Physicians Use of and Attitudes Toward Electronic Medical Record System Implemented at A Teaching Hospital in Saudi Arabia

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1 J Egypt Public Health Assoc Vol. 82 N o.5 & 6, 2007 Physicians Use of and Attitudes Toward Electronic Medical Record System Implemented at A Teaching Hospital in Saudi Arabia Moustafa M M Nour El Din Hospital Administration Division, Health Administration and Behavioural Sciences Dept., High Institute of Public Health, University of Alexandria ABSTRACT The present study aimed at investigating the usefulness of an electronic medical record (EMR) system implemented at a large teaching hospital in the Eastern province of Saudi Arabia. Demographic data, data about physician computer background and experience, level of use of core EMR system functions and physician satisfaction with EMR functions were collected from physicians employed at the target hospital for more than one year (n=142). Results revealed that high percentage of physicians were dissatisfied with EMR system ability to add content, to send messages, to access reference materials and to get timely IT support. Over 75% of physicians indicated positive impact of EMR on work and quality of care. Varying percentages of physicians ( %) never used one or more of the 10 investigated core EMR functions. Multinomial logistic regression showed that satisfaction with the EMR system and experience with computers were significantly associated with the use of EMR. It was concluded that the benefits of the EMR are not fully achieved at the study hospital as many core functions are either unknown or never used by physicians. Improvement of the current EMR training and improvement of key identified aspects of the EMR system are likely to improve physicians use of the system. Corresponding Author: Dr. Moustafa M. Nour El Din Dept. of Health Administration and Behavioural Sciences, High Institute of Public Health University of Alexandria, Egypt.

2 INTRODUCTION Of all the health information technology (IT) in current use, the electronic medical record (EMR) has the most wide-ranging capabilities and thus the greatest potential for improving quality. Research has demonstrated that EMR offer numerous advantages over traditional paper-based systems. Through rapid information retrieval and efficient data management, EMR systems have the potential to improve the quality of patient care and to control costs. This can be achieved through fewer adverse drug events, lower morbidity and mortality rates, seamless continuity of care, greater efficiencies, and lower costs. (1-3) While EMR is considered essential technology for improving efficiency and quality of health care, the high cost of EMR implementation has been a major barrier to widespread implementation of these systems. The major costs in acquiring a computer based-patient record (CPR) system include the costs of hardware, software, networking, ongoing maintenance, installation and training, and opportunity costs. (4) Despite the potential benefits of EMR systems, many attempts at implementing them have failed or met with high levels of user resistance for a variety of reasons which include lack of sensitivity to users suggestions, concerns about security, and the large work flow change that EMR systems bring. Implementations that failed have often been those with which physician users are dissatisfied. (5-7) The usefulness of electronic medical record systems has been evaluated using analysis of actual use, measuring satisfaction of users as satisfaction with a system is related to how useful it is perceived to be, or assessing the functionality of such electronic systems. (8-9) Analysis of actual use of electronic medical records was found to provide more information than user satisfaction or functionality of such records 348

3 systems. When assessing actual use of electronic medical record systems, the frequency of use had been employed as a possible indicator of how well systems are adapted to clinical work because a successful system ought to be used by most doctors for important tasks. (10-11) Many Saudi hospitals are adopting electronic medical records. However, there has been no formal evaluation of the use of these systems in Saudi hospitals. The present study aims at investigating the usefulness of an EMR system implemented at a large teaching hospital in the Eastern province through assessing use and satisfaction of physicians with the system. MATERIAL AND METHODS Setting and EMR System The study was conducted during the period from February 2006 to November 2006 at a University Hospital in Eastern Saudi Arabia. The hospital is a 444-bed teaching hospital which acts as a tertiary care center for the region. In 1997, an Electronic Medical Record (EMR) system Patient1 was implemented in the study hospital. In 2003, Patient1 has been rated by a specialized independent research firm (12), as one of the market leading Electronic Medical Record / Computerized Physician Order Entry (EMR/CPOE). It was also reported that Patient1 supports the largest U.S. public healthcare organizations with EMR/CPOE technology and has the highest usage among physicians of currently available clinical information systems. (12) Misys Healthcare Systems are currently the new owner of Patient1 who renamed it as Misys EMR. (13) At the study hospital, physicians, nurses and technicians are using the system as an integral part of their routine. All orders are subjected to a series of checks including drug allergies and drug interactions. 349

