notes
Time at which Patients’ Notes are Documented Frequency Percent Valid Percent Cumulative Percent
Valid During the encounter 32 63 63 63
After the encounter 19 37 37 100
Total 51 100 100
Interestingly, the findings on how often the healthcare providers in Saudi Arabia print out a Patient Visit Summary Report from the EHR for a patient at the end of the patient’s visit indicate that the providers could be experiencing difficulties in the usage of the EHR system. The findings indicated that only 25 percent of healthcare professionals do always print out a Patient Visit Summary Report from the EHR for the patients. A large majority (43 percent) never do this while 22 percent of the healthcare providers reported that sometimes they do print out the summary reports. Five respondents (10 percent) reported that they did not know. The large number of healthcare providers who sometimes or never print out the summary report from the EHR for their patients could be attributed to the significant number of providers (37 percent; see Figure 23 and Table 19) who document patients’ notes after the encounter. In addition, the large number of this group of healthcare professionals could be attributed to the lack of training in the use of EHR system which could have led to difficulty in how to use the system.
Figure 23: How Often Patient Visit Summary Report is Print out from EHR for Patients
Table 19: How Often Patient Visit Summary Report is Print out from EHR for Patients
How often summary reports are printed out from EHR system Frequency Percent Valid Percent Cumulative Percent
Valid Always 13 25 25 25
Sometimes 11 22 22 47
Never 25 43 43 90
Do not know 5 10 10 100
Total 51 100 100
4.6 Perceptions of Healthcare Providers in Saudi Arabia Regarding EHR System
4.6.1 Perceptions of healthcare professions in Saudi Arabia Regarding the Quality of EHR System
As illustrated in Figure 24 below, the perception of the respondents was sought regarding the quality of EHR system they were using. Majority of the respondent stated that the instructions and prompts in EHR system are helpful as 56 percent of the respondents reported that the instructions and prompts were helpful either most of the times or always/almost always. A significant percentage (12 percent) stated that the instructions and prompts were never/almost never helpful. In terms of downloading and uploading files into the EHR system, the majority of the respondents (35 percent) noted that most of the times it was easy while a significant number (29 percent) reported that it was always/almost always easy to upload and download files from the EHR system. Nevertheless, 10 percent thought it was never/almost never easy to upload and download files from the EHR system.
The respondents further noted that they were confident using the EHR system. Majority of the respondents (42 percent) stated that always/almost always felt confident while using the EHR system, while 23 percent reported that most of the times they felt the same. On the other hand, 13 percent and 4 percent said they never/almost never and sometimes respectively, felt confident while using the EHR system. However, majority of the healthcare providers in Saudi Arabia noted that they had difficulties restarting the EHR system whenever it stops. For instance, 22 percent of the users of EHR system noted that it is never easy to restart while 24 percent noted that sometimes it is not easy. This is comparable to 14 percent who noted that it was always easy to restart the EHR start if it stopped and 24 percent reported that most of the times it was easy to restart.
On the other hand, majority of the respondents thought the EHR system tends to respond quickly during usage. Of the 52 respondents who completed this question, 23 percent noted that it always responded quickly, 35 percent stated that most of the times it did, 13 percent did not know whether it did or not, 17 percent noted that sometimes it did, and 12 percent said it never did. Moreover, the healthcare providers (35 percent) noted that the EHR system never seemed to disrupt they way the normally arranged their work. In addition, 33 percent felt that the software sometimes did seem to disrupt how they usually arranged their tasks. Only 4 percent reported it always seemed disruptive to the normal task arrangements.
Equally, the respondents were positive in the perception of the menus or lists of information on the EHR system which majority (33 percent) thought were logical most of the times, 25 percent felt they were always logical. Nevertheless, 15 percent felt the organization of the menus on the EHR system never seemed logical.
Significantly, majority of the healthcare professionals (37 percent) noted that it was always easy to negotiate the system while 24 percent stated that most of the times it was easy to negotiate the various menus on the EHR system. Again a significant number (14 percent) felt it was never easy to move from one part a task to another while using the EHR system.
Nevertheless, most of the healthcare providers felt that the EHR system is easy to use 45 percent reported that they never found it difficult to remember how to perform certain tasks while using the EHR system. Only 4 percent noted that they always found it difficult to remember some of the ways of performing tasks. Similarly, 45 percent stated that they never sought for assistance when working with the EHR system; 47 percent felt that the EHR system never worked in ways that were difficult to understand while 24 percent reported that the contents of the EHR system were usually clear and legible. However, 22 percent stated that the contents of the EHR system were never clear and legible.
The healthcare providers also found the EHR system to be reliable and convenient. More than 50 percent of the respondent stated that they either always or most of the times could count on the EHR system to be up and available. Similarly, 24 percent reported that they have experienced operational problems like crashes while using the EHR system; however, 35 percent noted that they sometimes encounter operational problems while using EHR system. Most healthcare professionals (39 percent) found the EHR system to be always successful in completing tasks. Nevertheless, a significant number (14 percent) found the software never successful in task completion while 16 percent could never count on the EHR system to be up and available.
Figure 24: Perceptions of the Healthcare Providers about EHR System Quality
4.6.2 Perceptions of Healthcare Providers Regarding Information Quality of EHR System
The questionnaire also sought to understand the perception of healthcare professionals using EHR systems in Saudi Arabia regarding the accuracy and timeliness of information retrieved from the EHR system. As illustrated in Figure 25 below, the research findings established that healthcare professionals in Saudi Arabia who are using EHR system are satisfied with the information quality of EHR systems. For instance, majority of the respondents (40 percent) reported that the EHR system always provides them with all the information they need about the patient. 22 percent reported that most of the times the got the information they needed about their patients. However, a significant number (12 percent) noted that the EHR system never provided them with the all the information they needed about their patients.
On the question of whether EHR system screen provided a lot of extra information that were unnecessary, a significant number of the respondents (28 percent) noted that this was not the case. 44 percent reported that sometimes this was the case. Nonetheless, 6 percent stated that this was always the case. Furthermore, majority of the respondents (51 percent) stated that EHR system never had inaccurate information; 24 percent said sometimes it did have inaccurate information while 6 percent that it always did.
