Effect of Electronic Health Records on Patient Satisfaction and Waiting Time at Selected Hospitals, in Addis Ababa

Background: Electronic health records provide a great potential for improving the delivery of health services and decision-making abilities for all hospital stakeholders and for prudent management of health care resources.The main objective was to assess the effect of EHR on patient satisfaction and waiting time at Selected Hospitals, Addis Ababa. Methods: An institutional-based comparative cross-sectional study was conducted. The sample size was calculated using a double population-proportion formula, which comprised 184. Statement to conrm that all methods were carried out in accordance with relevant guidelines and regulations. After receiving ethical clearance from the Institutional Ethics Review Board and the Addis Ababa Health Bureau IRB, formal letters were written to Yekatit12 Hospital and Menelik II Referral Hospital.Written consent was taken for participants. Epidata V3.1 and SPSS software V25 were used for data entry and analysis respectively. Both bivariate and multivariate logistic regression analyses were performed to assess the presence and degree of association between dependent and independent variables. Statistically signicant variables were declared using an adjusted odds ratio with a 95% condence interval. Result: The mean waiting time at Yekatit 12 HMC was 60.2 ± 48.2 minutes and 82 ± 56.8 minutes at Menelik. Similarly, 74 (83.1%) at Yekatit 12 HMC and 31.8% at Menelik II Referral Hospital were satised with the service. Eye contact, clear communication, accessibility of the service, explanations of the medical procedures, involving patients in clinical decisions regarding their health care, and active listening to their opinions and questions had statistical signicance. Conclusion: Though patient satisfaction is not limited to those variables, overall client satisfaction and waiting time at Yekatit 12 Hospital Medical College were higher than those at Menelik II Referral Hospital, that could be attributable to the installation of EHR. As a result, the federal MOH and the respective RHBs should implement EHR in all health-care facilities. important to act accordingly. The study was conducted in Addis Ababa, the Capital city of Ethiopia, where the infrastructures are expected to be more accessible than other parts of the country. One health facility implementing EHR was selected to compare with one non-implementing with a similar service. Until the planned sample size was achieved based on the proportional sized allocation between medical facilities, participants were recruited consecutively. Epidata V3.1and SPSS software V25 were used for data entry and analysis respectively. Bivariate and multivariate logistic regression analysis was computed to control con-founders and to show satisfaction levels. Overall client satisfaction and waiting time at Yekatit 12 Hospital Medical College were higher than those at Menelik II Hospital, which could be attributable to the installation of EHR. The nding of this study shows that there huge difference in satisfaction level and waiting time at two sites even with comparable infrastructures, in the city.


