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Taibah University
Journal of Taibah University Medical Sciences (2014) -(-), 1e6
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JTUMED95_proof ■ 9 July 2014 ■ 1/6
Journal of Taibah University Medical Sciences
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Original Article 6667
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Physician satisfaction with electronic medical records in a major
Saudi Government hospital
Hana Alharthi, PhD, Adel Youssef, PhD *, Salma Radwan, BS,Sukainah Al-Muallim, BS and Al-Tuwaileb Zainab, BS
Department of Health Information Management & Technology, College of Applied Medical Science,
University of Dammam, Dammam, Kingdom of Saudi Arabia
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Received 20 November 2013; revised 2 January 2014; accepted 5 January 2014
*
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PlTa
صخلملا
بيبطلااضرىوتسمسايقلةساردلاهذهفدهت:ثحبلافادهأديدحتلاضيأفدهتو،ةينورتكلالاةيبطلاتالجسلاماظننعتاذةينورتكلإلاةيبطلاتالجسلابةصاخلاةيدرفلاةفصلا.ماظنلانعبيبطلااضرىوتسمبةلصلا
ةنابتساةئبعتميونتلامسقءابطأنمبلط:ثحبلاقرطنميأديدحتلنوسريبطابترالماعممادختسامتو.ةيتاذ
نعماعلااضرلاعمةيوقةقالعتاذةيدرفلاماظنلاتافصةساردليطخلارادحنالارابتخاقيبطتمتكلذدعب.ماظنلاماعلااضرلاوةنابتساللةسيئرلاتالاجمثالثلانيبةقالعلا.بيبطللةيصخشلاصئاصخللطبضلاةاعارمعمماظنلانع
اضرفلاخو.ةنابتسالاىلعابيبط115باجأ:جئاتنلا.تاعقوتلاةينورتكلإلاةيبطلاتالجسلاماظنببيبطلالكشبماظنلانعنيضارطقفءابطألانم%40ناكثيحماظنللبيبطلااضرنعؤبنتللصئاصخلامهأتناكو.ماعلمعلاريسعمجامدنإلايهو،ةعرسلاةيحاننمماظنلاءادأتامولعمبةصاخلاتقولاو،لامكلاو،ةقدلاكماظنلاتامولعمو.ضيرملا
ماظنلانعنيضارريغماعلكشبءابطألاناك:تاجاتنتسالاةتبثملاةمظنأللرمتسملامييقتلاهجوينأيغبني.تبثملا
Corresponding address: Department of Health Information
nagement & Technology, College of Applied Medical Science,
iversity of Dammam, PO Box 2435, Dammam 31441, Kingdom
Saudi Arabia.
E-mail: [email protected] (A. Youssef)
r review under responsibility of Taibah University.
Production and hosting by Elsevier
8-3612 � 2014 Taibah University. Production and hosting by Elsevi
p://dx.doi.org/10.1016/j.jtumed.2014.01.004
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ease cite this article in press as: Alharthi H, et al., Physician satisfaction with eibah University Medical Sciences (2014), http://dx.doi.org/10.1016/j.jtumed.
ذيفنتوايلبقتسمرايتخالاماظنلايمدختسمنمتاظحالملاو.ةينورتكلإلاةيبطلاتالجسلاةمظنأ
;ءابطألا;ةينورتكلإلاةيبطلاتالجسلا:ةيحاتفملاتاملكلاةيدوعسلاةيبرعلاةكلممملا;ةيموكحلاتايفشتسملا;اضرلا
Abstract
Objectives: The objectives of this study were to measure
physician satisfaction with a recently introduced elec-
tronic medical record (EMR) system and to determine
which of the individual attributes of EMR were related to
physician satisfaction.
Methods: One year after introduction of an EMR sys-
tem, physicians in an inpatient department were asked to
answer a self-administered survey. Pearson’s correlation
coefficient was used to determine which attributes were
significantly related to overall satisfaction with the sys-
tem. Linear regression analysis was then performed to
examine the association between the three main domains
of the questionnaire and overall satisfaction with the
system, with adjustment for physician demographic
characteristics.
Results: A total of 115 physicians answered the survey.
Only 40% were satisfied with the system overall. The best
predictors of overall satisfaction were performance in the
form of speed, integration with workflow, and patient in-
formation, such as accuracy, completeness and timeliness.
