Perceptions of healthcare professionals about the adoption and use of EHR in Gulf Cooperation Council countries: a systematic review

Introduction

The traditional paper-based medical record is rapidly being replaced by modern health information technologies (HITs) to better manage patient information.1 2 Electronic health records (EHRs) can assist healthcare providers in generating, storing and retrieving vital patient information, ranging from medical histories to lab diagnostics, for the provision of high-quality care at different levels.3–5 EHRs are crucial for improving patient safety, quality of care and the efficiency of patient care delivery, as well as reducing medical errors and healthcare costs.6 7 Menachemi and Collum further note that the system assists healthcare providers to easily share and access patient data at any point of care, resulting in enhanced delivery of care.8 These benefits have been associated with positive perceptions of the EHRs by healthcare professionals.9 10 Similarly, patients have largely reported positive perceptions and high satisfaction with the use of EHRs mainly due to benefits related to access to personal health records and acting as an educational resource despite having few concerns, such as disruption of doctor–patient interaction and privacy issues11 12 Thus, the EHR has emerged as an important tool for enhancing efficiency in healthcare processes, facilitating information sharing between healthcare providers themselves and between healthcare providers and their patients, and improving the quality of care as well as patient safety.

Due to these perceived benefits of EHRs in health service provision, the systems are increasingly adopted in various healthcare settings across the world. The countries in the Gulf Cooperation Council (GCC), namely Saudi Arabia, Kuwait, Oman, Qatar, United Arab Emirates (UAE) and Bahrain have also increased their investments in various forms of HITs to improve efficiency and delivery of healthcare services in hospitals and primary care centres.13 For example, the UAE launched a health information system (HIS), known as Wareed in 2011 to link electronic medical records in all public hospitals and clinics across Dubai and the Northern Emirates to improve efficiency in the public healthcare system.14 15 By the end of 2010, Oman had implemented the national repository of EHRs15 while Saudi Arabia committed $1.1 billion between 2008 and 2011 for the development of E-health programme and implementation of various health information tools, including EHRs to improve health and care services as part of its E-health strategy in Saudi Vision 2030.16 Despite these tremendous efforts in EHR adoption, there have also been notable challenges and barriers, such as increased costs during the implementation,17 18 privacy concerns19 and user acceptance.1 20 21 Khoja and colleagues13 noted that although cost/benefit analysis needs to be determined, the increasing demand and misuse of health technologies will most likely increase the overall costs. These challenges are more noticeable in the GCC nations and other developing countries compared with those with advanced economies because they still have less developed infrastructure and governance.22

Several other factors, such as the lack of adequate implementation policies, inadequate staff capabilities and capacity and distrust in the system have also been cited to contribute to the low adoption rates of EHRs and related HITs in the GCC countries.22 23 In relation to healthcare professionals who are the primary users of EHR systems in healthcare settings, their capabilities, including lack of the requisite skills and knowledge to use the systems due to lack of or inadequate training in health applications that discourage their use have been shown to have negative impacts on EHR adoption and use.13 23 Furthermore, healthcare professionals’ perception appears to play a significant role in EHR adoption and use with several theories and models predicting technology acceptance, such as the Technology Acceptance Model postulating that users’ attitude is a significant determinant of acceptance and use of new technology. However, little is known about the perceptions of healthcare professionals on the adoption and use of EHRs in healthcare settings in the GCC context. The objective of this paper is to report the findings from a systematic review of the literature examining the perceptions of healthcare professionals towards the adoption and use of EHRs in order to influence the implementation strategies, training programme and policy development in the GCC region. Although implementation and adoption are often used interchangeably, Murphy24 asserted that these terms differ in that the former is a short-term process of introducing an EHR system while adoption focuses on the long-term success through various strategies, such as providing adequate staff training. Conversely, the concept of use refers to actual utilisation of the EHR systems by the individual users to perform various functions during the process of care provision.25

