ArticlePDF Available

Abstract and Figures

No previous nationwide study has estimated to what extent electronic health records have been implemented in Jordanian hospitals. The purpose of this descriptive, cross-sectional study was to explore the level of adoption and use of electronic health records in Jordanian hospitals across allmajor healthcare service providers. The standardized American Hospital Association annual survey was used. The level of use of electronic functionalities of electronic health records was determined. The association of certain hospital characteristics with the adoption of electronic health records was examined. A proportion of 10.3% of the participating hospitals had a comprehensive use of electronic health records in all units, and 15.5% had a basic system in at least one unit. Most (74.2%, n = 72) had not implemented electronic health records. The hospitals with a higher rate of adoption were found to be larger, government, urban, and teaching hospitals that had coronary care units. The level of adoption of electronic health records in Jordan is relatively low. This fact should impel policy makers to resolve the challenges and obstacles for such adoption. National strategic plans are needed to address the goals and implementation processes of electronic health record systems in all Jordanian hospitals.
Content may be subject to copyright.
The Use of Electronic Medical Records in Jordanian
A Nationwide Survey
Ahmad Tubaishat, PhD, RN, Omar M. AL-Rawajfah, PhD, RN
No previous nationwide study has estimated to what extent
electronic health records have been implemented in Jordanian
hospitals. The purpose of this descriptive, cross-sectional
study was to explore the level of adoption and use of elec-
tronic health records in Jordanian hospitals across all major
healthcare service providers. The standardized American
Hospital Association annual survey was used. The level of
use of electronic functionalities of electronic health records
was determined. The association of certain hospital charac-
teristics with the adoption of electronic health records was
examined. A proportion of 10.3% of the participating hospi-
tals had a comprehensive use of electronic health records
in all units, and 15.5% had a basic system in at least one
unit. Most (74.2%, n = 72) had not implemented electronic
health records. The hospitals with a higher rate of adoption
were found to be larger, government, urban, and teaching
hospitalsthat had coronary care units. The level of adoption
of electronic health records in Jordan is relatively low. This fact
should impel policy makers to resolve the challenges and
obstacles for such adoption. National strategic plans are
needed to address the goals and implementation processes
of electronic health record systems in all Jordanian hospitals.
KEY WORDS: Electronic medical records, Health information
technology, Hospitals, Informatics, Jordan
The introduction of health information technology (HIT)
into healthcare industries is gaining pace.
There is much
greater investment in HIT in developed countries than ever
before. For example, 544 million was spent in Spain in 2009,
and in the United Kingdom, it was estimated that the expen-
diture on HIT reached approximately £12.8 billion in 2011.
In the United States, almost US $20 billion was allocated to
support the adoption of HIT in US hospitals in 2009.
2011, this figure had risen to $38 billion. The major force driv-
ing this generous expenditure is in fact an effort to control
healthcare costs. For example, in the United States, it was esti-
mated that the adoption of HIT could produce efficiency and
safety savings of $142 billion in US physiciansoffices and
$371 billion in US hospitals for 15 years (20042018).
The integration of HIT generally, and electronic medical
records (EMRs) specifically, in healthcare can not only reduce
costs but also enhance the quality of care.
Improvement of
quality of care can be the results of different benefits of EMRs
such as gathering accurate clinical information and coordinat-
ing the care process
; enhancing decision-making services
minimizing communication errors
; generating electronic re-
ports that are necessary for institutional, private, and public
; and improving patient safety.
The combi-
nation of EMRs with the computerized provider order entry
(CPOE) reduces the costs and reduces the duplication of lab-
oratory and radiology tests and investigations. The documented
effect of implementing EMRs on patient outcomes level
the national level
stimulates research around the world to
evaluate the extent of EMR implementation in healthcare
systems such as that of the United States,
Austria and
and Spain.
The importance of EMRs depends largely on their adoption,
application, and use.
There is wide variation on the reported
levels of adoption of EMRs around the globe.
This variation
could be due to lack of agreement on the definitions of EMRs,
the adoption of EMRs in terms of its capabilities,
ological differences in estimating the adoption level,
and con-
venience sampling techniques with low response rates from the
conducted surveys.
In 2008, the American Hospital Association (AHA) in part-
nership with the Office of the National Coordinator for HIT
of the Department of Health started to conduct an annual sur-
vey to assess the level of adoption of EMRs in US hospitals.
The first survey was conducted to estimate the level of adop-
tion of EMRs in 3049 US hospitals (response rate, 63.1%).
They surveyed the hospitals about the presence and absence
of certain electronic functionalities and whether these func-
tionalities were implemented in all or some hospital units.
Author Affiliations: Faculty of Nursing, Adult Health Nursing Department, Al al-Bayt University,
Mafraq, Jordan (Dr Tubaishat); and Faculty of Nursing, Sultan Qaboos University, Muscat, Oman
(Dr AL-Rawajfah).
The authors have disclosed that they have no significant relationships with, or financial interest in,
any commercial companies pertaining to this article.
Corresponding author: Ahmad Tubaishat, PhD, RN, Faculty of Nursing, Adult Health Nursing
Department, Al al-Bayt University, PO Box 130040, Mafraq 25113, Jordan (
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/CIN.0000000000000343
Volu me 0 0 | N umber 0 CIN: Computers, Informatics, Nursing 1
The results of this study revealed that only 1.5% of the US
hospitals had a comprehensive EMR system and 7.6% of
the hospitals had a basic EMR system. In a follow-up study,
these numbers were updated, where hospitals with a compre-
hensive system increased to 2.7%, and those who implement
the basic system increased to 9.2%.
Thereafter, the AHA
annual survey reported that the rate increased from 1.5% in
2008 for the comprehensive system to 34.4% in 2014, a more
than 22-fold increase. For the basic system with clinical notes,
the increase ranged from 7.6% in 2008 to 41.1% in 2014, a
more than five-fold increase.
A similar approach was followed in a study conducted in
Spain to measure the use of EMRs in Spanish hospitals.
an observational cross-sectional study, an electronic question-
naire was sent via email to 214 hospitals that refer to the
National Health Services in Spain (response rate, 30%).
The results found that 39.1% of the hospitals had a compre-
hensive system, and 32.8% used a basic system. In Korea, a
survey was conducted using the same methodology used in
the United States to measure the prevalence of EMRs in ter-
tiary teaching and general hospitals in Korea (N = 313).
From the responses of 122 hospitals (response rate, 39%),
they found that 5%of the hospitals had a comprehensive sys-
tem, and 32.2% had a basic system.
Another study located in the literature but with a different
methodology, which could make the comparison, is more dif-
ficult. One of these studies was conducted to measure the level
of adoption of clinical information systems in Greek public
A Web-based survey was sent out to 107 hospitals
that refer to the Greek National Health System, with a return
of 70 questionnaires (response rate, 65.4%). The question-
naire, which was developed for the study based on a literature
review, was completed by chief information officers (CIOs) in
the hospitals. The findings indicated that the adoption of in-
patient EMRs was 22.9%, without specifying the proportions
of basic or comprehensive systems.
In another different study, Hübner et al
compared the pre-
valence of nursing and medical systems in Austrian and German
acute care hospitals (N = 130 and 2172, respectively). All
hospitals in both countries received an identical question-
naire, with a relatively low response rate, which was 12.4% in
Germany and 34.6% in Austria. The 40-item questionnaire
covered the hospital characteristics, technological infrastruc-
ture, EMRs, and nursing information system. The results showed
that Austrian hospitals used more clinical IT systems than their
German counterparts, despite that both countries have a simi-
authors tie this difference to the presence of technological in-
frastructure and organizational changes that promote the
IT-friendly environment in Austria compared with Germany.