Although most of the respondents (36 percent) were in agreement that the information displayed by EHR system was always relevant to patients’ care, a significant number (14 percent) disagreed by noting it that the information was never relevant to patients’ care. Nevertheless, the respondents (42 percent) affirmed that the system allowed them to access information quickly; 22 percent agreed that most of the times this was the case while 14 percent disagreed by asserting that the system never allowed them to access relevant information faster enough.
The healthcare providers (34 percent) reported that the EHR system always provided them with up to date information on patient care; 24 percent concurred by noting that most of the times this was the case. Significantly, 14 percent had contrary opinion when they stated that the system never provided them with updated information. The respondents (36 percent) further asserted that the information in the EHR system was always presented in a useful format; 26 percent agreed by reporting that this was the case most of the times. Nonetheless, a significant number (14 percent) stated that this was never the case.
Healthcare providers (34 percent) also agreed that the information provided by EHR system had always included the level of detail they needed. 30 percent said this was the case most of times, while 20 percent could neither agree nor disagree. However, 12 percent noted that this was never the case. In addition, the respondents (47 percent) disagreed with the statement that the information in the EHR system seemed to disappear or change unpredictably. 22 percent noted that sometimes it did disappear unpredictably. Finally, the respondents were asked to assess whether the information in the help menu was useful. Majority (32 percent) stated it was always useful, 20 percent stated that most of the times it was useful while 14 percent said it was never useful.
Figure 25: Information quality of EHR system
4.6.3 Healthcare Professionals’ Satisfaction with the EHR System
The findings further showed that healthcare professionals in Saudi Arabia are satisfied with the EHR system based on their assessment of the EHR performance as compared to previous routines of accomplishing tasks. As illustrated in Figure 26 below, all the questions in this category received a positive score of 5 (‘easy’). For instance, majority of the respondents (54 percent) reported that EHR system had made it easy for them to improve document histories. In addition, 50 percent thought that EHR system had made it easy to improve on documenting physical examinations. However, there is evident that healthcare professionals in Saudi Arabia are experiencing difficulties in using EHR system since 16 percent and 20 percent had experienced some difficulty in improving document histories and improving documentation of physical examinations respectively. This trend is similar with the scoring received by other tasks as at least 20 percent of the respondent reporting that they experienced either ‘no change,’ ‘slight difficult,’ or ‘difficulty,’ while using EHR system to perform what they had previously performed manually.
Figure 26: Users’ satisfaction with the EHR system
4.6.4 Benefits of the EHR System as Perceived by Healthcare Professionals in Saudi Arabia
The respondents also agreed that EHR system has been beneficial to their professional practice. As illustrated in Figure 27, majority of the healthcare professionals agreed with the benefits of EHR system such as time saving, improve efficiency and effectiveness, ease of completing tasks, and improvement in healthcare provision. This is evidenced by the fact that majority of the questions in this category received positive rating of more than 50 percent. On the other hand, in what was consistent with response to other questions, some of the respondents disagreed with the statements assessing the benefits of EHR system to their work performance and practice in general. Negative response to the benefits of EHR system received at least 10 percent, which is an indication of the significant number of healthcare professionals who are finding it difficult to use EHR system or have negative perceptions and attitudes towards EHR system in their professional practice.
Figure 27: Benefits of the EHR system
4.6.5 Perceptions of Healthcare Professionals about Service Quality of the EHR System Service Providers
The respondents were also questioned about their satisfaction with the services they received from EHR service providers. The findings established that the healthcare professionals in Saudi Arabia are generally satisfied with the services offered by EHR service providers. For instance, the study asked the respondents to rate the nature of promptness with which EHR service providers offer technical support when required by the users of EHR systems. Most of the healthcare providers (65 percent) indicated that they sometimes received prompt services when they require technical support while 25 percent noted that there were always prompt services offered by EHR service providers. Nevertheless, 2 percent stated that they never received prompt services from the EHR service providers (see illustrations in Figure 28).
Figure 28: Timeliness of technical support
Significantly, the respondents added that the technical support provider by EHR service providers could be relied upon. As indicated in Figure 29 below, a significant number of the healthcare providers (41 percent) noted that the technical supports provided by the EHR service providers were always reliable. 49 percent that sometimes the technical supports were reliable. Most importantly, no respondent stated that the technical support was never reliable; however, 10 percent considered the question not applicable.
Figure 29: Reliability of technical support
In addition, the positive perception held by healthcare providers towards EHR service providers was also evidenced in the rating of the service providers’ involvement in the EHR system implementation. As shown in Figure 30 below, high number of the healthcare providers (40 percent) reported that the EHR service providers were always involved in decisions regarding the EHR system implementation while majority (42 percent) noted that the service providers were sometimes involved in decisions relating to the implementation of EHR system in their practice facilities. However, 4 percent reported that they never involved service providers in decision making relating to the adoption of EHR system.
Figure 30: Involvement of Providers in the Implementation of EHR System
As shown in Figure 31 below, 88 percent of the healthcare providers indicated that they would recommend their current EHR systems to others healthcare providers interested in adopting EHR systems in the practice. Although a significant number (12 percent) stated that they would not recommend their current EHR systems, the high percentage of those willing to recommend their EHR systems is proof enough that healthcare professionals in Saudi Arabia are satisfied with and recognise the benefits of EHR system to the practice.
Figure 31: Would you recommend your current EHR system to others
Finally, the respondents were asked about what they would change about their current EHR system given a chance. Although only seven respondents responded to this question, they provided some insightful information about what they consider as some of the challenges affecting usage of EHR system in the practice facilities. Some respondents noted that given a chance, they would introduce digital screening, adopt easier designs, change booking system, make radiographic aspect work independently from the EHR system, and change Arabic words into English words to promote legibility. On the other hand, some respondents felt that nothing should be changed about their current EHR systems.
CHAPTER 5: DISCUSSION & CONCLUSIONS
5.1 Challenges Affecting Implementation of EHR System in Saudi Arabia
The findings of this study present significant insights into the perceived barriers to implementation and adoption of EHR system in Saudi Arabia. Although the study established that the level of awareness about EHR system is high among the healthcare professionals in Saudi Arabia, the significant proportion of the healthcare providers in Saudi Arabia (i.e. 22 percent of the respondents as illustrated in Figure 13 above) who do not know about EHR system should be a cause for alarm since healthcare professionals are the primary users and beneficiaries of EHR system. Nevertheless, the lack of awareness of EHR system among some healthcare professionals in Saudi Arabia can be attributed to the fact that there is low level of adoption of EHR system in the country (as illustrated in Figure 14).
