FACTORS AFFECTING THE IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS SYSTEMS (EMRs) IN JORDANIAN HOSPITALS BILAL ALI YASEEN ALNASSAR

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1 FACTORS AFFECTING THE IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS SYSTEMS (EMRs) IN JORDANIAN HOSPITALS BILAL ALI YASEEN ALNASSAR DOCTOR OF PHILOSOPHY UNIVERSITI UTARA MALAYSIA 2012

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3 Permission to Use In presenting this thesis in fulfilment of the requirements for a postgraduate degree from Universiti Utara Malaysia, I agree that the Universiti Library may make it freely available for inspection. I further agree that permission for t11e copying of this thesis in any manner, in whole or in part, for scholarly purpose may be granted by my supervisor(s) or, in their absence, by the Dean of Awang Had Salleh Graduate School of Arts and Sciences. It is understood that any copying or publication or use of this thesis or parts thereof for financial gain shall not bc allowed without my written permission. It is also understood that due recognition shall be given to me and to Universiti Utara Malaysia for any scholarly use which may be made of any material from my thesis. Requests for permission to copy or to make other use of materials in this thesis, in whole or in part should be addressed to: Dean of Awang Had Salleh Graduate School ot'al-ts a~icl Scierices UUM College of Arts and Sciences llniversiti Utara Malaysia UUM Sintok

4 Abstrak Sisteln Rckod Perubatan Elckrronik (EMRS) mcrupakan satu aplikasi yang niembolchkan akses dan dapatan scmula da~a sejarah perubatan pcsakit. J'ada masa kini pclaksanaan EMRS hanya mcliputi tidak lebih 50% daripada hospital di Jordan, dan penyelidikan untuk n~engenal pasti faktor utama yang mempcngaruhi pclaksanaan EMRS di Jordan juga adalah terhad. Kajian ini bert~!juan untuk meninjau faktor yang mempcngaruhi pelaksanaan EMRS di hospital di Jordan. Model konsep, disesuaikan daripada Modcl Pencrimaan Teknologi (TAM), yang dibangunkan untuk mcngaitkan Faktor Organisasi (OF) dan Faktor Ciri lndividu (ICF) dengan pelaksanaan EMRS di hospital di ncgara Jordan. Soal selidik tadbir kendiri telah digunakan untuk mengumpul data daripada kakitangan proresional penjagaan kesihatan di dua buah hospital utama yang melaksanakan EMRS sepenuhnya. Penemuan menunjukkan bahawa OF mempunyai hubungan signifikan dengan Tanggapan Kemudahan Pcnggunaan (PEOU) dan Tanggapan Kebcrgunaan (PU), ICF mempunyai hubungan yang signifikan dengan PEOU, hubungan Pengguna - Pesakit mzmpunyai kaitan yang signifikan dengan PU kecuali Autonomi pengguna, PEOU pula mempunyai kesan yang signifikan dcngan PU, PU mempunyai hubungan yang signifikan dengan Sikap terhadap Penggunaan (ATU) kecuali PEOU, dan ATU mempunyai hubungan yang signifikan dcngan Niat Tingkahlaku Penggunaan. Hasil kajian ini menyumbang kepada peningkatan pengetahuan berasaskan tcori tentang penggunaan TAM dalam domain informatik kesihatan. Kajian ini telah menambahbaik model TAM yang menggabungkan PEOU dan PU, dengan mempertingkatan pcmbolch ubah OF dan ICF. Maka. dapatan kajian ini boleh membantu pembuat keputusan dalam merangka s~rategi-strategi pelaksanaan EMRS di Jordan. Kata kunci: Sistem Rekod Perubatan Elektronik, Model Teknologi Penerimaan, Faktor Organisasi, Faktor Ciri Individu

5 Abstract An Electronic Medical Record System (GMRS) is an application that ci~ables access and retrieval of a patient's mcdical history. Currently EMRS implcinentation does not encompass more than 50% of the hospitals in Jordan, and liinited research has been done in Jordan to identify the main factors affecting the implcrnentation of IZMRS. The aim of this study is to explore the factors that affect the EMRS implementation in Jordanian hospitals. A conceptual model, adapted from Technology Acceptance Model (TAM), was built to relate Organizational Factors (OF) and Individual Characteristic Factors (ICF) to EMRS implementation in Jordanian hospitals. Self-administered questionnaires were used to collect thc data from healthcare professionals in two major hospitals that have full implementation of EMRS. Findings indicated that OF has significant relationships with Perceived Ease of Use (PEOU) and Perceived Usefulness (PU), ICF has significant relationships with PEOU, User - Patient relationship has significant relationships with PU with exception of User Autonomy, PEOU has a significant effects with PU, PU has significant relationship with Attitude Toward Using (ATU) exception of PEOU, and ATU has a significant relationship with Behavioural Intention to Use. The finding of this study has led to the enhancement of the theoretical knowledge of TAM'S application in the health informatics domain. This study has extended the current model comprising PEOU and PU, by adding the 01; and 1CF. Consequently, the findings can assist decision makers in formulating EMRS implementation strategies in jordan. Keywords: Electronic Medical Record System, Technology Acceptance Model, Organizational Factors, Individual Characteristic Factors

