The implementation of health information technology (HIT) has been associated with improved quality of healthcare services, increased efficiency, and reduced costs of healthcare as well as provider satisfaction.1,2 Electronic medical records (EMRs) and electronic health records (EHRs) are the most common e-health technologies used in many healthcare settings today.3 Lu and colleagues noted that these computer-based record systems help healthcare professionals to manage patients’ health information and improve care.4 The healthcare outcomes of EHR/EMR are mainly attributed to the systems’ enormous benefits, including but not limited to the elimination of redundant paper-based processes,5,6 elimination of time-consuming procedures in recording and retrieving patient data,7 easy access to patient information,8 and improved communication between the multidisciplinary teams.9,10 Therefore, electronic health information systems (HISs) are crucial for the sustainability of healthcare organizations as the provision of high-quality care services likely to attract more clients resulting in increased profitability and growth.11

As the adoption of EHR/EMR systems is fast gaining pace in many healthcare settings worldwide, those in the Gulf Cooperation Council (GCC) countries are no exception.11 The governments and private players in the health sector of these nations have shown a great interest in EHR and made significant strides in promoting their adoption in healthcare as a means of improving patient care, controlling costs, and meeting other health needs and priorities.12 For instance, in Saudi Arabia, the Ministry of Health has promoted the introduction and adoption of modern technological systems to improve care quality.13 Despite these efforts, the use of EHR in these settings has met several challenges mainly attributed to governmental and organizational factors resulting in low acceptance and adoption rates.11 The government is a major player in the healthcare sector and may influence EHR implementation through complex policy frameworks and inadequate funding.

Similarly, healthcare organizations in the Gulf region continue to encounter challenges related to resource constraints such as finances and trained healthcare professionals to promote the implementation of information systems.11 Like most problems associated with new technology, healthcare facilities in the GCC countries also experience disparities in skills and knowledge of the EHR and EMR that affect their ability to implement electronic health systems fully.14,15 The perception of healthcare professionals who are the end-users of e-health technologies has also been found to influence the adoption and implementation of such systems.16,17 The providers may have varied perceptions of the tools based on personal skills, knowledge, and experience, among other factors. The system features (such as perceived usefulness and perceived ease of use) have also been linked with healthcare providers’ perception of electronic information systems.18 Therefore, perception appears as a significant determinant of user acceptance and use of HIT and satisfaction.19 However, the factors influencing health professionals’ attitude towards the use of health technology applications, particularly in the Gulf context is not clearly understood given that the countries in this region are newcomers in the area of HIT.11 We sought to review factors that influence the perception of healthcare professionals towards acceptance and use of EHR/EMR systems in GCC countries.

Methods

In this systematic review, we searched for all the relevant articles published between January 2007 and December 2016 in Medline, CINAHL, Informit Health Collection, Science Direct, ProQuest, PubMed, and Scopus databases. The search terms included: [perception OR attitude OR perspective OR beliefs] AND [electronic health record OR EHR OR electronic medical record OR EMR OR electronic record OR digital record OR digital medical record OR digital health record OR digitized record OR digitized record OR electronic health information system OR health information system OR HIS OR e-health OR digital health] AND [GCC OR Gulf Cooperation Council OR Gulf countries OR Bahrain OR Kuwait OR Oman OR Qatar OR Saudi Arabia OR United Arab Emirates OR UAE OR Middle East]. Two independent researchers reviewed titles and abstracts of all the identified papers. Additional studies were obtained by manually searching the reference lists of the identified papers. We selected empirical studies that met the inclusion criteria: 1) evaluated the perceptions of healthcare professionals towards the use or adoption of EHR or EMR technologies; 2) conducted in any type of healthcare facilities including primary, secondary, tertiary, private, and public as well as those located in urban and rural areas; 3) conducted in one or more of the Gulf countries; and 4) published in English. Full texts of the studies that met these criteria were retrieved and independently reviewed by the researchers, and disagreements were solved through a consensus.

The data were independently extracted from each of the included studies by the reviewers. The extracted information included the author, year of publication, country, study design, sample size, the type of HIS evaluated (EHR or EMR), the implementation setting, and the period from implementation to evaluation. The extracted data were entered into the MS Excel Spreadsheet. We assessed the quality of selected papers with the aid of the Covidence tool for managing systematic reviews.20 A narrative synthesis was used to summarize the findings. The study selection process is presented in Figure 1.

Results

The electronic database search identified 3010 articles. After removing duplicates and ineligible studies, 13 studies qualified for inclusion in this systematic review. All the studies were of a cross-sectional design. Most of the studies (61.5%) were conducted in Saudi Arabia and the rest in other Gulf countries (Kuwait, Oman, Bahrain, and the UAE). The sample size of the included studies ranged from 23 to 839 subjects. Whereas some studies involved participants from a single profession such as physicians14,19,21–24 and nurses,25,26 others used a mix of healthcare professionals. The overview of the included studies is presented in Table 1.

