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Professional Med J 2017;24(1):182-187. www.theprofesional.com
ELECTRONIC HEALTH RECORD SYSTEMS
182
The Professional Medical Journal
www.theprofesional.com
ELECTRONIC HEALTH RECORD SYSTEMS;
PERCEPTION AND EVALUATION AMONG PHYSICIANS IN PAKISTAN
Dr. Hamid Mehmood1, Dr. Muhammad Aslam2, Dr. Sadia Aslam3, Ammara Waqar4, Dr. Athar Khan5,
Yasir Hassan6, Dr. Faryal Murtaza Cheema7, Dr. Hassan Mujtaba8, Noor-e-Maham9
ORIGINAL PROF-3213
ABSTRACT…Introduction: e-Health is a combination of medical informatics, public health,
business and information technology. Health information technology has increased the
productivity by reengineering of health care but it requires new measurement tools to monitor
the impact of it .e-health is not only for the development of technologies but also it includes
proper planning, thinking, broad thinking to improve healthcare services with the help of
information and communication technology. Objectives: 1) To assess the perceptions of
physicians towards the use, effectiveness and efciency of EHR 2) To identify the differences
between electronic and paper based records 3) To evaluate the usage of Electronic Health
Records.4) To analyze satisfaction and challenges face by the physicians using EHR. Research
Design: This is an Exploratory and Descriptive Research. In this study hybrid research method
is used which includes qualitative and quantitative research methods. Sampling technique:
For this study, a purposive sample of 43 physicians was selected. The sample size was 60
but 17 responses were incomplete so they were excluded and the nal sample size was 43.
Data was collected from two different hospitals of Pakistan which include the physicians from
Shaukat Khanum Memorial Cancer Hospital and Research Centre, and Indus Hospital. Of the
43 participants, 51% were from Indus Hospital and 49% were from Shaukat Khanum Memorial
Cancer Hospital and Research Centre. Instrument: A structured questionnaire was used to
collect data and it was collected by email responses and direct interview. EHR Questionnaire:
A questionnaire was used in the study. The EHR Questionnaire has comprised of 24 items. This
questionnaire was developed by Msukwa. B.K.Martin.1 Data Analysis: Data analysis was done
by Statistical Package for Social Sciences (SPSS) and Microsoft Excel. Procedure: The sample
consisted of physicians from Shaukat Khanum Memorial Cancer Hospital and Research Centre,
and Indus Hospital from Karachi. EHR is a new technology and hospitals are moving towards
it, some are under process and very few like the above mentioned hospitals are using it. The
questionnaire was not complicated. It was a structured questionnaire with easy questions with
multiple options to ll in. Respondents were also acknowledged for their cooperation and
participation in the study. Conclusion: EHR should be used effectively, proper training is needed
to ensure that physicians are able to operate the system and can have maximum benets from
the technology by utilizing all its applications. The government should encourage adoption of
Electronic Health l Records in Pakistan by developing a public-private partnership. The study
focused also on EHR effectiveness by checking the working of EHR its quick and satisfactory
results its accuracy, adequacy, timeliness, user- friendliness, availability and reliability.
Key words: Evaluation, Perception, Electronic Health Records, Physicians.
1. Professor of Biochemistry
Amnay Inayat Medical College,
Lahore
2. Assistant Professor surgery
Amna Inayat Medical College,
Lahore
3. Assistant Professor
Gynaecology
Amna Inayat Medical College,
Lahore
4. UOL Lahore.
5. HOD, UIPH, UOL, Lahore
6. Assistant Professor
UOL, Lahore.
7. Allama Iqbal Medical College.
Lahore
8. Allama Iqbal Medical College,
Lahore
9. Amna Inayat Medical College,
Lahore
Correspondence Address:
Dr. Hamid Mahmood
Professor of Biochemistry
Amna Inayat Medical College, Lahore
drhamidmahmood373@gmail.com
Article received on:
17/12/2015
Accepted for publication:
15/10/2016
Received after proof reading:
18/01/2017
Article Citation: Mahmood H, Aslam M, Aslam S, Waqar A, Khan A, Hassan Y, Cheema FM,
Mujtaba H, Noor-e-Maham. Electronic health record systems; perception and
evaluation among physicians in Pakistan. Professional Med J 2017;24(1):182-
187. DOI: 10.17957/TPMJ/17.3213
INTRODUCTION
E-Health is an advance term which has brought
a revolution in the healthcare industry by using
information and communication technologies. It
was introduced in 1999.2
e-Health is an combination of medical informatics,
public health, business and information
technology. Health information technology has
increased the productivity by reengineering of
health care but it requires new measurement
tools to monitor the impact of it.3
e-health is not only for the development of
DOI: 10.17957/TPMJ/17.3213
Professional Med J 2017;24(1):182-187. www.theprofesional.com
ELECTRONIC HEALTH RECORD SYSTEMS
183
2
technologies but also it includes proper planning,
thinking, broad thinking to improve healthcare
services with the help of information and
communication technology.2
The TWAS-hosted 13th annual meeting of the
Coordinating Council of the Commission on
Science and Technology discussed about the
successful steps taken by COMSATS. It has
developed 16 centers of excellence.4
In this meeting, The COMSATS Institute of
Information Technology (CIIT ) in of Pakistan
proved to be one of the prosperous institutions.
