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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.
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The Use of Electronic Medical Records in Jordanian
Hospitals
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
SIGNIFICANCE
The introduction of health information technology (HIT)
into healthcare industries is gaining pace.
1
There is much
greater investment in HIT in developed countries than ever
before. For example, 544 million was spent in Spain in 2009,
2
and in the United Kingdom, it was estimated that the expen-
diture on HIT reached approximately £12.8 billion in 2011.
3
In the United States, almost US $20 billion was allocated to
support the adoption of HIT in US hospitals in 2009.
4
By
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).
5
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.
6
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
7
; enhancing decision-making services
8
;
minimizing communication errors
7
; generating electronic re-
ports that are necessary for institutional, private, and public
requirements
9
; and improving patient safety.
1012
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
4
and
the national level
9
stimulates research around the world to
evaluate the extent of EMR implementation in healthcare
systems such as that of the United States,
1316
Austria and
Germany,
17
Greece,
1
Korea,
18
and Spain.
2
The importance of EMRs depends largely on their adoption,
application, and use.
19
There is wide variation on the reported
levels of adoption of EMRs around the globe.
20
This variation
could be due to lack of agreement on the definitions of EMRs,
13
the adoption of EMRs in terms of its capabilities,
13,21
method-
ological differences in estimating the adoption level,
20
and con-
venience sampling techniques with low response rates from the
conducted surveys.
14
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.
16
The first survey was conducted to estimate the level of adop-
tion of EMRs in 3049 US hospitals (response rate, 63.1%).
14
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 (atubaishat@aabu.edu.jo).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/CIN.0000000000000343
FEATURE ARTICLE
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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%.
15
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.
16
A similar approach was followed in a study conducted in
Spain to measure the use of EMRs in Spanish hospitals.
2
In
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).
18
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
hospitals.
1
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
17
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-
larbudgetforHIT(2.6%inAustriaand2%inGermany).The
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
Jordaniangovernmentallocated8%ofthetotalnational
budget to the Ministry of Health.
22
The population in
2014 was thought to be approximately 6.5 million with
an estimated per capita income of US $5357.
22
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.
23
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-
gramstartedin2009asapilotschemeinonepublichospital
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.
23
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.
METHOD
Design
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.
24
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.
22
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,
FEATURE ARTICLE
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,
16
which
is deemed to be of high quality.
14
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.
16
Permission
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.
14
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.
14
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
14
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
14
further
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
TheprevalenceoftheadoptionofEMRswascalculatedusing
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.
RESULTS
According to Jha et als
14
definitions, the vast majority of par-
ticipating hospitals (72, 74.2%) were found to not implement
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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
2
=14.7,
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
2
=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
2
=14.7,P< .001). In addition,
the adaptation rate of EMRs was significantly associated
with hospital type (χ
2
=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)
FEATURE ARTICLE
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).
DISCUSSION
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,
16
the reported adoption
rates were 34.4% for comprehensive systems and 41.4% for ba-
sic systems. Recently, in Spain, Marca et al
2
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
17
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.
7
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.
25,26
According to Aldosari,
26
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
25
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
2
P
Size
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)
Region
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)
Location
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)
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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.
27
According to Anderson et al,
27
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.
23
It has been estimated that the cost of EMR
implementation can reach $63 000 per bed.
23
Therefore,
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.
6
It plays a major role in cost-saving
capabilities, where the duplication of laboratory and radiology
tests and medication dispensing will be minimized.
2
Unfortu-
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%,
respectively.
14
In a Spanish study, the figures was 39.1% and
50%, respectively
2
; in Korea, it was 80% for medications
18
;
and in a Greek study, the application of general CPOE systems
was 14.3%.
1
The electronic functionality of results viewing by different
healthcare providers and in different settings is a significant
component of any EMR system.
28
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%
14
and
80%,
2
respectively.
Table 3. Selected Functionalities and Their Level of Implementation in Jordanian Hospitals (N = 97)
n(%)
a
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)
a
n (%), number and percentage of hospitals across all EMR types and electronic functionalities.
FEATURE ARTICLE
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
14
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.
29,30
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.
31
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.
32
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.
29
LIMITATIONS
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.
CONCLUSIONS
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
canbeusedasabaselinereferencefortheevaluationofprog-
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
Acknowledgment
The authors thank the Deanship of Scientific Research at Al al-Bayt
University for funding this project (grant ID 4/2014/2015).
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FEATURE ARTICLE
8CIN: Computers, Informatics, Nursing Month 2017
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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.
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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.
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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.
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