Conclusion: Physicians were generally not satisfied with
the system. Continued evaluation of such systems and
feedback from users should guide future selection and
implementation.
er Ltd. All rights reserved.
lectronic medical records in a major Saudi Government hospital, Journal of2014.01.004
H. Alharthi et al.2
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JTUMED95_proof ■ 9 July 2014 ■ 2/6
PleTa
Keywords: Electronic medical records; Governmental hospi-
tal; Kingdom of Saudi Arabia; Physicians; Satisfaction
� 2014 Taibah University. Production and hosting by
Elsevier Ltd. All rights reserved.
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Introduction
Hospitals around the world are using electronic medicalrecords (EMRs) to help health care providers to deliver safer,better care to patients.1,2 EMR systems offer automated
electronic information processing for physicians in theirday-to-day work.3 The extent to which these systems aresuccessful depends strongly on the acceptance of the
physicians regarding the performance of such systems.4,5
Generally speaking, physicians prefer EMRs and considerthat these systems eliminate much paperwork and enhancethe methods by which they monitor their patients’ progress.6
Furthermore, EMR technology offers many benefits, such aslegibility and completeness of medical information anddocumentation, immediate access to information anywhere
at any time, a large clinical database and decision-supporttechniques.7 The introduction of new informationtechnology systems into an organization is certain to
change the workflow,8 and sometimes users are dissatisfiedbecause of problems in using the system that result indelays in ordering and disturb the workflow.9 Several
studies indicate failure of EMR systems due to lack of userinput and lack of evaluation of feedback on use of thesystem.10e12
Despite the drive by the Saudi Government to expand the
information technology infrastructure in the health caresystem, particularly the nationwide transition from paper-based medical records to EMRs, to the best of our knowl-
edge the level and extent of use of EMRs has been addressedin only two studies.2,13 Neither specifically describedphysicians’ views on EMRs. The objective of the study
reported here was to gain a better understanding ofphysicians’ satisfaction with EMRs. We therefore reportthe results of a survey conducted in a local Governmenthospital in Kingdom of Saudi Arabia to identify the
attributes of EMRs that are related to physiciansatisfaction. The results are expected to help decision-makers improve subsequent deployment of EMRs.
Materials and Methods
Study site and setting
This cross-sectional analytical observational study wasconducted in a 360-bed Government hospital in the EasternProvince, Kingdom of Saudi Arabia. The hospital has a
commercially available EMR system provided by the Min-istry of Health, use of which is mandatory in all departmentsof the hospital. The system integrates updated patient in-
formation from EMRs and contains clinical decision supportalgorithms, allowing physicians to use it as central source forordering and reviewing laboratory results. The study wasconducted 1 year after introduction of the system in the
hospital. The physicians eligible for inclusion in the study
ase cite this article in press as: Alharthi H, et al., Physician satisfaction with eibah University Medical Sciences (2014), http://dx.doi.org/10.1016/j.jtumed.
were specialists and general practitioners working in aninpatient department during introduction of the system and
who used the system routinely.
Survey preparation and data collection
The tool used to collect the data was a self-administeredsurvey based on the DeLone and McLean model,14e16
borrowed from the business world to measure the success
of information technology systems and used extensively tomeasure physician satisfaction with EMRs. The survey wasbased on a previously validated survey,17 supplementedwith items selected after a thorough review of the relevant
literature. The survey consists of 31 questions that coverthe user’s sociodemographic characteristics and satisfactionwith the system. It is divided into four domains: the first
(seven items) addresses overall satisfaction with the system,with questions about its performance, preference for paperrecords and preference for a different system; the second
(eight items) addresses system performance quality, withquestions about the ease of use of the system, speed andintegration with the workflow; the third domain (sevenitems) addresses the quality of the information, with
questions about the completeness, accuracy and availabilityof information at the right time; and the fourth domain(three items) addresses service quality, with questions
about introduction of the system and training.The responses were given on a five-point Likert scale,
ranging from “strongly disagree” (1) to “strongly agree” (5).
The reliability of the items was evaluated with Cronbach’salpha, and the values were all above 0.82, indicating satis-factory reliability. The face validity of each item was assessed
by the research team, a practising physician and experts ininformatics. After a pilot test of the survey conducted with 10physicians, some of the questions were reworded andrearranged.
The survey was distributed directly to 220 physicians be-tween 30 March and 25 May 2010 under the guidance of theMedical Director and the head of the information technol-
ogy department. Participation was voluntary, and re-spondents were assured that their responses would remainconfidential. Approval for the study protocol was received
from institutional review boards of both the hospital and theUniversity of Dammam.