This is consistent with the findings of previous studies which reported that not only do GCC member countries experience low level of EHR adoption, but also encounter a number of challenges associated with implementation of IT in healthcare practice (Alkaiji et al. 2014; Mattke et al. 2015; Mogli 2011). In fact the study has shown that the healthcare professionals who have been using EHR systems in their professional practice have little experience in using the systems. This affirms the fact that the most of the adoptions of the EHR systems in healthcare facilities in Saudi Arabia have been undertaken in the last five years, and the fact that there is generally low level of adoption of EHR systems in this country. Significantly, as of 2011, a partly 5-10 percent of healthcare facilities in the GCC countries had made efforts of adopting high standards heath record management, with even fewer number having adopted basic EHR system (Mogli 2011).
Moreover, the factors attributed to the low level of adoption of EHR system in Saudi Arabia were consistent with those established in past studies in the region and elsewhere. This study established that low level of adoption of EHR system by the healthcare facilities in Saudi Arabia was due to lack of funding, administrative problems, IT problems, and lack of knowledge, respectively (see Figure 15). Significantly, lack of funding was found to be the main factor hindering adoption of EHR system. This is consistent with the arguments made in Mattke et al. (2015) which indicated that lack of investment in IT in the healthcare sector was the main factor hindering adoption of EHR in many countries. In particular, Mattke et al. (2015) reported that healthcare funding by the Gulf region is generally low despite the fact that GCC countries fund much of healthcare needs of their nationals.
Similarly, the outcomes this study supported the findings of similar studies conducted in the region which established that adoption of EHR system in Saudi Arabia is negative influenced by financial factors (i.e. inadequate funding and costs of implementing EHR system); technical factors (lack of training in computers and IT); human factors (i.e. knowledge and behaviours); and organizational factors (i.e. administrative and management issues) (Almuayqil et al. 2015; Alshamari & Seliaman 2014; Hasanian et al. 2014; Khalifa 2013). However, as illustrated in Figure 15, the findings of this study is inconsistent with those of Khalifa (2013) which indicated that legal and political factors were also barriers to adoption of EHR system by healthcare facilities in Saudi Arabia. Considering the fact that the present study was conducted in Saudi Arabia, it can be assumed that the country’s government had improved legal and political framework for adoption of EHR system following the study by Khalifa (2013); thus, the zero score for the legal/regulatory variable.
In addition, the finding of the study which showed that administrative problems are the second most barriers to adoption of EHR system is consistent with the outcomes of previous studies. For instance, previous have demonstrated that the implementation of EHR system is challenged by a number of organizational factors including the change management processes and approaches, leadership, and the individual characters of healthcare facilities and practice environment (Ajami & Arab-Chadegani 2013; Lorenzi & Riley 2004). Similarly, as illustrated by the TOE framework, technological acceptance and usage is dependent on a number of organizational factors such as organizational traits, resources available both human and structural, communication protocol and procedures and the relationship between employees (Tushman & Nadler 1986).
Therefore, the findings demonstrated that the major challenges facing implementation of EHR system in Saudi Arabia are internal and not external to the healthcare facilities in this country. However, there were also some elements of external factors influencing adoption and usage of EHR system in Saudi Arabia. For instance, as reported in a large body of research on lack of EHR adoption in most countries (Lorenzi & Riley 2004; Mogli 2011), this study affirmed that lack of training is a major barrier to EHR adoption in Saudi Arabia. The study established that healthcare professionals in Saudi Arabia are lacking training on the use of EHR system, and for those have been trained, the training is minimal and inadequate to facilitate acceptance of EHR system (this is illustrated in Figure 20). Low training is also supported by the fact that most healthcare professionals do not know how to use the system. For instance, the findings on how often the healthcare providers in Saudi Arabia print out a Patient Visit Summary Report from the EHR for a patient at the end of the patient’s visit indicate that the providers could be experiencing difficulties in the usage of the EHR system (see Figure 23).
Interestingly, the main source training in EHR system is peer training. That is, most healthcare professionals in Saudi Arabia receive their training in EHR system from other practice staff while some receive training from practice trainer or vendor (illustrated in Figure 21). As such, there is evidence that healthcare professionals are not presented with adequate training opportunities (Alshamari & Seliaman 2014) as majority of the healthcare providers have too minimal training and experience to be relied upon to adequate train other practice staff. However, while the lack of or inadequate training on EHR system among healthcare professionals could be blamed on lack of training opportunities, it is important to note that personal values and attitudes (as discussed in details below) also influence whether individuals accept training and ultimately accept adoption of EHR in their practice (Al-Harbi 2011; Almuayqil et al. 2015; Mogli 2011).
The working conditions and environment could also be a factor hindering adoption of EHR system by the healthcare facilities in Saudi Arabia. Based on the research data obtained through this study, it was established that the healthcare providers in Saudi Arabia have relatively busy scheduling considering the number of patients that they see per hour in their practice facilities. For instance, majority of the healthcare providers in Saudi Arabia usually see at least three patients per hour. However, some normally seeing as many as 10 patients per hour at their health facilities, a pointer of the workload in the health facilities in Saudi Arabia (see illustrations in Figure 12).
Moreover, the study found that most healthcare professionals in Saudi Arabia work long hours in order to meet the high demand for healthcare services in the country. For instance, it was established that majority of healthcare professionals work for at least 45 hours per week at their respective practice facilities. The high demand for healthcare services and the evidence for overburden healthcare system have been noted in the literature (Parry 2013). While one would expect that such a working environment would serve as a catalyst for adoption of EHR system in order to ease the burden on healthcare service provision (Davidson & Heslinga 2006; Parry 2013; Westra et al. 2008), some studies in Saudi Arabia have noted that healthcare professionals do not have time to seek training on adoption and usage of EHR system (Al Alawi et al. 2014; Khalifa 2013).
