Do healthcare professionals perceive that the usage of automatic/electronic health records improves the quality of healthcare services in healthcare organizations in Gulf Cooperation Council Countries?

Published: 2021-07-07 00:23:50
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AbstractBackground: Electronic Health Record System (EHRS) is used largely in developed countries, though developing countries have also implemented the system in their healthcare industries. Electronic Health Record System (EHRS) is projected to increase the excellence of patient care, and its successful implementation depends upon the clinical perception of EHR systems. The much medical staff has resisted digitalization, observing the system as uncaring, confusing and dehumanizing. The literature showed physician’s perception and attitude towards the significance of the system to improve healthcare facilities but also identified the factors influencing the resistance in using the new system.Objective: The systematic research was conducted to evaluate the physician’s perception and satisfaction with the newly implemented EHRS in healthcare organizations to improve the quality of healthcare services in Gulf Cooperation Council Countries.Method: A systematic literature review is used to examine the physician’s and medical staff’s attitude, knowledge, satisfaction, preferences, and perception about the Electronic Health Record system. The study was focused on physicians, pharmacists, receptionist, medical staff, and nurses working in various hospitals in Gulf countries such as Saudi Arabia, Bahrain, Kuwait, U.A.E, and Oman. A narrative review of Scopus, PubMed, Proquest, Science Direct, Informit Health Collection, CINAHL, and Medline via OvidSP databases from 2007 to 2017.Result: The overall response of physician’s and other medical staff’s perception and satisfaction towards using EHR systems to improve healthcare services was positive. However, the study identified the negative perception of the system in Saudi Arabia, mainly because of the lack of sufficient technical training and personal preferences.Conclusion: Majority of the studies specified the positive perception and high satisfaction rates toward the newly implemented computerized record keeping system in Gulf Cooperation Council Countries. Physician’s agreed on the beneficial impacts of using electronic health record system to reduce errors and maintaining a proper record of patients especially in diseases like HIV which requires constant medical treatment and assistance. The review also revealed the barriers and factors influencing the adoption of EHRs in hospitals and medical care facilities. The major barriers identified to hinder the successful implementation and adoption were human barriers, financial barriers, organizational barriers, technical barriers, and regulatory barriers.Keywords: EHRs, Physicians, Perception, Barriers, AdoptionIntroductionElectronic health record system is a computerized form of a patient’s paper record. It is widely used in any healthcare organization to collect patient’s data such as medical history, prescribed medication use, and demographic information. The first world countries such as Canada and the United Kingdom have a nationwide EHR system. In 2012, 72% of office-based physicians used EMR/EHR systems in America. Keeping health records digitally is undergoing a transition not only in developed countries but also in developing countries.The developing countries lack a well-organized healthcare infrastructure to effectively fight against Malaria, Human Immunodeficiency Virus (HIV) among other deadly diseases that require constant medical assistance and treatment. The basic paper-based record keeping is not enough and needs to be substituted by a new, innovative electronic health record system.The study aims to investigate the physician’s perception of the impact of using electronic health record systems (EHRS/EMRS) to improve the quality of healthcare services in Gulf Cooperation Council countries. The literature review reflects the most current and pertinent research available on electronic health record systems in Gulf countries. In Saudi Arabia, the Saudi Ministry of Health (MOH) has taken initiatives to implement EMRS nation-wide. According to a research conducted by Shaker, Farooq, and Dhafar in 2015, 52.8% physicians appreciated EHRS positively in Saudi Arabia. However, here is the deficiency of awareness for the adoption of EHR systems among a series of administrative staff and medical professionals[1].EHR is an assisting tool which let doctors apply excellence development procedures in the field of treatment. The systems provide accuracy of information, the speed of communication, date revision, and data retrieval, and improve adherence to clinical practice guidelines in healthcare facilities[2]. The computerized clinical record system are useful for storage huge volume of regulatory information, administrative, and clinical information. These systems not only provide speed and accuracy but also decrease the rate of medical error, increase quality, and fulfill the regulatory audit. Physicians pursue the digital system as per a mean to upturn cost efficacy and advance value care[3]. It is a new way of communication and interaction among paramedical employees, nurses, and physicians. EHRs is reducing the medical cost by eliminating inappropriate care, inefficiency, and medical errors. The system is also capable of detecting unusual patterns such as the high number of lab investigations ordered by physicians, oddly high degrees of hospitalization or patient readmission.The successful