The whole world and almost all industries of production, entertainment, and services introduce computer technology to increase the pace and quality of customer service. The healthcare sector is no exception, and many medical organizations replace paper medical records with their electronic analogs. This method of storing patient information provides many advantages; however, the imperfection of the system, as well as its novelty for healthcare providers, causes problems in its use. Medical organizations in Saudi Arabia also face similar challenges that they need to overcome. For this reason, this study aims to identify factors that influence the acceptance of electronic medical records (EMR) by healthcare providers in tertiary care hospitals in Saudi Arabia by using the Technology Acceptance Model (TAM).
The electronic medical record has been used worldwide by healthcare organizations to increase the quality, safety, and efficiency of healthcare services provided to patients. EMR is defined as an electronic record of medical-related information on a patient that can be made, gathered, and accessed by healthcare providers and staff within one healthcare organization (Wang et al., 2003). Wang et al. (2003) stated that the EMR offers a wide range of benefits to physicians, clinic practices, and healthcare organizations. For example, it can facilitate physicians’ workflow and improve the quality of patient care and safety.
Following the increasing trend in the adoption of EMR worldwide, many healthcare organizations in Saudi Arabia have also shifted from paper-based medical records to EMR. Although the adoption of the EMR system in Saudi Arabia has introduced several advantages such as increasing accessibility and availability of medical information and atomization of physician’s workflows.
However, despite EMR’s advantages, some studies reported that users are dissatisfied because of problems in using the EMR that result in delays in ordering and disturb the workflow. These studies indicate the failure of EMR systems because of a lack of user input and a lack of evaluation of feedback on usage of the system. The extent to which the EMR system is successful depends strongly on the acceptance of the physicians regarding the performance of such systems (Alharthi, Youssef, Radwan, Al-Muallim, & Zainab, 2014). Consequently, it is necessary to analyze the acceptance of EMR by medical staff and problems which avoid their application in hospitals of Saudi Arabia.
The process of introducing EMR has been going around the world since its use helps to accelerate the process of obtaining information about patients by medical personnel. However, like all innovations, EMR requires time for adoption and adaptation to features of the medical sphere. The adoption of the EMR system in KFSH & RC has introduced several advantages such as increasing accessibility and availability of medical information and atomization of physician’s workflows. However, despite EMR’s benefits, some users are dissatisfied because of problems in using the EMR that result in delays in ordering and disturb the workflow.
Scientists conduct research in which they identify factors that impede the successful use of the new electronic system. There are also a few studies that tried to assess physicians’ satisfaction with EMR in Saudi hospitals. They demonstrate that the main problem of EMR systems is the lack of feedback from users and, thus, the impossibility of its improvement (Wang et al., 2003). However, such studies research EMR in different kinds of organizations or particular hospitals, but they do not evaluate the level of EMR use for KFSH & RC in Saudi Arabia. Therefore, the main problem is the absence of information about the acceptance and use of EMR by healthcare providers and factors that prevent their application and cause dissatisfaction in tertiary care hospitals in Saudi Arabia.
Aim and Objects
This study aims to identify those factors that are likely to encourage or inhibit the acceptance and use of the system by healthcare providers in tertiary care hospitals in Saudi Arabia. In particular, the objectives of this study are:
- to investigate the reasons affecting healthcare providers’ acceptance and use of EMR in a tertiary care hospital in Saudi Arabia based on the Technology Acceptance Model (TAM),
- to identify which of the individual elements of EMR affecting healthcare providers’ acceptance and use.
- to gain better insights regarding physicians’ views on EMR, which can be used to make informed decisions regarding the adoption of subsequent EMR.
The study of the factors that influence EMR’s acceptance and use requires careful analysis since various reasons can cause dissatisfaction with the electronic system. Application of the TAM system helps to systematize these factors into categories of perceived ease of use, usefulness, and system accessibility (Handy, Whiddett, & Hunter, 2001). Consequently, research questions are:
- What are the factors influencing the acceptance and use of EMR by healthcare providers in a tertiary care hospital in Saudi Arabia?
- How perceived ease of use influence healthcare providers’ acceptance and use of EMR? What factors of this category have a more significant impact?
- How perceived usefulness influence healthcare providers’ acceptance and use of EMR? What factors of this category have a more significant impact?
- How perceived system acceptability influences healthcare providers’ acceptance and use of EMR? What factors of this category have a more significant impact?
The Significance of the Study
This study aims to examine the problems that healthcare providers experience in using EMR that reduce their desire to apply them. For this reason, the research method that we propose identifies factors that interfere with the use of EMR in tertiary hospitals that can be used at the level of medical organizations, urban medical systems, and nationwide. This method will help reduce the search time for suitable ways of measurement and accelerate the assessment of EMR acceptance. At the same time, this model can be used both for theoretical research and its further refinement or adaptation for different national and cultural systems, as well as for practical applications.