6 Acknowledgement In the name of Allah and Ilis mercy, Lhe more you learn. the more you realize how little you know. We come to undcrsland that our accomplisl~ments are not possiblc without the help of Allah. The following arc just a few of the countless people who have helped me to complctc my Ph.D. studics. This research project would not havc becn possible without thc support of many people. First I wish to cxpress my gratitude to my supervisor, Dr. Mohd Syazwan Abdullah who has been very helpful and offcrcd invaluable, support and guidance. Deepest gratitude is also due to Associate Profcssor Dr. Wan Rozair~i Bt Sheik Osman. I am very grateful to my father Ali, Shrifa, and my mother, who gavc mc life, my brothers and their sons, Abu Ali, Abrahim, Esam, Yaseen, Jalal, Salam and Moad, who supported me during my study and my sisters and their sons who constantly inspired mc, and had unending faith in me, and nourished my passion for learning. They indulged my endless hours on numerous occasions with memorable conversations and lcssons that have lasted a lifetime. May Allah extend their ages for their good deeds and worship. I had a very fortune to study at UUM College of Arts and Science, for without their assistance, this study would not have been successful. Special thanks also to all my graduate friends from the Information Technology Department for sharing ideas and for their invaluable assistance. I would also like to thank my best friends, Dr. Ahmad, Dr. Omar, Meshal, Rafy, Stam, Dr. Abu Zad and Alaa Eddin. The completion of a Ph.D. program wss only possible because of their support and help. Lastly, I dedicate this thesis to the spirit of my grandmother Mariam and my cousin Samia who died by medical error at the end of 2006, and I thank the Malaysian people for their hospitality.

7 Table of Contents.. I'er.m~ss~on to Use... i Abst~.ak... ii... Abstract Acknowled, clement Table ol Contents List of Tables... x I>ist of Figures... sii... List of Appe~idices... XIII List of Abbreviations... xi\. CHAPTER ONE. INTRODUCTION Background Motivation of the Research Problem Statement Research Questions Research Objectives Scope of the Study Research Contribution Research Strategy Thesis Organization Chapter 1 : Introduction Chapter 2: Literature Review Chapter 3: Research Methodology... I Chapter 4: Data Analysis and Results Chapter 5: Discussion of Results Chapter 6: Conclusion and Future Rescarch CHAPTER TWO. LITERATURE REVIEW Introduction Healthcare Information Technology (HIT) Electronic Medical Record System (EMRs) Types of EMRs 2 3 V

8 2.3.2 Characteristics of EMRs > Functionallt~cs oi kmrs Advantages of EMRs Rcsearch Using Tccllilology Acccptancc Models (1'AMs) Factors Affecting 1:MRs Implemcnlation Organi~ational 1, cadcrship Users Involveinent and Participation Training and Substrate to Learning Iligh Cost of EMRs Implementations User-Patient Relalionship Users' Background of Computers User Autonomy Resistance to New Technology TAM in Healthcare application and EMRs implementation Conclusion CHAPTER THREE. RESEARCH METHODOLOGY Introduction Purpose of Rcscarch Research Procedure Conceptual Model of the Research Hypotheses Formulation Overview of EMRs in KAUH and JH EMRs functionalities in KAUH and JH Hospitals Research Approach Causal vs. Correlation Unit of Analysis... ~ Research Instrumc~~t Development Instrument Scale Items Questionnaire Design Demographics of Study Population and Rcsearch Sampling

9 3.8.5 Calculation of Samplc Si~c and Respotlse Uatc Facc Validity... I Construct Val~dity Convergent Validity Discriminant Validity Pre-Test... I Pilot Iest.....I Survey Administration Data Handling Data Coding Data Screening and Treatment Composite Factors Reliability and Validity of Measuremerlt Items Data Analysis Conclusion CHAPTER FOUR. DATA ANALYSIS AND RESULTS Introduction The Data Quality Data Inspection Visual Inspection Missing Data Normality Assessment Respondents' Profile Exploratory Factor Analysis Reliability Test Validity Testing Construct Validity Convergent Validity Discrim~nant Val~d~ty Statistical Conclusion Validity Correlation Analysis