Statistical analysis
Summary statistics for the study population were calcu-lated as frequencies and proportions for categorical vari-ables, and means and standard deviations for continuous
variables. Negative statements were reversed. To simplify thepresentation of level of satisfaction, the scale was collapsed,such that responses 4 and 5 were combined into “satisfied”
and 1, 2 and 3 into “not satisfied”. Pearson’s correlationcoefficient was used to determine which individual attributesof the system were significantly related to overall satisfaction
with the system.Mean overall satisfaction was determined byaveraging the answers to the seven questions. The remainingitems on the questionnaire were then correlated with themean overall satisfaction score. Linear regression analysis
was performed to examine the association between the three
lectronic medical records in a major Saudi Government hospital, Journal of2014.01.004
Table 2: Mean responses and agreement with statements on
overall satisfaction with the system. Q2
Mean
score (SD)
Agreement with
the statement
% (No.)
Positively worded statements:
Overall satisfaction with
system performance
3.2 (0.92) 40.0 (46)
Overall satisfaction with
system information
3.4 (0.87) 50.0 (57)
Overall satisfaction with
technical support
3.3 (0.88) 46.5 (53)
Overall satisfaction with
the system
3.4 (0.89) 48.7 (56)
Overall mean of positive
statements
3.3a(0.74) 46.3
b
Negatively worded statementsU:Prefer to go back to paper records 3.3 (1.15) 61.4 (70)
Prefer to use a different system 3.7 (0.92) 90.3 (102)
Benefit to quality of care is
less than expected
3.6 (0.88) 85.1 (97)
Overall mean of negative
statements
3.5a (0.68) 78.9b
Likert scale: 1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neutral,
4 ¼ agree, and 5 ¼ strongly agree.a Difference between overall means, p ¼ 0.01.b Difference between mean proportions, p < 0.001.
Satisfaction with EMR 3
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JTUMED95_proof ■ 9 July 2014 ■ 3/6
main domains of the questionnaire and overall satisfaction,with adjustment for physicians’ demographic characteristics.
An alpha of <0.05 was considered to be statistically signifi-cant. Stata 12 was used for the analyses.
Results
Of 220 physicians who used the system daily in inpatient
departments, 115 were included in the final analysis, repre-senting a 52.3% response rate. Table 1 shows the physiciancharacteristics; 71% were male, 64% were Saudi, and theaverage age was 39.8 years. Of the respondents, 70%
worked in medical departments and 30% in surgicaldepartments. General practitioners and specialists werefairly evenly distributed.
Overall satisfaction
Table 2 shows physician satisfaction with the system.
Only 40% were satisfied with the system; furthermore,61% were willing to totally abandon the system and goback to paper records. Of the physicians surveyed, 90%
wanted to change the system, and 70% of those who didnot want to go back to a paper system wanted to changethis particular system. The mean of negatively stated items
on overall satisfaction with the system (such as going backto paper records, prefer to use a different system) wasgenerally higher than that for positively stated statements(overall satisfaction with the system performance and
system information) (3.5 vs 3.3, p ¼ 0.01). Also, the meanpercentage agreement with negatively stated statementswere higher than that with positively stated statements
(78.9% vs 46.3%, p < 0.001).
Satisfaction with the quality of the system
As shown in Table 3, physician satisfaction with theperformance and quality of information in the system wasmoderate at best. Of the six items on quality of
performance, only two items, “system easy to use” and
Table 1: Survey response rate and demographic characteristics
of participants.
Frequency (%)
Number contacted 220
Responses 115 (52.3%)
Age (years) (mean, SD) 39.8 (9.9)
Sex
Female 33 (28.7)
Male 82 (71.3)
Nationality
Saudi 73 (63.5)
Non-Saudi 42 (36.5)
Years of practice (years) (mean, SD) 12.3 (9.8)
Profession
General 52 (45.2)
Specialist 63 (54.8)
Department
Medical 81 (70.4)
Surgical 34 (29.6)
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Please cite this article in press as: Alharthi H, et al., Physician satisfaction with eTaibah University Medical Sciences (2014), http://dx.doi.org/10.1016/j.jtumed.
“security is acceptable”, were satisfactory to about 65% of
the respondents. About 50% agreed with the statements“features allow me to perform my work well” and “theperformance of the system is reliable”. Fewer than half of
the respondents agreed that “the system is fast” and “thesystem is integrated with my workflow”.
Satisfaction with the quality of information and service
For the seven items assessing information quality(Table 3), just above 60% of the physicians agreed with onlythree items, “the information is accurate”, “relevant” and
“in acceptable format”. Less than half the physiciansagreed that “the information is complete” or “availablewhen needed”.