5.2 Successes in the Implementation of EHR System in Saudi Arabia
Despite the numerous challenges and barriers affecting adoption of EHR system in Saudi Arabia, a number of positives were noted in the attempts by the healthcare facilities in the country to implement EHR system. One of the positives is that there is a high level of awareness about electronic health records systems among healthcare professionals in Saudi Arabia. This success factor can be attributed to the fact that most healthcare facilities in the country have attempted to adopt EHR system in the last five years (Hasanian et al. 2014; Khalifa 2013; Mogli 2011), and to the fact that EHR system and its benefits to the healthcare practice has been widely studied and reported in the literature (Hillestad et al. 2005; Kellermann & Jones 2013; Mattke et al. 2015). Therefore, like most regions and countries, Saudi Arabia is grappling with numerous health challenges such as a high number of obesity cases across age groups, and a high number of people with chronic lung diseases and heart diseases (Parry 2013), which has heightened the need to seek better healthcare delivery solutions (Mogli 2011).
In addition, the study established that healthcare facilities in Saudi Arabia are receiving significant support from their governments in terms of funding for EHR adoption and implementation. In what is consistent with the assertions of Mattke et al. (2015) to the effect that GCC governments fund and provide most healthcare services for their nationals, this study found that the main source of funding for the implementation of EHR system in Saudi Arabia is government aid. Although grants and loans are also available, they are less common as compared to the government aid (see Figure 17). Although researchers have noted that the GDP allocations for healthcare in Saudi Arabia are relatively lower as compared to those in Western countries (Mattke et al. 2015; Parry 2013), it is worth noting that the Saudi government has undertaken the initiative of developing and implementing world-class EHR system across Saudi Arabia (Parry 2013). For instance, Parry (2013) reported that health representatives from the six GCC countries made a visit to the UK (one of the countries with the highest adoption rate of EHR system) in September 2013 to explore and learn on how the UK experience could be translated to the Gulf States. In addition, Alkraiji et al. (2014) noted that there were positive development in some of the countries in the region (i.e. UAE, Bahrain and Saudi Arabia) where government initiatives to improve adoption of EHR systems in their healthcare facilities are facilitating acceptance and usage of EHR system by healthcare providers.
It is also worth noting that despite the numerous challenges facing adoption of EHR system in Saudi Arabia, such as lack of adequate training, a significant number of healthcare professionals in the country are very comfortable with computer technology. In other words, the healthcare professionals in Saudi Arabia are computer literate and therefore, could efficiently and effectively use the EHR system in their practice. This finding contradicts some of the studies conducted in the region which indicate that the level of computer skills and expertise is generally low (Khalifa 2013). Although technical factors such as lack of training and expertise in using EHR system are some of the challenges hindering adoption of EHR system in the Saudi Arabia (as noted earlier), it is worth noting that a significant percentage of the healthcare professionals in the country (58 percent, as illustrated in Figure 14) were using EHR system.
Moreover, the study has established that the adoption rate of EHR system has increased in recent years. In other words, despite the numerous challenges and barriers facing the implementation of EHR system in Saudi Arabia, the healthcare facilities in the country have accelerated adoption of EHR system in their operations and healthcare delivery. However, the findings show that most of the adoptions have taken place in the last five years as more than 80 percent of the healthcare professionals reported that their practice facilities implemented EHR system not earlier than 2010.
According to Aldosari (2014) the rates of adoption of EHR system was impressive in Riyadh, Saudi Arabia than in other districts in the country. For instance, of the 22 private and non-profit healthcare facilities he investigated, 11 had implemented fully functioning EHR system, 8 were in the implementation process, while 3 were yet to adopt. Although Aldosari (2014) noted that there were significant variations in the level of EHR system implementation across the healthcare facilities investigated as 16 different types of EHR system were being used across the facilities that had implemented the systems, it is important to note that the adoption of EHR system in the Gulf region has been increasing in recent years.
5.3 Perceptions of Healthcare Professionals in Saudi Arabia regarding EHR System
The perception of the healthcare providers in Saudi Arabia in regards to the benefits of EHR system revealed both challenges and successes of EHR adoption in the practice facilities in Saudi Arabia. While majority of the healthcare professionals currently using EHR system pointed to its advantages in facilitating delivery of healthcare services, some were less optimistic of its benefits to their professional practice.
5.3.1 Perceived Ease of Use
The perception of the healthcare professionals was sought regarding the quality of EHR system they were using. The findings indicated a number of key insights regarding the perceptions and attitudes of the healthcare professionals towards EHR adoption and usage in healthcare practice. As noted by DeLone & McLean (2003), an effective and beneficial IT system is one that is characterised by quality system. In other words, an EHR system, like any other IT system, should be reliable, easy to use, flexible, quite responsive, readily available, easy to learn, and more adaptable (DeLone & McLean 2003; Petter et al. 2008; Venkatesh & Davis 2000). Significantly, the study established that healthcare professionals in Saudi Arabia perceived the system attributes of EHR system as beneficial. For instance, the healthcare practitioners noted that the instructions and prompts in EHR system are helpful. In addition, healthcare providers in Saudi Arabia noted that they had no difficulties in downloading and uploading files into the EHR system. This is an indication of the responsiveness of EHR system as perceived by users (see Wang 2008)
Moreover, it was established that healthcare professionals were able to confidently use the EHR system. The level of confident of the healthcare professionals could be attribute to the fact that majority of the healthcare practitioners (98 percent) were comfortable in their usage of computers (as illustrated in Figure 19 above). Further, the high level of confident among healthcare providers in Saudi Arabia is an indication that EHR system is easier to use considering the fact that most of the healthcare professionals reported that they had limited training and experience in EHR use in their professional practice. This finding challenges the arguments presented in Lorenzi & Riley (2004) which assert that healthcare providers see EHR system as cumbersome as opposed to paper-based records and as difficult to learn and adapt.
The positive perceptions of healthcare providers in Saudi Arabia towards EHR system was further illustrated by the fact that a significant majority (60 percent) thought that EHR system tends to respond quickly during usage (see Figure 24). In addition, the healthcare providers (35 percent) noted that the EHR system never seemed to disrupt the way they normally arranged their work. In other words, EHR system is quite adaptable to the work arrangements of healthcare providers in Saudi Arabia. According to Petter et al. (2008), system adaptability is one of the key components of system quality that determines system usage and user satisfaction with an IT system. In addition to system adaptability, the healthcare professionals also found EHR system quite reliable. This is based on the research findings of this study which indicated that healthcare providers were positive in their perception of the menus or lists of information on the EHR system with majority of the healthcare providers (58 percent) noting that the menus on the EHR system were always logical (see Figure 24).