In Jordan, healthcare services are primarily delivered though
four major health sectors: government, royal medical services
(military), private, and university affiliated. In 2014, the
budget to the Ministry of Health.
The population in
2014 was thought to be approximately 6.5 million with
an estimated per capita income of US $5357.
In 2009, the Jordanian government initiated the first
E-health program in Jordan (Hakeem Program). The Hakeem
project was derived from an open-source health information
system known as the VistA program, which was originally de-
veloped by the US Federal government.
VistA consists of sys-
tems, linked databases, and end-user interfaces such as patient
administration records, radiology, pharmacy, pathology sys-
tems, and nursing documentation systems. The Hakeem Pro-
and one health center. After the pilot, the project intended to
cover all hospitals operated by the Ministry of Health and the
Royal Medical Services. The main goal was to improve the
documentation system in these hospitals, as well as to improve
the quality and safety of healthcare services.
Despite these ef-
forts to improve the computerization of healthcare services, to
date, there has been no nationwide, scientific study that has es-
timated the level of implementation of EMRs in Jordanian hos-
pitals. Therefore, the primary aim of this nationwide survey was
to explore the level of adoption and use of EMRs in Jordanian
hospitals across all major healthcare service providers. Sec-
ondary to this was the desire to investigate possible associa-
tions between the level of adoption and hospital characteristics.
This survey used a descriptive, cross-sectional design. The
cross-sectional design is an appropriate design to report the
adoption rate of EMRs in the Jordanian hospitals. Further-
more, the intention of this study was to generate findings that
can be generalized to the status of EMRs in Jordan and other
countries that have a similar healthcare system, and this
design is capable to meet this purpose.
Setting and Sample
The sampling frame of the study was composed of all Jordanian
hospitals listed by the most recent Ministry of Health annual
statistical report.
For easy management of data collection,
Jordan was divided into three main geographical regions:
north, middle, and south. Second, a complete list of all hospitals
from each healthcare provision sector (government, military,
private, and university affiliated) in each region was created.
The final sampling frame consisted of 104 hospitals, of which
31 were government (29.8%), 59 were private (56.7%), 12 were
military (11.5%), and two were university-affiliated (1.9%)
hospitals. The hospitals serve different populations such as
adult, pediatrics, maternity, and psychiatrics. For the purpose
of this study, hospitals were categorized into major teaching,
2CIN: Computers, Informatics, Nursing Month 2017
minor teaching, and nonteaching hospitals. A major teaching
hospital was defined as a hospital that is recognized by the
Ministry of Health as a teaching institution and regularly
accepts health-related students for training. Minor teaching
hospitals, on the other hand, are those that are not officially
recognized by the Ministry of Health as teaching hospitals
but accept health-related students on a nonregular basis.
Finally, a nonteaching hospital is one that does not accept
health-related students for training and is not officially
recognized as a teaching institution.
Data Collection Procedure
After establishing the sampling frame and gaining ethical
approval, contact information including addresses and
telephone numbers were recorded for each hospital. All hos-
pitals were invited to participate in the survey by means of a
phone call to a manager or nursing director. After the initial
agreement to participate, an on-site visit by a research assistant
was arranged. During the on-site visit, the CIO was asked to
fill out the survey. For hospitals that do not employ a CIO, the
nursing directors or head nurses were asked to fill out the sur-
vey. No biases in terms of participation or responses were
noted from the survey respondents.
Data Collection Tool
The data collection instrument used in this study was based
on the one used by the AHA annual HIT survey,
is deemed to be of high quality.
This tool was chosen for
the current study because it underwent through rigorous de-
velopmental techniques. The tool developers appraised the
existing tools in the past 5 years. Then, it was reviewed by field
experts. After that, it was pilot tested by CIOs and hospital
managers, and comments were solicited from health infor-
matics experts. In 2008, the AHA, in partnership with the
Office of the National Coordinator for HIT in the Depart-
ment of Health, began to conduct an annual survey to assess
the level of adoption of EMRs in US hospitals.
to use the tool was granted before this study commenced. This
data collection tool covers 24 electronic functionalities re-
lated to the use of EMRs. The electronic functionalities are
organized under four major areas: clinical documentation
(seven functionalities), for example, patient demographic, phy-
sician and nursing assessments, medication lists, and so forth;
results viewing (six functionalities), for example, viewing labo-
ratory, radiology and diagnostic test results, and consultant re-
ports; CPOE (five functionalities), for example, nursing orders
and medical orders including laboratory, radiology, and med-
ication orders; and decision support (six functionalities), for
example, drug allergic or interaction alerts, clinical guidelines
and reminders, and drug dosing support. The list of electronic
functionalities in the original tool was established based on the
consensus of a panel of experts in the fields of HIT, health
policy, health services, and survey research.
In the current study, the original version of the survey was
used, without any modification or translation, since the English
language is widely used and understood by medical and techni-
cal staff in Jordanian hospitals. Besides using the original survey,
information about the hospitalscharacteristics was also col-
lected, namely, bed capacities, location and region, type of hos-
pital, teaching status, and the availability of coronary care units,
which is considered a marker of a high technology setting.
Respondents were asked to indicate the presence or absence
of 24 electronic functionalities of the records system in their
hospitals and the extent of their implementation or whether
there were any future plans to implement them. Furthermore,
respondents were asked to indicate whether their hospital had
fully implemented the functionalities in all major hospital units,
had implemented them in one or more (but not all) major hos-
pital units, or had not yet implemented them in any unit.
In the current survey, we followed Jha et als
criteria for
classifying hospitals according to the extent of their use of EMRs.
Hospitals were classified as having a comprehensive EMR
system if they demonstrated the use of all 24 functionalities
in all units. Conversely, hospitals were classified as having a
basic EMR system if they demonstrated the use of eight specific
functionalities in at least one major unit. Jha et al
categorized the basic EMR system into basic with or without
clinical notes (physician and nursing assessment notes). The
current survey also followed the same categorization of the
basic EMR system (Table 1).
Ethical Considerations
The study was approved by the research and ethics committee of
the School of Nursing and the Deanship of Academic Research
at Al al-Bayt University, as well as by the participating hospitals.
The act of completing the survey was taken as a proof of con-
sent. Participation was completely voluntary, and anonymity
was ensured; no personal identification data were required from
either the hospital or the personnel who filled in the survey.
Statistical Analysis
three definitions of EMRs: comprehensive, basic with clinical
notes, and basic without clinical notes. Bivariate analyses were
used to examine the relationship between hospital character-
istics (size, region, location, type of hospital, teaching status,
and presence of coronary care units) and adoption of a basic
or comprehensive EMR systems. The Pvaluewassetatthe
level of .05 to designate the statistical significance.
According to Jha et als
definitions, the vast majority of par-
ticipating hospitals (72, 74.2%) were found to not implement
Volu me 0 0 | N umber 0 CIN: Computers, Informatics, Nursing 3
any EMRs and relied completely on paper records. Ten of
the participating hospitals (10.3%) were classified as having
comprehensive EMRs and implemented the system in all
major units. The remaining 15 hospitals (15.5%) were classi-
fied as having a basic EMR system (Table 1).
