Judul PI:
PEMBUATAN APLIKASI PENGOLAH DATA PASIEN KLINIK Dr. LINDA HALIM MENGGUNAKAN VISUAL BASIC 6.0 DAN MICROSOFT ACCESS
PEMBUATAN APLIKASI PENGOLAH DATA PASIEN KLINIK Dr. LINDA HALIM MENGGUNAKAN VISUAL BASIC 6.0 DAN MICROSOFT ACCESS
PROGRESS AND CHALLENGES IN THE
IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS: A SYSTEMATIC
REVIEW
Rihab Hasanain1, Kirsten Vallmuur and
Michele Clark
School of
Public Health and Social Work, Queensland University of Technology, Brisbane,
Australia
School of
Psychology and Counselling, Queensland University of Technology,
Brisbane,
Australia
School of Clinical Sciences, Queensland University of Technology,
Brisbane, Australia
ABSTRACT
Electronic
Medical Record (Emr) Systems Are Being Implemented Increasingly Worldwide.
Saudi Arabia Is One Of Developing Countries That Commenced Implementing Such
Systems In 1988. Whilst Emr Uptake Has Been Low In Saudi Arabia Until Now, A
Number Of Hospitals Have Implemented Emr Systems Successfully. This Paper
Analyses Available Studies (N=28) In The Literature Regarding Emr Implantation
In Saudi Arabia To Identify The Progress Of Emr Implementation To Date And To
Identify The Facilitators And Barriers To Implementation.
KEYWORDS
Electronic
Medical Records; Health Information Systems;.
1. I
As populations grow and age additional demands are placed
on healthcare facilities and providers. Globally, Health Information Systems
(HIS) and technologies are being used increasingly and are seen as a way to
increase hospital efficiency and the quality of patient care (1). HIS enable
healthcare providers to document relevant patient information and provide
efficient and improved healthcare services(2). Healthcare organizations achieve
these outcomes through the use of HIS such as Electronic Medical Records (EMR),
Computer Based Patient Records (CBPR), Automated Health Records (AHR) and
Electronic Patient Records (EPR) all of which enable patient information to be
recorded electronically. For the purposes of this study the term EMR includes
any of the aforementioned systems.
The uptake of EMR systems throughout the world has occurred
at different rates, with developing countries tending to lag behind more
developed nations (3). Globally, the idea of recording patient health record
electronically commenced during the 1960s (4). EMR systems were introduced in
1988 in Saudi Arabia, to improve the Saudi healthcare system and its services
and to assist in better meeting the demands placed on health organizations
(4). The Saudi Ministry of Health (MOH)
made the introduction of EMRs as one of its priorities and it plans to
implement
EMR nationwide (4). The Saudi MOH expected a number of
improvements to the healthcare
DOI: 10.5121/hiij.2014.3201 1
system from EMRs including reduced patient waiting times,
improved flow of patient information and a reduction in errors and the
duplication of records (5).
There are several successful examples of EMR implementation
in Saudi Arabia and some hospitals have even earned excellence awards for their
EMR implementation achievements(4). However, it has also been noted in the
literature that systems such as EMRs are uncommon within Saudi hospitals(6). A
number of challenges to EMRs implementation have been identified as key factors
hampering EMR uptake (6). The purpose of this article is to review the
literature in order to identify EMR implementation progress to date in Saudi
Arabia and to also identify the factors which have assisted and hindered EMR
implementation in this context.
1.1. EMRs
Numerous authors have defined the term EMR in the
literature. While there is no generally agreed definition, there are a number
of recurring concepts which have been presented by several organizations (7)
(8) (9). The National Alliance for Health Information Technology (NAHIT) has defined
EMR as ‘an electronic record of health-related information on an individual
that can be created, gathered, managed, and consulted by authorized clinicians
and staff within one healthcare organization'. In other words, EMR is a
computerized record that maintains patients’ health related data, which is
available to be used and accessed, only by authorized personnel, in order to
deliver health care services within the health organization(7) .
2. OBJECTIVES
The objectives of this study are to undertake a systematic
review of the literature in order to examine the current status and
availability of EMRs in Saudi Arabia, and identify the facilitators and
barriers impacting EMR implementation. An additional objective was to explore
the initiatives undertaken by the MOH for EMR implementation and to outline its
achievements to date in the adoption of EMRs.