Methods

Article selection

A priori inclusion and exclusion criteria were applied to guide article selection for inclusion. Specifically, an article was included if it meets all of the following criteria: (1) examined the perceptions of healthcare providers towards the adoption or use of EHR in healthcare prior to, during and after implementation; (2) reported factors influencing users’ perceptions; (3) was conducted in any of the GCC countries listed in the search terms; (4) was a peer-reviewed, empirical research paper; (5) was published between January 2006 and December 2017; (6) the full-text of the article was available for review and (7) was published in English or Arabic language. Review articles, opinions and commentaries were excluded from this review.

Applying the PRISMA approach26 for article selection, the online software Covidence was used to facilitate article selection. After removing duplicate articles, two reviewers (BA and KB-H) independently screened the titles and abstracts of the identified articles against the eligibility criteria. The full-text of selected articles were then examined independently by the two reviewers, followed by process of concordance. The reviewers then extracted relevant titles from the reference lists of the selected articles, and the above screening process was repeated until saturation was reached, and there was an agreement between the two reviewers. Figure 1 summarises this process.

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Figure 1

Study selection process. EHRs, electronic health records; EMR, electronic medical records.

Results

Applying the article selection process detailed above, 14 articles were selected for inclusion in this review. The selection process and the number of records excluded at each stage is presented in figure 1.

Selected articles varied across a number of areas, as shown in table 1. More than half of the articles8 were conducted in the Kingdom of Saudi Arabia29–36 and the remaining in other four countries of the GCC: Oman,37 38 Kuwait,39 40 UAE41 and Bahrain.42 Nine papers were published within the last 5 years, that is, between 2014 and 2019.29 30 32–36 41 42 A variety of settings are represented, with ten articles examining the hospital setting,29–38 three in primary health centres,39–41 and one examining both hospitals and primary health.42 Furthermore, the articles varied in their participant cohorts, including physicians,29 34 35 37 38 40 41 nurses,30 33 or a combination of occupations.31 32 36 39 42 Study designs included cross-sectional using surveys,29–40 42 or a focus group interviews of physicians.41 All articles had a high quality score of at least 12 except one31 which had a score of 9.

Discussion

The findings in this systematic review identified that healthcare professionals in GCC countries have varied perceptions of the EHRs regarding the systems’ benefits and challenges or risks of use. However, the perceptions are largely influenced by various factors that can be classified at the individual, organisational or system-level and are likely to affect the successful adoption of the EHR.

The review identified a perception that the adoption of EHRs results in improvements across access to clinical data, communication, work efficiency, quality of care, patient safety including reduced medical errors and costs. These findings are concurrent with other studies.9 43–45 King and colleagues noted that majority of physicians in the USA perceived the EHR to be useful in ambulatory care practice due to its benefits in enhancing overall patient care, enabling access of patient data remotely and reducing medical errors.43 Further, Tharmalingam et al 45 reported that healthcare professionals in Canada perceived the interconnected EHRs to be valuable in improving the quality of care since they enable access to medical data at any point of care. Thus, the positive perception of an EHR by healthcare professionals in GCC countries identified in this review could be attributed to the perceived benefits of EHR. Krousel-Wood et al 9 similarly found a positive association between EHR benefits and perceptions of the EHR. These findings suggest that healthcare providers in the GCC countries have positive perceptions of EHRs due to their potential benefits; thus, they are more likely to adopt the system which would increase the adoption and use in healthcare.

