Evaluating the healthcare professionals' perceptions about the adoption of electronic health records in primary care centres in Riyadh City, Saudi Arabia

Electronic health records (EHRs) play a critical role in improving the quality of health care and patient safety. An EHR can facilitate the provision of patient care by providing several clinical benefits to both the healthcare providers and patients. The literature shows that these systems are being increasingly adopted in many healthcare settings globally. There is also evidence that various factors can hinder or promote the adoption and use of the systems. Many hospitals in Saudi Arabia are also rapidly adopting EHRs; however, the same is not true in primary care settings. As such, there is little published literature examining the adoption and use of EHRs in primary care in Saudi Arabia. This study evaluated the perceptions of healthcare professionals towards the adoption of EHRs in primary care centres (PCCs) in Riyadh City, Saudi Arabia. This thesis was based on a modified version of the Technology Acceptance Model (TAM) as a theoretical framework and drew from both the published literature and the findings of a large survey of healthcare providers to inform a conceptual framework for the adoption and use of EHRs in primary care settings in the Gulf Cooperation Council (GCC) countries. The adopted TAM has five attributes, namely external variables, perceived ease of use, perceived usefulness, attitude towards use, and intention to use that help to explain users' behaviour towards the adoption, acceptance, and use of technology. Applying this model, this thesis examined the influence of individual, organisational and system characteristics on the healthcare professionals' perceptions of EHR in primary care, including perceived usefulness, perceived ease of use and satisfaction, to predict the adoption and use of EHR in PCCs in Saudi Arabia and the GCC countries at large. Using a positivist paradigm as the research lens, the study employed a survey to evaluate the perceptions of healthcare professionals in primary care in Riyadh city, Saudi Arabia. All 1710 healthcare providers working in PCCs in Riyadh city were invited via email to complete an online survey on the secure Research Electronic Data Capture (REDCap) system between 30 November 2017 and 30 January 2018. A total of 1127 participants completed the survey, representing a 65.9% response rate. Quantitative results were analysed using Statistical Package for Social Sciences (IBM\\(^¬¨vÜ\\) SPSS v.20.0), and open-ended comments were thematically analysed in MS Excel. The findings from the survey identified that the majority of primary care providers in Riyadh perceived EHRs to be an important tool in primary care (77.0%). Respondents reported a strong level of agreement across several areas of potential benefits to the individual providers or primary care organisations. For example, the benefits to the individual healthcare professionals included improved communication between healthcare providers and patients (73.7%), reduced time in health data documentation (75.2%), and provision of access to practice standards (73.6%). Some of the benefits to PCCs were decreased paper-based documentation (77.1%), provision of access to patient data and analysis (76.8%), and reduction in medical errors (63.5%). Furthermore, respondents reported a low level of agreement across several areas of perceived obstacles at the individual, organisational or system level, such as the system decreases interaction between healthcare professionals and patients (20.5%), increases health professionals' workloads (23.5%), is too complicated and not user friendly (17.0%), is 'down' frequently (20.9%), compromises patient safety (18.8%), and does not provide adequate data security (19.6%). The only conflicting result was that nearly half (45.3%) of the respondents agreed that the need for frequent revisions due to technological advancement was a perceived barrier to using EHRs in primary care. The findings also identified that primary healthcare providers in Riyadh were satisfied with EHR in primary care (69.1%) with strong perceptions that these systems improve quality of care (74.8%) and patient safety (65.8%). Analysis of the qualitative data identified additional information that corroborates the quantitative findings of the perceptions of the healthcare professionals towards EHR benefits and obstacles in primary care. Based on their personal experiences, the respondents reported several benefits of EHR with the most emerging ones being, for example, better delivery of healthcare due to improvement in all aspects of patient care (45.7%), increased productivity and efficiency (26.5%), improved sharing of information between healthcare providers (26.5%), and enhanced access to past medical history (24.1%). Conversely, lack of staff training in EHRs emerged as the main obstacle to EHR adoption in primary care settings in Riyadh (39.2%). Others included poor IT infrastructure (15.5%), reduced practice