COMSATS Institute of Information Technology
(CIIT ) started a project named as COMSATS
Internet Services (CIS) to build up an IT
infrastructure.
eHealth has allowed for online medical care and
has improved the basic healthcare services even
in the locations where accessibility is very difcult.
It is progressing day by day and now three large
hospitals are expanding eHealth technologies.
The pilot project of Aga Khan University is to
improve the e-Health Services in Northern Pakistan
by and funds of Aga Khan Foundation, Geneva.
The main goal of this project is to provide mobile
technologies such as GPRS in villages where
there are no services and satellite connectivity is
blocked because of border restrictions.
This project will develop a tele-consultation link
for patient management including referral of MCH
using e-Health services. It has also aimed to start
e-learning programmes and improve monitoring.5
E-health provides good quality of care to the
patients and help the healthcare professionals
to make better decisions, patients are more
aware of their rights and they take responsibility
of their own health. Now Government is also
taking interest in health needs and supporting
the development of health information systems in
the country. Due to e-health services people are
aware of risks and prevention of diseases.6
Like other developing countries Pakistan started
using information and communication technology
in healthcare. It is not implemented in the country
as a whole because of limited resources and also
it could be because clinicians are not trained to
use the technology.
The above gure shows the networking and
services for telemedicine. The services are
provided in JPMC Karachi, Nishtar Hospital
Multan, Holy Family Hospital Rawalpindi and
many other remote hospitals like DHQ Badin, DHQ
Thatta, DHQ Dadu, DHQ Naushera Feroze, DHQ
Vehari, DHAQ Khanewal, DHQ Lodhran, DHQ
Muzaffargarh, DHQ Chakwal, THQ Talagang,
THQ Murree and RHC Bassal.
In spite of all the hurdles this is the fact that
e-Health is very important mainly because mostly
the population of Pakistan is living in rural areas
which are not accessible so there is a need of
information and communication technologies to
provide better delivery of health care equally to
all.
The above gure shows Architecture of EHR.
There are many computer systems which are
linked to the EHR application server. It contains a
database system all are connected with different
departments like Pharmacy, Laboratory and
Radiology.
Figure-1. Telemedicine Network & Services
Professional Med J 2017;24(1):182-187. www.theprofesional.com
ELECTRONIC HEALTH RECORD SYSTEMS
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It should assist the physicians in making decisions
at the right time. The aim of EHR should be also
to provide security to the medical records of the
patients considering ethical and legal issues. It
should be utilize for secondary purposes such
as research, quality assurance and policies
regarding healthcare.
History of EHR
Lawrence L. Weed a physician in 1960s rst
introduced Electronic Health Records. He
suggested a system which can save medical
records of the patients in the electronic form to
improve the delivery of care. This work started
at the University of Vermont in 1967 to convert
paper based medical records into electronic form.
The health care professionals and the IT experts
developed a problem oriented medical record.
In the same year Mayo clinic started developing
Electronic Medical Record System.
In 1970 the problem oriented medical record started
working in a medical ward of the Medical Centre
Hospital of Vermout. Touch screen technology
was introduced and then drug information was
added to the system for the doctors to check the
dosages, side effects, diagnostic and treatment
plans etc. Many research institutions were
involved in the process of implementing an EHR
and it increased during 1970s and 1980s. The
inpatient systems were introduced by The Help
system and Duke the Medical Record system.
Registries record introduced the combination of
both in patient and out patient’s records system.
With the advancement of Information and
Communication Technologies many more
features were introduced in the EHR. In the 21st
century it is becoming a compulsion to install the
EHR in the hospitals.7
SUBJ ECTS & METHODOLOGY
Research Design
This is an Exploratory and Descriptive Research.