Analysis of the selected studies identified several factors related to individual or system characteristics to influence the perceptions of healthcare professionals towards EHR/EMR in the Gulf region. Moreover, it was found that the perception can be positive or negative. The major individual factor reported by the studies to affect the attitude of healthcare providers towards EHR/EMR was a lack of computer literacy skills.1,14,22,27,28 This personal characteristic resulted in a negative perception of the systems, fear to use them, and low satisfaction levels. On the other hand, most of the factors were related to the system, and were associated with positive perception and high user satisfaction. They mainly involved factors related to the perceived ease of use and the perceived usefulness. Health professionals who had a positive perception of EHR/EMR felt that the systems offer several benefits and are useful. The reported benefits included easy access to patient information and other health records by providers and patients,15,23,26–28 enhanced ease of writing referral letters,15,23 increased use of practice guidelines,14 enhanced communication between healthcare providers and patients,1,21 better decision-making,14 reduced medical errors,1,21,24,27,28 and improved quality of patient care.24,26,27 The systems were also reported to save time in health documentation processes,14,21,22 eliminate paperwork,22 increase efficiency in work operations,19,22,25,28 increase user productivity,28 and reduce overall healthcare cost.27 One study also reported that the providers felt that the tools are easy to use and therefore improves work efficiency within health facilities.13

EHR and EMR systems were also found to have disadvantages that result in a negative perception that is likely to derail the acceptance and use among healthcare professionals. Some healthcare professionals reported that the systems require a longer time to document health data,14,21,25 lack the ability to procure lab results,15,23 increase risk of error,13 and do not guarantee patient confidentiality.26 They were also perceived to be complex, making them difficult to use,19,24,25 unreliable due to the risk of power failure,25 and costly.28 These findings on the factors influencing the perception of healthcare professionals are presented in Table 2.

Discussion

Evidence from this systematic review showed a positive correlation between EHR/EMR characteristics (perceived usefulness and perceived ease of use) and a positive attitude. Conversely, lack of computer skills and system deficiencies were negatively associated with the healthcare professionals’ perception. These findings suggest that both individual or system factors may influence healthcare professionals’ perception towards EMR/EHR whereby technology benefits and the users’ ability to use the systems are associated with positive perception. In contrast, disadvantages and challenges are associated with negative perceptions. Therefore, system features, as well as personal characteristics, appear as significant determinants of acceptance and use of the systems and other HITs. The perceived usefulness, represented by the benefits of using EHR/EMR in healthcare and perceived ease of use, appeared as the motivating factors to adopting these technologies among healthcare professionals from the Gulf countries. The attributes result not only in positive perception but also increase user satisfaction associated with high likelihood of accepting and using the systems within healthcare practice. These findings are in tandem with those reported in other studies.17,29–31 For instance, Mitzner and colleagues found that positive attitudes were associated with the activities supported by technology in general, its convenience, and useful features.29 Significant positive correlations have also been found between positive perceptions of perceived usefulness and perceived ease of use of EHR and EMR and acceptance of the technologies among nurses.30,31 It is important to note that this systematic review identified computer literacy as the only personal factor influencing perceptions of healthcare professionals in the GCC countries, which is consistent with Al-Mujaini and peers’ finding of a significant association between low level of computer knowledge and low satisfaction and reduced performance among physicians following the implementation of an EMR system.14 However, this finding was surprising because of the influence of other demographic characteristics such as age, gender, and EHR/EMR experience on the perception of perceived usefulness, perceived ease of use, and attitude towards the systems’ adoption and use, which have been widely investigated in the literature,14,17,30 seem to be lacking in the GCC context. This could be explained by the fact that HITs are still new in the region, and few studies have been conducted in this area.

Conversely, the finding of negative associations between the disadvantages or challenges of using EHR/EMR technologies and perceptions of the healthcare professionals was not surprising. The systems are expected to be easy to use, make healthcare processes easier, and improve the quality of health outcomes.8,32,33 Therefore, any deviation from these objectives would result in dissatisfaction, negative attitude, and increased risk of rejection. Previous studies have similarly shown that the challenges encountered while using HIT may act as perceived barriers and threats to adopting the systems in hospitals.14,34 Therefore, understanding the factors that contribute to technology acceptance is important for successful implementation. The lack of computer literacy skills, which emerged as the most personal characteristic resulting in a negative perception of EHR/EMR systems, could be related to increased risk of errors while entering the patients’ data into the system. It also suggests that healthcare professionals in the region and beyond should be adequately trained on these technologies. Training is important because it improves the knowledge and computer skills of the user which is associated with positive perception and acceptance of new technology.15,35,36 Training should also focus on other areas, such as ensuring patient privacy and confidentiality while using the systems. Other challenges, such as complexity, can be overcome by developing systems that meet the users’ needs and engaging the healthcare professionals at all stages of implementation. The management and tool developers should also offer adequate support to the healthcare professionals to improve their attitude towards EMR/EHR systems.

Conclusion

Factors influencing healthcare professionals’ attitude towards EHR/EMR systems are mainly related to their perceived ease of use, usefulness, and needs of the user as well as personal factors. The benefits of the systems and ease of use are associated with positive perceptions. Therefore, successful implementation of HIT should consider the healthcare providers’ preferences, needs, and perceptions. Health professionals and particularly those in the Gulf region need to be trained about EHR/EMR to equip them with the necessary knowledge and skills to achieve the systems’ desired outcomes in improving the quality of healthcare services. Future studies should investigate more demographic factors that may influence healthcare professionals’ perception and adoption of HIT in Gulf countries.

Disclosure

The authors declared no conflicts of interest. No funding was received for this study.

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