use of electronic health record system is crucially dependent upon the clinical perception of EHRs. The literature review of fourteen articles from different countries in the Middle East is focused on determining the physician’s satisfaction and perception of the HERs. The research led in the United Arab Emirates (U.A.E) concluded that doctors are happy with the system and have an optimistic opinion about the system[4]. Similarly, researchers conducted in Saudi Arabia indicate the positive attitude of nurses towards EHRs[5] and they agree on the benefits of using this system[6]. An article from Taibah University of Medical Sciences in 2014, stated the dissatisfaction of physicians with the digital system significantly associated with the quality of the information and the performance of the system[7]. Another study showed an increasing adoption of the EHRs in Saudi Arabia however it indicated the computer training and literacy rate directly proportional to the clinical efficiency and EHR satisfaction[8].Two types of research conducted in Kuwait have shown a very positive perception of EHRs by the physicians and their confidence in the efficiency and accuracy of EHR systems. The majority of physicians participated in a study has reported the EHR system as easy to use. However, In Oman physicians indicated low satisfaction with the current EHR system because of its poor and inappropriate usage[9]. Most of these studies showed the positive attitude and high satisfaction of physicians in electronic health record system, however, there are several barriers and challenges involved in the adoption of a digital system.Adopting the new technology is always challenging. Nurses are the biggest part of the medical personnel in the critical care facilities; therefore, nurse’s advocacy of the electronic health record system is a crucial factor prompting its implementation. The process of adopting EHR systems is growing rapidly within the healthcare industry. The Medical secretaries and the nurses interact with EHR systems as receptionists, transcriptionists, and nursing diagnoses, write nursing care plans, check physician orders, and record vital signs. This makes them the primary users of the system, but the evaluation of EHRs by nurses has received less devotion[10].The major barriers identified by several types of research that delay the effective deployment and adoption of EHR systems in Saudi Arabia are human barriers and financial barriers. Human barriers refer to the healthcare professional’s knowledge, personal beliefs, and attitude regarding the health record adoption[11]. While financial barriers include insufficient money and funding to implement EMR system.The studies investigated the barriers and factors affecting the user satisfaction with Electronic Health Record System and concluded that the physicians agree on the usefulness of the digital system to record medical history but adopting new technology is challenging. Computer literacy and training can improve the satisfaction. Another important element to improve the physician adoption of the system is the involvement of the primary users in developing the EHR system and ask for the recommendation of how to improve the interface. The implementation of a computerized system is not as challenging as providing the maintenance and the technical support to sustain the system. Low budget countries face difficulties in technically maintaining the system and thus indicate the need for improved technical training.Research Methodology A systematic literature review is used to examine the physician’s and medical staff’s attitude, knowledge, satisfaction, preferences, and perception about the Electronic Health Record system. The study was focused on physicians, pharmacists, receptionist, medical staff, and nurses working in various hospitals in Gulf countries such as Saudi Arabia, Bahrain, Kuwait, U.A.E, and Oman. The literature review was concentrated on the government and private hospitals in different regions of Saudi Arabia, i.e., Makkah, Jeddah, Taif, and Riyadh. In Oman, Bahrain, Kuwait, and U.A.E several clinical specialists, public hospitals, and primary healthcare centers were investigated. A narrative review of Scopus, PubMed, Proquest, Science Direct, Informit Health Collection, CINAHL, and Medline via OvidSP databases from 2007 to 2017.Identification and selection of dataThe key words used to search the databases were (“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”).Topic statement/ questionPerceptions of HCP about EHRs in GCCKeywords:(“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 “digitised record” OR “digitized record” OR “electronic health information system” OR “health information system” OR “HIS” OR “ehealth” 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”)Databases – list all that you think we should searchScopus, PubMed, Proquest, Science Direct, Informit Health Collection, CINAHL, and Medline via OvidSPLimit it for dates?01/01/2007 – 31/12/2016Limit it to journal articles?Yes – peer reviewedInclude systematic reviews?NoLimit it to “English”No, include ArabicAnything else for the search strategy?No  Selection Criteria The selection criteria is peer reviewed articles and include English and Arabic languages. After the filtration from 64 articles, I selected 14 studies best suited to my research. The articles selected for systematic review were written by native authors of Gulf countries. These authors have better insight knowledge of the country as compare to any foreign author. The countries have been selected on the basis of already implemented EHR systems in private and government