The current utilization of information technology in healthcare stems from a need to deliver better healthcare and to meet patients’ growing demands. Patients’ demands have changed, and their expectations have increased, which requires upgrading the healthcare industry to meet such expectations. Primary patients’ expectations include the 24/7 availability of medical services, accessibility to their electronic medical records (EMRs), effective and reliable online appointment systems, and reduced patient waiting times in doctors’ offices (Meyers, 2003). One solution to overcome healthcare service issues in meeting patients’ demand is to utilize information and communication technologies (ICT). ICT integration into the healthcare sector enables and facilitates the redesign of healthcare services in a way that satisfies patients’ increasing demands (Lee et al., 2011). The implementation of IT/ICT in the healthcare context can be in one or more of the following forms: EMRs, electronic health records (EHRs), computerized physician order entry, clinical decision support systems (CDSS), mobile healthcare systems, and picture archiving and communication system (PACS) (Ahlan & Ahmad, 2014; Aldosari, 2012; Aljarboa et al., 2019; Alsulame et al., 2016).
According to Lee et al. (2011), the hospital information system (HIS) is one of the primary forms of ICT integration in healthcare. A HIS is defined as “a comprehensive, integrated information system designed to manage the administrative, financial and clinical aspects of a hospital. It aims to achieve the best possible support of patient care and administration by electronic data processing” (Ismail et al., 2010, p. 16-24). A HIS can also be defined as “an information system that performs the function of processing data, information and knowledge in the secondary and tertiary healthcare levels” (Lee et al., 2011, p. 2129–2140). A HIS supports hospitals’ management in making the right decisions by providing the needed information at the right time. It empowers hospitals to access, evaluate, and extract insights from healthcare data, which contribute to patient care and overall quality improvement (Ismail et al., 2010). The predictable core benefits for implementing HISs are quality improvement for healthcare services, price reduction, and reduction of medical errors (Fraser et al., 2005). In developing countries, HIS implementation provides an exceptional opportunity to leverage the quality of healthcare services, decrease healthcare costs, and improve productivity and resource utilization (Williams & Boren, 2008).
According to Gell & Gitter (2008), a HIS performs five key functions:
- Clinical order entry. This function involves organizing and managing all medical services that a patient needs, such as examinations, admission and surgery appointments, and medical counseling. It is considered as the most crucial function of any HIS.
- Scheduling. Because HIS is an integrated information system, it synchronizes all medical information in a timely and systematic manner in order to shorten patients’ waiting time and enhance the quality of healthcare services.
- Electronic patient record/electronic medical record. This refers to the electronic collection of patient information during any interaction between that individual and the hospital. This includes patient medical history, examination results, clinic visit details, and billing information. Patients’ records are stored in a much-secured way, so only authorized people can access, retrieve, and review them.
- Structured reporting. As mentioned above, a HIS supports management in making decisions; it is an interactive reporting tool that replaces traditional paper reports. By using a database, the system is also capable of providing a visual presentation and illustration of data.
- Process management. In addition to the benefits a HIS provides to improve medical services to patients, it helps in organizing and managing the administrative and business processes to deliver such services. A HIS provides the workload along with the required activities for each user according to his or her role. Also, a HIS shows the necessary procedures and steps required to deliver patient treatment.
One of the HIS elements that has received significant attention in HIS research is EMRs/EHRs. These are defined as “a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter—as well as supporting other care-related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting” (HIMSS, n.d.). EHR systems enable hospitals to save and safeguard patients’ current and historical information, and to provide patients with greater accessibility to their digital records through an online platform or mobile applications (Holden & Karsh, 2010) (Table 1).
Due to the effective role of EMR systems in upgrading and enhancing health services quality, EMRs are considered as the core element of HIS and the healthcare infrastructure (Al-Sobhi et al., 2011; Chaudhry et al., 2006). A research study for identifying the benefits of implementing and using HISs and EMRs was conducted in four Saudi hospitals that fully employed these technologies. The study targeted doctors, nurses, technicians, and administrative staff who have experienced using HISs and EMRs. The study revealed the following 10 perceived benefits and advantages for implanting a HIS and EMR, ranked in descending order: “1) Improved information access, 2) Increased healthcare professionals productivity, 3) Improved efficiency and accuracy of coding and billing, 4) Improved quality of healthcare, 5) Improved clinical management (diagnosis and treatment), 6) Reduced expenses associated with paper medical records, 7) Reduced medical errors, 8) Improved patient safety, 9) Improved patient outcomes and 10) Improved patient satisfaction” (Khalifa, 2017). According to Bozaykut et al. (2016), there is high adoption and implementation of HISs in developed countries, which in return results in quality improvement in healthcare delivery and reduction in medical errors. At the same time, because of some challenges and barriers, the healthcare industry is progressing slowly in healthcare technology and HIS adoption and implementation (Anastassopoulos et al., 2012; Menachemi et al., 2004).
