- HIM: Changing Across the Nation and the World
- Assessing the Planning and Implementation Strategies for the ICD-10-CM/PCS Coding Transition in Alabama Hospitals
- Evaluating the Usability of a Free Electronic Health Record for Training
- Exploring Patient Satisfaction Before and After Electronic Health Record (EHR) Implementation: The Kuwait Experience
- ICD-9 to ICD-10: Evolution, Revolution, and Current Debates in the United States
- Investigation of Physicians’ Attitudes Concerning the Implementation of International Classification Systems of Diseases as a Precondition for Evidence-based Policy Making
- Tele-ICU: Efficacy and Cost-Effectiveness of Remotely Managing Critical Care
- Validating Competence: A New Credential for Clinical Documentation Improvement Practitioners
by Eiman Al-Jafar, PhD
Patient satisfaction has gained the focal position in well-planned healthcare delivery systems. The objective of this study was to investigate patient satisfaction with the quality of services provided before and after the implementation of electronic health records (EHRs) at Primary Health Care Centers (PHCCs) in Kuwait. A self-developed questionnaire was used. A random sampling was used to select 700 subjects. The response rate was 74 percent. The majority of participants (67 percent) were 19 to 34 years of age. Of the participants, 63 percent were female and 92 percent were Kuwaiti nationals. Before EHR implementation, respondents’ disagreement regarding the doctor’s carefulness in conducting the examination, uses of medical terminology, explanations for medication given, and time given for a patient was more than 30 percent. Disagreement regarding the rest of the questions related to the patient/physician relationship after EHR implementation was also higher (25 percent to 39 percent).
Keywords: electronic health records, patient satisfaction, primary healthcare
“Empirical studies of the [electronic health record (EHR)] have increased”1 recently, but few studies have explored the impact of EHRs on patients’ satisfaction and the physician-patient relationship.
Patient satisfaction has gained the focal position in modern-day, well-planned healthcare delivery systems. Much attention within the healthcare industry is focused on patients’ satisfaction with the quality of healthcare services. Several lines of research have converged on the finding that care providers’ interactions with patients and their families have remarkably strong effects on clinical outcomes, functional status, and even physiologic measures of health.2, 3 Measurement of such interactions is used as a key indicator of healthcare quality by many physicians and consumer groups. It gives useful feedback to clinicians and managers on perceived performance and satisfaction with care that may not be apparent through more traditional audit measures.4–7 However, patient satisfaction has not been widely studied with respect to implementation of EHRs.8
A study conducted by Menachemi and Collum indicated that the potential benefits of EHRs include improved clinical, organizational, and societal outcomes. Clinical outcomes include improving the quality of care provided to patients and reducing medical errors. Organizational outcomes include financial and operational benefits. Societal outcomes include the improved ability to conduct research, improved population health, and reduced costs.9
The Ministry of Health in Kuwait implemented various projects aimed at improving the quality of healthcare services. These comprehensive projects targeted primary, secondary, and tertiary levels of care. One project was the implementation of EHRs at the Primary Health Care Centers (PHCCs).10 The move toward implementing EHRs was a result of many factors and problems faced by the Ministry of Health. The Ministry of Health recognized the need for accurate, complete, and comprehensive patient information and data for providing quality healthcare, delivering accurate statistics, helping in the planning process, evaluating treatment effectiveness, and facilitating the decision-making process. In addition, EHRs have the potential to advance the quality of healthcare.11–17
Patients who get healthcare services from Kuwait’s PHCCs are often observed to complain about the quality of the services provided in general. A study was conducted in 2006 to investigate patients’ satisfaction with primary healthcare in Kuwait after the implementation of EHRs without considering patients’ satisfaction before the implementation.18 Although EHR implementation has several advantages, barriers to EHR adoption remain.19 Some of the barriers may include the effects on eye contact and time spent with patients.20, 21 Therefore, this study sought to identify patients’ perception of and satisfaction with the quality of the services provided at the PHCCs before and after the implementation of EHRs. In particular, the level of satisfaction with physicians, administrative staff (receptionists), routine procedures and paperwork, waiting time before seeing the doctor, time spent at the doctor’s office, working hours, and appointment availability were analyzed.
The significance of this study lies in assessing the level of healthcare quality as perceived by patients, identifying gaps between patient expectations and actual process, providing an empirical base for changes to be made by policy makers, offering feedback to care providers, and, in the long run, indicating changes that should be made in the medical curriculum.
The Kuwait Health Care Delivery System includes more than 78 PHCCs. For this study, the population consisted of all patients who visited the various PHCCs in Kuwait. The data were collected using a self-developed questionnaire. The questionnaires were distributed among patients at the time of their visits at PHCCs during morning and evening shifts from September 2004 to December 2004. A total of 700 questionnaires were distributed at various clinics. At each clinic, patients were selected randomly. The patient’s agreement to participate in the study was obtained before each questionnaire was completed.