4 Study Design Cross - sectional analytical design. Target Population The target population included physicians working at the target hospital for more than one year. Intern physicians were excluded because they are employed for one or less than one year. Sampling Design The target population was identified through the Human Resources Department. The total number of attending physicians with more than one year of employment was 329. Physicians fulfilling the inclusion criteria were approached through the head of each department and the aims of the study were explained by the investigators. Physicians who accepted to participate (n= 215) were handed the questionnaire. The response rate was 66.0%. There was no significant differences between respondents and non-respondents regarding gender, job title and specialty. Study Techniques 1. Identification of the EMR system functions Exploration of the functions that can be performed by the hospital EMR system was obtained by conducting unstructured interview with the hospital information technology (IT) project manager followed by review of available EMR system documents including the Misys Healthcare Systems web site. (13) 350

5 2. Development and testing of questionnaire: A draft questionnaire was developed based on the identified EMR system functions and review of relevant literature. (14-16) A pre-coded questionnaire was designed to gather the following data: Demographic information about respondents Physician computer background and experience Level of use of core EMR system functions Physician satisfaction with EMR functions Physician overall satisfaction with EMR system The draft questionnaire was distributed to 10 physicians to pre-test the relevance of items, the understanding of questions and the format of the questionnaire. Based on the results of the pre-testing, 4 questions were added, 2 were deleted, and another were 4 reworded for more clarification. The final questionnaire consists of 57 items. Responses of physicians regarding their satisfaction with EMR functions were provided in a 3 point Likert scale: strongly agree, agree, disagree, and strongly disagree. Physicians rated their level of use of each core EMR functions as never, rarely, frequently and always. Physicians rated their overall use of the EMR as infrequent, frequent and very frequent use. Physician were instructed to select Infrequent use if they use EMR for less than 25% of cases and to select Very Frequent use if they use it for 75% or more of their cases. Statistical Analysis Descriptive statistics was performed to describe the characteristics of physicians and physician s attitudes to EMR characteristics. For bivariate analyses, we used Chi-squared test to assess the association of categorical variables. In case of sparse data, the Fisher s exact 351

6 probability was used as indicated. The cutoff value for statistical significance was set as The selected dependent variable in the present study is the 3- categories EMR use by physicians. A multinomial logistic regression model was used to examine the odds of being a frequent user or very frequent user as opposed to infrequent user. Two equations were developed to derive the adjusted odds ratios and their confidence intervals. (17) The adjusted odds ratios (OR) were used to show how physician characteristics are associated with categories of use of EMR. All independent variables that showed p-values less than 0.10 in the univariate analysis were included in the multinomial logistic regression analysis. The number of respondents who were very satisfied with the EMR system was small (7 physicians) which disturbed the calculation of the multivariate model. Consequently, we merged both very satisfied with satisfied to form one group satisfied. Forward stepwise selection of independent variables was performed to identify significant variables contributing to models. All analyses were performed using the Statistical Package for the Social Sciences (SPSS) software, version RESULTS Table (1) shows the distribution of respondents according to age, gender, job title and specialty at the study hospital. Regarding age, the majority of respondents (over 90%) were below 50 years. Males accounted for over two thirds (75.4%) of respondents. Residents constituted 52.1% of respondents. Table (2) shows physicians satisfaction with system information and terminology, screen design, system capabilities and technical support of the EMR system at the study hospital. More than half of physicians (ranging between 53.5% %) agreed to all statements 352

7 except for four statements namely, system facilitates adding content, system facilitates sending messages, availability of support and availability of reference materials. These four statements showed high percentage of physician disagreement as over 50% of respondents disagreed and strongly disagreed to them. Screen design and layout had the highest category mean score (2.80 ± 0.60). Technical support and service had the lowest category mean score (2.28 ± 0.97) which is significantly lower than the other 3 categories (95% CI, ). Table (1): Distribution of the Respondents According to Age, Gender, Job Title and Specialty at the Study Hospital Characteristic Number n=142 Percentage Age < > Gender Male Female Job title Resident Specialist Consultant Specialty Surgery Internal medicine Pediatric Obstetric & gynecology Table (3) shows physicians satisfaction with the effect of EMR on work and quality of patient care at the study hospital. Over 75% of physicians agreed (both agreed and strongly agreed) regarding all statements favoring the positive impact of EMR on work and quality of care. The overall mean score was 2.91 ±