hospitals to analyze the perception of users regarding the usefulness of EHR systems in hospitals. The objective of selected articles were to analyze the perception of physicians about EHR systems and identify the barriers and factors influencing the adoption of the digital record keeping system. This fulfills the objective of my research and helps to strengthen my hypothesis.Table 3Data Synthesis Studies included in quantitative synthesis (meta-analysis) (n = 14  )Studies included in qualitative synthesis (n = 14 )Full-text articles excluded, with reasons (n = 28  )Full-text articles assessed for eligibility (n =  42  )Records excluded (n =  20 )Records screened (n = 64 )Records after duplicates removed (n = 2008 )Additional records identified through other sources (n = 0  )Records identified through database searching (n =  6460 )Research result267  Scopus4339PubMed230ProQuest500Informit Health Collection811CINAHL313Medline via OvidSP6460TOTALResultsAfter analyzing fourteen articles from different countries in Middle East region, it has been clear that the overall physician’s perception is positive regarding the usefulness of electronic health record system. However there are numerous concerns and barriers regarding the successful implementation and user satisfaction of EHR system. Let’s have a deeper look at the results in Saudi Arabia. Total 14 articles were systematically reviewed to determine the physicians’ perception about EHRS in the perspective of its efficiency so as to increase its benefits and functionalities and to identify hurdles supposed by various healthcare professionals to the acceptance of EMRs in different regions of Middle East especially in Saudi Arabia.The participants of these studies were physicians, pharmacists, nurses, administration staff, laboratory staff and receptionists from primary health care services, government hospitals, and private hospitals in Makkah, Riyadh, Taif, and Jeddah regions. The time span of these researches conducted in Middle East was from 2009 to 2014. Out of fourteen articles twelve of them showed positive perception about the EHR system and two article showed negative satisfaction with the use of EHR system. There were several barriers and concerns mentioned by physicians during the research in the adoption and implementation of the system and the study also discussed the factors influencing the perception of the physicians regarding the usefulness of the system.First let’s have a look at the physician’s positive factors regarding the perception of the system discussed in studies conducted in Saudi Arabia, Oman, Bahrain, Abu Dhabi, and Kuwait. Physicians in Saudi Arabia believe the electronic record system improve timeliness, performance and quality of healthcare facilities[12]. It increases accessibility of the patient’s record and it improved the patient care via better communication among the patient’s care team members. The system improve the overall healthcare services in hospital by automating them[13]. Electronic record keeping system has improved efficiency, quality of care, reduced error, and enhance patient safety[14]. Computerized record keeping system enhances the security and confidentiality of the patients as compare to paper-work[15]. The search conducted in Kuwait described the system as easy to use and it help professionals in updating their competencies and capabilities to expand research in their fields[16]. The system help them in writing referral letters for consultation easily and provide improved access to the summary of sufferer’s specifics[17]. Oman physicians have very positive attitude towards the EHR systems. It improve the work in terms of quality and performance, allow physicians to pursue further progressive practices in their careers[18]. The EHR system improve cost efficiency, interaction among nurses, physicians, and paramedical staff, reduce medical errors and inefficiency[19]. Bahrain, and Abu Dhabi also indicated positive perception regarding the usefulness of EHRs in improving and advancing medical facilities[20][21].The major barriers and constrains in the implementation, adoption, and user satisfaction of the systems in Saudi Arabia and other Middle East countries  were categorized as human barriers, professional barriers, organizational barriers, technical barriers, financial barriers, and regulatory barriers[22]. Human barriers were lack of awareness of the benefits of using EHRs, lack of computer knowledge and experience using EHRs, fewer health informatics specialists, and negative perception about the ability to use EHRs system. Professional barriers identified in the research were lack of motivation to train and learn the use of EHR system, lack of time, more professional accountabilities, decrease productivity, lack of healthcare professional’s support to EHR system. Organizational barriers includes incompatible workflow with EHRs, lack of experience to choose and implement the best EHR system in the hospital, lack of experience to evaluate the performance of EHR system, providing insufficient training or monitoring to the hospital staff, and have no strategic plan to implement and adopt EHR system[23]. Technical barriers refers to lack of guidelines and manuals for using EHR system, maintenance problem and insufficient technical support for software/hardware, old and slow computer terminals and communication networks, difficulty in data entry and data retrieval, difficult user interface, and insufficient computer terminals. Financial barriers comprises of high initial cost implementation and lack of resources, high maintenance and operation costs, lack of feasibility