The ICT adoption and technology acceptance literature classifies the adoption challenges into three classes: organizational challenge/organizational characteristics, human challenge/individual characteristics, and technological challenge/technological characteristics (Hu et al., 1999; Zakaria et al., 2010). In particular, the employment of such systems in developing countries involves numerous challenges and is still at the early stages (Alsharo et al., 2019). These challenges are mentioned in the literature around HIS adoption in developing countries and are mainly categorized into three categories: economic, such as high costs and limited and insufficient financing; technical, such as poor or inadequate infrastructure; and political challenges like wars and immigrants. Also, developing countries suffer from healthcare professionals’ scarcity and limited access to advanced technologies (Ahlan & Ahmad, 2014; Fraser et al., 2005). In fact, the extent of these challenges’ effect on HIS implementation varies from one developing country to another, as they maintain different resources, populations, and market sizes (Ahlan & Ahmad, 2014).
A study conducted by Almaiman et al. (2014) aimed to explore health information technology (HIT) implementation and to identify the main associated challenges with using electronic health applications (eHealth) in primary healthcare centers (PHCCs) in the Kingdom of Saudi Arabia. The data for the study was collected through academic search and interviewing IT personnel working in the National Guards for Health Affairs and the Ministry of Health and primary healthcare directors. The sample covered five areas of the kingdom: Riyadh, Hail, Arar, Rafha, and Najran. The findings showed that HIT adoption and use is growing in Saudi Arabia (SA), but it still is in its early stage. HISs at PHCCs in SA contributed to some advantages, such as lowering the “no-show rate” for patients who had booked appointments and improving service quality. The majority of PHCCs in SA maintain the basic required infrastructure for ICT and have the needed IT resources that include intranet and database resources. Despite this, the utilization of HISs and electronic health applications is below the potential use; for example, most services used through HISs at PHCCs in SA are booking appointments and updating users’ information. This low utilization is due to reasons such as system failure, difficulty in using and navigating the online system, negative attitudes toward using the systems, and work overload (Almaiman et al., 2014).
Additionally, the study identified two critical challenges for HIS implementation in PHCCs. First, the distribution, implementation, and utilization of HISs varies between PHCCs located in cities and rural areas. Second, the majority of PHCCs in SA use EMRs along with paper-based medical records, which affects the quality of data (Almaiman et al., 2014). The same challenges were reported in another study on EMR use in SA (Al-Sobhi et al., 2011). Additionally, EMR implementation in SA has been met with further barriers such as policies, organizations’ technical infrastructure, users’ resistance to change, training, and costs. One study targeted 185 nurses across three public hospitals where the same EHR was implemented in the Eastern Province of SA; the study revealed some barriers in using the EHR system (ordered from most to least frequently cited): “loss of access to medical records transiently if computer crashes or power fails,” “lack of continuous training/support from IT staff in the hospital,” “additional time required for data entry (i.e., more workload),” “system hanging up problem,” “complexity of technology,” and “lack of customizability of the system according to users’ needs” (El Mahalli, 2015).
Similarly, another study targeted 19 governmental hospitals located in the Eastern Province of SA that identified some challenges in EHR system implementation. These challenges were centered on doctors’ and nurses’ resistance and lack of seriousness in inserting the needed inputs to use system functions such as patient prescriptions, progress notes, and patient diagnoses (Bah et al., 2011). Furthermore, the confidentiality of patient information presents a considerable challenge for medical institutions in SA. Organizations that fail to keep patient information secure are subject to disciplinary actions from the Saudi Ministry of Health. Electronic medical services provided in Saudi hospitals are not unified and combined at the local or national levels, which results in data quality problems such as duplication, inconsistency, missing data, and inaccuracy. Such issues threaten data security and increase healthcare costs (Almaiman et al., 2014).