productivity and disruption of the workflow (13.5%), lack of adequate technical support (9.8%), and low-quality service provision in primary care (9.4%), among others. There were several associations identified in the analysis of the data. The canonical correlation showed that healthcare professionals' perceptions of EHR benefits were strongly associated with satisfaction with EHRs in primary care (canonical correlation coefficient, r = 0.91). Conversely, the perceptions of the obstacles to adopting EHRs had a medium negative association with the healthcare professionals' satisfaction (canonical correlation coefficient, r = 0.45). These findings suggest that perceived usefulness and perceived ease of use had a positive association with healthcare professionals' perceptions towards the adoption of EHRs in primary care settings in the GCC countries. However, these perceptions were influenced by external factors related to the individual users, organisation and system. The individual or sociodemographic characteristics of the respondents were found to influence these perceptions; however, they had mixed results. Significant associations were found between the healthcare professionals' perceptions of EHR benefits and occupation, age, experience working outside Saudi Arabia and previous training in EHRs (p < 0.05). For instance, occupation was significantly associated with the healthcare professionals' perceptions of EHR benefits such as easy access to information from past medical records (˜ìv°\\(^2\\)(8) = 69.722, p < 0.001), reduced time in documenting patient data (˜ìv°\\(^2\\)(8) = 32.47, p < 0.001), and decreased paper-based documentation (˜ìv°\\(^2\\)(8) = 51.876, p < 0.001). However, only age and occupation were significantly associated with the perceptions of obstacles to adopting EHR. Gender, nationality and length of experience working in PCCs had significant associations with the perceptions of most EHR benefits as opposed to most EHR obstacles, which were significantly associated with nationality and experience working outside Saudi Arabia. Whereas previous experience in EHRs had no significant associations with the perceptions of most EHR benefits, it had no significant associations with the providers' perceptions of all the listed EHR obstacles. Gender, length of experience working in PCCs and previous training had no significant associations with the perceptions of most EHR obstacles. Furthermore, mixed results were found on the influence of the respondents' sociodemographic characteristics on the healthcare professionals' satisfaction with EHRs in primary care. Significant associations were found between satisfaction with EHRs and age (˜ìv°\\(^2\\)(4) = 29.293, p < 0.001), gender (˜ìv°\\(^2\\)(2) = 14.453, p < 0.001), occupation (˜ìv°\\(^2\\)(8) = 52.687, p < 0.001), nationality (˜ìv°\\(^2\\)(2) = 15.232, p < 0.001), length of experience working in PCCs (˜ìv°\\(^2\\)(4) = 30.163, p < 0.001), previous experience working outside Saudi Arabia (˜ìv°\\(^2\\)(2) = 83.446, p < 0.001), and previous training in EHRs (˜ìv°\\(^2\\)(2) = 43.059, p < 0.001). Previous experience in EHRs had no significant associations with the healthcare professionals' satisfaction with EHRs in primary care (˜ìv°\\(^2\\)(2) = 3.386, p = 0.184). As postulated in the conceptual framework, this study indicated that individual, organisational, and system characteristics (external variables) influence the perceptions of primary healthcare providers in Riyadh city, Saudi Arabia, towards EHRs in primary care. These perceptions are also related to satisfaction with EHRs, which is likely to influence the acceptance and use of the system. In particular, the perceived usefulness and perceived ease of use of the EHRs are associated with positive attitude towards EHRs in primary care. On the other hand, lack of perceived usefulness and perceived ease of use, including the obstacles, such as compromised patient safety, decreased interaction between healthcare professionals and patients, increased healthcare professionals' workloads, and complexity of the system, are associated with negative attitudes and low satisfaction with the EHRs. From the study results, a conceptual framework for the adoption of EHRs in primary care in Saudi Arabia was derived. The conceptual framework showed that primary healthcare professionals in Riyadh had a positive perception of EHRs due to their perceived usefulness and perceived ease of use, hence they were more likely to accept the system in the primary care setting. However, there were also reported challenges and risks of using EHRs in primary care that were associated with negative perceptions of the system. It was also shown that the perceptions of the healthcare professionals were influenced by individual, organisational, and system characteristics. The personal characteristics, including occupation, age, and previous experience outside Saudi Arabia had a significant influence on the healthcare professionals' perception of EHRs' usefulness and ease of use. For example, physic...