studies that show the benefits of implementing the system. Regulatory barriers identified were lack of procedures/policies that run EHRs on hospital level, lack of laws or legislations at national level, EHRs threaten confidentiality of health information, corruption, information loss, and hacking[24].The factors influencing the adoption and positive perception about its usefulness among physicians and medical staff were service quality and technical support along with English language proficiency and computer training. The users will high language proficiency and computer knowledge showed high satisfaction and adoption rate.The systematic review of 14 articles helped figuring out the physician’s perception and the factor influencing these perception in the usefulness and successful implementation of the electronic health record system in the healthcare industry.Table 3#AuthorsName of systemDomainTime period from implementation to evaluationMethod and Study designMain objective of the studyCountryParticipantsType such physician and nurse or others1Hani Abdulsattar Shaker, Mian Usman Farooq, Khalid Obeid DhafarPhysician’s perception about electronic medicalrecord system in Makkah Region, Saudi Arabiawww.avicennajmed.comJuly to Aug 2009Questionnaire of 15 Closed-ended questionsRegulate the physicians’ opinion regarding EHRS in the perspective of its efficiency in order to improve its benefits and functionality Makkah Region, Saudi ArabiaPhysicians working in 6 different hospitals2Azza El.MahalliAdoption and Barriers to Adoption ofElectronic Health Records by Nurses inThree Governmental Hospitals in EasternProvince, Saudi Arabiahttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4632875/Feb 2012Cross-sectional, paper-basedquestionnaireMeasure the acceptance and hurdles to the use of an digital health record keepingsystem by nursesEastern province, Saudi ArabiaNurses3Mohamed KhalifaBarriers to Health Information Systems and ElectronicMedical Records ImplementationA Field Study of Saudi Arabian HospitalsThe 3rd International Conference on Current and Future Trends of Information andCommunication Technologies in Healthcare (ICTH)2013Questionnaire To classify, identify, and examineobstacles supposed by  healthcare professionals to the acceptance of EHRs so as to deliverproposals on positive options and actionsSaudi Arabiahealthcare professionals4 Rihab A. HASANAINa, Kirsten VALLMUURb, Michele CLARKElectronic Medical Record Systems in Saudi Arabia: Knowledge and Preferences of Healthcare Professionals Journal of Health Informatics in Developing CountriesNovember 2011 and January 2012Quantitative methodology(quantitative questionnaire)The study purposes to inspect both the awareness and inclinations of potential or current EHR users.Saudi Arabiaphysicians, pharmacists, nurses, administration staff, laboratory staff and receptionists5Hanan Asiri, Bakheet AlDosari and Basema SaddikNurses’ attitude, acceptance and use of ElectronicMedical Records (EMR) in King AbdulAziz Medical City(KAMC) in Riyadh, Saudi ArabiaMerit Research Journal of Medicine and Medical SciencesMarch 2014Cross- sectional study, Questionnairediscover the indirect and direct effects of the  Professional factors andOrganizational factors  onnurses’ acceptance and attitude of the EHR systemRiyadh, Saudi ArabiaNurses6Husain Alzobaidi,Elham Zolaly, Bakur bin Sadeq, AbdulRhamn Alghamdi, Emad T Ahmed6Attitudes toward implementing electronic medical recordamong Saudi physiciansInternational Journal of Medical Science and Public HealthJanuary to February 2014cross-sectional survey, QuestionnaireEvaluate the willingness of the medical doctors in Al-Hada Military Hospital city concerning implementation of EHR in TaifSaudi ArabiaPhysicians7Kamel A. Alsaleh, Sadoun Faris Al-AzmiCare providers experience with the newly implemented electronic medical record system at the primary healthcare centers in KuwaitBulletin of alexandria faculty of medicine (online)November 2005 to January2006User interaction satisfaction questionnaire (QUIS)Assess the participants  interaction approval with  anew installed EHRS in the hospitals and healthcare centersKuwaitPhysicians, receptionists, pharmacists8Abdullah Al-Mujaini, Yahya Al-Farsi, Abdulla Al-Maniri, Anuradha Ganesh1Satisfaction and Perceived Quality of an Electronic Medical Record System in aTertiary Hospital in OmanOman Medical JournalJune 2011cross-sectional survey,QuestionnaireAssess the practice, attitude, and knowledge,of physicians concerning the Electronic Health Record(EHR) system.OmanPhysicians9Hana Alharthi, Adel Youssef, Salma Radwan,Sukainah Al-Muallim, and Al-Tuwaileb ZainabPhysician satisfaction with electronic medical records in a majorSaudi Government hospitalJournal of Taibah University Medical Sciences30 March and 25 May 2010Pearson’s correlation coefficient,  Linearregression analysis, QuestionnaireEvaluate participant’s approval with a newly deployed electronic Health record (EHR) system and to find which of the specific characteristics of EHR were connected to Doctors satisfaction.Saudi ArabiaPhysicians10Kamel A. Alsaleh, Sadoun Faris Al-Azmi,Ojayan A. Al OjayanPhysicians perception about the newly implemented EMRS at the primary Healthcare Centers in KuwaitBulletin of alexandria faculty of medicine (online)November 2005 to January 2006Structured QuestionnaireElicit the opinion of the physician working in the primary health care facilities in Kuwait to the newly introduced EMRS, and its advantagesKuwaitPhysicians11May Alasmary & Ashraf El Metwally & Mowafa HousehThe Association between Computer Literacy and Trainingon Clinical Productivity and User Satisfaction in Usingthe Electronic Medical Record in Saudi ArabiaJournal of medical systems, 2014, Singapore20 February2013Cross-sectional study, self-prepared questionnaire, interviews,Search theconnotation between computer learning and medical efficiency, occupation, and age, participants’ approval of thefreshly applied EHR at PSMMC along with thelink of user approval with position and ageSaudi ArabiaPhysicians, Nurses12Mohammed Al Farsi, Daniel J. West JrUse of Electronic Medical Records in Oman and PhysicianSatisfactionJournal of medical system, 2006November. 