Introduction
In recent years, there has been a greater focus on concerns associated with a healthcare evaluation. As a result, it has been proposed that healthcare evaluations should include not only clinical effectiveness and economics but also social acceptability to healthcare customers. A well-thought-out, well-implemented electronic health records (EHR) strategy can improve healthcare service delivery while also boosting employee and patient interactions. A formal EHR evaluation rarely examines patients' perceptions of care quality after the system is implemented. 1,2 Measurement of hospital performance provides a signi cant potential for healthcare system improvement and accountability additionally as it allows you to specify what hospitals do and compare it to original aims to ascertain where you'll improve. A comprehensive factor for the patients within the health care organizations is that the criteria considered for the acceptable and desirable treatment, which is rapid and suitable. Prompt treatment during a hospital means minimizing the time for getting a health service with a stress on favorable treatment. Waiting time is a metric used to evaluate patient satisfaction, managerial effectiveness, and equity within the provision of health care to healthcare consumers. It's also considered a measurable parameter for assessing the effectiveness of the hospital department and its professionals in providing better service. 3,4 Nowadays, the appliance of electronic information and communication technology within the health care system (EHR) has increased worldwide and allowed patients to supplement and update their information, cultivates shared knowledge between clinicians and patients. Timeliness and patient-centered are among the important attributes of quality service. Patient waiting time is the period between a patient's arrival at the outpatient department and his or her entry into the consulting room. 5,6,7,8 The structured EHR data provide the potential to access point-of-care data which will be used to inform practice and conduct research and for physicians with essential practice-level information when meaningful usage is implemented, which incorporates standard and consistent data entry in certain elds. 9 Fully functional EHR was attributed with 22.4 percent reduced ED duration of stay and 13.1 percent lower diagnosis/treatment time as compared to ED with minimal or no EHR. The relationship, however, varied depending on the patient's level of acuity also as the diagnostic services provided. Surprisingly, ED with basic EHR wasn't more e cient on average, and their e ciency wasn't linearly associated with the amount of EHR features used. 10 In Ethiopia, the ve-year perspective strategic plan stated as the health sector transformation plan, which had been implemented from 2015 to 2020, envisioned modernizing data handling and utilization through electronic health management information systems and strengthening the EHR system within the health care industry but still challenges continued with the data management.
Before the implementation of EHR at Yekatit 12 Hospital medical college most complaint area of the client was lost chart that they await an extended time even not seen on the same day with a retrieval rate of but 60% from regular Hospital report system. The introduction of the EHR initiated an enormous transition in health care compared to paper-based medical records (PMR). Saving time, avoiding lost paperwork, and increasing patient participation in their care are just a few of the bene ts and overall delivery of health care, but recent data on their effect on the physician-patient relationship is limited. It is critical to understand that computers used for care do not reduce patient satisfaction because this is frequently an accurate proxy for the physician-patient relationship. 11 This study assessed satisfaction at institutions where EMR is implemented compared to where EMR isn't implemented. Since there is no such developed EHR system in Ethiopia, we'd like to assess the effect of EHR on patient satisfaction and waiting time. The results of this study also will provide baseline information related to the effect of EHR within the area and help stakeholders like policymakers, the Ministry of Health, Ministry of Education, and other Organizations to need appropriate measures to reinforce this data management system to possess the improved quality of taking care of the clients in terms of patient satisfaction, patient waiting time.

Study area and design
A comparative cross-sectional study was carried out at Yekatit 12 HMC and Menelik II Referral Hospital OPDs (both regular and an emergency), from March to April 2021in selected Hospitals of Addis Ababa. Yekatit12 Hospital Medical College, formerly Bethesaida Hospital (1915), is located in Addis Ababa, Arada Sub-city, a woreda 6, near the Addis Ababa "sidist kilo "campus. It provides emergency and outpatient services to approximately 230,000 individuals each year. The hospital began implementing EHR in 2012, with four phases, for better data administration and utilization, and is now in the fourth phase, with a success rate of 95%.
Menelik II referral hospital, meanwhile, is a historical public hospital in Ethiopia's capital city, Addis Ababa, in the Yeka sub-city, and is one of the government hospitals under Addis Ababa city administration. It was found in 1909 and is one of the government hospitals under the Addis Ababa city administration.

Populations and Sampling
All patients attending outpatient (OPD) and Emergency department (ED) for clinical care from March to April 2021 were the source population and those who ful ll the inclusion criteria were the study population during the study period. All patients who had a hearing de cit, psychiatric disorders, were seriously ill, and who are intoxicated at emergency were from the study.
A total sample of 177 patients were included in the study (89 from EMR implementing hospitals and 88 from hospitals with no EMR). The sample size was calculated using double proportion formula, for both satisfaction) and waiting time with the assumption of a 95%CI, 5% margin of error, and estimated level of satisfaction and waiting time in Kuwait,2006. 15 The maximum sample was taken for comparing proportions was used to make a valid statistical computation. To compensate for non-response, a 10% contingency, and proportion allocation was done depending on the patient load to the speci c department (additional le 1)

Data collection tools and procedures
Participants were recruited through systematic sampling in which patients were rst registered by nurses on OPD/Emergency register then according to the proportion allocation study participants were selected then informed to the data collector. Informal consent was obtained from each respondent before the interview and con dentiality of responses were assured. By using a structured questionnaire, which was adapted from different literature, information about the social-demographic characteristic of the respondents, service satisfaction, waiting time, triage time, and other related data were collected.

Operational de nitions:
Waiting time-is "the length of time from when the patients registered at reception by EHR or manually to the time the patient sees Doctor for evaluation at Emergency and OPD, 1hr is cut off point for OPD" Overall satisfaction level 75% and above response rate of the ve satisfaction measuring items were categorized as "satis ed" and those who scored less than 75% of the ve satisfaction measuring items were categorized as "unsatis ed" [21].