3. METHODS
An extensive search of research in the field of EMRs in
Saudi Arabia was conducted using health databases and related articles were
extracted. Databases searched for this
study included Emerald, ProQuest, PubMed, SAGE Journals, Informit, Health
Reference Centre and Google Scholar. Relevant reports in English language were
extracted and a manual search of the references lists of review and other
articles was undertaken. The search targeted studies between the years 2003
until 2013, as no studies were found prior to the year 2003. The main search
terms included Electronic Medical Records and Electronic Health Records,
associated with the text ‘Kingdom of Saudi Arabia’. A further search was
conducted using other relevant keywords, in order to expand the search strategy
follows:
Saudi AND Electronic Medical Record* OR Electronic Health Record*, Saudi AND EMR OR EHR, Saudi AND Health Information System*, Saudi AND Computer Based Patient Record OR Automated Health Record*, Saudi AND Electronic Patient Record* OR EPR, Saudi AND AHR OR CBPR, Health
Informatics AND Saudi.
3.1. Information Source
The collected scholarly information included articles,
theses, conference papers and presentation slides that were extracted from the
databases as well as from the reference lists of studies sourced through the
search of the databases. The included papers were selected based on a number of
eligibility criteria in order to meet the purpose of this review.
3.2. Eligibility Criteria
All included studies were required to meet the eligibility
criteria of this review. The criteria included studies that only focused on
Saudi healthcare organizations and which described EMR status and availability
in Saudi Arabia. Studies which focused on EMR implantation barriers,
facilitators and initiatives in Saudi Arabia were also eligible for inclusion.
Studies included in this review had to be published between 2003 and 2013 and
written in English. All included studies
were prescreened for relevance based on the inclusion criteria. Any located studies
that did not focus on Saudi Arabia or were not relevant to the area of EMR were
not eligible for inclusion.
2.3. Data Management
The identified references from all searched databases were
imported into bibliographic software (EndNote version X4.0.2).
3. Result
|
Figure 1. Flow diagram of systematic search strategy
3.1. The Ministry of Health and other
organizations Initiatives
In 2008, Altuwaijri mentioned in an article that the Saudi
MOH recently proposed an ambitious nation-wide implementation plan that would
include all Saudi healthcare sectors (6) and enable the linking of both public
and private healthcare organizations (16). At the beginning or early stage of
implementation, the main issue needing to be accomplished was having a
sufficient HIS to record and improve health related information, however, it
was not necessarily computer based (4).
The Saudi Ministry of Health has spent millions of dollars
developing and improving the healthcare system and services provided in Saudi
Arabia, as well as implementing and improving HIS technologies (17). However,
initiatives to implement HIS such as EMRs were all conducted independently by
MOH and other governmental hospitals (6) Thus, it was and has been difficult to
integrate patients’ records, as patients have different records in different
hospitals run by
different governmental bodies (6). This situation occurs in
most of the public and private hospitals in Saudi Arabia(6). Therefore, there
is no standard EMR system used in the country (6). A complicating factor to
nation-wide implementation appears to be the existence of a number of
healthcare organizations that were under different governmental jurisdictions,
such as the National Guard Health Affair (NGHA) and the Ministry of Defense and
Aviation(17). It is noted that these institutions and several other hospitals
have accomplished distinguished achievements in many fields including EMR
implementation(17). However, because some of these non-MOH organizations set
their own priorities and selected systems best aligned with their own needs,
there was variation in the way EMRs were implemented (17). Such early variation
in EMRs between governmental departments would lay the foundation for making
attempts at uniform, national implementation problematic(17). The private sector similarly established its
own systems, with little coordination with other sectors (4). While most of the
extant literature focuses on MOH hospitals, there is some literature about
hospitals in other sectors that also provide learning about EMR implementation
in Saudi Arabia.
After several MOH hospitals initiated and implemented their
own EMR system (6), in the year 2000, the Saudi government initiated a reform
committee to review healthcare services (17). The reform committee highlighted
a lack of a good HIS to manage patient records (17). Then, in 2002, an
information technology strategic plan was developed based on the reform
committee’s
recommendations, and it aimed to
develop a national Electronic Medical Record system (18). In order for the plan and its aim to be
accomplished, a number of steps were recommended by the reform committee (17).