8 Table (2): Satisfaction of Physicians with System Information and Terminology, Screen Design, System Capabilities and Technical Support of the EMR System at the Study Hospital. EMR system characteristic System information and terminology System gives me the information I need Strongly disagree No. % Disagree No. % Agree No. % Strongly agree No. % Templates are well suited to my specialty Terminology is related to performed tasks System increase my ability to add important content Category mean score (95% CI) Screen design and layout Screen organization is clear ± 0.79 ( ) Sequence of screens is clear Screen layout can be easily modified Category mean score (95% CI) System capabilities System facilitates my ability to send massages/reminders to colleagues ± 0.60 ( ) System is fast enough Unscheduled downtime rarely occurs I have never lost important patient information due to hardware malfunction Category mean score (95% CI) 2.78 ± 0.80 ( ) Technical support and service EMR company provides excellent ongoing support and service System reference material are available Category mean score (95% CI) ± 0.97 ( ) Overall mean score (95% CI) 2.66 ± 0.80 ( ) 354

9 Table (3): Satisfaction of Physicians with the Effect of EMR on Work and Quality of Patient Care at the Study Hospital. Statement With EMR, I am able to finish my work much faster than before Strongly disagree Disagree Agree Strongly agree No. % No. % No. % No. % EMR improves my productivity EMR eliminates a lot of paperwork EMR reduces my risk of making errors System has a positive impact on quality of care Mean score (95% CI) 2.91 ± 0.71 ( ) Table (4) shows physician s use of core EMR functions at the study hospital. Out of the 10 examined functions, more than half of physicians were unaware of the availability of three functions namely, providing patient education, analyzing outcome of care, and finding patients with certain characteristics (52.1%, 53.5%, 54.9% respectively). Regarding functions that were never used by physicians, the function updating diagnoses was ranked first (54.9%) followed by providing patient education (32.4%). Entering orders and obtaining results functions were the most commonly used function being always used by 58.5% and 48.6% of physicians respectively. Table (5) shows relationship between physician s usage pattern of the EMR system and six factors at the study hospital. The proportion of physicians older than 50 years was higher among infrequent users than 355

10 among frequent and very frequent users being 18.7% versus, 14.1% and 1.8% respectively. Both specialists and consultants had a higher proportion of infrequent use (43.8% and 25.0% respectively) than for frequent (25.3% and 24.0% respectively) and very frequent use (32.7% and 7.3% respectively). The proportion of physicians who had low experience with computers was higher among infrequent users than among frequent and very frequent users being 43.8% versus, 5.6% and 3.6% respectively. Out of 142 surveyed physicians, 108 (76.1%) were satisfied and constituted 84.5% of frequent users and 78.2% of very frequent users. The difference between infrequent, frequent and very frequent users was statistically significant for three factors namely, job title, experience with computers and overall satisfaction with the EMR system (p = 0.04, p < 0.001, p< respectively). Table (6) shows the results of multinomial stepwise logistic regression. Age, job title, experience with computers and overall satisfaction showed p-values less than 0.10 in the univariate analysis and were entered in the multivariate model. Only two factors, namely, satisfaction with the EMR system and experience with computers were significantly associated with the use of EMR. Satisfied physicians are more likely to be frequent and very frequent users (OR= and respectively). Physicians who rated their experience with computer as average are more likely to be frequent and very frequent users (OR= 17.0 and 20.4 respectively). Physicians who rated their experience with computer as high are more likely to be very frequent users (OR= 25.53). 356

11 Table (4): Physician s Use of Core EMR Functions at the Study Hospital FUNCTIONS Create notes (history and physical exam) Unaware of function No. 18 % 12.7 Never No. % Use of function Rarely Frequently No. % No. % Always No. % Enter orders (lab, radiology, others) Review/obtain lab and radiology results Update diagnoses Review currently received medications Write prescriptions Examine drug interaction when writing prescription Provide patient education Analyze outcome of care of patients groups Find patients with certain characteristics Total* * Total responses of 142 physicians to 10 EMR functions by category of use. 357

12 Table 5: Relationship Between Physician s Characteristics and Usage Pattern of the EMR System at the Study Hospital Factor Physician s usage pattern of the EMR system Infrequent use Frequent use Very frequent use n = 16 n = 71 n= 55 Significance No. % No. % No. % test Age < > X 2 =8.1 p= 0.09 Gender Male X 2 = 4.6 Female p= 0.11 Job title Resident Specialist Consultant Specialty Surgery Internal medicine Pediatric Ob & gyn* Experience with Computers Low Average High FE=9.7 p= 0.04 FE = p= 0.11 FE=27.4 p<0.001 Attendance of EMR training Yes X 2 = 4.3 No p= 0.12 Overall satisfaction Dissatisfied Satisfied Very satisfied FE = Fisher s Exact Probability * Obs & gyn = Obstetrics & gynecology FE = 23.7 p<