The results of the study also have a practical application, since they will give an idea of the reasons for the inaccessibility of EMR in tertiary hospitals in Saudi Arabia. These results will be used to improve the EMR system, staff training, or replacement of devices, which will lead to more efficient exploitation of new electronic systems. Thus, this study has a significant impact on the development of EMR in hospitals in Saudi Arabia and the improvement of healthcare quality.
The Gap in the Literature
Literature studies on the topic have shown that no work analyzes the factors affecting the acceptance and use of EMR in tertiary hospitals in Saudi Arabia. Some of the reviewed scientific works used the TAM system for EMR analysis; however, researches were conducted in other countries, for example, New Zealand and Iran (Handy, Whiddett, & Hunter, 2001; Rafiei, Shahin, Tavakoli, Jahanbakhsh, & Mokhtari, 2013). Other studies applied different methods for assessing and identifying problems or investigated the issue in other branches of medical organizations (Aldosari, Al-Mansour, Aldosari, & Alanazi, 2018; Jabali & Jarrar, 2018). Nevertheless, a research work that determinates all the factors influencing EMR in KFSH & RC is absent.
This study is divided into four chapters that reveal and answer the research questions. The first chapter outline the issues that led to conduct this research and the purposes of this paper. The second part is a literature review on the topic that determines the main objectives of the study and the issues. The third chapter describes the research design and methods that include research variables, hypothesis, and model of the study. The last part is the methodology that explains the details of conducting research.
The Literature Review
The purpose of this study is to identify factors that influence the replacement of handwritten patient medical records with their electronic versions in a tertiary care hospital in Saudi Arabia. The literature on this topic was studied to determine the main objectives of the study and the issues necessary for the survey. The reviewed articles consider both the Technology Acceptance Model (TAM) and its components, as well as other barriers affecting the implementation of electronic medical records (EMR). In addition, a possible field of application of the results was studied to determine the relevance of the work. However, the literature review showed that despite a large number of scientific papers on the topic of electronic medical records, studies on tertiary care hospitals in Saudi Arabia are almost absent, and the data are not systematized.
The basis of this research work is the TAM, which has been repeatedly used in the studies of EMR. The current study is based on an article by Handy, Whiddett, and Hunter (2001), who modernized the classical TAM model by dividing the factors into three categories of perceived ease of use, usefulness, and acceptability. The most useful part of this work is accessibility factors, which scientists investigate from the angle of the need to obtain specific information by different categories of medical staff (Handy, Whiddett, & Hunter, 2001). However, almost two decades have passed since the publishing of this study, and its results applied to New Zealand.
The article by Aldosari, Al-Mansour, Aldosari, and Alanazi (2018) also uses this model by applying it to the realities of modern Saudi Arabia but without taking into account the factors of information accessibility and with sampling within a single hospital. Therefore, although both articles have the necessary data for the current research, their results do not cover all the information or require updating.
For complete coverage of the factors that impede the use of EMR, literature that analyses various barriers to the introduction of these technologies in Saudi Arabia by using both TAM and other assessment systems has also been studied. The research by AlJarullah, Crowder, and Wills (2017) uses the TAM model, namely perceived ease of use and usefulness, and also considers factors such as the confidentiality of information, involvement, and autonomy of physicians.
Thus, the article discovers a new barrier that can be explored in the context of the accessibility of information or confidentiality, since not all categories of employees may have the same information about the patient. The article by Jabali and Jarrar (2018) also explores this side of the accessibility issue because one of its main points is the protection of electronic medical records from hacking, stealing, and using by intruders. However, these studies have a wide range of respondents, which do not match with tertiary care hospitals in Saudi Arabia.
An article by Hasanain, Vallmuur, and Clark (2015), whose main purpose is to study the usability and ease of use of EMR, was also considered. This work confirmed the hypotheses and findings of other authors about the barrier preventing the use of EMR by staff and identified such an essential aspect in this category as complicated interface and inability to use programs due to the lack of Arabic translation. The research of Rafiei, Shahin, Tavakoli, Jahanbakhsh, and Mokhtari (2013) also refers to the part on the ease of use, or more precisely, on the appearance of EMR because the authors study the flaws of the interface and its impact on the use of programs. Since this research was conducted in Iran, the question may also apply to the study of EMR acceptance in Saudi Arabia.