About half of the responding physicians agreed that the
level of training and level of on-going support were accept-able (Table 3).
Correlations with overall satisfaction
Although overall satisfaction with the system was statis-tically significantly correlated with all the system attributes,the correlations were weak to moderate (range, 0.27e0.57).
Two items, “speed of the system” and “information is up todate”, were highly correlated with overall satisfaction withthe system (r ¼ 0.56, p < 0.001 and 0.57, p < 0.001 respec-
tively). Items that showed moderate correlations with overallsatisfaction were “reliable system performance” (r ¼ 0.5),“completeness of information” (r ¼ 0.53), “accuracy ofinformation”(r ¼ 0.52) and “information available when
needed” (r ¼ 0.52) (Table 3).
lectronic medical records in a major Saudi Government hospital, Journal of2014.01.004
Table 3: Perceptions of system, information quality and system
functionality and correlations to overall satisfaction.Q3
Dimension Agreement
with statement
% (n)
Correlation
with overall
satisfactiona
(r)
System performance quality
Easy to use 64.4 (74) 0.32
Fast (minimal wait between
screen and start-up)
41.7 (48) 0.56
Integrated with the my workflow 47.8 (55) 0.47
Security is acceptable. 65.2 (75) 0.31
Features allow me to perform
my work well.
54.8 (63) 0.27
Reliable performance 51.3 (59) 0.50
System information quality
The information is complete. 45.2 (52) 0.53
The information is up to date. 54.8 (63) 0.57
The information is accurate. 63.5 (73) 0.52
The information is relevant. 63.5 (73) 0.43
Available when needed 49.6 (57) 0.52
The format is acceptable. 61.7 (71) 0.45
Service quality
Implementation process
was acceptable.
61.7 (71) 0.45
Level of training is acceptable. 49.6 (57) 0.31
Level of on-going support
is acceptable.
55.7 (64) 0.30
a p < 0.001.
H. Alharthi et al.4
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In the multiple linear regression analysis, the domains
system quality and information quality remained significantpredictors of overall satisfaction with the system (b ¼ 0.19,95% confidence interval, 0.01e0.36; and b ¼ 0.25, 95%
confidence interval, 0.10e0.41, respectively) after adjustmentfor confounding (Table 4).
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Discussion
One of the most crucial findings of our study was low
overall satisfaction with the system by the majority of thephysicians: 65% expressed general dissatisfaction withEMRs. Furthermore, 61% wished to abandon the system
and go back to paper records, and 90% asked for anotherEMR system. The overall satisfaction of the physicians wassignificantly associated with the quality of information and
Table 4: Multivariate relations between system attributes and
overall satisfaction.
Quality attribute b (SE) p 95% CI
System performance
quality
0.19 (0.09) 0.03 0.01e0.36
System information
quality
0.25 (0.08) 0.004 0.10e0.41
Service quality �0.04 (0.06) 0.53 �0.15 to 0.08
Multivariate linear regression analysis with adjustment for phy-
sicians’ age, sex, nationality and speciality.
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Please cite this article in press as: Alharthi H, et al., Physician satisfaction with eTaibah University Medical Sciences (2014), http://dx.doi.org/10.1016/j.jtumed.
performance of the system. Despite their overall negativeattitude to the system, the physicians acknowledged that
the technology would probably improve the quality ofcare.
The system was considered easy to use by 64% of the
physicians, a finding similar to those of other studies.18,19
Nevertheless, 58% of the physicians were dissatisfied withthe speed of the system, reporting that it took a long time
to move between screens and that the system was slow tostart up. Clinicians in other studies had similarconcerns.20,21
The literature reports conflicting views on the security of
such systems, some physicians considering that they protectinformation well,22,23 while in another study only 30% ofphysicians had a positive view of the effect of computers
on patient privacy.24 In our study, system security was theattribute for which the physicians reported the greatestsatisfaction. They may have considered that individual
health information in this country is generally not abused,whereas in other countries patients with certain diseasesmay be denied jobs or health insurance coverage.