13 Table (6): Adjusted Odds Ratios of Significant Factors Associated with Use of EMR at the Study Hospital Characteristics Satisfaction Dissatisfied* Frequent users (vs infrequent users) OR p-value (95 % CI) Very frequent users (vs infrequent users) OR p-value (95 % CI) Satisfied ( ) Experience with computers Low* ( ) Average 17.0 ( ) ( ) 0.03 High 8.18 ( ) ( ) OR = odds ratio, CI = confidence interval. *Reference group DISCUSSION This cross sectional study assessed the usefulness of an implemented electronic medical record (EMR) system through assessing physician usage pattern and satisfaction with the system. Physicians enrolled in the study were all employed for more than one year, thus, they were likely to be familiar with the system. The present study revealed that physicians were unaware of 27.9% of investigated core EMR functions while 20.1% of these functions were never used by physicians (table 4). This indicates that about 48% of the core functions were not utilized by physicians which reduces the usefulness of the implemented EMR system. 359

14 Regarding the pattern of using the system, the present study revealed that high proportion of physicians use the system as an order entry and results reporting system rather than benefiting from the rest of available functions. This is shown as both functions were known to all physicians and were always used by a high proportion of physicians (Table 2). This may be attributed to the presence of a hospital policy which mandates ordering investigations using EMR system. Moreover, functions that are not needed on day to day basis are the least to be used by physicians. For example, finding patients with certain characteristics and analyzing outcome of care of patients groups. The present study investigated the effect of several factors on the use of EMR system using univariate and multivariate techniques. Age, gender, job title and specialty were not significantly associated with the frequency of use of the system. This indicates that such personal factors which are beyond the control of the hospital do not play an important role in the use of the system. These factors were not associated with the use of the EMR system in a study conducted in Norway. (9) The present study revealed that EMR training conducted at the study hospital was not significantly related to frequency of use of the system. This may be attributed to the ineffectiveness of the one day EMR training conducted at the study hospital. The need for a longer period of training and the use of other methods of training should be explored. Studies have explored several teaching methods to clinicians on EMR use including one-on-one training and online tutorial. (18,19) Both methods showed better results than traditional lecturing method that is used at the study hospital. Multinomial stepwise logistic regression showed that two factors were significantly related to using the EMR system, namely, experience 360

15 with computers and overall satisfaction. Regarding experience with computers studies showed that familiarity with computers aresignificant factor with frequent EMR use by physicians. (20, 21) Moreover, a study conducted in US (2001) suggested that users prior computer experience would be more related to systems that resemble Microsoft windows style. (2) Although the user interface of the implemented EMR at the study hospital is character-based that is different from Microsoft windows style, physicians experience with computer was still related to the frequency of use. User satisfaction has been described as essential to the survival of any electronic system. Regarding overall satisfaction, the present study revealed that satisfied physicians with the implemented EMR system at the study hospital are significantly more likely to use the system than dissatisfied physicians. Similar results have been reported in other studies. (2,6-8) Investigating physician satisfaction with different EMR system characteristics was conducted to get more insight regarding important EMR system dimensions that affect physicians satisfaction with the implemented system. Results revealed that high proportion of physicians positively perceived the impact of EMR on work and quality of care. In addition, it was found that the majority of physicians (88.7% agree and strongly agree) were in agreement with the statements concerning the speed of the system. This may be attributed to the design of the system that is based on hierarchical database instead of relational databases which has proven lower response time. (21) Despite the perceived potential benefits to work, physicians were dissatisfied with the ability to add content, send messages, availability of technical support, and availability of reference materials. According 361