10 4.7 Multiple Rcgrcssion Analysis I I Iypothcs~s I estlng Summary of I Iypoti~cscs 'l'csting Important Factors I Iypothcscs and Modcl Evaluation Conclusion CHAPTER FIVE. DISCUSSION OF RESULTS Introduction Organizational Factors [hat Affcct EMRs Implcmentation Organization Leadership User Involvement and Participation Training and Substrate to Ixaming High Cost of EMRs Implementation Individual Factors affecting EMRs Implementation User Patient Relationship User Autonomy Resistance to New Technology Perceived Ease of Use Perceived Usefulness Attitudcs Toward Using Organizational Factors Individual Characteristic Factors Important Factors Conclusion 184 CHAPTER SIX. CONCLUSION Introduction Review of Factors Affecting of Implementation EMRs Development of Rescarch Model Based on TAM Validation of the Model Contributions Limitations of the Study

11 6.4 Direction for 1:ulurc Rescal.ch Summary REFERENCES

12 List of Tables Table 2. I I Ahl ill I lealt11ca1.c anti I:hll<h Tahle 3.1 I<chc.i~~.ch l'r.ol,ositio11s \\ it11 Inciep cncic~~t and I>cp cndent \.ariahles , 9.. I able.).- I he liesc~a1.c.11 li! l,nthcse.; Table 3.3 I>itl-erenccs I3ct\\ cell ()~~alitati\. e and (>uantitoti\ c Data Table 3.4 Code and I-actor I>escriptions for PlJ. PEOll and RI Table 3.5 Code and I-actor l>esc~.iptions for OF and 11: Table 3.0 S~r~nrnal-! 01' Sampling Six ~ IKACl I tl a~~d. IH... I06 Table 3.7 Size Sa111ple li)r Given Pop~rlation Size... I07 Table 3.5 Suln~lla~.! ol' Response Rate *fable 3.0 Keliabilit! C'oefticicnt for Multiple Items in Pilot Study 'Table -I. 1 Outliers List Table 4.2 Respnntients I'rnfile Surntllar! Table 4.3 Items [Iropped During E\ploratnry Factor Analysis Table -1.4 Reliabilit? Analpis Table 4.5 Summar!. ol'correlation of Variables Table 4.6 C'orrelatio~ls Matrix Table 4.7 ANOVA Significance of Overall Multiple Regression Relationship Table 4.8 Multiple Regression Analysis for Perceived Ease of IJse... Table 4.0 ANOVA Significance of O\.c.raIl Regression Relatinnsl~ip Table Multiple Regression Anal! sis l'or Perceived Uscfi~lness Table 4.1 I ANOVA Signiticance of User Patient Relationship by Regression Relationship Table 4.12 Reycssion Analysis betiveen User Patient Relationships and usefi~lness Table 4.13 ANOVA Siyniticance of Ease of Use by Regression Relationship Table 4.14 Regression Analysis betneen Ease of Use and Perceived Usefi~lness ?'able 4.15 ANOVA Significance for Ease of Use and CJsefulness by Regression Analysis Tnble 4.16 Regression Analysis bet\\een Ease of Use and Usefillness on Attit~~de Toward Using Table ANOVA Significance of IJsefi~lness by liegression Relatior~sliip Table Regression Analysis betileen Usefi~lness on Attit~~de 'To\vard Using EhlKs Table AIVOVA Sig~~iticance of Attit~lde To\vard to Use by Regression Relationship Table 4.20 Regession Analysis between Attitude Toward Using EMRs arld Table 4.21 ANOVA Significance of Organizational Factors by Regression Relationship 147 x I40

13 'Table 4.22 Kc'~I.c\s~~oI~ :\11;11!sis I~c(\\c'c'~r O~.s.~liiz.~lic~~i.~l I-actors ;rliii I~seli~lriess... I48 Tahlr 4.23 i\no\':l Signilic:i~ic.c 0 1 I~icii\.idrlnl I..ac~o 1.s I?! Kcg~.ession Kc.l~~~io~isIiil~ 'l'a(llc lieg~.c\iic)~i.\~lal! si:; bc.l\\c.cn I~idi\. itlr~.rl I..rc~o~.s 2nd 13s t. 01'I!se... I49 'l'abl c >\NOVA Signi ticallie OK [Clos~ I~iil)~l.l.i~it l;ac[or b! Step\\ ibc lic'gr~'sio11... I50 Table Stc.p\\ isr Iit'y~~c'ssio~i /1\1ial! sis ot' MOSImpol.tanl Factor 'I'ablc 4.27 Srlmliiar! 01'1 l\.porlirsc.s

14 List of Figures 1.iyr11.e 1. 1 Kcscnrch S1ratt.y) Figt~l-e 3. I 'l'ht.or\. of Reasoned Actio~i I. igure 3.2 Technoloy).\cct.l>tancc Allodel (1-AM) Fig~irt' 3. I RCSC.II.C'~I Pl.act.dure (adapted li.om tlaslina. 3009) l:ig~~re 3.2 Conceptual hlodel of thc Reseilrch Fig~~..t: 4. I Sull~rnar!. ol' Hypotheses and Kescarch Model

