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Taibah University
Journal of Taibah University Medical Sciences (2014) 9(3), 213e218
Journal of Taibah University Medical Sciences
www.sciencedirect.com
Original Article
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
Received 20 November 2013; revised 2 January 2014; accepted 5 January 2014Available online 10 July 2014
*
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صخلملا
ماظننعبيبطلااضرىوتسمسايقلةساردلاهذهفدهت:ثحبلافادهأةصاخلاةيدرفلاةفصلاديدحتلًاضيأفدهتو،ةينورتكلالاةيبطلاتالجسلا.ماظنلانعبيبطلااضرىوتسمبةلصلاتاذةينورتكلإلاةيبطلاتالجسلاب
لماعممادختسامتو.ةيتاذةنابتساةئبعتميونتلامسقءابطأنمبِلُط:ثحبلاقرطاضرلاعمةيوقةقالعتاذةيدرفلاماظنلاتافصنميأديدحتلنوسريبطابترانيبةقالعلاةساردليطخلارادحنالارابتخاقيبطتمتكلذدعب.ماظنلانعماعلاطبضلاةاعارمعمماظنلانعماعلااضرلاوةنابتساللةسيئرلاتالاجمثالثلا.بيبطللةيصخشلاصئاصخلل
ماظنببيبطلااضرفلاخو.ةنابتسالاىلعابيبط115باجأ:جئاتنلاطقفءابطألانم%40ناكثيح.تاعقوتلاةينورتكلإلاةيبطلاتالجسلااضرنعؤبنتللصئاصخلامهأتناكو.ماعلكشبماظنلانعنيضارلمعلاريسعمجامدنإلايهو،ةعرسلاةيحاننمماظنلاءادأماظنللبيبطلا.ضيرملاتامولعمبةصاخلاتقولاو،لامكلاو،ةقدلاكماظنلاتامولعمو
نأيغبني.تبثملاماظنلانعنيضارريغماعلكشبءابطألاناك:تاجاتنتسالارايتخالاماظنلايمدختسمنمتاظحالملاوةتبثملاةمظنأللرمتسملامييقتلاهجوي.ةينورتكلإلاةيبطلاتالجسلاةمظنأذيفنتوايلبقتسم
تايفشتسملا;اضرلا;ءابطألا;ةينورتكلإلاةيبطلاتالجسلا:ةيحاتفملاتاملكلاةيدوعسلاةيبرعلاةكلممملا;ةيموكحلا
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.
8-3612 � 2014 Taibah University.
duction and hosting by Elsevier Ltd. All rights reserved.
p://dx.doi.org/10.1016/j.jtumed.2014.01.004
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 system,
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 system. Linear
regression analysis was then performed to examine the as-
sociation between the three main domains of the question-
naire 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.
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.
H. Alharthi et al.214
Introduction
Hospitals around the world are using electronic medical
records (EMRs) to help health care providers to deliver safer,better care to patients.1,2 EMR systems offer automatedelectronic information processing for physicians in their
day-to-day work.3 The extent to which these systems aresuccessful depends strongly on the acceptance of thephysicians 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 as
legibility and completeness of medical information anddocumentation, immediate access to information anywhereat any time, a large clinical database and decision-support
techniques.7 The introduction of new informationtechnology systems into an organization is certain to changethe workflow,8 and sometimes users are dissatisfied because
of problems in using the system that result in delays inordering and disturb the workflow.9 Several studies indicatefailure of EMR systems due to lack of user input and lack
of evaluation of feedback on use of the system.10e12
Despite the drive by the Saudi Government to expand theinformation 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 described
physicians’ views on EMRs. The objective of the studyreported here was to gain a better understanding ofphysicians’ satisfaction with EMRs. We therefore report
the results of a survey conducted in a local Governmenthospital in Kingdom of Saudi Arabia to identify theattributes 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 was
conducted in a 360-bed Government hospital in the EasternProvince, Kingdom of Saudi Arabia. The hospital has acommercially 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 for
ordering and reviewing laboratory results. The study wasconducted 1 year after introduction of the system in thehospital. The physicians eligible for inclusion in the study
were specialists and general practitioners working in aninpatient department during introduction of the system andwho used the system routinely.
Survey preparation and data collection
The tool used to collect the data was a self-administered
survey based on the DeLone and McLean model,14e16
borrowed from the business world to measure the successof information technology systems and used extensively to
measure 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, with
questions 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’s
alpha, and the valueswere all above 0.82, indicating satisfactoryreliability. The face validity of each item was assessed by theresearch team, a practising physician and experts in infor-
matics. After a pilot test of the survey conducted with 10 phy-sicians, some of the questions were reworded and rearranged.
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 receivedfrom 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 threemain 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,
Table 2: Mean responses and agreement with statements on
overall satisfaction with the system.
Mean
score (SD)
Agreement with
the statement
% (No.)
Satisfaction with electronic medical records 215
representing a 52.3% response rate. Table 1 shows thephysician characteristics; 71% were male, 64% were Saudi,
and the average age was 39.8 years. Of the respondents,70% worked in medical departments and 30% in surgicaldepartments. General practitioners and specialists were
fairly evenly distributed.
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 statements:
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) 78.9
b
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 did
not want to go back to a paper system wanted to changethis particular system. The mean of negatively stated itemson overall satisfaction with the system (such as going back
to paper records, prefer to use a different system) wasgenerally higher than that for positively stated statements(overall satisfaction with the system performance andsystem information) (3.5 vs 3.3, p ¼ 0.01). Also, the mean
percentage agreement with negatively stated statementswere higher than that with positively stated statements(78.9% vs 46.3%, p < 0.001).