16 to a study conducted to evaluate 11 electronic medical record systems including Misys system, the latter system received the lowest rank with regard to content (documentation of patient care) and communication. (15) Technical support and service had significantly lower mean score than the other investigated dimensions (2.66 ± 0.80, SD ). Weak technical support of the system may be attributed to the fact that the system is not maintained and supported by the owner company rather than by a local subcontractor. Improving content, communication and technical support is likely to improve physicians use of the system. The results of the present study may not necessarily reflect the generic issues related to an EMR but, rather, may be merely related to the characteristics of the system implemented at the hospital and its hardware and software components. CONCLUSION AND RECOMENDATIONS The present study revealed that the benefits of the EMR are not fully achieved at the study hospital as many core functions are either unknown or never used by physicians. However, high proportion of physicians were satisfied with aspects of the implemented system and positively perceived its effect on quality and outcome of care. Meanwhile, high proportion of physicians were dissatisfied with certain aspects of the system such as content, communication and technical support. Experience with computers and overall satisfaction were significantly associated with frequency of use of EMR system while demographic such as factors, job title, specialty and attendance of EMR training at the study hospital did not play significant role in physicians use of the system. Information technology training to physicians without prior computer experience and improvement of the current one -day EMR training may improve the use of the system. Improving 362

17 certain aspects of the EMR system such as content, communication and technical support is likely to improve physicians use of the system. REFERENCES 1. Miller RH, Sim I. Physicians' use of electronic medical records: barriers and solutions. Health Affairs 2004; 23(2): Murff HJ, Kannry J. Physician satisfaction with two order entry systems. J Am Med Inform Assoc. 2001; 8: Harrison JP, Palacio C. The role of clinical information systems in health care quality improvement. Health Care Manag ;25: Agrawal A. Return on investment analysis for a computer-based patient record in the outpatient clinic setting. J Assoc Acad Minor Phys. 2002;13(3): Lawler F, Cacy JR, Viviani N, Hamm RM, Cobb SW. Implementation and termination of a computerized medical information system. J Fam Pract. 1996;42(3): O connell R, Cho C, Shah N, Brown K, Shiffman RN. Take N: Differential EHR satisfaction with two implementations under one roof. Journal of the American Medical Informatics Association. 2004; 11: Lee F, Teich JM, Spurr CD, Bates DW. Implementation of Physician Order Entry: User Satisfaction and Self-reported usage patterns. JAMA. 1996;3: Mazzoleni MC, Baiardi P, Giorgi I, Franchi G, Marconi R, Cortesi M. Assessing users satisfaction through perception of usefulness and ease of use in the daily interaction with a hospital information system. Proceddings of the American Medical Information Association Annual Fall Symposium. 1996: Laerum HL, Ellingsen G, Faxvaag A. Doctors' use of electronic medical records systems in hospitals: cross sectional survey. BMJ. 2001; 323: Cork RD, Detmer WM, Friedman CP. Development and initial validation of an instrument to measure physicians' use of, knowledge about, and attitudes toward computers. J Am Med Inform Assoc. 1998;5:

18 11. Sittig DF, Kuperman GJ, Fiskio J. Evaluating physician satisfaction regarding user interactions with an electronic medical record system. Proc AMIA Symp 1999; Health Data management. Vendor ranking on customer satisfaction. Available from: [cited Jan. 15] 13. MISYS HEALTHCARE SYSTEMS. [cited Jan. 15] Available from healthcare.com/ 14. Sittig DF, Krall MA, Dykstra RA, Russell A, Chin HL. A survey of factors affecting clinician acceptance of clinical decision support. BMC Med Inform Decis Mak. 2006;6: Edsall RL, Adler KG. An EHR user-satisfaction survey: advice from 408 family physicians. Fam Pract Manag 2005;12(9): Lærum H, Faxvaag A. Task-oriented evaluation of electronic medical records systems: development and validation of a questionnaire for physicians. BMC Med Inform Decis Mak. 2004; 4: SPSS Inc. SPSS regression models Chicago, IL: SPSS Inc., 2004, P Edmonson SR, Esquivel A, Mokkarala P, Johnson CW, Phelps CL. Using technology to teach technology: design and evaluation of bilingual online physician education about electronic medical records. AMIA Annu Symp Proc. 2005;: Kirshner M, Salomon H, Chin H. An evaluation of one-on-one advanced proficiency training in clinicians' use of computer information systems. Int J Med Inform. 2004;73(4): Loomis GA, Ries S, Saywell RM, Thakker NR. If electronic medical records are so great why aren t family physicians using them? J Fam Pract. 2002; 51: Likourenzos A, chalfin D B, Murphy DG, Sommer B, Davidson SJ. Physician and nurse satisfaction with an electronic medical record system. The Journal of Emergency Medicine. 2004; 27: Oppel A. J. Database demystified.california: McGrow-Hill,

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