Of a total of 104 hospitals in Jordan, 97 (93.2%) agreed to
participate in the study. Of the total participating hospitals,
56.7% were private hospitals. Only one university hospital par-
ticipated in the study. Most participating hospitals (56, 57.7%)
were small hospitals with a capacity of less than 100 beds. Most
of the hospitals (62.9%) were located in the middle region,
where the capital is located. Private hospitals accounted for
most of the participating hospitals (56.7%) in this survey.
Most of the participating hospitals (64.9%) were nonteach-
ing hospitals (Table 2).
Bivariate analysis revealed that the adoption rate of EMRs
was significantly associated with the hospital size (χ
P= .005). Small hospitals (<100 beds) that implement EMRs
accounted for 12.5% (n = 7). Furthermore, the adoption rate
of the EMRs was significantly associated with the hospital
location (χ
=11.4,P= .003). Only 8.3% of the hospitals
(n = 3) in rural areas were implementing EMRs. Likewise, a
vast majority of nonteaching hospitals (92.1%, n = 58) were
not implementing EMRs (χ
=14.7,P< .001). In addition,
the adaptation rate of EMRs was significantly associated
with hospital type (χ
=30.9,P< .001). The adoption rate
of EMRs in government hospitals (33.3%) was higher than
those of the private (21.8%) and military (18.2%) hospitals
(university hospital was not included in this comparison since
only one hospital falls into this category) (Table 2).
Wide variations were found to exist in the application
of the electronic functionalities of EMR systems imple-
mented in Jordanian hospitals (Table 3). For example,
41.2% of the hospitals reported that they have electronic
documentation of patient demographics in all units. However,
only 8.3% of the hospitals implemented the physician notes
Table 1. Electronic Functionalities Required for Classifying Hospitals as Having Basic or Comprehensive EMR
Systems (N = 97)
EMR Functions Required Comprehensive EMR Basic EMR With Clinician Notes
Basic EMR Without
Clinician Notes No EMR System
Electronic clinical information
Patient demographics (( (
Physician notes ((
Nursing assessments ((
Problem lists (( (
Medication lists (( (
Discharge summaries (( (
Advance directives (
Computerized provider order entry
Laboratory tests (
Radiology tests (
Medications (( (
Consultation requests (
Nursing orders (
Results management
View laboratory reports (( (
View radiology reports (( (
View radiology images (
View diagnostic test results (( (
View diagnostic test images (
View consultant reports (
Decision support
Clinical guidelines (
Clinical reminders (
Drug allergy alerts (
Drug-drug interaction alerts (
Drug-lab interaction alerts (
Drug dosing support (
No. (%) hospitals 10 (10.3) 9 (9.3) 6 (6.2) 72 (74.2)
4CIN: Computers, Informatics, Nursing Month 2017
or nursing assessment notes functionality across all units
and departments.
Furthermore, in the results viewing section, 44.3% of the
hospitals claimed to use a feature that enables staff to view ra-
diology reports; and 39.2%, diagnostic test results, in all units.
Computerized provider order entry for laboratory tests was
reported as being applied in all units in 13.2% of the hospitals.
Finally, only 7.3% of the hospitals implemented the decision
support functionality for clinical guidelines, and 8.2% imple-
mented the decision support functionality for drug-drug inter-
action alerts (Table 3).
Results from this study revealed that 10.3% of Jordanian
hospitals are using comprehensive EMR systems, 9.3% are
using basic systems with clinical notes, 6.2% are using basic
systems without clinical notes, and approximately 75% are
still relying on a paper charting system. The current survey
used the same definitions and methodology as the AHA survey.
On the basis of the latest AHA survey,
the reported adoption
rates were 34.4% for comprehensive systems and 41.4% for ba-
sic systems. Recently, in Spain, Marca et al
reported a 39.1%
use of comprehensive systems and a 32.8% use of basic sys-
tems. Likewise, based on data collected in 2007, Hübner
et al
reported an implementation rate of 11.9% in Austrian
hospitals and 7% in German hospitals. However, in the same
study, it was reported that 52.4% of Austrian and 38.8% of
German hospitals had already begun the installation of a
comprehensive EMR system.
Noticeably, all the previous
studies were conducted in developed countries. Using these
data as a benchmark for the Jordanian data is not fully appro-
priate because of the huge differences in resources and the
overall healthcare systems. Unfortunately, however, studies
regarding the adoption of EMRs in developing countries
are scarce. The only studies found that were undertaken in
developing countries were conducted in Saudi Arabia.
According to Aldosari,
50% of the hospitals in Riyadh
are implementing comprehensive EMRs, another 36% have
systems that could be described as works in progress, and
14% have not adopted any electronic system. Similarly,
Bah et al
reported an adoption rate of 16% for 19 public
hospitals in Eastern Province, Saudi Arabia. However, data
generated from these studies were based on a limited num-
ber of hospitals from one region in Saudi Arabia. Therefore,
data from our current nationwide survey can be used as a
self-benchmarking indicator to evaluate the progress of EMR
adoption among Jordanian hospitals.
The results revealed that, although private hospitals ac-
counted for more than half of the total number of Jordanian
hospitals (56.7%), most of these (78.2%) do not implement
Table 2. Characteristics of Participating Hospitals and Adoption of EMR Systems (N = 97)
Characteristic No. (%) Hospitals
Comprehensive EMR System
(n = 10)
Basic EMR System
(n = 15)
No EMR System
(n = 72) w
Small (099 beds) 56 (57.7) 3 (5.4) 4 (7.1) 49 (87.5) 14.7 .005
Medium (100399 beds) 35 (36.1) 5 (14.3) 9 (25.7) 21(60.0)
Large ( 400 beds) 6 (6.2) 2 (33.3) 2 (33.3) 2 (33.3)
North 24 (24.7) 5 (20.8) 2 (8.3) 17 (70.8) 5.5 .279
Middle 61 (62.9) 4 (6.6) 12 (19.7) 45 (73.8)
South 12 (12.4) 1 (8.3) 1 (8.3) 10 (83.3)
Urban 61 (62.9) 7 (11.5) 15 (24.6) 39 (63.9) 11.4 .003
Rural 36 (37.1) 3 (8.3) 0 (0.0) 33 (91.7)
Type of hospital
Government 30 (30.9) 9 (30.0) 1 (3.3) 20 (66.7) .001
Private 55 (56.7) 1 (1.8) 11 (20.0) 43 (78.2) 25.8
Military 11 (11.3) 0 (0.0) 2 (18.2) 9 (81.8)
University 1 (1.0) 0 (0.0) 1 (100.0) 0 (0.0)
Teac hing sta tus
Major teaching hospital 13 (13.4) 3 (23.1) 4 (30.8) 6 (46.2) 30.9 .000
Minor teaching hospital 21 (21.6) 6 (28.6) 7 (33.3) 8 (38.1)
Nonteaching hospital 63 (64.9) 1 (1.6) 4 (6.3) 58 (92.1)
Dedicated coronary care unit
Yes 43 (44.3) 9 (20.9) 12 (27.9) 22 (51.2) 21.2 .000
No 54 (55.7) 1 (1.9) 3 (5.6) 50 (92.6)
Volu me 0 0 | N umber 0 CIN: Computers, Informatics, Nursing 5
any level of EMRs. One of the major factors that explain the
low implementation rate is the high cost of implementing
EMR systems. The direct and indirect cost of EMR imple-
mentation is well documented in the literature as a major
barrier of EMR adaptation.
According to Anderson et al,
in countries that showed high implementation rates of EMRs,
such as Australia, Canada, Germany, Norway, and the
United Kingdom, the government plays a major role in
supporting and funding the implementation of such systems.