First and foremost, the committee recommended building a workforce specialized
in health informatics, as skills in this areas were noted to be in scare supply
(17). Other recommendations included the establishment of centers of excellence
and professional associations in the field of health informatics (17). As a
result of review’s recommendations, the
King Saud bin AbdulAziz University for Health Sciences
(KAU-HS) at the National Guard, developed a two year Master program in health
informatics, which commenced in 2005 (17). This program assisted in increasing
the number of people in the workforce in this specialized field; by providing
them with the requisite knowledge to practice in the field of health
informatics in Saudi Arabia (17).
Apart of the Master’s program, in 2005 the KAU-HS also
developed the Saudi Association for
Health Informatics (SAHI), as the reform committee
recommended (17). One of the main objectives of the SAHI, was to conduct a conference
every two years (19), focusing on e-health and health informatics issues in
Saudi Arabia (20). The first conference was conducted in 2006 (10), and other
conferences were held in 2008, 2010 and 2012 (21). The SAHI is the only recognized association
in Saudi Arabia that focuses on the topic of Health Informatics and conducts
events to discuss this topic and assist in the development of e-health in the
country (18). The reform committee also recommended the need to establish a
center of excellence for health informatics (21). Later in 2002, the KSAU-HS
and the NGHA proposed the establishment of an electronic healthcare centre of
research excellence (E-CoRE) (21). This
centre would assist in the development and implementation of e-health
applications and health information technology and its management in Saudi
Arabia (21). The creation of the E-CoRE would also assist in achieving an
improved healthcare delivery process as well as its quality and efficiency
(21).
As a further initiative by the NGHA to expand the
capability of the EMR system and the quality of services at King Abdulaziz
Medical City’s (KAMC) Ambulatory Care Center (ACC) of
NGHA, a short messaging services (SMS) appointment reminder
was implemented in 2008 (22). The SMS was integrated with the EMR system, which
had a positive effect on improving the efficiency of it services by for example
decreasing the rate of missed outpatient appointments (22). This initiative
highlights the advantages of having EMRs, from which other Saudi hospitals may
benefit. Another initiative to promote and develop HIS such as EMRs, is that
the King Faisal Specialist Hospital and Research Centre (KFSH&RC) in Riyadh
established an e-health center in 1993 (23). E-health technologies include
patient related electronic health records, telemedicine and several other
information and communication health related technologies used in healthcare
originations (24).
3.3.1. The NGHA Experience for a Successful EMR Implementation
The NHGA has four hospitals and 60 primary and secondary
healthcare centers in different regions of Saudi Arabia (14). The four
hospitals are located in four different cities; Riyadh, Jeddah, Dammam and Ahsa
(28). The NGHA health organizations have 2000 in-patients beds and serve 2.5
million out-patients and 60,000 in-patients annually (33). All four NGHA
hospitals have EMR systems that are integrated with each other (18), meaning
that all four hospitals are linked and share an EMR system (18). The NGHA started to consider EMR
implementation as far back as early the 1990s (14), and thus was a leader in
this type of initiative in Saudi Arabia (14). In 1999, the NGHA developed its
first IT strategic plan for implementing EMR (14). The NGHA IT strategic plan
consisted of two main phases for EMR implementation and development (14). The first
phase was the “IT visioning phase” run by an IT steering committee (14). Phase
one aimed to establish an informatics department and information system (14).
Additionally, phase one was responsible for ensuring that both the “IT
visioning phase” and the proposed IT project were
coordinated (14). Phase one focused on all the deployment,
evaluation and improvement aspects of the EMR which were to follow.
The second phase of the NGHA IT strategic plan was the
“achieving of the IT vision” phase (14).
In order for the NGHA to fulfill this second phase, it
developed an Information System and Informatics Department (ISID) (14). Since
the NGHA had an IT department prior to the IT strategic plan, there was a need
to link both the previous IT department with the new IT strategic plan (14).