Moreover, it was necessary to study the issue of the medical service providers and KFSH & RC impact on the implementation of EMR to confirm the relevance and applicability of the results. Alfarra (2016) notes that providers and KFSH & RC have a direct influence on the adoption of computer programs and the replacement of hand-written copies of medical records. Therefore, the results obtained during the study can be applied and aimed at accelerating and improving the transition to the electronic system for storing medical data, which makes this topic relevant.
However, all the literature examines different aspects and barriers to the adoption of EMR by healthcare providers and does not present complete, systematic information. Most studies have a limited sample of respondents and do not study the proposed scientific question in a tertiary care hospital in Saudi Arabia. For this reason, the current research paper intends to bridge this gap and provide the necessary scientific information.
In conclusion, the review of the scientific literature on this topic showed that although the issue of introducing EMR has been studied, there is a lack of knowledge about a tertiary care hospital in Saudi Arabia. The studied articles provide a versatile view of the issues that will be proposed in this research and identify the area of the results’ application. However, the information obtained requires systematization and use for a more accurate category of hospitals.
Research Design and Method
The study will be conducted at a tertiary care hospital in Saudi Arabia. The hospital should be running EMRs for a more extended time than any other hospital in the country, which will allow getting sufficient information and experiences for investigation in this study. Data will be collected from the hospital to provide a true reflection on the status of EMR usage in Saudi Arabia.
This study uses the TAM model to identify survey questions and analyze data. Therefore, independent variables are categories of characteristics such as perceived ease of use, perceived usefulness, and perceived system acceptability, and the issues that enter into them. Dependent variables are the acceptance and utilization of EMR by health providers. The answers to the survey’s questions also can be determined by the socio-demographic characteristics of the participants; therefore, the study will include such variables as age, gender, educational level, job title, and previous computing experience.
The utilization of EMR system computing experience, functions, usage frequency, and attitude towards EMRs also has to be analyzed to evaluate the correlation between the use of EMR and influencing factors. These values will be calculated, as well as technical, managerial, and infrastructural factors, by mean sum scores. Chi-square analysis will be used to assess associations among socio-demographic variables. These variables will help to collect and analyze data with minimal deviation and give accurate results.
The purpose of this study is to identify factors that influence the attitude of healthcare providers to the EMR system and, therefore, its use. A review of the literature and studies that use TAM allows making some assumptions about these factors. Therefore, this research aims to test the following hypotheses:
- H1. Perceived Ease of Use will positively influence healthcare providers’ acceptance and use of EMR.
- H2. Perceived Usefulness will positively influence healthcare providers’ acceptance and use of EMR.
- H3. Perceived System Acceptability will positively influence healthcare providers’ acceptance and use of EMR.
The research model is designed for the assessment of factors influencing the acceptance and use of electronic medical records by healthcare providers in a tertiary care hospital. The primary purpose of this research is to assess factors influencing the acceptance and use of electronic medical records by healthcare providers in a tertiary care hospital. Instead of developing a new model of the factors that influence user-acceptance of information systems, this study adapted Davis’ commonly used Technology Acceptance Model (TAM) to the healthcare environment (Davis, Bagozzi, & Warshaw, 1989; Davis, 1993; Venkatesh & Davis, 1996; Lederer, Maupin, Sena, & Zhuang, 2000).
This model suggested that a person’s belief that the system is easily accessible and can increase his or her productivity are fundamental factors determining the acceptance of such an information system for a user.
Moreover, perceived ease of use and perceived usefulness are the essential criteria that determine system usage. However, the literature on the medical use of information technology proposes that health professionals might refuse to accept and use systems that they perceive as easy to use and useful. This situation happens if the system does not handle adequately serious issues such as the security of information and the privacy of the data (Thakurdas, Coster, Gurr, & Arroll, 1996). Consequently, the model was extended to include the concept of “perceived system acceptability” as a separate factor that can influence users’ attitudes towards the system and their actual use of the system. The extended TAM used in this study is shown in Figure 1.
Therefore, the design and research method are based on an extended TAM, which includes characteristics analyzing perceived ease of use, perceived usefulness, as well as perceived system acceptability and security of data. Dependent, independent, and socio-demographic variables and methods of their analysis are defined by the features of this model. The hypotheses that the study intends to test are also designed on an extended TAM.
A survey of healthcare workers in a tertiary care hospital that has been using the EMR system for the longest time is the most appropriate analysis method for this study. The results of this research can be applied to other tertiary hospitals by analogy, which improves the adoption of a new electronic system. Consequently, the sample of participants will be random, but among those people who are healthcare providers and have encountered using the EMR system.