In Jordan, the vast majority of hospitals (90%) that have im-
plemented comprehensive EMR systems are government
hospitals. These hospitals were mainly funded by the Hakeem
project, which started in 2009 with an intention to support the
implementation of EMRs in all Ministry of Health and mili-
tary hospitals.
It has been estimated that the cost of EMR
implementation can reach $63 000 per bed.
Jordanian healthcare policy makers should create a strategic
plan to support hospitals to implement EMRs. Joint ventures
between public and private healthcare sectors can facilitate
adoption rate and reduce the associated costs. These possible
joint ventures can help in unifying operating systems and
improving data aggregation and data management. Further-
more, this will assist with setting national health strategic
plans based on unified and robust data.
Beside the high cost associated with EMR implementation,
awareness of benefits of EMRs may play a major role on the
adoption decision of EMRs. This study was unable to evalu-
ate the awareness factor. Future studies should consider differ-
ent factors that may affect the adoption decision including the
awareness of EMRs.
The CPOE is considered an essential infrastructure needed
for EMR implementation.
It plays a major role in cost-saving
capabilities, where the duplication of laboratory and radiology
tests and medication dispensing will be minimized.
nately, the use of CPOE in Jordanian hospitals was found
to be very low in the current study. The percentage of hos-
pitals that applied the CPOE for laboratory tests in all
units was 13.2%, and for medications, it was 11.9%. In the
United States, the corresponding figures were 20% and 17%,
In a Spanish study, the figures was 39.1% and
50%, respectively
; in Korea, it was 80% for medications
and in a Greek study, the application of general CPOE systems
was 14.3%.
The electronic functionality of results viewing by different
healthcare providers and in different settings is a significant
component of any EMR system.
In the current study, more
than one-third of the hospitals used EMRs for documenting di-
agnostic test results and radiology reports in all units. Studies
from developed countries have shown much higher rates of ap-
plication of this functionality. For example, in the United States
and Spain, the functionality was applied in rates of 75%
Table 3. Selected Functionalities and Their Level of Implementation in Jordanian Hospitals (N = 97)
Fully Implemented
in All Units
Fully Implemented in
at Least One Unit
Implementation Began or
Resources Identified
No Implementation/No
Specific Plans
Electronic clinical information
Patient demographics 40 (41.2) 11 (11.3) 8 (8.2) 38 (39.2)
Physician notes 8 (8.3) 10 (10.4) 1 (1.0) 77 (80.2)
Nursing assessments 8 (8.3) 7 (7.3) 1 (1.0) 80 (83.3)
Problem lists 11 (11.1) 9 (9.3) 4 (4.1) 73 (75.2)
Medication lists 7 (7.2) 11 (11.3) 6 (6.2) 73 (75.2)
Discharge summaries 12 (12.4) 6 (6.2) 5 (5.2) 74 (76.2)
Results management
View radiology reports 43 (44.3) 13 (13.4) 4 (4.1) 37 (38.1)
View radiology images 22 (22.6) 11 (11.3) 13 (13.4) 51 (52.6)
View diagnostic test results 38 (39.2) 12 (12.4) 6 (6.2) 41 (42.2)
View consultant reports 28 (28.8) 10 (10.3) 5 (5.1) 54 (55.1)
Computerized provider order entry
Laboratory tests 13 (13.4) 8 (8.2) 5 (5.1) 71 (73.2)
Radiology tests 9 (9.3) 4 (4.1) 3 (3.1) 81 (83.5)
Medications 11 (11.3) 7 (7.3) 4 (4.1) 75 (77.3)
Decision support
Clinical guidelines 7 (7.3) 0 (0.0) 3 (3.1) 87 (89.7)
Clinical reminders 10 (10.4) 0 (0.0) 7 (7.3) 80 (82.5)
Drug allergy alerts 9 (9.3) 0 (0.0) 5 (5.1) 83 (85.6)
Drug-drug interactions alerts 8 (8.2) 0 (0.0) 4 (4.1) 85 (87.6)
n (%), number and percentage of hospitals across all EMR types and electronic functionalities.
6CIN: Computers, Informatics, Nursing Month 2017
Although the findings from this study can be used as a cor-
nerstone for any strategic plan regarding the implementation
of EMRs in the healthcare system in Jordan, the study has
not examined barriers related to the implementation decision.
Jha et al
commented that the lack of attention given by policy
makers to EMR adoption is one of the major reasons for the
low adoption rate in US hospitals. In Jordan, it is important
to investigate possible barriers related to the implementation
of EMR systems. Investigations should be directed toward all
healthcare providers (physicians, nurses, pharmacists, and other
healthcare professionals), as well as policy makers, at hospital
level and the level of the healthcare sector as a whole. Moreover,
Jordanian healthcare professionalssatisfaction and acceptance
of EMR functionalities need to be explored, and the benefits
and drawbacks of the existing system should be evaluated. Fur-
thermore, studies into cost-effectiveness are needed to explore
the economic impact of implementing EMRs in Jordanian hos-
pitals. Finally, given the low rate of EMR adoption in Jordanian
hospitals, this is an appropriate time for designing studies
that aim to evaluate the clinical outcomes (eg, quality of care
and patient safety) associated with prospective implementation.
Data generated from this study are considered robust and
reflect the healthcare system in Jordan. With the criteria of
surveying all Jordanian hospitals from all major healthcare
providers, this study was able to overcome any possibility of
selection and information bias. Moreover, with the stratifica-
tion scheme used in the study, itwaspossibletocontrolover
different confounding variables related to hospitals that par-
ticipated in the study. Giving this, results from this study can
be generalized at the Jordanian national level. Furthermore,
the results can be generalized to all countries where the use
and awareness of EMR implementation are low.
For countries with limited resources, such as Jordan, it is
important to document area of improvement in the health-
care system. Results from this study documented a very impor-
tant area of improvement related to the adoption of EMRs
in the Jordanian healthcare system. With no doubt, results
from this study can inform healthcare stakeholders and gov-
ernment leaders on the needs and importance of EMRs.
On the basis of the results from this study, different health-
care and nursing bodies can develop a national strategic plan
to support and encourage the adoption of EMRs. Moreover,
these healthcare bodies can play a major role in advocating the
patient right for safe and quality care. Extensively, research
documented that EMRs improve patient safety and quality
of care.
A pressure can be exerted by these healthcare
bodies on the decision makers to foster the adoption of EMRs.
Decision makers in Jordan should realize this low rate of
adoption of EMRs, and they should work collaboratively to
enhance the implementation of EMRs in all hospitals. Infor-
matics experts should have a role in designing, purchasing,
and evaluating the EMRs to make sure that the system met
the usersneeds effectively and efficiently.
Moreover, they
should maximize the usersacceptance of this technology by
explaining the potential benefits from using the EMRs. Users
acceptance is a crucial factor for successful implementation.
This study has important implications for nursing educa-
tion. Nurse educators should incorporate nursing informatics
and HIT courses within their curriculum. This will prepare
future nurses for effective use of EMRs in their daily practice.
Moreover, nurses with knowledge about EMRs can play a
major role in selecting, designing, and implementing EMRs
in their hospitals. Lack of knowledge and computer skills
was identified as a major factor of resistance to the acceptance
of EMRs by healthcare professionals.
This study focuses on the adoption rate of EMRs in Jordanian
hospitals, and we did not investigate their actual use or effective-
ness. Moreover, a wide range of systems from different vendors
are used in Jordan, which could make applying one standard
survey tool difficult and the comparison or aggregation of
the data from different systems problematic. Furthermore,
it was difficult to compare the adoption rate of the current
article with the internationally reported one, for two reasons.