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 the quality of the system
As shown in Table 3, physician satisfaction with theperformance and quality of information in the system was
moderate at best. Of the six items on quality ofperformance, only two items, “system easy to use” and“security is acceptable”, were satisfactory to about 65% ofthe 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 ofthe respondents agreed that “the system is fast” and “the
system is integrated with my workflow”.
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)
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 only
three items, “the information is accurate”, “relevant” and“in acceptable format”. Less than half the physiciansagreed that “the information is complete” or “available
when 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 to
date”, 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 overall
satisfaction 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).In the multiple linear regression analysis, the domains
system quality and information quality remained as signifi-cant predictors of overall satisfaction with the system
(b ¼ 0.19, 95% confidence interval, 0.01e0.36; and b ¼ 0.25,
Table 3: Perceptions of system, information quality and system
functionality and correlations to overall satisfaction.
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.216
95% confidence interval, 0.10e0.41, respectively) after
adjustment for confounding (Table 4).
Discussion
One of the most crucial findings of our study was lowoverall 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
performance of the system. Despite their overall negativeattitude to the system, the physicians acknowledged that thetechnology would probably improve the quality of care.
The system was considered easy to use by 64% of thephysicians, a finding similar to those of other studies.18,19
Nevertheless, 58% of the physicians were dissatisfied with
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.
the speed of the system, reporting that it took a long timeto move between screens and that the system was slow to
start up. Clinicians in other studies had similar concerns.20,21
The literature reports conflicting views on the security ofsuch systems, some physicians considering that they protect
information well,22,23 while in another study only 30% ofphysicians had a positive view of the effect of computerson patient privacy.24 In our study, system security was the
attribute for which the physicians reported the greatestsatisfaction. They may have considered that individualhealth information in this country is generally not abused,whereas in other countries patients with certain diseases
may be denied jobs or health insurance coverage.Only 48% of the physicians considered that the system
was integrated well with their workflow, an important factor
in 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 properly
integrated. Many complex technological and social issuesmust be addressed in introducing such systems,25 and amiddle 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 with
the completeness or accuracy of the information: only 45%reported that the information was complete and 64% that itwas accurate. This is surprising, as we would have expected
higher percentages of the clinicians to report more positiveviews on one of the main advances introduced byEMRs.24,27,28 Lack of accuracy and completeness of
information, as indicated in this study, should alert thehospital management to improve reporting fromdepartments that provide patient information, such aslaboratory and radiology departments. This includes both
conducting the requested tests without unnecessary delayand 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 byresearchers 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 improves
the efficiency and productivity of users but also increases thelevel of physician satisfaction and their desire to continue touse 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 outthat younger users found the training adequate because of
their prior experience with computers.27 Although most ofour study population was young, they were dissatisfiedwith their training on EMRs. The physicians in our study
might also have been experienced computer users butexpected more sophisticated training. Additionally, onlyhalf found that the system support was acceptable.O’Connell et al.31 also found that only 50% of users
considered the level of support acceptable. Delayedsupport from the information technology department whenneeded can increase physicians’ frustration with the system.
Studies have shown that good support by information
Satisfaction with electronic medical records 217
technology departments and better collaboration withphysicians improves the success rate of already installed
systems.4,18
When we examined how the three main dimensions of thisstudy were related to overall satisfaction, we found that the
strongest predictor of overall satisfaction was the quality ofinformation, particularly when it was up-to-date, accurate,complete and available when needed. This was followed by
the 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 are
essential for physician satisfaction.9,32,33 A user-friendlydesign makes the system easy to use and increases the levelof acceptance and willingness to use it. We found a non-
significant association between system support and overallsatisfaction, which was not consistent with the results ofmost other studies.20,34 The need for information system
support depends on the sophistication of the system andthe number of functions. It is not clear if physiciandissatisfaction in our study with system support was due tothe fact that the system was not sophisticated and had only
basic functions, which did not require as much support asin other studies. Future studies of physician satisfactionwith EMRs should include the level of system
sophistication to allow for proper comparisons.The fact that this survey was conducted 1 year after
introduction of the system may partly explain the overall
dissatisfaction of the users, particularly as use of the system ismandatory. User satisfaction might, however, increase overtime 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 ofa system but not others,6 the best strategy for increasingacceptance would be to maximize positive perceptions of
all 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 Thisconsistent finding among studies reaffirms the importance
of system attributes such as speed, quality of informationand compatibility with physician workflow in theiracceptance, irrespective of physician characteristics.
The two main limitations of this study were that it wasperformed in one Government hospital with one EMRsystem, 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 commonin satisfaction surveys, this may have introduced selection
bias. Voluntary respondents to satisfaction surveys gener-ally tend to have more positive or more negative perceptionsof issues.
Conclusions
This study shows that physicians were generally dissatis-fied with the EMR system and that various aspects of thesystem require improvement. Hospital management and
stakeholders 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 from
users should guide future selection and introduction of EMRsystems. Despite the huge investment in health informationsystems and the push by the Ministry of Health for wide
implementation of EMRs, the results of this study andothers13 indicate that the choice and introduction of EMRsystems in Saudi hospitals still needs to be improved.
Conflict of interest
The authors have no conflict of interest to declare.
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