The NGHA specifically recruited a number of staff and provided them with
training in Health Informatics in order to manage this linkage (14). Later, in 2001, the NGHA purchased an EMR
system for all NGHA sites (14). From then the NGHA implemented the system in
Riyadh site (14). In 2004, the system was fully implemented and was operational
in only the Riyadh site (14). In 2010, the system was implemented and
operational in all NGHA sites as well (14). Furthermore, the EMR system at the
NGHA served more than 15,000 users in 2010 (14). After completing this phase,
the lessons learnt from this experience were documented (14). The main lesson
learned was that an IT strategic plan was a crucial aspect for successful EMR
system implementation (14). Furthermore,
there were potential risks that the organization needed to be aware of and
mitigate (14). Then, the outcomes, benefits and lessons learned from all
pervious activities were recorded and submitted to the “IT visioning phase”, to
ensure that the goals of the strategic plan were accomplished (14). The study
also mentioned that the availability of an IT department and its role as well
as the role of qualified staff and saw these factors as key lessons for
successful implementation (14). Other lessons learned included sufficient and
appropriate training for users, system integration and the availability of a
strong project manager (14). Having a defined and well-structured plan for
implementing EMR system in the NGHA hospitals has also been attributed to
assisting successful implementation (14). In fact the EMR implementation in
NGHA hospitals has been noted as one of the best examples of EMR implementation
in Saudi Arabia and possibly in other surrounding Arab countries (14). In 2010,
the Arab Health Conference awarded the NGHA the Middle East excellence award in
electronic health records(34). This award was the first award to be received by
a Saudi health organization (14).
Furthermore, the NGHA implemented an additional feature for
the EMR system (33). The NGHA implemented a computerized physician order entry
(CPOE), which was integrated with the available EMR system (33). CPOE is a
system that improves the workflow by notifying the users of any alerts or
errors, such as when there is a duplicate order for a treatment (33). The COPE
system has several other features, and all data entered in the system are
linked with the EMR system (33). Addressing potential user resistance and
providing training sessions were aspects that the NGHA considered as important
when adopting this new system (33). Another study in Saudi Arabia also
emphasized the importance of the availability of training sessions in order to increase
users’ satisfaction (24).
After reviewing the NGHA experience in implementing EMR
system in all NGHA sites, it is clear that EMR implementation is an achievable
task in Saudi Arabia. It is however, acknowledged that implementation in four tertiary
NGHA hospitals may be less complex than implementation across 244 MOH
hospitals. Nonetheless, the NGHA
experience appears to provide lessons for other health providers seeking to
implement EHRs. Clearly EMR implementation is assisted by appropriate planning,
resources, skills and management. Although EMR uptake is low in Saudi, other
hospitals can benefit from the NGHA experience, as all NGHA sites are in Saudi
and thus share some cultural and contextual commonality with other Saudi
hospitals.
3.3.2. The Armed Forces hospitals Experience for
a Successful EMR Implementation
There are five Armed Forces hospitals under the Saudi
Ministry of Defense and Aviation (11) and all five hospitals have a fully
implemented and integrated EMR system (35). In 2007, the first system was
implemented and was operational in the north-western region of Tabuk Armed
Forces hospital (35). The EMR system of the Armed Forces hospitals was
considered to be the largest EMR system operating in Saudi Arabia (35). Once again implementation of EHRs in the
Armed
Forces hospitals may be less complex due to the smaller
number of hospitals, compared to the MOH.
Additionally, a military culture with a clear chain of command and
decision making may have assisted the implementation of a fully integrated EMR.
3.3.3. King Faisal Specialist Hospital and
Research Center Experience for a Successful EMR Implementation
The King Faisal Specialist Hospital and Research Centre
(KFSH & RC) is noted as a leading healthcare provider in Saudi Arabia
(4). It first introduced telemedicine
and health HIS in 1993
(4). The KFSH & RC hospital in Riyadh has almost fully
implemented an EMR system (11), and is reported to have the latest IT (6).
Having reviewed the literature about EMR implementation in
Saudi Arabia, the review now turns to discuss the identified barriers.
4.1. Social Barriers
A number of social barriers have been identified by various
authors, with the main social barriers being lack of computer literacy and
resistance to use of new system (36). Another identified barrier to EMR implementation
in Saudi Arabia is the language issue, since Arabic is the first language and
yet the systems which are implemented are in English (36). Although these
barriers had not previously been identified in Saudi Arabia, they are in
keeping with findings in the broader international literature. Both Alanazy’s
and Hasanain’s research shows that implementation barriers were apparent
despite the two studies occurring in different time periods as well as in
different geographical arrears (central region in 2006 and western region in
2010, respectively). Thus time alone will not solve or overcome barriers to EMR
implementation (3), and effective measures are needed to facilitate the
implementation of such systems.
As previously mentioned physician concern with workloads
when using EMRs in Saudi hospitals, was reported to be a barrier for EMRs
implementation (29). A study by Aldosari (2003) in Saudi Arabia, examined
physicians’ attitudes towards EMRS (1). The study found that the attitudes of
physicians are affected by several factors (1). Some of these
factors were healthcare organizations’ support, ease of using the system and
the potential benefits of using EMRs (1).