The healthcare providers in Saudi Arabia were also positive about the navigability of the EHR system. The practitioners noted that they always found it easier to navigate and negotiate the system. Furthermore, the healthcare providers found EHR system easy to use as the study established that most healthcare providers in Saudi Arabia did not have difficulty remembering how to perform certain tasks and were able to complete the tasks on their own without asking for assistance. Based on these positive perceptions and attitudes of healthcare providers in Saudi Arabia regarding quality of EHR system (and drawing on the updated D&M IS Success Model (DeLone & McLean 2003)), it can be concluded that EHR system is easy to use and therefore facilitates intention to use and actual usage as well as satisfaction of healthcare providers.
However, considering the fact that not all respondents perceive system quality of the EHR system as beneficial, the views of the minority are worth taking into account in understanding the challenges and successes in the EHR adoption in Saudi Arabia. For instance, a significant number of the respondents (averaging 20 percent, as illustrated in Figure 24 & 26), had negative opinions and perceptions towards system quality of the EHR system. In addition, the healthcare professionals noted that it was always difficult to restart the EHR system whenever it stopped. As consistent with previous studies in Saudi Arabia which found technical factors as some of the major challenges affecting adoption of EHR system by the region’s health facilities (Alkaiji et al. 2014; Khalifa 2013; Mogli 2011), this study has established that some healthcare professionals have negative perceptions towards EHR system usage. Moreover, considering the fact that this question was responded to by almost all the respondents including those that reported earlier that they did not use EHR system in their current practice facilities, it can asserted that the some healthcare providers would reject the system based on these preconceived perceptions and attitudes (Khalifa 2013; Mattke et al. 2015). Nevertheless, such preconceived perceptions and attitudes towards EHR system can be overcome through training as this study has established that majority of those who received training have positive attitudes towards the system quality of the EHR. However, Mattke et al. (2015) note that experience in such countries as UK, Australia, Denmark, and the Netherlands which have seen successful adoption of EHR system, indicate that it is nearly impossible to achieve universal adoption and use of EHR system.
5.3.2 Perceived usefulness and benefits of EHR System
The healthcare professionals in Saudi Arabia also had positive perceptions and attitudes towards the usefulness and benefits of EHR system to their practice. For the healthcare providers were asked to rate the information quality of the EHR system with regards to how it contributes to the success of their practice. Most of the healthcare professionals found the EHR system quite reliable and convenient. More than 50 percent of healthcare providers using EHR system stated that they either always or most of the times could count on the EHR system to be up and available. According to DeLone & McLean (2003), a beneficial IT system should be concise and timely to facilitate users’ ability to complete their tasks. In addition, an IT system should possess other information quality attributes such as better security of information and content, relevance to the user, easily understood by the user, accurate and complete information, and personalised information, for it to be considered beneficial by the users (DeLone & McLean 2003; Petter et al. 2008).
Significantly, the healthcare providers confirmed that most of the attributes of information quality of EHR system were beneficial to their healthcare practice. For instance, the study established that healthcare providers in Saudi Arabia the EHR system had complete information and content which facilitated their healthcare provision as they always got the information they need about the patient and patient care. In addition, the healthcare providers in Saudi Arabia noted that they found the information and content of EHR system accurate and relevant to their healthcare practice. In particular, majority of the healthcare providers considered the accuracy and relevance of the information on EHR system to be beneficial to how they deliver care as the information quality of EHR system allow them to access information about patient easily and faster.
These positive attributes of EHR system as perceived by the healthcare providers in Saudi Arabia are consistent with the finding of Alsahafi (2012) who noted healthcare providers tend to see EHR system as promoting evidence-based practice, as it allows for easy accessibility to patient and support information and enables secure, reliable and timely management of patient information. On the other hand, the findings are inconsistent with the previous studies conducted in Saudi Arabia which argued that one of the challenges facing implementation of EHR system in the countries was perceived technical challenges of EHR system. For instance, Hasanian et al. (2014) and Alshamari & Seliaman (2014) noted that the healthcare providers in Saudi Arabia were concerned about the complex nature of EHR systems as well as about the security of information about their patients. Similarly, the findings of this study are inconsistent with those of Bates (2005) which stated that the adoption of EHR system in the U.S. was hampered by healthcare professionals’ concerns about privacy, time, and maintenance of the system.
Importantly, as some studies conducted in Saudi Arabia have demonstrated, there is generally a high level of awareness of the usefulness and benefits of EHR system among healthcare professionals in the Gulf (Al-Harbi 2011; Khalifa 2013). This study established that most of the healthcare professionals in Saudi Arabia thought that EHR system facilitated their healthcare practice. As illustrated in Figure 26, most of the healthcare professionals using the EHR system were positive about the benefits of the system to how they delivered healthcare to their patients. For instance, some of the benefits reported by the healthcare providers include: improvement in document histories; improvement in documenting physical examinations; improvement in documenting allergies; improvement in documents ICTY and CD9-Codes for bilking purposes; improvement in keeping medication lists updated; improvements in ordering laboratory and radiology tests; improvement in reviewing laboratory and radiology tests; improvement in writing prescriptions; improvement in reviewing prescriptions; improvement in reviewing prescriptions; improvement in monitoring medication safety at the point of prescription (e.g. drug-allergy, drug-drug interactions, etc.); and improvement in monitoring patient medication adherence, among other benefits (see illustration in Figure 26).
Similarly the findings of this study confirms the conclusions made by Al Alawi et al. (2014) who noted that physicians in UAE were generally satisfied with EHR system especially with the orders and results of the radiology and laboratory functions which they considered particularly important components of EHR system. Contrary to Al Alawi’s et al. (2014) study which focused on physicians only, the fact that this study investigated the perceptions of various healthcare professionals regarding the benefits of EHR system to their practice makes the findings of this study significant as they demonstrate that EHR system is perceived as beneficial and useful to various professional practice in the healthcare sector in Saudi Arabia.