2002nonexperimentaldesign surveyMeasure doctor’sFulfilment with the system by the identification negative and positive effects of EHR after introducing it in OmanOmanPhysicians13Shamma Al Alawi, Aysha Al Dhaheri, Durra Al Baloushi,Mouza Al Dhaheri,Engela A M PrinslooPhysician user satisfaction with anelectronic medical records system inprimary healthcare centres in Al Ain:a qualitative studyBMJ Journals3 March 2012descriptive qualitative study, open-ended questionsTo explore physician satisfaction with EMRS, to recognize and discover the key restrictions of the EHRs and lastly to submit references to eliminate these restrictions.Abu DhabiPhysicians14Aysha Ebrahim Abdulla,Shurooq Yousif Ahmed,Maryam Abdulrahman Alnoaimi,Hayat AliUsers’ Satisfaction with theElectronic Health Record (EHR)in the Kingdom of BahrainInternational Journal of E-Health and Medical CommunicationsJuly-September 2016Qualitative and quantitative surveyInspect the influences that have impact on end-users’ contentment with the existingEHRs in BahrainBahrainUser of EHR System Table 4Author Factors affecting the  Healthcare professionals’ perception on the use of electronic health records improves the quality of healthcare services in healthcare organizationsMain Results of each articles and key findings.Positive factors that mention by health professional regarding electronic medical record.Negative factors that mention by health professional regarding electronic medical record.Factors improve the quality in health services   that mention by health professional regarding electronic medical record. Article #1 The system improves timeliness, performance, and quality. Physicians believe the system can increase excellence of services for patients.It surges the work burden, decreases thecommunication between users, not convenient for data entry as compare to paper-workThe future study should focus on EMRS users other than Makkah region, to evaluate the perception of physicians and user over the years, assess the present standing of awareness relative to the past efforts to increase the positive perceptionThe participants of the study showed positive perception of EHRS was by 52.8%.  but particular trepidations about its easy to use and workflow disruption wereconflicting by them Article #2Improved availability of the patient data,  EHR improved patient care via bettercommunication between participants of the patient’s care teamSudden computer crashes that can cause loss of access to medical records, No training or technical support for staff in hospitals, time taking while data entry, disturbed communication between physician and patient, system hanging up problemsTo further improve the system, periodic assessment should be made to analyze the degree of utilization of various system functionalities and make development accordingly, provide technical support 24/7 in the hospital, try to customize the EHR system according to the user needUnderutilization of EMR system functionalities in almost every hospital.Article #3Improve overall healthcare services in hospitalsRegulatory barriers, HumanBarriers, Professional barriers, technical barriers, financial barriers, organizational barriers Multi-phase approach should be used to improve awareness of the benefits and importance of using EHRs. Provide proper capital investment and funding, monitor and protect the system, increase computer terminals at the point of careFinancial and human barrier are two main categories of challenges in the way of effective implementation of electronic health record systemArticle #4 The physicians have positive response on the use of EHRS and improvement in English language skill and computer learning levels of staff, would improve level of EMR literacy. Thus, stuff will easily use the system and it will improve adoption and satisfaction.The study described barrier in the adoption and satisfaction of physicians. These barriers were lack experience and knowledge using EHR systems; and staff struggle to using the systemThe language proficiency and computer knowledge are connected to EMRS adoption and user perception about the system. Hospitals should assess the English language proficiency and computer skills prior to the implementation of the system   Both education level and English literacy were considerably associated with EHR literacy and computer literacyArticle #5 Electronic record keeping system has improved efficiency, quality of care, reduced error, and enhance patient safety. Group setting trainings are preferred by nurses.Nurses complained about redundancy of work, time consuming and the system interfere with their manners and communication skills and negatively impact their patient care and their attendance to the patient’s needManagement should include the users of system in the entire life cycle from designing to implementation , value their feedback and suggestionsNurses have a positive attitude towards the EMR system. Yet, a source of conflict withmanagement might be presentArticle #6EMR systems improve the quality of care, it reduces the risk of making medical error, more