The questionnaire aimed to collect data on participants’ demographic characteristics. In addition, general questions on the clinics’ location, cleanliness, and decoration were included. Moreover, three separate sections addressed the patient/physician relationship before and after implementation of EHRs and the attitudes of other professionals at the clinics. At the end of the questionnaire, three open-ended questions were included. Before the data collection, the questionnaire was pretested for construct validity and reliability. The questionnaires were piloted with 20 patients, and a few adjustments were made regarding the wording of some questions.
Data were analyzed using SPSS software. For reporting, descriptive statistics were used. In addition, factor analysis was used to identify the common significant factors regarding the patients’ satisfaction with the services of the clinics.
The response rate was 74 percent, with 518 patients participating out of 700 surveys distributed. The patients who visited the PHCCs included 344 (67 percent) who were 19 to 34 years of age, followed by 81 (16 percent) between 35 to 49 years and 80 (15 percent) who were 18 years of age or below. Only 12 (2 percent) of the patients were 50 years or older. Among the patients, 325 (63 percent) were female and 189 (37 percent) were male. Regarding nationalities of the patients, 465 (92 percent) were Kuwaiti and 42 (8 percent) were non-Kuwaiti. (See Table 1.)
Regarding visits to PHCCs, 475 (93 percent) had previous visits, while only 38 (7 percent) of the patients had never visited the PHCCs previously. Among the patients, 335 (65 percent) had a visit during the last 3 months, 99 (19 percent) during the last 6 months, and 81 (16 percent) during the last year or earlier. Among the patients, 83 percent had a waiting time of 20 minutes or less to see a doctor, while 17 percent had to wait more than 20 minutes. Among patients who had to wait more than 15 minutes, 18 percent were given an explanation for the delay.
General characteristics related to the clinics include the greeting on arrival, which 25 percent of the patients reported as poor, followed by the waiting room decor (reported as poor by 23 percent), waiting time (reported as poor by 19 percent), promptness of attention (18 percent poor), waiting room comfort (16 percent poor), and courtesy of the receptionist (14 percent poor). Regarding the convenience of the clinic’s location, only 6 percent reported it as poor and 7 percent reported it as fair; the rest of the respondents reported it as good, very good, or excellent. (See Table 2.)
The distribution of characteristics of the patient/physician relationship before the implementation of EHRs is presented in Table 3. More than 30 percent of respondents disagreed or strongly disagreed with items regarding the doctor’s carefulness about the examination, use of medical terminology, explanations provided for prescribed medication, and time allotted for the patient. The percentage of respondents disagreeing or strongly disagreeing with the other items related to the patient/physician relationship varied from 23 percent to 29 percent.
Table 4 shows the data on the patient/physician relationship after EHR implementation. After implementation of EHRs, the percentage of patients agreeing or strongly agreeing with questions related to the patient/physician relationship after implementation of EHRs, (e.g., the doctor focuses on EHR screen rather than on patient, I believe EHR took doctor’s attention from me, at visit, doctor pays more attention to typing, and EHRs increase trust in physicians) varied from 36 to 50 percent.
Data on the behavior of the other professionals at the PHCCs shows the following: except for effective treatment and professionalism of staff at PHCCs, patients’ agreement on other questions were 50 percent or more. Slightly more than 50 percent of the patients did not agree regarding the effectiveness of treatment and other staff members’ professionalism at the PHCCs. This part of the survey is excluded from this study but will be addressed in a future study.
The majority of Kuwait’s population use the PHCCs as the first step to access healthcare services. The initial implementation of EHRs by the Ministry of Health in Kuwait took place at the PHCCs in 2002. This study aimed to investigate patient satisfaction with the quality of services provided before and after the implementation of EHRs at the PHCCs in Kuwait.
The results of exploratory factor analysis are presented in Table 5 and Table 6. Factor analysis is used to identify the common factors that explain the patients’ relationship with the physician before and after implementation of EHRs and the relationships with other professionals working at the PHCCs. Using the factor loadings from factor analysis also helps to identify the construct validity of our questionnaire. Table 5 presents the factor analysis of items related to the patient/physician relationship before EHR implementation. Factor analysis identified two common factors on the basis of eigenvalues greater than 1, which explain 56 percent of total variations. The loadings of the two factors vary from 0.62 to 0.82, which showed that the construct validity of these items is very high. The first factor explains whether the physician is taking enough time to address patients’ questions, such as by explaining the patient’s medical problem, test, procedure, or prescribed medication, which makes a patient feel confident about the doctor. The second factor explains items that reduce the patient’s confidence in the doctor.
The factor analysis of items related to the patient/physician relationship after EHR implementation identified three common factors on the basis of eigenvalues greater than 1, which explain 66 percent of total variations. The factor loadings vary from 0.57 to 0.90, which again showed that the construct validity of these items is very high. It was easy to name the three factors identified here. The first factor explained the patients’ perception regarding improvement in the quality of care due to the implementation of EHRs. For example, some patients indicated that using EHRs improved relations with the physician and increased trust in the physician’s performance. The second factor explained the patients’ feeling about the shift of the doctor’s attention from the patient to the computer screen, such that less eye contact was received. Finally, the third factor explained the patients’ perception of the negative impact due to the computerization. For example, some patients did not see improvement in the clinic’s system after EHR implementation. (See Table 6.)