Significantly, the findings of this study contradicts that the arguments in previous studies conducted in the US which attribute lack of EHR adoption to healthcare providers’ perception of difficulties to share information with other healthcare providers (Bates 2005; Mattke et al. 2015). According to Bates (2005), most physicians were less optimistic about the benefits and usefulness of EHR system to their practice since the systems lacked interoperability function making difficult to share information across healthcare practice. Mattke et al. (2015) added that GCC countries also lack a robust, interoperable EHR system in their healthcare facilities. However, the findings of this study have established that healthcare professionals in Saudi Arabia consider EHR system as important in improving their communication, especially in communicating referral information from sub-specialist. As such, contrary to the arguments made in Mattke et al. (2015), EHR system has enabled to “talk to each other” and improve coordination of healthcare across different healthcare providers.
The positive perceptions of healthcare professionals in Saudi Arabia about the benefits of EHR system were further illustrated by the fact that most of the practitioners considered the system as time saving, improving efficiency and effectiveness, enhancing task completion and improvement in healthcare provision. While this is consistent with findings of studies conducted in the Gulf region and elsewhere (Al-Harbi, 2011; Hillestad et al. 2005; Khalifa 2013; Mattke et al. 2015), it is also important to point out that a significant number of healthcare professionals in Saudi Arabia are less optimistic about the benefits of EHR system. As illustrated in Figure 27, in what was consistent with response to other questions, some of the healthcare professional felt that disagreed with the statements assessing the benefits of EHR system to their work performance and practice in general. As such, it can be argued that while most healthcare providers in Saudi Arabia see EHR system as beneficial to their delivery of care to patients, there are a few but significant number of healthcare providers who are experiencing problems associating with operating EHR system while providing care.
On one hand, this can be attributed to the technical problems identified earlier in this study as well as in other studies conducted in the Gulf region and elsewhere (Bates, 2005; Hasanian et al. 2014; Khalifa 2013; Mattke et al. 2015). For instance, as the findings of this study demonstrates, a significant percentage of the healthcare providers in Saudi Arabia, 16 percent and 12 percent reported that ‘[they] have to work longer hours to see the same number of patients with the EHR system’ and that ‘using the EHR system has caused disruptions to [their] workflow’ respectively (see Figure 27). On the other hand, this can be attributed to the negative perceptions and attitudes some healthcare providers have towards EHR adoption and usage. For instance, as illustrated in Figure 24, 25, and 26, some of the healthcare professionals were reported earlier to have no idea of what EHR system and to have never used EHR system, felt that the it the information quality and system quality of the EHR system presented a challenge to healthcare practice. Similarly, Bates (2005) reported that most physicians have negative perceptions and attitudes towards EHR system because of time concerns and fear about security and privacy of data, among other concerns.
Nevertheless, it is worth noting that the physicians’ concerns about maintenance of the system and the vendors’ untrustworthiness, as reported by Bates (2005) are not factors hindering adoption of EHR system by the healthcare facilities in Saudi Arabia. On the contrary, this study has established that healthcare professionals in Saudi Arabia are generally satisfied with the service quality they received from their EHR service providers. For instance, the healthcare providers in Saudi Arabia perceived the EHR service providers to be quite responsive when it comes to demand for technical support by the healthcare practitioners. In addition, the nature of technical support provider by EHR vendors and service providers was considered reliable. However, the findings challenges the arguments made in Hasanian et al. (2014) which attributed low adoption rate of EHR system in Saudi Arabia instability of EHR vendors and service providers.
Most significantly, it was established that the EHR vendors and service providers were more involved in the implementation phase of EHR system in the healthcare facilities in Saudi Arabia. This is supported by the findings of Mogli (2011) who established that healthcare facilities in Saudi Arabia were pursuing vendor developed EHR system. However, it can be deduced that the services and supports offered by EHR vendors are focused more on implementation and technical support and less on training of healthcare providers and staff on how to operate and use EHR systems. This argument is supported by the fact that majority of healthcare providers in Saudi Arabia receive their training in EHR system from practice staff while vendors and practice trainers offer a minimal support in terms of training (see illustration in Figure 21).
It is also worth noting that majority of the healthcare providers in Saudi Arabia were willing to recommended their current EHR system to the other healthcare practitioners. As illustrated in Figure 31, 88 percent of the healthcare providers indicated that they would recommend their current EHR systems to others healthcare providers interested in adopting EHR systems in the practice. The 12 percent who felt that they could not recommend their current EHR system to other practitioners demonstrate the fact that some healthcare providers experience technical problems and have negative attitudes towards EHR system and its importance in healthcare practice.
However, the fact that an overwhelming majority asserted that they would recommend their current HER system is evidence enough that healthcare professionals in Saudi Arabia are satisfied with and recognise the benefits of EHR system to the practice. Significantly, this evidence challenges the previous studies that have attributed the low adoption of EHR system in Saudi Arabia to social and human factors such as negative behaviours, beliefs, attitudes and perceptions (Hasanian et al. 2014; Khalifa 2013). The study shows that healthcare professionals who are currently using EHR system are quite positive about their benefits and importance to the healthcare practice. However, it could be the negative behaviours, attitudes, perceptions, and beliefs are associated with healthcare professionals who are yet to encounter, adopt or use EHR system in their professional practice.
CHAPTER 6: SUMMARY, RECOMMENDATIOINS AND FUTURE RESEARCH
6.1 Summary
This study focused on the challenges and successes in the adoption of EHR system in the healthcare facilities in Saudi Arabia by focusing on the perceptions of healthcare providers in the country. To achieve this objective, the research employed quantitative research methods to obtain quantitative data from a group healthcare professional in Saudi Arabia. The research data were analysed and presented using descriptive statistics as illustrated in chapter four of the dissertation report. Based on the research findings and the discussion presented in chapter 4 and 5 respectively, a number of inferences and conclusions can be made to inform future research on EHR adoption in Saudi Arabia and elsewhere.
One of the conclusions that can be drawn from this study is that the healthcare providers in Saudi Arabia generally have positive perceptions and attitudes towards EHR systems and their benefits to healthcare practice. Although there are a significant number of healthcare professionals who have negative perceptions and attitudes towards EHR systems and their benefits, it is important to note that most of the healthcare professionals who have had encounter with EHR systems in their practice consider the systems beneficial to their healthcare practice. As a positive factor in the implementation of EHR system, this is an indication that increased adoption of EHR system by healthcare facilities in the country could facilitate increased acceptance and usage of the systems in delivering better and effective care to patients in Saudi Arabia.