The negative perceptions identified in this review are largely related to the challenges and risks of using an EHR. This includes complex and non-user-friendly systems, workflow and communication disruptions, increased workload, security and privacy issues, high initial costs, inadequate training and lack of EHR literary as well as language challenges. A previous study in the USA46 reported similar challenges, including complexity and lack of adequate technical support. Moreover, an international survey involving 45 countries from different settings found a negative perception and low satisfaction with EHR in 67% of respondents, citing issues such as poor usability, limited functionality and lack of user training.47 Negative perceptions have been found to be negatively associated with user satisfaction and acceptance of technology.45 48 Thus, the identified negative perceptions towards EHR among the healthcare professionals in the GCC countries could act as a potential barrier to the successful adoption of EHRs in these settings as opposed to positive perceptions that are perceived as facilitators for EHR adoption.49 50

This systematic review also identified that healthcare professionals’ attitude towards EHR is influenced by various factors. Specifically, they included personal, organisation or system factors such as age, perceived usefulness and organisational support. Previous studies have also shown the influence of these factors on healthcare professionals’ perception of EHR.21 50–52 At the individual level, Duarte and Azevedo51 showed that younger professionals in Brazil were more satisfied with EHRs than older counterparts which is similar to the findings of this systematic review. Moreover, computer literacy and training have been found to be positively associated with increased users’ satisfaction and acceptance of technology.21 50 52 The system factors including perceived usefulness and perceived ease of use were found to be positively associated with healthcare professionals’ perceptions of EHRs. Previous studies have similarly reported that perceived usefulness and perceived ease of use of a system could increase acceptance and use of a technology that facilitate adoption.48 53 Tubaishat52 also found that these system attributes were associated with positive perceptions of EHRs among Jordanian nurses. Although this systematic review did not find a significant association between management support and nurses’ attitudes towards an EHR, previous studies have shown that organisational factors such as organisational culture and IT support have a significant influence on users’ perceptions that affect the adoption and implementation of the EHRs.54 55 In the view of these findings, it is important for healthcare organisations in the GCC countries to take into account these factors that are likely to influence users’ perceptions of EHRs and ultimate adoption. Consideration of the influencing factors will also help in early identification of barriers to EHR adoption and adequately addressing for better adoption results.

The findings in this review identified perceptions that are unique to the GCC considering that the member states have similar social, economic and political characteristics.22 The countries are in a crucial stage of adopting EHR and other HISs with their healthcare systems undergoing a gradual change in infrastructural developments fuelled by the growing economy. They have also experienced increased diversity in the health workforce. Thus, this review identifies healthcare professionals’ perceptions as a key area of improving adoption and implementation of EHR in GCC healthcare settings. Furthermore, the review underscores the importance of deploying effective training programme targeting all the healthcare professionals irrespective of age or occupation to improve their skills and knowledge of the health information management systems that in turns improves adoption. This systematic review also highlights the need for the GCC nations to adopt EHRs that meet the specific needs and preferences of their users, such as those designed in Arabic, which is the most spoken language in these settings, rather than English-based systems that create language challenges. This would require the involvement of the healthcare providers, who are the end-users of the EHR systems, the system developers and healthcare organisations in the GCC in all stages of the design process to address the implementation challenges related to usability and customisability of the system. Lastly, governments of the GCC countries should develop appropriate and favourable policies for EHR implementation in all government and private facilities to improve overall adoption rates at the national levels as part of a strategy for providing high-quality care to the citizens.

Conclusion

This systematic review evaluated the current literature reporting healthcare professionals’ perceptions of EHR adoption in the GCC countries and the factors influencing these perceptions. Professionals in these countries perceived EHR to be beneficial in healthcare service provision by improving patient safety and quality of care, access to patient health information, workflow and communication between healthcare providers and patients as well as reducing healthcare costs in the long run. The perception of these benefits could facilitate the adoption of EHRs in these settings. Conversely, the impact on workflow and communication disruptions, inadequate training, high initial costs and privacy and security issues may hinder the successful adoption of an EHR. The healthcare professionals’ perceptions of the EHRs are, however, influenced by various factors at the individual, organisational or system levels. Therefore, the governments and policymakers in GCC countries should adequately understand the factors that are likely to affect the successful adoption and use of EHRs. Significant emphasis should be placed on human factors with healthcare professionals targeted as the end-users of the systems.