One limitation of this study is the low participation of non-Kuwaitis in the study (8 percent) although they form the majority of Kuwait’s population.
As noted above, data on the behavior of other professionals on the healthcare team working at the PHCCs were excluded from this study but will be used in a future study. Another exclusion was the results of the three open-ended questions because of difficulty in categorizing participants’ answers into limited themes.
EHRs in healthcare settings pose challenges to medical practice.22 Therefore, more studies of EHR implementation and its effects on the medical practice in general and on physician-patient relationships are needed.
This study’s results show decreased physician attention toward patients during patient visits due to the use of EHRs. EHR implementation should support positive relationships with patients and improve the quality of care.23 Implementation of EHR systems in gradual phases in healthcare facilities will help the healthcare professionals adapt to the system as well as maintain good physician-patient relationships.24
The data were gathered during 2004, when technology use was not as common among Kuwait’s population as it is today. Hence, a similar study will be conducted in the near future to investigate further the impact of EHR systems on patients’ satisfaction. The new study will include a larger sample size to better represent the population in Kuwait.
More studies should be conducted related to EHRs and the improvement of patient care. EHR training should be introduced for the various health care professionals and in medical schools’ curricula.25 Other studies should be conducted after more years have passed since EHR implementation to investigate the cost-benefit factors.
This research was supported by Kuwait University, grant no. ZN 03/04.
Eiman Al-Jafar, PhD, is a faculty member in the Department of Health Information Administration, Faculty of Allied Health Sciences at Kuwait University, Kuwait.
- Shield, R. R., R. E. Goldman, D. A. Anthony, N. Wang, R. J. Doyle, and J. Borkan. “Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation.” Annals of Family Medicine 8, no. 4 (2010): 316–26.
- Kenagy, J. W., D. M. Berwick, and M. F. Shore. “Service Quality in Health Care.” Journal of the American Medical Association 281, no. 7 (1999): 661–65.
- Bolus, R., and J. Pitts. “Patient Satisfaction: The Indispensable Outcome.” Managed Care 8, no. 4 (1999): 24–28.
- Thorne, L., and N. Kitchen. “Auditing Patient Experience and Satisfaction.” British Journal of Neurosurgery 16, no. 3 (2002): 243–55.
- Garrison, G. M., M. E. Bernard, and N. H. Rasmussen. “21st-Century Health Care: The Effect of Computer Use by Physicians on Patient Satisfaction at a Family Medicine Clinic.” Family Medicine 34, no. 5 (2002): 362–68.
- Goetz Goldberg, D., A. J. Kuzel, L. B. Feng, J. P. DeShazo, and L. E. Love. “EHRs in Primary Care Practices: Benefits, Challenges, and Successful Strategies.” American Journal of Managed Care 18, no. 2 (2012): e48–e54.
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- Al-Azmi, S. F., A. M. Mohammed, and M. I. Hanafi. “Patients’ Satisfaction with Primary Health Care in Kuwait after Electronic Medical Record Implementation.” Journal of the Egyptian Public Health Association 81, nos. 5–6 (2006): 277–300.
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- O’Connell, R. T., C. Cho, N. Shah, K. Brown, and R. N. Schiffman. “Take Note(s): Differential EHR Satisfaction with Two Implementations under One Roof.” Journal of the American Medical Informatics Association 11, no. 1 (2004): 43–49.
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- El-Kareh, R., T. K. Gandhi, E. G. Poon, L. P. Newmark, J. Ungar, S. Lipsitz, and T. D. Sequist. “Trends in Primary Care Clinician Perceptions of a New Electronic Health Record.” Journal of General Internal Medicine 24, no. 4 (2009): 464–68.
- Al-Azmi, S. F., A. M. Mohammed, and M. I. Hanafi. “Patients’ Satisfaction with Primary Health Care in Kuwait after Electronic Medical Record Implementation.”
- Ash, J. S., and D. W. Bates. “Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion.” Journal of the American Medical Informatics Association 12 (2005): 8–12.
- Linder, J. A., J. L. Schnipper, R. Tsurikova, A. J. Melnikas, L. A. Volk, and B. Middleton. “Barriers to Electronic Health Record Use During Patient Visits.” AMIA Annual Symposium Proceedings (2006): 499–503.
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- Shield, R. R., R. E. Goldman, D. A. Anthony, N. Wang, R. J. Doyle, and J. Borkan. “Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation.”
- Goetz Goldberg, D., A. J. Kuzel, L. B. Feng, J. P. DeShazo, and L. E. Love. “EHRs in Primary Care Practices: Benefits, Challenges, and Successful Strategies.”
- Shield, R. R., R. E. Goldman, D. A. Anthony, N. Wang, R. J. Doyle, and J. Borkan. “Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation.”
Eiman Al-Jafar, PhD. “Exploring Patient Satisfaction Before and After Electronic Health Record (EHR) Implementation: The Kuwait Experience.” Perspectives in Health Information Management (Spring 2013): 1-12.