security and confidentiality than paper work.Time taking process Physicians presented an inspiring belief and awareness about the possible benefits of applying electronic health record systemArticle #7Improve the quality and care of patients, it helps them in updating their capabilities and competenciesDifficult to useLaunch massive program of computer literacy, upgrade its system with newer and more effective version of EMRSMost of the physicians see the EHRs as easy to work withArticle #8Improve their work in terms of performance and quality, allow physicians to follow further progressive practices than would not be possible with paper-based records,  Decrease medical error, Patient access to personal health records and health information through EHTs is now progressively  possible, To get all users to a suitable level of understanding with the particular EMR system software, the hospital should provide training. 15.6% physicians sees current EMRs as an effective tool while 29.4% of participant considered EHRs not worth the effect and time necessary to handle it.Article #9Allow physicians to perform their work wellIt takes extra time to start the system, Difficult to use, takes more time to enter data, not accurate, User interface is confusingConstant assessment of deployed EHR systems and response fromphysicians should lead future choice and institution of EHRsystemsDoctors were mostly not contented withthe EHR systemArticle #10It provided physicians better access to the summary of patient details, write referral letters for consultation easilySystem’s inability to procure lab results electronicallyMinistry of health and physicians should work together to improve the system. Further studies should made at private healthcare centers and hospitalsThe result indicated a very positive perception of the EMRSArticle #11The physicians and nurses agree to the high benefits of computer training and it boosts their satisfaction with the electronic system, No advance computer skills required to operate the EMR systemAdoption barriers were the reason for low satisfaction rates in the study, the physicians have high satisfaction rates than nursesThe study was limited to physician and nurses of one region, future studies should overcome this limitationEHR consumers with more computer knowledge were more satisfied while working withthe EHR than consumers with less computer knowledge Article #12A technique to maximizecost efficiency,  quality care,  developing new forms of communication and interaction between paramedical employees, physicians, and nurses  Decreasing health care costs causing from inappropriate care, inefficiency, and medical errors3 major concerns were  cost of hardware, software and upkeep with upgrade,malfunction i.e. when computer is not operational, concern for confidentiality,The study recognizes significant suggestions for health executives and people who work in the Department of Information Technology (MOH) for introducing and implementing other administrative or technicalinnovationsMedical doctor and physicians are largely contented with EHR. Physicians believe in the system to improve the healthcare facilities Article #13Physicians were satisfied with the results and orders of radiology and laboratory functions.  They were also pleased with the electronic recommendation role, declaring that it saved time and decreased errorsThe system appears multifaceted originally, concern about patient’s perception about the system, and require computer skills. Many patients were unhappyAdditional researches required to bedone between other patients and healthcare practitioners to discover their perception and attitude about the EMRphysicians were satisfiedwith the EHR system in spite of primary problems withapplicationArticle #14System’s technical accuracy, Appearance, System quality, Information quality are the factors  influences end-user satisfaction Providing EHRs users with comprehensive, significant, high excellence, on time info, given their importantinfluence on gratification,  Growing users’ faith by having them with trustworthy outcome and information content to makeEMR reliable,  maximizing system performance by making EHR usage easy, consistent, well-organized, fast to access toinformation, and responsive to users’ requestsThe most effectivefactors in the users’ satisfaction with EHR were directly service quality and technical support, withsystem and information quality indirectly through trustDiscussion The systematic review showed physicians positive perception about electronic health record system. There has been increasing acknowledgement of the part of EHRs in the delivery of healthcare facilities in recent years, and the use of EHR systems are increasing not only in developed countries but also developing countries. The advantages, benefits and positive impacts of using a computerized system in hospitals improved the ratio of EHRs implementation in hospitals. The successful implementation and adoption of a system is highly depends upon the user perception of its usefulness and benefits to improve the quality of the services.Electronic health record system have many advantages over paper record keeping system and it overcomes the limitation of paper in terms of storage, management of data, page fall out, and error correction. The resolution of this systematic review was to identify the perception of physicians and how they see the electronic record keeping system in Middle East. There are numerous advantages of using EHRs in hospitals. Developing countries are also gradually replacing the old record keeping system with new computerized record system