Only 48% of the physicians considered that the system
was integrated well with their workflow, an important factorin overall satisfaction with the system. Cheng et al.8
commented that EMR systems create new workflows,
which may result in human error over time if not properlyintegrated. Many complex technological and social issuesmust be addressed in introducing such systems,25 and a
middle ground must be reached between clinical workflowand software features while not compromising patients’safety or the quality of care.26
Patient information is critical for delivering the best care;however, in our study, the physicians were not satisfied withthe completeness or accuracy of the information: only 45%reported that the information was complete and 64% that it
was accurate. This is surprising, as we would have expectedhigher percentages of the clinicians to report more positiveviews on one of the main advances introduced by
EMRs.24,27,28 Lack of accuracy and completeness ofinformation, as indicated in this study, should alert thehospital management to improve reporting from
departments that provide patient information, such aslaboratory and radiology departments. This includes bothconducting the requested tests without unnecessary delay
and entering accurate, timely results into the system.The screen layout was acceptable to 62% of the physi-
cians, who considered that information was presented in asuitable format. These results are similar to those reported by
researchers at hospitals in the USA.19 Others have found,however, that the screen layout is confusing and difficult tofollow, hindering use of EMRs by physicians.7,22 A user-
friendly screen layout for information not only improvesthe efficiency and productivity of users but also increases thelevel of physician satisfaction and their desire to continue to
use the system.Less than half of the physicians considered that the level
of training was adequate, a percentage similar to those inother studies.21,29,30 Morton and Wiedenbeck pointed out
that younger users found the training adequate because oftheir prior experience with computers.27 Although most ofour study population was young, they were dissatisfied
with their training on EMRs. The physicians in our study
lectronic medical records in a major Saudi Government hospital, Journal of2014.01.004
Satisfaction with EMR 5
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JTUMED95_proof ■ 9 July 2014 ■ 5/6
might also have been experienced computer users butexpected more sophisticated training. Additionally, only
half found that the system support was acceptable.O’Connell et al.31 also found that only 50% of usersconsidered the level of support acceptable. Delayed
support from the information technology department whenneeded can increase physicians’ frustration with the system.Studies have shown that good support by information
technology departments and better collaboration withphysicians improves the success rate of already installedsystems.4,18
When we examined how the three main dimensions of this
study were related to overall satisfaction, we found that thestrongest predictor of overall satisfaction was the quality ofinformation, particularly when it was up-to-date, accurate,
complete and available when needed. This was followed bythe quality of the system itself, particularly that it was fast,reliable and integrated well with the workflow. These find-
ings confirm those of several previous studies that efficient,fast systems that provide useful patient information areessential for physician satisfaction.9,32,33 A user-friendlydesign makes the system easy to use and increases the level
of acceptance and willingness to use it. We found a non-significant association between system support and overallsatisfaction, which was not consistent with the results of
most other studies.20,34 The need for information systemsupport depends on the sophistication of the system andthe number of functions. It is not clear if physician
dissatisfaction in our study with system support was due tothe fact that the system was not sophisticated and had onlybasic functions, which did not require as much support as
in other studies. Future studies of physician satisfactionwith EMRs should include the level of systemsophistication to allow for proper comparisons.
The fact that this survey was conducted 1 year after
introduction of the system may partly explain the overalldissatisfaction of the users, particularly as use of the system ismandatory. User satisfaction might, however, increase over
time as they become more experienced in use of the system.6
To address that issue, a new survey should be conducted. Assatisfaction tends to improve with regard to some aspects of
a system but not others,6 the best strategy for increasingacceptance would be to maximize positive perceptions ofall aspects of the system during its introduction.35
Satisfaction with the system in our study was not associ-ated with the demographic characteristics of the participants,including age, sex, nationality, profession or department,which is consistent with several other studies.6,36e38 This
consistent finding among studies reaffirms the importanceof system attributes such as speed, quality of informationand compatibility with physician workflow in their
acceptance, irrespective of physician characteristics.The two main limitations of this study were that it was
performed in one Government hospital with one EMR
system, and the results may not be generalizable to othertype of hospitals or hospitals with different EMR systems;and only 52% of the eligible physicians participated in thesurvey. Although relatively low response rates are common
in satisfaction surveys, this may have introduced selectionbias. Voluntary respondents to satisfaction surveys gener-ally tend to have more positive or more negative perceptions
of issues.
Please cite this article in press as: Alharthi H, et al., Physician satisfaction with eTaibah University Medical Sciences (2014), http://dx.doi.org/10.1016/j.jtumed.
Conclusions
This study shows that physicians were generally dissatis-
fied with the EMR system and that various aspects of thesystem require improvement. Hospital management andstakeholders such as the Ministry of Health could benefit
from the views expressed by the physicians in this study.Continued evaluation of installed systems and feedback fromusers should guide future selection and introduction of EMR
systems. Despite the huge investment in health informationsystems and the push by the Ministry of Health for wideimplementation of EMRs, the results of this study andothers13 indicate that the choice and introduction of EMR
systems in Saudi hospitals still needs to be improved.
Conflict of interest
The authors have no conflict of interest to declare.
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