In this study hybrid research method is used
which includes qualitative and quantitative
research methods.
Sample
For this study, a purposive sample of 43
physicians was selected. Data was collected from
two different hospitals of Pakistan which include
the physicians from Shaukat Khanum Memorial
Cancer Hospital and Research Centre, and Indus
Hospital. Of the 43 participants, 51% were from
Indus Hospital and 49% were from Shaukat
Khanum Memorial Cancer Hospital and Research
Centre.
Instrument
A structured questionnaire was used to collect
data and it was collected by email responses
and direct interview.
EHR Questionnaire
A questionnaire was used in the study which
comprised of 24 items. This questionnaire was
developed by Msukwa. B.K.Martin.
DATA ANALYSIS
Data analysis was done by Statistical Package for
Social Sciences (SPSS) and Microsoft Excel.
PROCEDURE
The instruments were administered after taking
the consent. Respondents were briey informed
about the purpose of the study. Full information
was given to them and they were allowed to ask
any question in case of confusion. After handing
over the scale, they were asked to read the
Figure-2. Architecture of HER
Professional Med J 2017;24(1):182-187. www.theprofesional.com
ELECTRONIC HEALTH RECORD SYSTEMS
185
instructions carefully and were assured about the
condentiality of their responses. Some of the
part of data was collected through emails.
The sample consisted of physicians so the data
was collected from hospital of Lahore which was
Shaukat Khanum Memorial Cancer Hospital
and Research Centre, and Indus Hospital from
Karachi. It was a structured questionnaire with
easy questions with multiple options to ll in.
Respondents were also acknowledged for their
cooperation and participation in the study.
RESULTS
The present study is designed to investigate the
perception and evaluation of electronic medical
record systems among physicians in Pakistan.
For this purpose physicians of different hospitals
were selected to fulll the objectives of the study.
This study used one questionnaire.
Age of physicians using of Electronic Health l
Records
Age in years Frequency (%)
20-25 4 (09)
26-30 11 (26)
30-35 16 (37)
36-40 06 (14)
41 and above 06 (14)
Table-I. Age distribution of physicians using EHR
(N=43).
The above table shows show that there were
04 physicians of the age group 20-25 years,
11 physicians of the age group 26-30 years,
16 physicians of the age group 30-35 years, 6
physicians of the age group 36-40 years and 06
physicians of the age group 41 and above out of
43 physicians. The minimum age group was 20-
25 and the maximum age was 41 and above. This
was calculated by SPSS.
The results in table 5 shows there were 12%
physicians with having experience less than 6
months, 14% with experience of 6-12 months,
16 % with experience of 13-18 months, 26 %
with experience of 19-24 months and 32% with
experience of above 20 months. The study
revealed that 75% of participants had used the
EHR for more than six months.
DISCUSSION
Pakistan is a developing country. Like other
developing countries Pakistan is also moving
towards electronic systems to improve the
healthcare delivery system. In this study two
hospitals were selected to be included in the
research. There are many hospitals that are
moving towards technology and Electronic
Medical Record Systems. Mostly have started
but not fully implemented the system. Lack of
professionalism among workers, corruption, false
data entry to create revenue and lack of evaluation
and monitoring put the system in great difculty.8
There are very few researches on Electronic
Medical Record with reference to Pakistan. So this
study was planned in order to nd out working of
Electronic Medical.
4
Time Period Period worked in the
Hospitals (%)
Period used paper based
records (%) Period used EHR (%)
less than 6 months 5 (12%) 6 (14%) 11 (26%)
6-12 months 6 (14%) 7 (16%) 8 (19%)
13-18 months 7 (16%) 9 (21%) 10 (23%)
19-24 months 11 (26%) 10 (23%) 9 (21%)
above 24 months 14 (32%) 11 (26%) 5 (12%)
Total 43 (100%) 43 (100%) 43 (100%)
Table-II. Experience of physicians with respect to usage to Paper based records, Electronic records and overall
working period in hospitals
Experience of physicians
Professional Med J 2017;24(1):182-187. www.theprofesional.com
ELECTRONIC HEALTH RECORD SYSTEMS
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Records and the satisfaction of physicians due
to this technology. The Indus hospital is the
Pakistan’s rst paper less hospital. Indus Hospital
started its journey in 1st July 2007. It is free of cost.
In 23rd June 2008, the Indus Hospital registered
as Company under section 42 of Companies
Ordinance. It is running its own Hospital
Management.
Information System which is fully computerized
and truly paperless system based on Oracle.