First, there is limited evidence existing about the topic of in-
terest in the developing countries, and second, there is a dif-
ference in the healthcare systems between the developed and
developing countries that makes the comparison between
them difficult. Finally, although this study was successful in
documenting the rate of EMR use in Jordanian hospitals,
the study was unable to give more details about the possible
reasons of low adoption rate. Future research should be di-
rected to explore barriers related to the adoption of EMRs
in Jordanian hospitals.
The use of EMR systems in Jordan is still in its infancy. The
EMR system in Jordan is focused mainly on the viewing of
diagnostic test results. Other features are still not commonly
implemented. This is the first Jordanian study to estimate the
level of adoption of EMRs in Jordanian hospitals at the na-
tional level, which is found to be 10.3% for the comprehensive
system that was used in all major units. Results from this study
ress in the adoption of EMR systems in Jordanian hospitals in
the future. National strategic plans are needed to address
goals and implementation processes of EMR systems in all
Jordanian hospitals. Plans should be composed of all aspects
of implementation such as transition from basic and paper-
based systems to comprehensive systems and the training of
human resources and healthcare personnel.
Volu me 0 0 | N umber 0 CIN: Computers, Informatics, Nursing 7
The authors thank the Deanship of Scientific Research at Al al-Bayt
University for funding this project (grant ID 4/2014/2015).
1. Kitsiou S, Manthou V, Vlachopoulou M, Markos A. Adoption and sophistication
of clinical information systems in Greek public hospitals: results from a
national web-based survey. Paper presented at: XII Mediterranean Conference
on Medical and Biological Engineering and Computing. 2010.
2. Marca G, PerezAJ, Blanco-GarciaMG, MiravallesE, Soley P, Ortiga B.The use
of electronic health records in Spanish hospitals. HIM J. 2014;43(3): 3744.
3. Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and safety
of health care: a systematic overview. PLoS Med. 2011;8(1): e1000387.
4. Lee J, Dowd B. Effect of health information technology expenditure on patient
level cost. Healthc Inform Res. 2013;19(3): 215221.
5. Hillestad R, Bigelow J, Bower A, et al. Can electronic medical record systems
transform health care? Potential health benefits, savings, and costs. Health
Aff (Millwood). 2005;24(5): 11031117.
6. Abraham J, McC ullough J, Parente S, Gaynor M. Prevalence of electronic health
records in US hospitals. JHealthcEng. 2011;2(2): 121142.
7. Gentles SJ, Lokker C, McKibbon KA. Health information technology to facilitate
communication involving health care providers, caregivers, and pediatric
patients: a scoping review. JMedInternetRes. 2010;12(2): e22.
8. Foraker RE, Kite B, Kelley MM, et al. EHR-based visualization tool :a doption rates,
satisfaction, and patient outcomes. EGEMS (Wash DC). 2015;3(2): 1159.
9. Pagliari C, Detmer D, Singleton P. Potential of electronic personal health records.
BMJ. 2007;335(7615): 330333.
10. BlumenthalD, Glaser JP.Information technology comes to medicine. NEnglJ
Med. 2007;356(24): 2527.
11. Berkowitz L, McCarthy C. Innovation With Information Technologies in Healthcare.
XVIII ed. London, England: Springer Science & Business Media; 2013.
12. Jiang T, Yu P. The impact of electronic health records on client safety in aged
care homes. Stud Health Technol Inform. 2014;201: 116123.
13. Furukawa MF, Raghu TS, Spaulding TJ, Vinze A. Adoption of health information
technology for medication safety in U.S. hospitals, 2006. Health Aff (Millwood).
2008;27(3): 865875.
14. Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records
in U.S. hospitals. N Engl J Med. 2009;360(16): 16 281638.
15. Jha AK, DesRoches CM, Kralovec PD, Joshi MS. A progress report on electronic
health records in U.S. hospitals. Health Aff (Millwood). 2010;29(10) :
16. Charles D, Gabriel M, Searcy T.Adoption of Electronic Health Record Systems
Among US Non-federal Acute Care Hospitals: 2008-2014 (ONC Data Brief,
No.23). Washington, DC: Office of the National Coordinator for Health
Information Technology; 2014.
17. Hübner U, Ammenwerth E, Flemming D, Schaubmayr C, Sellemann B. IT
adoption of clinical information systems in Austrian and German hospitals:
results of a comparative survey with a focus on nursing. BMC Med Inform Decis
Mak. 2010;10: 8.
18. Yoon D, Chang B-C, Kang SW, Bae H, Park RW. Adoption of electronic health
records in Korean tertiary teaching and general hospitals. Int J Med Inform.
2012;81(3): 196203.
19. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information
technology on quality, efficiency, and costs of medical care. Ann Intern Med.
2006;144(10): 742752.
20. Jha AK, Fer ris TG, Donelan K, et al. How common are electronic health records
in the United States? A summary of the evidence. Health Aff (Millwood).
2006;25(6): w496w507.
21. Laschober M, Maxfield M, Felt-Lisk S, Miranda DJ. Hospital response to public
reporting of quality indicators. Health Care Fina nc Rev. 2007;28(3): 6176.
22. MOH. Ministry of health (MOH)-Jordan, annual repor t, 2014. Http://
Accessed June 11, 2014.
23. Nassar DA, Othman M, Yahya H. Implementation of an EHR system (Hakeem) in
Jordan: challenges and recommendations for governance. Him-Interchange.
2013;3(3): 1012.
24. Polit DF, Beck CT. Essentials of Nursing Research: Appraising Evidence for Nursing
Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
25. Bah S, Alharthi H, El Mahalli AA, Jabali A, Al-Qahtani M, Al-kahtani N. Annual
survey on the level and extent of usage of electronic health records in
government-related hospitals in Eastern Province, Saudi Arabia. Perspect
Health Inf Manag. 2011;8: 1b.
26. Aldosar i B. Rates, levels, and determinants of electronic health record system
adoption: a study of hospitals in Riyadh, Saudi Arabia. Int J Med Inform.
2014;83(5) : 330342.
27. Anderson GF, Frogner BK, Johns RA, Reinhardt UE. Health care spending and
use of information technology in OECD countries. Health Aff (Millwood).
2006;25(3) : 819831.
28. de la Torre-Díez I, González S, López-Coronado M. EHR systems in the Spanish
public health national system: the lack of interoperability between primary
and specialty care. JMedSyst. 2013;37(1): 9914.
29. Boonstra A, Versluis A, Vos JF. Implementing electronic health records in
hospitals: a systematic literature review. BMC Health Serv Res. 2014;
14(1): 370.
30. Hypponen H, Saranto K, Vuokko R, et al. Impacts of structuring the electronic
health record: a systematic review protocol and results of previous reviews.
Int J Med Inform. 2014;83(3): 159169.
31. Rojas CL, Seckman CA. The informatics nurse specialist role in electronic
health record usability evaluation. Comput Inform Nurs. 2014;32(5):
32. Hackl WO, Hoerbst A, Ammenwerth E. Why the hell do we need electronic
health records?EHR acceptance among physicians in private practice in
Austria: a qualitative study. Methods Inf Med. 2010;50(1): 5361.
8CIN: Computers, Informatics, Nursing Month 2017
... Although EHRs were introduced in Jordan during the last decade, they have not yet been fully implemented (Tubaishat & Al-Rawajfah, 2017). Several institutions are working on introducing complex health information systems with many modules in different healthcare settings in order to handle the expanding technology. ...