The collection and analysis of information on the topic require the use of a cross-sectional study and quantitative analysis method. A survey is the most appropriate method of data collection for this issue as it will help determine the decisive factors in each category through the number of respondents’ answers. In addition, the obtained numbers will be compared with the data on the use of EMR in the hospital, which will help determine the reliability of the information, as well as the correlation between influencing factors and acceptance of the electronic system.
The most suitable sampling method for this research is a simple random selection in a particular group of population. The study aims to determine factors that influence the use of the EMR system in a tertiary care hospital in Saudi Arabia. Consequently, healthcare workers in King Faisal Specialist Hospital and Research Centre in Saudi Arabia who are aged 25 to 55 and use the EMR system are the group of the population that will be participating in the survey. The sample size is 5 people who agreed to participate in the survey. Due to ethical considerations, confidentiality will be assured to all participants, and the respondents will be given a brief description of the research and its objectives.
The main survey tool for collecting data is an online questionnaire divided into socio-demographic data and questions according to the extended version of TAM (Table 1-3). Answer options vary in five options from “Strongly Agree” to “Strongly Disagree.” The main tools of calculation and evaluation are tools of statistical analysis. SPSS program will be used for data analysis, version 22.0. Descriptive statistics will be done; a P-value of 0.05 or less will be significant.
A Technology Acceptance Model (TAM) for Electronic Medical Records Systems
Part one: Socio-demographic characteristics
- Specialty: …………….
- Job title: ……………….
Perceived Ease of Use
|Statement||Strongly agree||Agree||Neutral||Disagree||Strongly disagree|
|I would be more likely to use an EMR if it were easy to use|
|an EMR that is clear and understandable would be easier to use|
|an EMR that was easy to remember how to use would be easier to use|
|an EMR that could be accessed whenever one wants, not just at set times, would be easier to use|
|an EMR that has a user-friendly interface (Windows-type) would be easier to use|
|an EMR that is easy to learn would be easier to use|
Table 1. Perceived Ease of Use.
|Statement||Strongly agree||Agree||Neutral||Disagree||Strongly disagree|
|I would be more likely to use an EMR that I thought would improve my work performance|
|I would be more likely to use an EMR that offered advantages for my work|
|I would be more likely to use an EMR that helps to protect against medical litigation|
|an EMR that assisted in improving communication and information sharing (between primary and secondary care) would be useful|
|an EMR would assist in improving seamlessness of care (between primary and secondary care) would be useful|
|an EMR that enabled me to work more quickly would be useful|
|an EMR that decreases the workload and/or pressure on myself and my practice would be useful|
|an EMR that makes my job easier would be useful|
|an EMR that meets the goals/needs of myself, my patients, practice, population would be useful|
|an EMR would assist in improving the quality of patient care would be useful|
|an EMR that can hold anyone who makes any changes accountable for those changes would be useful|
|an EMR that was acceptable in court in the place of paper records would be useful|
Table 2. Perceived Usefulness.
Perceived System Acceptability
|Statement||Strongly agree||Agree||Neutral||Disagree||Strongly disagree|
|There should be different levels of access for different groups of people, i.e., health professionals, administrative staff, etc|
|Certain information should be ‘hidden’ from general access, i.e., sensitive issues like HIV results, mental health records, etc|
|Anyone with a legitimate reason to access the EMR should be able to access any information they feel relevant for their reason|
|Information types: |
What information you feel should be transferred to/from an organization-wide EMR:
|Clinically relevant obstetric information|
|Past medical and surgical history|
|Mental health consultations|
|Personal and social history, such as marital status, smoking, alcohol, drug usage|
|Sexual health consultations|
|Termination of pregnancy details|
|I will more likely agree to use an EMR if data is secure and confidential|
|I will more likely agree to use an EMR if the data is accurate and factual|
|I will more likely agree to use an EMR if there is patient consent (to put their information on the EMR)|
|I will more likely agree to use an EMR if there is obvious ownership of the data|
|The information within an EMR should be used for clinical patient care|
|The information within an EMR should be used for audits|
|The information within an EMR should be used for research|
|The information within an EMR should be used for clinical teaching|
|The information within an EMR should be used for medico-legal purposes|
|The information within an EMR should be used for administration, such as bed occupancy figures, staffing levels|
|The information within an EMR should be used for financial considerations, such as budgeting, contracting, managed care|
Table 3. Perceived System Acceptability.
The quantitative analysis method and survey are necessary methods for collecting and analyzing information. The questionnaire is carefully designed to cover all the factors that may affect EMR acceptance fully. These data collection methods and static analysis tools will help test hypotheses about the impact of ease of use, usefulness, and accessibility of EMR on their acceptance by healthcare workers at KFSH & RC in Saudi Arabia.
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