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 expenditure 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 driving this generous expenditure is in fact an effort to control healthcare costs. For example, in the United States, it was estimated that the adoption of HIT could produce efficiency and safety savings of $142 billion in US physicians’ offices and $371 billion in US hospitals for 15 years (2004–2018).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 coordinating the care process7; enhancing decision-making services8; minimizing communication errors7; generating electronic reports that are necessary for institutional, private, and public requirements9; and improving patient safety.10–12 The combination of EMRs with the computerized provider order entry (CPOE) reduces the costs and reduces the duplication of laboratory and radiology tests and investigations. The documented effect of implementing EMRs on patient outcomes level4 and the national level9 stimulates research around the world to evaluate the extent of EMR implementation in healthcare systems such as that of the United States,13–16 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 methodological differences in estimating the adoption level,20 and convenience sampling techniques with low response rates from the conducted surveys.14
In 2008, the American Hospital Association (AHA) in partnership with the Office of the National Coordinator for HIT of the Department of Health started to conduct an annual survey to assess the level of adoption of EMRs in US hospitals.16 The first survey was conducted to estimate the level of adoption 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 functionalities were implemented in all or some hospital units. 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 comprehensive 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 questionnaire 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 comprehensive 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 tertiary 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 system, 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 difficult. 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 questionnaire, 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 inpatient EMRs was 22.9%, without specifying the proportions of basic or comprehensive systems.
In another different study, Hübner et al17 compared the prevalence 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 questionnaire, 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 infrastructure, 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 similar budget for HIT (2.6% in Austria and 2% in Germany). The authors tie this difference to the presence of technological infrastructure 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 Jordanian government allocated 8% of the total national 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 developed by the US Federal government.23 VistA consists of systems, linked databases, and end-user interfaces such as patient administration records, radiology, pharmacy, pathology systems, and nursing documentation systems. The Hakeem Program started in 2009 as a pilot scheme in one public hospital 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 efforts to improve the computerization of healthcare services, to date, there has been no nationwide, scientific study that has estimated the level of implementation of EMRs in Jordanian hospitals. 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. Secondary to this was the desire to investigate possible associations 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. Furthermore, 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, 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 hospitals 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 survey. 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 developmental 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 informatics experts. In 2008, the AHA, in partnership with the Office of the National Coordinator for HIT in the Department 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 related to the use of EMRs. The electronic functionalities are organized under four major areas: clinical documentation (seven functionalities), for example, patient demographic, physician and nursing assessments, medication lists, and so forth; results viewing (six functionalities), for example, viewing laboratory, radiology and diagnostic test results, and consultant reports; CPOE (five functionalities), for example, nursing orders and medical orders including laboratory, radiology, and medication 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 technical staff in Jordanian hospitals. Besides using the original survey, information about the hospitals’ characteristics was also collected, namely, bed capacities, location and region, type of hospital, 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 hospital units, or had not yet implemented them in any unit.
In the current survey, we followed Jha et al’s14 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 al14 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).
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 consent. 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.
The prevalence of the adoption of EMRs was calculated using three definitions of EMRs: comprehensive, basic with clinical notes, and basic without clinical notes. Bivariate analyses were used to examine the relationship between hospital characteristics (size, region, location, type of hospital, teaching status, and presence of coronary care units) and adoption of a basic or comprehensive EMR systems. The P value was set at the level of .05 to designate the statistical significance.
According to Jha et al’s14 definitions, the vast majority of participating hospitals (72, 74.2%) were found to not implement 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 classified 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 participated 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 nonteaching hospitals (Table 2).
Bivariate analysis revealed that the adoption rate of EMRs was significantly associated with the hospital size (χ2 = 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 (χ2 = 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 (χ2 = 14.7, P < .001). In addition, the adaptation rate of EMRs was significantly associated with hospital type (χ2 = 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 implemented 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 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 radiology 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% implemented the decision support functionality for drug-drug interaction 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,16 the reported adoption rates were 34.4% for comprehensive systems and 41.4% for basic systems. Recently, in Spain, Marca et al2 reported a 39.1% use of comprehensive systems and a 32.8% use of basic systems. Likewise, based on data collected in 2007, Hübner et al17 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 appropriate 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 al25 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 number 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 accounted for more than half of the total number of Jordanian hospitals (56.7%), most of these (78.2%) do not implement 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 implementation 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 implemented 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 military 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. Furthermore, 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 evaluate the awareness factor. Future studies should consider different 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 Unfortunately, the use of CPOE in Jordanian hospitals was found to be very low in the current study. The percentage of hospitals 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%, respectively2; in Korea, it was 80% for medications18; 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 diagnostic test results and radiology reports in all units. Studies from developed countries have shown much higher rates of application of this functionality. For example, in the United States and Spain, the functionality was applied in rates of 75%14 and 80%,2 respectively.
Although the findings from this study can be used as a cornerstone 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 al14 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 professionals’ satisfaction and acceptance of EMR functionalities need to be explored, and the benefits and drawbacks of the existing system should be evaluated. Furthermore, studies into cost-effectiveness are needed to explore the economic impact of implementing EMRs in Jordanian hospitals. 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 stratification scheme used in the study, it was possible to control over different confounding variables related to hospitals that participated 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 healthcare system. Results from this study documented a very important 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 government leaders on the needs and importance of EMRs.
On the basis of the results from this study, different healthcare 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. Informatics experts should have a role in designing, purchasing, and evaluating the EMRs to make sure that the system met the users’ needs effectively and efficiently.31 Moreover, they should maximize the users’ acceptance 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 education. 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
This study focuses on the adoption rate of EMRs in Jordanian hospitals, and we did not investigate their actual use or effectiveness. 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 interest in the developing countries, and second, there is a difference 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 directed 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 national level, which is found to be 10.3% for the comprehensive system that was used in all major units. Results from this study can be used as a baseline reference for the evaluation of progress 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.
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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