... The pilot phase (2009)(2010)(2011)(2012)(2013)(2014)(2015) of the EHS system that covered 14 hospitals, 22 comprehensive health centers, and 52 primary healthcare centers (The National Strategy for Health Sector in Jordan, 2015-2019) was presented as a project derived from an opensource health information system known as the VistA program. VistA is composed of many applications linked to large databases, including patient administration records, radiology, pharmacy, and nursing documentation systems (Tubaishat & Al-Rawajfah, 2017). The study aims at describe the nursing leadership styles, training methods for nurses, and the level of use of EHRs by nurses in Jordan. ...
Full-text available
Background: The current evidence supports the fact that implementing electronic health records (EHRs) provide high-quality services to patients. Purpose: To assess level of practice of nursing leadership characteristics during the implementation of EHRs as perceived by nurses Method: A cross-sectional survey design was used. Results: Data were collected from 213 nurses, the majority of participants (72.3%) were females. Of them, 45% reported receiving full support from their leaders in using the EHRs and reported receiving full support from their leaders in using the EHRs. Classroom-based training was the most frequently used teaching method during the implementation of EHRS (59.6%). Conclusions: this study demonstrated that all three nursing leadership styles were practiced during the implementation process of the EHRs: setting directions, developing people, and redesigning their organizations. The most commonly practiced item was clarifying the reasons for using the EHRs. Such information could enhance effective adoption of EHRs by nurses.
... Therefore, it becomes necessary to evaluate information systems to provide evidence on system functional status and its fitness for purpose with a view to inform future deployments. Maximum benefits of information systems (IS) implementation can only be realized if the systems are deeply used in the post-adoption phase [17]. As such, evaluation of actual use of EHRs once implemented provides vital information relevant to informing approaches to improve success of existing and subsequent implementations. ...
... System use is the utilization of an IS in work processes by individuals, groups or organizations [11]. A number of studies have measured the actual EHRs use in terms of extent, frequency, duration of use and functions of the system based majorly on behavioural response of users through questionnaires, interview and/or focus group discussions [2,11,17,25,26]. However, only limited evaluation studies utilizing computer-generated data to assess EHRs use are available. ...
Full-text available
Background Health facilities in developing countries are increasingly adopting Electronic Health Records systems (EHRs) to support healthcare processes. However, only limited studies are available that assess the actual use of the EHRs once adopted in these settings. We assessed the state of the 376 KenyaEMR system (national EHRs) implementations in healthcare facilities offering HIV services in Kenya.Methods The study focused on seven EHRs use indicators. Six of the seven indicators were programmed and packaged into a query script for execution within each KenyaEMR system (KeEMRs) implementation to collect monthly server-log data for each indicator for the period 2012-2019. The indicators included: Staff system use, observations (clinical data volume), data exchange, standardized terminologies, patient identification, and automatic reports. The seventh indicator (EHR variable Completeness) was derived from routine data quality report within the EHRs. Data were analysed using descriptive statistics, and multiple linear regression analysis was used to examine how individual facility characteristics affected the use of the system.Results213 facilities spanning 19 counties participated in the study. The mean number of authorized users who actively used the KeEMRs was 18.1% (SD = 13.1%, p
... They suggested a new middleware architecture that facilitates secure data exchange and allows access to the database server regardless of the time or location [21]. Tubaishat and Alrawajfah measured the level of use of e-health records in Jordanian hospitals based on the American Hospital Association annual survey that measures the level of adoption of e-health services [22]. They concluded that the level is relatively low. ...
... They concluded that the level is relatively low. A very low percent of hospitals uses EHR in all hospital's divisions; some uses EHR in one division and most hospitals don't use the EHR [22]. Rasmi et al. proposed a model that concentrates on the role of the behavior of health care professionals in using EHR system in Jordan [23]. ...
Full-text available
Hakeem is one of the e-health systems that were implemented in Jordan to support the health care and services of medical sectors by connecting public health hospitals all around Jordan. This study was carried out as a unique and first study to investigate the effectiveness of Hakeem health system according to the international health information systems standards. The Health Metrics Network (HMN) framework and standards for country health information systems are used to measure the Hakeem system from different perspectives to ensure that it meets its objectives to maintain the required level of medical services in Jordan compared to international systems. The study was conducted on 522 respondents of Hakeem system users from four hospitals and ten health centers in Jordan. Data were collected by a valid and reliable questionnaire and interviews and analyzed by SPSS software. The study results indicated that the conformity extent of Hakeem system’s components with HMN framework and standards are in different agreements percentages. Some components are with acceptable percentages such as the integration polices and data processing while other components are with moderate, low and very lower percentages that needed improvements. In the light of the results, the study introduces some recommendations to improve Hakeem system such as improving the technical support of entire system as well as the services used in pharmacy unit.
... Other studies [11,[37][38][39][40][41] assessed the adoption and satisfaction with HISs based on features but not on what was missing. Generally speaking these studies found, just like ours, similar levels of satisfaction with the features. ...
Full-text available
Background Care for people with an Intellectual Disability (ID) is complex: multiple health care professionals are involved and use different Health Information Systems (HISs) to store medical and daily care information on the same individuals. The objective of this study is to identify the HISs needs of professionals in ID care by addressing the obstacles and challenges they meet in their current HISs. Methods We distributed an online questionnaire amongst Dutch ID care professionals via different professional associations and care providers. 328 respondents answered questions on their HISs. An inventory was made of HIS usage purposes, problems, satisfaction and desired features, with and without stratification on type of HIS and care professional. Results Typical in ID care, two types of HISs are being used that differ with respect to their features and users: Electronic Client Dossiers (ECDs) and Electronic Patient Dossiers (EPDs). In total, the respondents mentioned 52 unique HISs. Groups of care professionals differed in their satisfaction with ECDs only. Both HIS types present users with difficulties related to the specifics of care for people with an ID. Particularly the much needed communication between the many unique HISs was reported a major issue which implies major issues with inter-operability. Other problems seem design-related as well. Conclusion This study can be used to improve current HISs and design new HISs that take ID care professionals requirements into account.
... . Rekam medis merupakan berkas yang berisi catatan tentang identitas pasien, pemeriksaan, pengobatan, tindakan, dan pelayanan lainnya yang diterima pasien oleh pemberi pelayanan Kesehatan (4) . (11) . ...
In the current era of global competition, it requires every hospital as a health service facility to be able to provide quality services in order to foster patient loyalty as service users. The medical record is one of the medical support services which is the basis for assessing the quality of medical services. Completeness of medical record files in RSUD Syekh Yusuf Kab. Gowa in a period of three years has fluctuated, namely 20% in 2017, 66% in 2018, and decreased in 2020 to 17%. This study aims to determine the description of medical record data management at RSUD Syekh Yusuf Kab. Gowa 2019.This study used a qualitative descriptive research method with the selection of informants using a purposive technique, and 6 informants were obtained, including 4 medical record officers, 1 head of the inpatient room, and 1 head of the medical records department.The results of the interview showed that the personnel in the medical records department were deemed insufficient, the flow and SOP were not implemented, the facilities and infrastructure were inadequate. In the implementation of medical records, there are still files that are filled in incompletely which results in delays in making reports.It is hoped that the hospital management will increase the number of personnel so that there is no double burden on officers, provide training for medical record officers, and pay attention to facilities and infrastructure to switch from a conventional system to an electronic-based system.