The study has shown that healthcare professionals in Saudi Arabia perceive EHR system as beneficial to their practice. For instance, most of the healthcare providers in Saudi Arabia felt that EHR systems help them improve on patient care, deliver better and effective care for patients, save time, facilitate convenience in healthcare practice, and promote security and access of patient data. In other words, the healthcare providers in Saudi Arabia demonstrated that they were significantly satisfied with the system quality, information quality, and service quality attributes of EHR system. Therefore it can be argued that EHR system is perceived by healthcare providers in Saudi Arabia as beneficial to the healthcare providers, patients, healthcare facilities, and by extension, the societies in the GCC countries at large.
Significantly, the positive perceptions and attitudes of healthcare providers in Saudi Arabia towards EHR adoption can be attributed to a number of success factors in the country. For instance, it is noted that there is significantly high level of awareness among healthcare providers in Saudi Arabia about EHR system and its benefits. While one may attribute the high level of awareness in the country to the significant attention EHR system has received in both research and practice, it is worth noting that the country has experienced some positive developments in the adoption of EHR system in recent years. For instance, the healthcare facilities in the country have experienced significant uptake of EHR system in the last five years as more and more facilities have either adopted or are in the process of adopting EHR systems.
The increased adoption of EHR system in recent years as well as the positive attitudes and perceptions of EHR system among healthcare providers in Saudi Arabia can also be associated with the fact that a significant number of healthcare professionals in the country are very comfortable with computer technology. That is to say, the ability of healthcare professionals in Saudi Arabia is relatively high, something that can be positively related to increased adoption of EHR system in last five years since implementation of EHR system would require that staff and healthcare professionals are trained and sensitize on the benefits of the system in order to enhance implementation success rate.
In addition to the high level of awareness of EHR system and its benefits to healthcare practice, the positive perceptions and attitudes of healthcare providers in Saudi Arabia can also be attributed to the significant role of the government of Saudi Arabia. As illustrated by the research findings and literature, the healthcare facilities in Saudi Arabia are highly dependent on the government for infrastructure and financial support. As such, a large proportion of EHR systems adopted by hospitals in the country can be attributed to the government support. Therefore, it can be concluded that the positive perceptions and attitudes of healthcare professionals in Saudi Arabia are positively correlated with the Saudi government’s initiatives to introduce and improve the use of EHR systems in their hospitals. This is because, in recent years, the government of Saudi Arabia has been focusing on the implementation of world class IT systems in their respective healthcare facilities, something that forces them to sensitize and enlighten staff and healthcare providers about the EHR system and its benefits. Importantly, this is supported by the fact that the increased governmental initiatives and supports for EHR adoption have been positively influencing adoption of EHR system in the last five years.
On the other hand, it is worth noting that there are a number of challenges and barriers that are influencing adoption of EHR system as well as the perceptions and attitudes of some of the healthcare professionals in Saudi Arabia. Even though the study demonstrated that there is a high level of awareness of EHR system among healthcare providers in Saudi Arabia, there are a small, but significant number of healthcare providers who are not aware of EHR system and its benefits. Similarly, the study established that there are a small, but equally significant number of healthcare providers in Saudi Arabia who have negative perceptions and attitudes towards EHR system and its benefits. This is not only worrying considering the fact that healthcare professionals are the primary users and beneficiaries of EHR system, but also demonstrates the challenge of EHR adoption in Saudi Arabia.
One could argue that these negative experiences have been caused by the late adoption of EHR system in Saudi Arabia or by the fact that there is still low level of EHR adoption despite increased efforts in the last five years. This argument is support by the findings of this study which have demonstrated that the healthcare professionals who have been using EHR systems in their professional practice have little experience in using the systems. In addition, there is low level or minimal training received by healthcare providers in Saudi Arabia which is noted as a significant factor in the adoption of EHR by healthcare facilities in the country. The low of level of training is attributed to technical factors as well as negative attitudes and behaviours towards EHR system which influence acceptance of training and ultimately, whether individual healthcare providers use the EHR system effectively and efficiently.
Moreover, the implementation of EHR system in Saudi Arabia is hampered by lack of adequate funding, administrative problems, technical factors, and lack of knowledge. Although the Saudi government has accelerated the EHR adoption efforts in recent years, funding was found to be a major issue affecting the adoption of EHR system and therefore may have a negative impact on how staff and healthcare providers perceive EHR system. The fact that healthcare facilities in Saudi Arabia are heavily dependent on government funding for delivery of healthcare means that they are incapacitated in their attempts to implement EHR into their healthcare system. As such, this creates an impression that EHR systems are expensive to acquire, implement, and maintain. This is further complicated by administrative problems which, as established in this study, mean that healthcare professionals do not trust their leaders to facilitate the adoption of EHR system.
The working conditions and environment could also be a factor hindering adoption of EHR system by the healthcare facilities and influence perceptions and attitudes of healthcare providers in Saudi Arabia. This study has established that the healthcare providers in Saudi Arabia have relatively busy scheduling considering the number of patients that they see per hour in their practice facilities. Moreover, the study found that most healthcare professionals in Saudi Arabia work long hours in order to meet the high demand for healthcare services in Saudi Arabia. While these working conditions confirm the arguments present by previous studies which indicate that Saudi Arabia is grappling huge demand for healthcare services, it also worth noting social and cultural issues could be factors influencing the busy schedule of most healthcare professionals and their attitudes towards EHR system. That is, because most people in this region prefer more interactional encounter with their patients, they would take much long hours interacting with patients and would see EHR systems as a hindrance to healthy interaction with and deliver of care for patients.
6.2 Recommendations
Based on the challenges facing the adoption of EHR system in Saudi Arabia, this study has chosen to offer recommendations for the improvement of EHR adoption and healthcare delivery in the country, as one of its objectives. One of the recommendations of this study is that Saudi government should increase funding support for healthcare facilities in the country in order to enhance EHR adoption. This can be achieved by increasing budgetary allocation to healthcare since the healthcare facilities in the country are heavily dependent on their respective governments for financial support. In addition, the government of Saudi Arabia should put more efforts in enhancing the capacity of their healthcare facilities to implement EHR system. Apart from providing financial support, the governments could also achieve through infrastructural support that enable individual healthcare facilities to build reliable and robust IT infrastructure.