HIS implementation is a growing trend in developed countries, and many developing countries, including SA, are moving toward establishing and adopting one or more forms of HIS (Alsharo et al., 2019; El Mahalli, 2015). In spite of the benefits HISs provide to healthcare institutes in the developing countries, it doesn’t assure users’ adoption and acceptance (Esmaeilzadeh et al., 2015). At the same time, the HIS adoption literature shows that more than 50% of health information systems are not used because of factors such as the extensive time needed for digitizing patients’ records, checking and evaluating HIS decisions, and users’ refusal or resistance (Kilsdonk et al., 2010). The usefulness of any great technology can be measured by the number of uses and its employment in achieving its purposes. Thus, various technological barriers appear when users start interacting with the technology. Some of these barriers are issues relating to ease of use, usefulness, complexity, usability, output quality, compatibility, and observability. These technological challenges are studied through human–computer interaction. Also, user acceptance plays a major role in the successful adoption of healthcare IT solutions and systems (Aldosari, 2012; Alsharo et al., 2019). For these reasons, studying users’ behavior toward using and accepting the system can improve the system implementation and performance (Kilsdonk et al., 2010). The HIS adoption literature shows that many HIS implementations fail as a result of users’ resistance or rejection (Kijsanayotin et al., 2009; Spetz et al., 2014). Consequently, exploring the factors that impact the users’ adoption is significant to overcome the implementation challenges that may hinder the system success (Cresswell et al, 2013). Based on that, this study aims to explore patients’ perceptions of the adoption of the online services of an EMR system.
User behavior toward new technology can be illustrated and expected by some theories and models such as the theory of reasoned action (Fishbein & Ajzen &, 1975), the technology acceptance model (TAM) (Davis, 1989), the motivational model (Davis, 1989), the theory of planned behavior (Ajzen, 1991), a combined TAM and TPB (Taylor & Todd, 1995), diffusion of innovation theory (Moore & Benbasat, 1991; Rogers, 1962; Rogers, 2010), and the Unified Theory of Acceptance and Use of Technology (UTAUT) (Venkatesh et al., 2003).
In the context of HIS adoption and acceptance in SA, Mohamed & El-Naif (2005) conducted a quantitative study in a military hospital in Riyadh to explore opinions and perceptions on the implementation of an EMR system. The sample included 105 physicians, 109 nurses, and 120 patients, who were surveyed on the current medical records department (MRD) and the quality of MRD services. However, only physicians were surveyed concerning EMRs. The study revealed that physicians at the time of the study had negative perceptions toward conversion from the current paper-based MRD to an EMR system. Only 31.3% of physicians believed it was time to move to EMRs, 68.7% believed that the existing MRD was more credible than EMRs, and more than 90% of the hospital physicians believed EMRs would add a burden on them, as EMRs require significant data entry from their side. Also, more than 80% of the sample physicians believed EMRs would decrease their productivity.
Another quantitative study by Bah et al. (2011) was conducted to measure EHR system adoption across the governmental hospitals located in the Eastern Province of SA. The study targeted the hospitals’ IT managers. Out of 19 hospitals, only three hospitals used the same EHR system. The implemented system provides five main functionalities: chart review, decision support, order entry, documentation, and additional tools. For chart review functions, the system can obtain and review lab and radiology results, review progress notes, and monitor current and past medications and medication refills. The decision support functions of the system include receiving drug interaction and drug-allergy alerts when writing prescriptions, and highlighting test results that are out of normal range. Order entry functions enable the hospital staff to enter the lab, radiology, and pharmacy orders. Also, the EHR systems have some documentation functions that involve the systems’ ability to create and maintain patient-related medical problem lists and common medication lists, identify patient-specific allergies, and document patient discharge instructions. Finally, the additional tools of the systems include managing patient referrals, automating coding of disease conditions, generating health statistics, and performing data backup and disaster recovery (Bah et al., 2011).
The Ministry of Health in SA has set many standards and policies for electronic health services to ensure effective and reliable implementation (Alkabba et al., 2012). Yet Alkabba and colleagues highlighted that the implemented systems were not capable of or not utilized to perform the following functionalities: creation and reviewing of scanned documents, communications, allowing hospitals’ physicians to access patient records over the Internet when they are outside the hospital, and allowing patients to access their health records over the Internet (Bah et al., 2011). A similar study was carried about by Aldosari (2014) to examine the status of the EHR system in Riyadh as a sample of SA. Riyadh has a total of 30 hospitals; of these, 22 (16 governmental and 6 private) were surveyed to determine the rate, level, and determinants of EHR adoption. The study targeted project managers, medical directors, heads of IT departments, and EHR development teams. A total of 280 respondents completed the survey across all hospitals. The study found that for the rate of EHR adoption in Riyadh, of 22 hospitals, 19 had fully or partially adopted an EHR system. Of the hospitals included in the sample, 50% (11 hospitals) had implemented a fully functional EHR system, 36% (8 hospitals) were in the process of implementing an EHR system, and 14% (3 hospitals) had not yet implemented a system.