Another study by Mohamed and El-Naif in 2005, assessed
physician, nurse and patient views of EMRs and physicians’ views for using EMR
systems in the Military hospital in Riyadh (38). It was noted that 90% of the physicians were concerned
that using such a system would mean that they would have to enter the data into
the system (38).Their main concern was that reviewing results electronically
and entering data would take more time than traditional paper-based methods
(38). Also, the majority of the physicians were worried that the system would
decrease their productivity and cause them see fewer patients (38). Physicians with low computer literacy had
more concerns with perceived workload issues stemming from EMR usage (38). It
was recommended in Mohamed and El-Naif’s study that there is a need to engage
physicians and practitioners in computer activities and training in order to
successfully implement EHRs (38). It was also recommended that strong support
needs to be provided by the MOH for all stages of implementing EMRs (38). As
well as identifying barriers, Hasanain’s (2010) study also suggested a number
of solutions to address EMR implementation barriers. The preferred solution by
the study participants for the “Lack of knowledge and experience to use
computers amongst health personnel” barrier was educating and training the
staff in how to use the new system. Such a
solution can be accomplished by undertaking a needs
assessment protocol followed by a tailored training program or courses based on
the results of that assessment (36).
4.2. Technical Barriers
Examples of technical barriers that were identified in
previous research were instability of EMR vendors, lack of system standardized
systems and complexity of the implemented EMR system (36). In 2011, a study
referred to other EMR technical barriers that needed to be addressed, in order
to have a national and integrated system in Saudi Arabia. These barriers were
integration issues due to the diversity of the implemented HIS (37), security
concerns with using the system (39), and lack of having a universal patient
identifier (40). These barriers are considered to be serious hindrances to any
EMR implementation plan. Lack of standard EMR systems in Saudi hospitals is an
additional barriers hindering the implementation of a national EMR system (41).
EMR system implementation should ideally have regular
evaluation during each stage of implementation (28). Such evaluations would
lead EMR implementation to be more feasible as lessons could be learned from
previous experiences (28). This barrier of a lack of a standard for EMR
implementation exists due to the absence of a national regulator. (10). Regular
evaluation, a national regulator and using a standardized system are core
features for an integrated EMR system (10), as should be incorporated into any
future EMR implementation in Saudi Arabia (18).
4.3. Resources Barriers
Hasanain (2010) identified a number of additional barriers
(36) which related to resources. These additional barriers include a lack of
human resources, lack of computers for staff and a lack of other technological
recourses such as printers and even ink.
All in all, the identified EMR barriers in Saudi hospitals
appear to be obstructing EMR adoption (16) . Some of these barriers were
identified in 2006, and confirmed in a study in 2010.
5. DISCUSSION AND CONCLUSION
Overall, the exact level of EMR implementation nationally
in Saudi Arabia could not be determined from the literature. Studies of MOH
hospitals tended to be conducted in particular towns or regions and from this
information, it would appear that implementation has been slow and low. The
roll-out of EMRs in NGHA, military and private hospitals appears to be more
advanced and may have been assisted by factors such as culture and autonomy in
decision making and the smaller size of the organizations compared with MOH
hospitals.
The literature reveals that the low uptake of EMR
implementation in MOH hospitals is due to a number of technical, social and
resource barriers. It is noted that the MOH has undertaken a number of
initiatives and actions to implement and improve EMRs in its hospitals.
Initiatives are still underway and plans for a national integrated EMR system
is one of the main priorities of the Saudi MOH. Clearly coordinated and
coherent initiatives are needed to assist integrated EMR implementation in
Saudi Arabia.
The current study had a number of limitations. The studies for inclusion spanned only a
decade and articles in the field grew in number toward the end of the decade.
It is possible that more facilitators and barriers may have been identified, if
the time period had been longer. There were however, no studies in the field,
in Saudi Arabia in the years prior to 2003. Only articles written in English
were included in the study, which may have limited the findings. Finally, the
literature focused on EMR implementation is Saudi Arabia, and thus the extent
to which the findings can be extrapolated to other jurisdictions is limited.
Despite the limitations of the current study this article
is the first to systematically review the progress of and challenges to EMR
implementation in Saudi Arabia. It is also the first study which has developed
a chronology of EMR implementation milestones from the extant literature.
Improving the awareness of the challenges to successful implementation and
documenting the progress to date, may assist Saudi hospitals as they plan for a
national integrated EMR system.
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