There International Collaborations are with
Harvard school of Public Health, University of
Texas Health Science Center, MIT, University of
Iowa, Partners in Health and MSF.
The second hospital which was selected for
investigation was Shaukat Khanum Memorial
Hospital and Research Centre. Shaukat Khanum
Memorial Hospital and Research Centre was
established in 1994, it is recognized as one of
the credible hospital to provide quality care to
patients free of cost. The accreditation is from
AACME (American Academy of Continuing
Medical Education) since August 2009. It is
under the project of Shaukat Khanum Memorial
Trust. It has spent over Rs. 9 billion in treatment
and currently 75 % of patients are receiving
treatment by nancial support. It has 1,524
consultants, physicians & surgeons. Shaukat
Khanum Memorial Hospital is running Hospital
Management Information System (HMIS).
NetSol Technologies Inc has developed a
partnership with Shaukat Khanum Memorial
Cancer Hospital for IT development in the
worldwide health sector. NetSol’s Hospital
Management Information System (HMIS)
solution provides day to day ofce operations for
proper management of administration. It is using
integrated machines like PACS that is Picture
Archiving and Communication System. Shaukat
Khanum Memorial Hospital is using EHR with
Oracle Database (Hybrid database (OLTP/DSS);
24x7 availability).
Limitations and Suggestions
Before implementing an EHR we should apply
change management which is an approach to shift
organization from the current state to future state.
There are operational changes, technological
changes and behavioral changes. We should
focus on behavioral changes more because
physicians are used to of making decisions by
their own for the patients and writing prescriptions
on the paper. They feel they are expert in their eld
so they don’t need the technology. There should
be awareness programs about the benets of
EHR before implementing an EHR to convince
the physicians to adopt the technology.
In Pakistan there are only few hospitals using
EHR which are also not taking the full advantage
of it. There are many EHR systems with no
communication if there is one system in the whole
country it would be perfect in communication as
well as useful for the policy makers and researchers
to access the data and make developments.
CONCLUSION
Electronic Health Records provide many benets
to all the stakeholders of healthcare system. It will
become standard of care in the near future. The
initiatives of evaluating EHRs in Pakistan in this
study will hopefully give an idea of the benets and
user satisfaction through EHR. The government
should encourage adoption of Electronic Health
l Records in Pakistan by developing a public-
private partnership. Overall in this study the
physicians were satised with the working of EHR.
In their opinion there is a signicant change in the
quality of care provided to the patients and also
the waiting time is reduced. The training should
have a proper curriculum and should be updated
from time to time. The study used perceptions of
doctors to evaluate the efciency and usage of
the EHR system which includes quality data, user
friendly and patients and physicians satisfaction.
The study focused also on EHR effectiveness
by checking the working of EHR its quick and
satisfactory results its accuracy, adequacy,
timeliness, user- friendliness, availability and
reliability.
Copyright© 15 Oct, 2016.
5
Professional Med J 2017;24(1):182-187. www.theprofesional.com
ELECTRONIC HEALTH RECORD SYSTEMS
187
REFERENCES
1. Msukwa.M,http://www.medcol.mw/commhealth/mph/
dissertations/martin%20msuk wa_Approved.pdf, 2011.
2. Della. V, http://www.jmir.org/2001/2/e22/, 2012.
3. Rand. Cooperation,http://www.rand.org/topics/elec-
tronic-medical-records.html,2012.
4. Twast,http://twas.ictp.it/news-in-home-page/news/
ehealth-in-pakistan,2012.
5. Anwar. S, http://healthmarketinnovations.org/program/
improving-health-services-North-Pakistan-through-
ehealth, 2012.
6. Parras. S, http://www.technologytimes.pk/2012/03/03/
health-for-all-e-health-in-Pakistan-prospective/, 2012.
7. Pinkerton. K, http://ezinearticles.com/?History-Of-Elec-
tronic-Medical-Records & id=254240.
AUTHORSHIP AND CONTRIBUTION DECLARATION
Sr. # Author-s Full Name Contribution to the paper Author=s Signature
1
2
3
4
5
6
7
8
9
Dr. Hamid Mehmood
Dr. Muhammad Aslam
Dr. Sadia Aslam
Ammara Waqar
Dr. Athar Khan
Yasir Hassan
Dr. Faryal Murtaza Cheema
Dr. Hassan Mujtaba
Noor-e-Maham
Researcher
Co-researcher
Data Collection
Data Analysis
Data Analysis
SPSS Application
References
References
References
“If you want to fly,
you have to give up the
stuff that weights you down.”
Unknown
6