Since implementation of new ideas or technologies in any organization would be hindered by resistance of staff and employees, it is important that those tasked with implementing EHR system in healthcare facilities in Saudi Arabia adopt effective change management approaches in order to succeed. The project managers as well as the implementation teams will need to adopt good communication approaches in order to avoid uncertainty that might lead to change resistance. As recommended by Daigrepont & McGrath (2011), an effective communication plan should be able to address staff requirements, project vision and objectives, and project milestones. There is also a need to involve healthcare providers and staff in the adoption of EHR system in order to avoid change resistance and improve EHR acceptance and usage.
As noted in this study, some of the healthcare providers in Saudi Arabia are experiencing technical problems and find it difficult to properly use EHR system. For this reason, it is recommended that project managers and those tasked with implementing EHR system should focus on providing adequate and relevant training before, during, and after implementation of EHR system to enhancing acceptance and use of the system by healthcare providers. Since the study established that majority of healthcare providers in Saudi Arabia receive training from practice staff, it is recommended practice staff and colleagues should be empowered to deliver quality and better training. This is because studies have shown that involving colleagues in staff training enhances level of individual participation and technology acceptance (Nistor, Baltes, & Schustek 2012).
Moreover, there is a need for EHR vendors to take into varied needs of healthcare providers across healthcare facilities and across country. This is important because healthcare providers are faced with different and unique experiences in the practice. In essence, EHR vendors need to customise the EHR system to the needs of an organization or group of healthcare providers based on social and cultural factors. For Saudi Arabia EHR market, the EHR vendors may consider introducing digital screening, adopting easier designs, changing booking system, making radiographic aspect work independently from the EHR system, and changing Arabic words into English words to promote legibility – as recommended by some of the healthcare providers in Saudi Arabia.
Finally, the leadership and management of healthcare facilities in Saudi Arabia need to improve on the administration and management approaches in order to inspire healthcare providers and other staff to accept and use EHR system. as the study established that administrative problems were significant barriers to adoption of EHR system, having more proactive and transformational leadership would be essential in facilitating adoption and acceptance of EHR system in Saudi Arabia. It is not only necessary for top management and leadership to demonstrate an unwavering support for the implementation of EHR system as well as an awareness of the limitations and capabilities of EHR system, they would also need to communicate IT strategy of their individual organizations to all staff and healthcare providers in order to enhance successful implementation and adoption of EHR system.
6.3 Limitations and Future research
This study has made significant contribution to research and practice. Not only will the findings of this study inform future research, they will also inform and improve healthcare practice especially the adoption of IT by healthcare professionals in Saudi Arabia. However, the reliability and relevance of the findings of this study to future healthcare practice is limited by the fact that technology is always changing. That is to say, the positive experiences, perceptions, attitudes, and behaviours of healthcare professionals in Saudi Arabia may change over the next years and influence level and rate of EHR adoption due to changes in existing processes and systems. Similarly, the negative perceptions, behaviours, attitudes, and experiences of some healthcare professionals in Saudi Arabia may change as new and easier to IT systems and processes are introduced and adopted in healthcare practice. For instance, the emergence of SGH We Care App is expected to influence how patients interact with healthcare providers in Saudi Arabia. As such, it is recommended that future research consider the changes in the EHR technology and how they influence healthcare practitioners’ perceptions and attitudes towards adoption of the system into healthcare practice. In particular, future studies may need to focus on investigating whether changes in EHR systems influence changes in perceptions of healthcare providers and whether the changes in the system influence rate and level of adoption.
In addition, the scope of this study was limited to Saudi Arabia and how the perceptions of healthcare providers in the country have influenced adoption of EHR system in the country’s healthcare facilities. While the study used quantitative research methods to generate research data that could be generalised to the entire country, the study did not focus on the experiences of healthcare providers in other GCC countries. For instance, the economic growth differences between Saudi Arabia and the other five member countries of GCC means that the region have specific and unique differences in how healthcare providers perceive EHR system and its benefits to healthcare practice. Thus, it is recommended that future studies should attempt to investigate if there are differences in perceptions of healthcare providers in the region towards the adoption of EHR. In particular, researchers may focus on conducting comparative study in order to determine whether there are unique differences in how EHR adoption is perceived by healthcare professionals in each of the six member countries of GCC.
It is also important to stress that this study used quantitative research methods with an aim of obtaining generalisable data. In addition, the use of quantitative research methods and standardised approaches means that the study can be replicated in future and/or in different area with the creation of comparable research outcomes. While the reliance on structured data was suitable for the objectives of this study, the use of convenience sampling may have compromised the representativeness of the sample. It was also difficult to encourage the respondents to complete the online questionnaire as some respondents had limited skills in using computers while others had problems with English language. As such, the true perspective of EHR adoption in Saudi Arabia may not have been captured appropriately. Based on this understanding, future studies may consider adopting qualitative research methods to obtain detailed information about perceptions of healthcare professionals towards EHR system in specific healthcare facilities in Saudi Arabia by observing respondents in their natural setting. Besides, qualitative research methods are highly recommended for investigating people’s and groups’ perceptions of the world and how they construct meaning out of their experiences (Gravetter & Forzano 2012). In addition, use of random sampling technique is recommended for future quantitative research.
Furthermore, as illustrate in the fourth chapter of the dissertation, the researcher summarised the research findings using simple descriptive statistical approaches. In essence, the research findings were summarised into frequencies, percentage, and measures of central tendency, and illustrated in graphs, tables, and charts. Although the descriptive statistics used were appropriate in achieving the research objectives of this study, the study did not conduct correlation analysis to measure the extent to which various variables are related to each other. For instance, the study did not conduct correlation analysis between adoption of EHR system (as an independent variable) and healthcare providers’ perceptions (as dependent variables). Correlation analysis may have provided a clear picture of the factors (from the most significant to the least significant) influencing adoption of EHR system in Saudi Arabia. It is from this perspective that this study suggests that future research may consider conducting empirical research techniques in order to identify variables of interest that can be carefully measured and statistically analysed to determine the extent to which the variables influence each other.
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