Quality control measures and data management
The questionnaire was pretested (5%) on clients of selected Hospitals one week before the actual data collection period. The training was given to data collectors with close supervision. To ensure consistency, the questionnaire was written in English, translated into Amharic, and then back into English.The data gathering tool was only slightly altered as a result of the input received during the pretest. Cronbach's Alpha test, which was 0.89, was used to determine the tool's reliability and validity. All collected data were checked for completeness, accuracy, and consistency by the principal investigator then communicated to the data collectors on the next day.
Collected data were coded, checked for completeness, entered into Epidata V3.1, and exported to SPSS version 25 for analysis. Incomplete information or missed data were excluded from the study. During analysis, the responses of "very satis ed" and 'satis ed' were classi ed as satis ed and responses of 'very dissatis ed', 'dissatis ed', and 'neutral' as dissatis ed.
The study variables were described using descriptive statistics such as mean, median, and frequency. The association between the independent variable and the outcome variable was investigated using binary logistic regression analysis. The variables with signi cant relationships at a P-value of 0.25 were then incorporated in multiple logistic regressions to exclude co-founders and select the most important predictors. Comparisons of proportions were performed using the χ2-test and mean using the student t-test. Statistical signi cance was declared at 95% CI and p-values of 0.05 to discover the amount of difference between the EHR implemented group and the control group.

Ethical Consideration
Here is statement to con rm that all methods were carried out in accordance with relevant guidelines and regulations. After receiving ethical clearance from the Institutional Ethics Review Board and the Addis Ababa Health Bureau IRB, formal letters were written to Yekatit12 Hospital and Menelik II Referral Hospital, as well as written permission to conduct the study from both the hospitals' administration and the relevant body.Respondents were advised of their right to refuse or terminate the interview at any moment. They were also told that their data and information would be kept private and would not be shared with anybody outside of the relevant organizations.    Good explanation of the medical procedures 5 times more likely satis ed than those who were not explained about the procedure and laboratory tests is highly associated with patient satisfaction which increased satisfaction 4 times more than those with no explanation. However, no statistically signi cant associations were observed between study site, registration at the reception, waiting for the area, eye contact with their treating physician, communication, laboratory test explanation, respect, and maintenance of privacy, frequency of visiting the center, or time spent with the physician during the examination.[ Table 4]. The electronic medical record helps to enhance patient outcomes by reducing the risk of medical errors and improving the quality and safety of inpatient care. There is no replacement for having immediate access to precise information regarding a patient's condition and medical history in the o ce. With EMRs, critical patient information becomes as mobile as our patients. In line with this, the current study found a high level of satisfaction with the medical care outcome following the adoption of the EMR system. Individuals have the ability to better maintain and manage their health, as well as adhere to treatment plans more easily.

Conclusion
The overall client satisfaction at yekatit 12 Hospital Medical College is 83.1% which has great improvement from the previous study that could be contributed to the implementation of EHR while it is low for Menelik II Referral Hospital which was 31.3%.
Therefore I, recommend AARHB shall implement EHR in all health facilities to improve health outcomes especially to increase client satisfaction and to decrease waiting time to get health services.

Declarations Ethical Consideration
After receiving ethical clearance from the Institutional Ethics Review Board and the Addis Ababa Health Bureau IRB, formal letters were written to Yekatit12 Hospital and Menelik II Referral Hospital, as well as written permission to conduct the study from both the hospitals' administration and the relevant body.Respondents were advised of their right to refuse or terminate the interview at any moment. They were also told that their data and information would be kept private and would not be shared with anybody outside of the relevant organizations.

Consent for publication
Not applicable Availability of data and materials All data relevant to the study are included in the article but upon reasonable request from the authors (garomakitesa@gmail.com) can be contacted.

Funding -None
Competing interests -None 22. Tayelgn A, Zegeye DT, Kebede Y. Mothers' satisfaction with referral hospital delivery service in Amhara Region, Ethiopia. BMC pregnancy and childbirth. 2011;11(1):1-7. Level of patient satisfaction related to our patient department services at Yekatit 12 Hospital Medical College and Menelik II Referral Hospital, Addis Ababa, Ethiopia,2021.