in primary healthcare services to improve healthcare services. In Gulf countries, health care industry is paying attention toward the implementation of EHRs in private and government hospitals. The EHRS provides many advantages and physicians sees the computer system as a way to increase cost efficiency, improve quality care, increase interaction and communication among nurses, physicians, and medical staff. The system also increased physician’s ability to validate quality and research improvements and customer satisfaction, reduced manual functions, eliminating physician documentation time, improved coordination of information and time among laboratory, hospitals, physician offices and other paramedical staff through official exchange of health information. Saudi Arabia has prioritized the expansion of e-Health along with the evolution from old paper-based health record system to electronic health record. The study regarding the positive perception of EHRs showed two stems; EHRs improve the quality of practice and computers are important for practicing of medicine, were appreciated by majority of physicians[25]. Many believe EMR has the potential to lessen medical budget, increase efficacy and excellence of care, improve patient safety and reduce errors[26][27].The implementation of EHRs in many hospitals and healthcare providers have benefitted the operative and resourceful data processing but the adoption and user satisfaction has acknowledged little devotion. Negative beliefs, attitudes and behaviors of physicians and healthcare professionals toward EHR systems hinder the successful implementation of electronic health records and health information systems. The resistance of physicians to use and accept electronic medical records and information system is possibly one of the major barriers that delayed the successful implementation and adoption of such system. To address this issue quality of change management actually plays vital part in successful implementation of the system. The important factors for making EHR support quality management are organizational settings, data quality, allocation of resources, multiple purposes, participation of medical staff, adaptation of work processes, and management engagement[28].Regardless of the obvious interest and great concern in implementing and adopting electronic health records system in both developing countries and developed countries, there is a large gap between planning for the introduction of the EHRs to hospitals and the accomplishment of application of such systems and functioning them optimally to accomplish the primary benefit and purpose expected. In Gulf countries physician’s perception about EHRs adoption is greatly influenced by English language proficiency, computer expertise, and technical support provided[29][30][31]. The positive attitudes regarding the adoption depends upon the awareness and beliefs about the potential benefits of implementing EHRs. According to the study conducted in Saudi Arabia most of the physicians who have awareness regarding the potential benefits of EHR system showed positive response and believed in easiness of using EMRs[32].Designing the EHR systems according to the needs of users is essential for increasing the satisfaction and adoption of the system by the users. The research conducted on Turkey and other developing countries indicate the underutilization in almost all the EMRs functionalities and unnecessary design complication makes it ever harder to follow the system[33]. That is why it is important for management to involve the end user such as physicians, nurses and medical staff to involve them in the cycle of implementing the new EHR system and design the system according to the feedback of the end users. Unnecessary complications in design often led to the negative perception regarding the system and participants hesitate to adopt the new computerized system.In developing countries human factors are not the only influencers in unsuccessful implementation of the system but also the organizational settings and technical support plays an important part in it. Organization can develop better future plans for implementing a system by understanding their physicians and nursing staff training and technical needs. Almost every country have computers and networking systems, the real challenge is the maintenance and technical support required afterwards. In developing countries, the costs and technology of such advanced electronic record system as well as the lack of computer skills of hospital staff, lack of facilities for data processing, and lack of technical expertise are the key issues to be addressed while implementing electronic health record system in hospitals.Implementing a large setup such as EHR systems requires substantial staff and other resources, this implies extensive organizational transformations [15]. Health organizations can help healthcare professionals to adopt the system better by providing sufficient computer training and technical support. Health care facilities should implement the system with simple user interface and encourage their staff to use new system by giving awareness regarding the potential benefits of the system. Organization should also conduct periodic assessment to assess the utilization of the EHRs functionalities and make enhancement accordingly. To reduce the language barrier between the system and the users, hospitals should facilitate the staff with sufficient language proficiency training. Health organization should also formulate the laws and legislation regarding the use of EHRs and to protect the confidentiality of the