15 List of Appendices :\ly>t'ridis A 1.ettc.r~ ol'.lor.dn~i t lospirals Apl~eiidis 13 Tlie Origilial Itclns ol'(>uestiorinai~~c \\ it11 Iniri:ll C'ronbac11.s Alpha Al~pendis C -Flit' (>~lestiol~riaire A1.p eridis D Ilescriptiv c. Statistics of Respuncierir's C'Iiar.acter.~strcs Al~pendis 13. 4nal)sis of Multiple Regressions Appendix I. Iics~rlrs on Open Ended Questions - Coritent Ar~al\.sis Appendix G Letre rs of Urii\.er.siti IJta1.a Malaysia Apper~tiis H Letter of Statistics Anal!.sis Xlll

16 List of Abbreviations A('R A I 13 B I ('BPR C'CD CDO C'DR CEO CPOE CPT DO I D'I'PB DV EFA El -IR EMRs EPR HIT HS ICD Amcricatl C'ollegc ol'liheunl:~tolog\ ilttit~~d~ I ~\\i\l.d I3~h:\\ io111. Rcl~a\ ioural Intention C'om~x~ter-Bascd l>atient Record C'nntinuitj ol'c'are Iloc~rment Care Deli\ er! Organi~ntion Clinical Data lie posit or^ Chief Luecilti\/e Ofliccr C'ompitterized Pli! sicinn Order Entries Current I-'rocedi~laI '1 crminolog! Diffi~sion ot' Inno\ ation I heor! Decomposed l'lieor! of Planned Behaviour Llependent Variable Explolatary Factor. Analysis Electronic klealtli Record Electronic h.lcdical Record System Elect~.onic Patient Record 1 lealthcare Inforlnation 1 ethnology Healthcare System International Classification of Diseases

17 I (-'I- IC'I 1 I I I V.I ti KAI IH M1 Nl IS Mnl l M S.A PCB PE IJr:OCJ PMK PIJ SCT SN SNOrvIEU SPSS TAM TAM2 TP B TKA I I ~ ~ O I. I : I ~ ~ I O I I C omm~~nicatio~i Technology Ir~lcn\i\ e C':II~. I In~t Inli>r~iial~on I'echnolog~ I~iclepe~icient Variable lo~.d,ln I Inhpilal King Ahd~~llaIi I lnivel-sity Hospital bledical Informatics Management lnf'ormation S) stelm Ministq ol'liealth Measure of Sampling Adcquaci\ Perccivcd Bchavioural Control Perthrmancc t xpectancy Perceived Eaw of I I \t. Paper Medical Record Perceived Usefi~lness Social Cognitive lhcory Sub.jective Norm S ste~natizes Nomenclature of bledicine-clinical Terms Statistical Package for Social Science Technolog) Acceptance Model Technolog).lcceptance Model 2 Theory of Planned Behaviour Theory of Jieasoned Action

18 [ ibll I('!!ni\e~.sit! hlihsissil,l,i I-lealtli Care I I I I :S.;/\ I ser Inte~'llce I~lnitetl Statcs ol'ilmt.rica L "'1'11 (~17. I 111 i lied 'l'llt'or!. of' Acccpta~ice and ljse of Technolog! I li~.lbl M'110 I~l~~ivcrsiti I~1tat.a klala!,sia Miorld I~lealth Organization

19 CHAPTER ONE INTRODUCTION 'l'l~is chapter presents the background infor~natio~i of tlie researcl~. the researcl~ moti\/;ltion. problem statement and tlie stud),'s ob-jcctives. The chapter also presents the scope of' the study and the research c~ntributions. Finally. this chapter ends \vitl~ a discussion on resea~+cl~ strategy and the organization of this thesis. 1.1 Backgl-ound Traditionall). hospitals keep paper-based profiles of patients to keep track of patients' illness l?isto~-y. tlieir developinent and tl~cir overall general hcaltli conditions. 7r1iougli this traditional tecl~nique has long been adopted. it is not without practical problems. One I i\ ing example of the shortcoming of traditional hospital profiling systems of patients' data \\as demonstrated by flurricane Katrina in Ne\v Orleans in the United States of America in Hurricane Katrina destroyed tlie hardcopies of medical records of i~ntold numbers of people, hence bringing new attention to the need for electronic medical records. Lost medical records expose patients to considerable risk of medical mistakes bccause physicians \\;ere unable to draw connections bet\\;een the current I~ealtl~ conditions of the patients and their medical history namely on diagnosis. drugs, effccts and surges) risks assessment (Terry. 2009). The increasing numbers of hospitals and the number of patients in recent years have posed a burden to the profiling system of patients. rendering it inadequate or precisely 1

20 The contents of the thesis is for internal user only

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