... 12 A recent national survey reported that only 10.3% of the Jordanian hospitals had comprehensive electronic medical records (EMRs) and implemented the system in all major units, 15.5% of the hospitals were classified as having a basic EMR system, and 72% of the hospitals did not use any EMRs and relied completely on paper records. 13 Compliance of Jordanian nurses with BCMA was not reported; therefore, results of this study will provide knowledge about common practices of BCMA, aiming at fostering the maximum benefits of this new technology in enhancing patient safety. ...
Medication administration using bar-code medication administration technology enhances the verification of medication administration rights. Nurses' compliance with bar-code medication administration procedure is essential to maximize the benefits. This study evaluated the current rate of nurses' compliance with bar-code medication administration use through direct observation. A descriptive design was used and 134 RNs were recruited from two public hospitals located in the middle region of Jordan. Compliance with bar-code medication administration was evaluated using an evidence-based checklist of 17 items. Participants' compliance with the bar-code medication administration was 55%, which had a significant positive correlation with their level of comfort using bar-code medication administration, usefulness, and ease of use, perceived job productivity, and overall rating of bar-code medication administration. Stakeholders can benefit from assessing end-user acceptance and perceptions regarding the bar-code medication administration technology to promote acceptance and compliance.
... In the Arab world, the support of the implementation of EMRs by gov- ernments and legislations is still in its infancy [3], and the adoption of EMRs is still lagging. EMRs were implemented in 25% in hospitals in the area of Makkah [4], 15% in government-related hospitals in Eastern Province of Saudi Arabia, 6.67% in Egyptian hospitals [5] and 10% in Jordanian hospitals [6]. High implementation and maintenance costs, decreased productivity due to workflow disruption, and questionable financial returns are among the leading barriers against the use of EMR than with the patient [7]. ...
Background: A commonly stated barrier to adoption of electronic medical record (EMR) is fear of a negative impact on physician-patient communication. Systematic reviews have shown that there is limited literature addressing the patients' perspective as compared to the physicians' perspectives. Aim: This study aims to understand patients' perspective on the effect of EMR on physician-patient communication in an ambulatory setting. Design and settings: This is a qualitative study using semi-structured interviews with 49 patients at a multi-physician family medicine clinic in a large academic medical center in Beirut, Lebanon. Materials and methods: At the end of the visit with the physicians, the patients were approached by the clinical assistant to conduct an interview concerning the patient-doctor communication in the presence of electronic medical record. The interview was conducted in a private office by an experienced researcher. Results: Almost all patients reported that computer use during the encounter did not affect the quality of communication with their physician. Five themes emerged from the analysis of the interviews: (1) EMR use in clinic is considered a necessity; (2) EMR use by physicians is efficient in record keeping and information retrieval; (3) physicians balance between using the computer and paying attention to patients; (4) computer use by physicians might affect communication about personal and intimate issues; (5) concomitant computer use while listening to the patient was not considered disturbing. Conclusions: Most patients appreciated EMR use by physicians during the clinical encounter and acknowledged its benefits despite the presence of some concerns. Most patients did not consider that EMRs affect communication with physicians negatively especially when used in a balanced manner. Attention rather than eye contact is what mattered the most for patients.
Full-text available
This research presents a quantitative analysis of 121 published papers specific to Jordan's e-government researches (EGR) throughout the years 2009- January 2021 through a meta-analysis systematic process. The focus EGR specific to Jordan is due to the fact that the e-government studies conducted in Jordan context are among the highest publications in developing countries. Study results reveal that the majority of EGR in Jordan have adopted a quantitative approach rather than qualitative or multi-method evaluation approaches and none of EGR adopted a design research approach or action research approach involved researcher(s) and practitioner(s). While a fair number of EGR take a theory-based approach, the majority of them rely on common and traditional theories (e.g., TAM and UTAUT), neglecting many other potential theories to use e.g., expectation confirmation and technology-organization-environment theories. EGR in Jordan has overwhelmingly focused on specific e-government topics (e.g., citizens' acceptance and adoption besides evaluating e-government websites or portals) and thus more research orientation should go further toward other recent topics e.g., continuous-use intention and /or post-adoption, citizens resistance, privacy and security issues as well as to capture new trends and priorities in the e-government domain such as anticipatory e-government, smart government, participatory governance, smart city, and data-centric governance that all are critically required to advance EGR in Jordan. The study findings provide opportunities for future areas of research, which contribute to more diversity of EGR in Jordan. The study helps to develop reliable knowledge and leads to ideas for new studies that are anticipated to be of significant value for both academics and practitioners. While the findings might be restricted to Jordan's context, nevertheless, it would encourage other e-government scholars to conduct similar studies for their own countries.
Little is known about the adoption rate of electronic health records in primary healthcare settings. This study aimed to estimate this adoption rate in Jordan, using a national survey with a descriptive cross-sectional design. The first step was to review the annual report of the Jordanian Ministry of Health as a basis for identifying the sample, which are primary healthcare settings. Then, Electronic Health Solutions, the company that vends electronic health record systems in Jordan, was used to determine which primary healthcare settings were using these electronic record systems. The final task was to determine which functionalities of the system were being used in these settings, and for this, a telephone survey of key personnel was conducted. It was found that 21.6% of the primary healthcare settings were using electronic health records, while the other 78.4% were still relying on paper records. The results also showed that the adoption rate of electronic health records was significantly associated with the type of the setting (P < .001), its size (P < .001), location (P < .001), and region (P = .04). As a conclusion, the adoption rate in Jordan is still in its infancy compared with those in developed countries. Policy and decision makers should therefore be focused on minimizing any challenges or obstacles to such adoption.
Full-text available
Electronic health records (EHRs) have the potential to enhance patient-provider communication and improve patient outcomes. However, in order to impact patient care, clinical decision support (CDS) and communication tools targeting such needs must be integrated into clinical workflow and be flexible with regard to the changing health care landscape. The Stroke Prevention in Healthcare Delivery Environments (SPHERE) team developed and implemented the SPHERE tool, an EHR-based CDS visualization, to enhance patient-provider communication around cardiovascular health (CVH) within an outpatient primary care setting of a large academic medical center. We describe our successful CDS alert implementation strategy and report adoption rates. We also present results of a provider satisfaction survey showing that the SPHERE tool delivers appropriate content in a timely manner. Patient outcomes following implementation of the tool indicate one-year improvements in some CVH metrics, such as body mass index and diabetes. Clinical decision-making and practices change rapidly and in parallel to simultaneous changes in the health care landscape and EHR usage. Based on these observations and our preliminary results, we have found that an integrated, extensible, and workflow-aware CDS tool is critical to enhancing patient-provider communications and influencing patient outcomes.
Full-text available
Electronic health records (EHRs) are promising tools to improve quality and efficiency in health care, but data on their adoption rate are limited. We identified surveys on EHR adoption and assessed their quality. Although surveys returned widely different estimates of EHR use, when available information is limited to studies of high or medium quality, national estimates are possible: Through 2005, approximately 23.9 percent of physicians used EHRs in the ambulatory setting, while 5 percent of hospitals used computerized physician order entry. Large gaps in knowledge, including information about EHR use among safety-net providers, pose critical challenges for the development of policies aimed at speeding adoption.