patients. Every new system takes time and effort in the initial phase of implementation, organization should provide the staff sufficient time to understand the newly implemented system.Conclusions and Recommendations  Majority of the studies specified the positive perception and high satisfaction rates toward the newly implemented computerized record keeping system in Gulf Cooperation Council Countries. Physician’s agreed on the beneficial impacts of using electronic health record system to reduce errors, increase cost efficiency, improve quality care, increase interaction and communication among nurses, physicians, and medical staff and maintaining a proper record of patients especially in diseases like HIV which requires constant medical treatment and assistance.The review also revealed the barriers influencing the adoption of EHRs in hospitals and medical care facilities. The major barriers identified to hinder the successful implementation and adoption were human barriers, financial barriers, organizational barriers, technical barriers, regulatory barriers. Human barriers were lack of awareness of the benefits of using EHRs, lack of computer knowledge, and negative perception about the ability to use EHRs system. Professional barriers identified were lack of motivation to train and learn the use of EHRs, lack of time, lack of healthcare professional’s support to EHRs. Organizational barriers includes incompatible workflow with EHRs, providing insufficient training or monitoring to the hospital staff, and have no strategic plan to implement and adopt EHRs[34]. Technical barriers refers to lack of guidelines for using EHRs, and maintenance problem and insufficient technical support for software/hardware. Financial barriers comprises of high initial cost implementation and lack of resources, and high maintenance and operation costs. Regulatory barriers identified were lack of procedures/policies that run EHRs on hospital level, and lack of laws or legislations at national level.  Regardless of the obvious interest and great concern in implementing and adopting electronic health records system in both developing countries and developed countries, there is a large gap between planning for the introduction of the EHRs to hospitals and the accomplishment of application of such systems and functioning them optimally to accomplish the primary benefit and purpose expected. In Gulf countries physician’s perception about EHRs adoption is greatly influenced by English language proficiency, computer expertise, and technical support provided[35][36]. The positive attitudes regarding the adoption depends upon the awareness and beliefs about the potential benefits of implementing EHRs.To improve the adoption in physicians and medical staff, organizational reforms are necessary such as understanding their physicians and nursing staff training and technical needs. Implementing a large setup such as EHRs requires substantial staff and other resources, this implies extensive organizational transformations. Health organizations can help healthcare professionals to adopt the system better by providing sufficient computer training and technical support. Health care facilities should implement the system with simple user interface and encourage their staff to use new system by giving awareness regarding the potential benefits of the system. Organization should also conduct periodic assessment to assess the utilization of the EHRs functionalities and make enhancement accordingly.The following recommendations are offered to improve the user satisfaction and perception on the use of EHRs improves the quality of healthcare services in healthcare organizations in Gulf Countries:Provide additional computer training to the staff. Advance technical support to help users get used to the system.Provide educational courses and trainings to improve English language proficiency.Provide technical education courses to improve the technical support in the hospital.Identify underutilization of the system functionalities by assessment surveys from the users regarding the utilization and efficiency of the system.To improve the awareness among physicians and medical staff member, organize seminars and briefing on the benefits and importance of using EHRs in hospitals.Organize workshops to update the knowledge of physicians, nurses and medical staff.Improve the electronic health record system (EHRS) user interface by designing friendly front end with customize functionalities to fulfill the need of the hospital.Ensure end user involvement in the designing and development of the EHR system.Use data standard to validate the data on the systemUse explicit instructions with each icon to help user understand the system easilyResearch studies and surveys should conducted to improve the user experience of the system and to analyze the needs of users to improve system accordingly.Hospital authorities should form laws and regulations to protect the security and confidentiality of patients.Do appropriate organization of the hospital resources in the phases of EHRs implantation.Redesign the medical workflow of the hospital according to the EHRs system.Properly maintain and upgrade the computer network to avoid any sudden system failures.Provide guidelines and manuals to educate the staff and end users regarding the systemProvide enough time to users to understand the system fully before shifting to it.To increase the system productivity, identify the factors that slowing down the data entry process or other functions. Ask users to assess the system from time to time.

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