Unlike the Eastern Province of SA (Bah et al., 2011), the 19 adopted hospitals implemented different EHR systems. Regarding the EHR system adoption level, three adoption phases were considered: implementation, maintenance, and improvement. For the implementation phase, the study found there was low preparation for the needed actions for the conversion from the current paper-based record system to an electronic one. For the maintenance phase, the major weakness was centered on software updates and maintaining and updating the CDSS. Concerning the improvement phase of EHR adoption, HIS communication and sharing is the main issue (Aldosari, 2014). With respect to EHR system adoption determinants, the study examined three primary determinants: hospital size, hospital ownership, and the EHR system development team. First, hospital size was reported to be positively related to the level of care complexity. Larger and tertiary hospitals had advanced EHR adoption. For the hospital ownership (public or private), the study findings showed that public hospitals were more advanced in the system implementation and maintenance phases than were private hospitals, which had better performance in the system improvement phase (Aldosari, 2014).
Additionally, a study on EHR adoption and barriers from nurses’ perspective was conducted by El Mahalli (2015), which targeted 185 nurses in three public hospitals where the same EHR systems were implemented in the Eastern Province of SA. The applied systems provided some functionalities analogous to the ones in the study by Bah et al. (2011). The study revealed the underutilization of all EHR functionalities across the three hospitals. Also, similar to the findings of Bah et al. (2011), there was no utilization of any communication features; there were zero instances of using tools that “[allowed] patients to use the Internet to access parts of their health records” (El Mahalli, 2015).
For other forms of HISs, a study carried by Aldosari (2012) investigated radiology users’ acceptance of a PACS in the radiology department at King Abdulaziz Medical City hospital in Riyadh, SA. The study used a modified TAM that contained three constructs: perceived usefulness (PU), perceived ease of use (PEOU), and change. In addition, a survey was conducted to validate the proposed model, and the targeted population (89 respondents) was radiology staff: consultants, radiologists, residents, technologists, and others who used the PACS in their work in the radiology department. The study concluded that all constructs in the proposed model (i.e., PU, PEU, and change) had a significant effect on radiology staff acceptance and the use of the PACS (Aldosari, 2012).
A recent study carried by Aljarboa et al. (2019) aimed to explore the factors of CDSS adoption in the context of the Saudi healthcare sector and to identify the possible use challenges of such technology. CDSS is a computerized mechanism that “provides clinicians with knowledge, intelligently filtered or presented at appropriate times, to enhance health and healthcare, and can be seen as an effective pathway to improve patient safety, providing, for instance, alerts for error reduction” (Zikos & Delellis, 2018). The study targeted nine physicians from various specializations at different public and private hospitals and used qualified semi-structured interviews and applied some modifications to the UTAUT model constructs to fit both the healthcare and SA contexts. Two constructs were added to UTAUT: diagnostic accuracy and patient confidence. The study concluded that only five factors affected the physicians’ intention to use CDSS: performance expectancy, effort expectancy, facilitating conditions, diagnostic accuracy, and patient confidence. The social influence determinant was reported as an insignificant factor (Aljarboa et al., 2019). Table 2 shows a summary of the studies mentioned above.
As per the literature, HISs contribute in improving healthcare productivity and cost-effectiveness, empowering patients by involving them in healthcare decision making and reducing medical errors (Zhang, 2002). On the other hand, there have been few investigations and studies regarding patients’ adoption and acceptance of health IT solutions that require their inputs. Most adoption and acceptance studies focus on hospital staff, which includes physicians, nurses, medical directors, decision makers, laboratory technicians, and pharmacists (Alshahrani et al., 2019).
Considering this article’s scope, which focuses on Saudi Arabia, the Ministry of Health in SA has prioritized the digitizing of health records and the development of electronic solutions in the healthcare context (Bah et al., 2011). The Ministry of Health has also made a variety of agreements to smooth the adoption and implementation of EMRs in primary healthcare centers. Nevertheless, the use of EMRs among Saudis is uncommon (Al-Sobhi et al., 2011). It is difficult to track the adoption of EHRs in SA due to limited publications in that area. A review of the 31 currently available publications on eHealth in Saudi Arabia showed that eHealth implementation and adoption is growing. On the other hand, the number of studies is limited and not growing at the same pace (Alsulame et al., 2016). Very few research studies have been conducted to quantify or measure the adoption of such technology (Aldosari, 2014), and none of these studies, to the author’s knowledge, has focused on patients as among the HIS users. On this basis, this study aims to answer the following research question: What are the factors influencing patients to accept and use the online services of an EMR system?