Full-text available
Background The literature on implementing Electronic Health Records (EHR) in hospitals is very diverse. The objective of this study is to create an overview of the existing literature on EHR implementation in hospitals and to identify generally applicable findings and lessons for implementers. Methods A systematic literature review of empirical research on EHR implementation was conducted. Databases used included Web of Knowledge, EBSCO, and Cochrane Library. Relevant references in the selected articles were also analyzed. Search terms included Electronic Health Record (and synonyms), implementation, and hospital (and synonyms). Articles had to meet the following requirements: (1) written in English, (2) full text available online, (3) based on primary empirical data, (4) focused on hospital-wide EHR implementation, and (5) satisfying established quality criteria. Results Of the 364 initially identified articles, this study analyzes the 21 articles that met the requirements. From these articles, 19 interventions were identified that are generally applicable and these were placed in a framework consisting of the following three interacting dimensions: (1) EHR context, (2) EHR content, and (3) EHR implementation process. Conclusions Although EHR systems are anticipated as having positive effects on the performance of hospitals, their implementation is a complex undertaking. This systematic review reveals reasons for this complexity and presents a framework of 19 interventions that can help overcome typical problems in EHR implementation. This framework can function as a reference for implementers in developing effective EHR implementation strategies for hospitals.
Full-text available
This study collects and critically reviews the published literature to synthesize the risk factors for client safety in residential aged care and the potential contributions of electronic health records to reducing these risks. Three major types of risk factors for client safety were identified: risk factors related to the person's health; those related to the health and aged care system serving the person and those related to human error. Multiple strategies at all levels of an aged care organization are needed to reduce risks and improve client safety. Electronic health records can be one of the effective organizational mechanisms because it improves access to better information and integrates intelligent functions to support point-of-care decision making.
Full-text available
This paper (1) presents the protocol of an on-going systematic literature review on the methods of structuring electronic health record (EHR) data and studying the impacts of implemented structures, thus laying basis for the analysis of the empirical articles (2) describes previous reviews published on the subject and retrieved during the search of bibliographic databases, and (3) presents a summary of the results of previous reviews. Cochrane instructions were exploited to outline the review protocol - phases and search elements. Test searches were conducted to refine the search. The abstracts and/or full texts of review papers captured by the search were read by two of the team members independently, with disagreements first negotiated between them and if necessary eventually resolved in the team meetings. Additional review articles were picked from the reference lists of the reviews included in our search results. The elements defined in the search strategy and analytic framework were converted to a data extraction tool, which was tested by extracting data from the reviews captured by the search. Descriptive analysis of the extracted data was conducted. The 12-stage review protocol that we developed includes definition of the problem, the search strategy and search terms, testing the strategy, conducting the search, updating search from references found, removing duplicates, defining the inclusion and exclusion criteria, exclusion and inclusion of papers, definition of the analytic framework to extract data, extracting data and reporting results. Our searches in fifteen electronic bibliographic databases retrieved 27 reviews, of which 14 were included for full text analysis. Of these, 11 focused on medical and three on nursing record structures. The data structures included forms, ontologies, classifications and terminologies. Some evidence was found on data structure impact on information quality, process quality and efficiency, but not on patients or professionals. The 12 step review protocol resulted in a variety of reviews of different ways to structure EHR data. None of them compared outcomes of different structuring methods; all had a narrower definition of the Intervention (a specific EHR structure) and Outcome (a specific impact category). Several reviews missed a clear connection between the data structures (interventions) and outcomes, indicating that the methods and applications for structuring patient data have rarely been viewed as independent variables. The review protocol should be defined in a manner that allows replication of the review. There are different ways of structuring patient data with varying impacts, which should be distinguished in further empirical studies, as well as reviews.
Full-text available
This study investigate the effect of health information technology (IT) expenditure on individual patient-level cost using California Office of Statewide Health Planning and Development (OSHPD) data obtained from 2000 to 2007. We used a traditional cost function and applied hospital fixed effect and clustered error within hospitals. We found that a quadratic function of IT expenditure best fit the data. The quadratic function in IT expenditure predicts a decrease in cost of up to US$1,550 of IT labor per bed, US$27,909 of IT capital per bed, and US$28,695 of all IT expenditure per bed. Moreover, we found that IT expenditure reduced costs more quickly in medical conditions than surgical diseases. Interest in health IT is increasing more than ever before. Many studies examined the effect of health IT on hospital level cost. However, there have been few studies to examine the relationship between health IT expenditure and individual patient-level cost. We found that IT expenditure was associated with patient cost. In particular, we found a quadratic relationship between IT expenditure and patient-level cost. In other word, patient-level cost is non-linearly (or a polynomial of second-order degree) related to IT expenditure.
The aims of this study were to describe the level of adoption of electronic health records in Spanish hospitals and to identify potential barriers and facilitators to this process. We used an observational cross-sectional design. The survey was conducted between September and December 2011, using an electronic questionnaire distributed through email. We obtained a 30% response rate from the 214 hospitals contacted, all belonging to the Spanish National Health Service. The level of adoption of electronic health records in Spanish hospitals was found to be high: 39.1% of hospitals surveyed had a comprehensive EHR system while a basic system was functioning in 32.8% of the cases. However, in 2011 one third of the hospitals did not have a basic electronic health record system, although some have since implemented electronic functionalities, particularly those related to clinical documentation and patient administration. Respondents cited the acquisition and implementation costs as the main barriers to implementation. Facilitators for EHR implementation were: the possibility to hire technical support, both during and post implementation; security certification warranty; and objective third-party evaluations of EHR products. In conclusion, the number of hospitals that have electronic health records is in general high, being relatively higher in medium-sized hospitals.
Objective Outside a small number of OECD countries, little information exists regarding the rates, levels, and determinants of hospital electronic health record (EHR) system adoption. This study examines EHR system adoption in Riyadh, Saudi Arabia. Materials and Methods Respondents from 22 hospitals were surveyed regarding the implementation, maintenance, and improvement phases of EHR system adoption. Thirty-seven items were graded on a three-point scale of preparedness/completion. Measured determinants included hospital size, level of care, ownership, and EHR system development team composition. Results Eleven of the hospitals had implemented fully functioning EHR systems, eight had systems in progress, and three had not adopted a system. Sixteen different systems were being used across the 19 adopting hospitals. Differential adoption levels were positively related to hospital size and negatively to the level of care (secondary versus tertiary). Hospital ownership (nonprofit versus private) and development team composition showed mixed effects depending on the particular adoption phase being considered. Discussion Adoption rates compare favourably with those reported from other countries and other districts in Saudi Arabia, but wide variations exist among hospitals in the levels of adoption of individual items. General weaknesses in the implementation phase concern the legacy of paper data systems, including document scanning and data conversion; in the maintenance phase concern updating/maintaining software; and in the improvement phase concern the communication and exchange of health information. Conclusion This study is the first to investigate the level and determinants of EHR system adoption for public, other nonprofit, and private hospitals in Saudi Arabia. Wide interhospital variations in adoption bear implications for policy-making and funding intervention. Identified areas of weakness require action to increase the degree of adoption and usefulness of EHR systems.
Health information technology is revolutionizing the way we interact with health-related data. One example of this can be seen in the rising adoption rates of electronic health records by healthcare providers. Nursing plays a vital role in electronic health record adoption, not only because of their numbers but also their intimate understanding of workflow. The success of an electronic health record also relies on how usable the software is for clinicians, and a thorough usability evaluation is needed before implementing a system within an organization. Not all nurses have the knowledge and skills to perform extensive usability testing; therefore, the informatics nurse specialist plays a critical role in the process. This article will discuss core usability principles, provide a framework for applying these concepts, and explore the role of the informatics nurse specialist in electronic health record evaluation. Health information technology is fundamentally changing the clinical practice environment, and many nurses are seeking leadership positions in the field of informatics. As technology and software become more sophisticated, usability principles must be used under theguidance of the informatics nurse specialist to provide a relevant, robust, and well-designed electronic health record to address the needs of the busy clinician.