Evaluation of effectiveness for using of Electronic Health Information System at Al-Rajhy Assiut University Hospital for Liver

Introduction

Hospital Information System (HIS) is comprehensive software for patient’s information integration for transfer and exchange comprehensive patient’s information between wards to accelerate process of patient care, improve quality, raise satisfaction and reduce costs. Electronic Hospital Information Systems (e-HISs) are “computer systems that collect, store, process, retrieve, display, and communicate timely information needed in practice, education, administration and research (Aghazadeh, et al, 2013)

Electronic health record (EHRs) consider as a part of (e-HIS) systems that can enable hospitals to store and retrieve complete patient information to be used by health care providers, and sometimes patients, during a patient’s hospitalization, over time, and across care settings. Any health care system must depend on a well formed information system to achieve a successful management. Data are the center of all decision making in health care. So the data should be reliable, complete and well-structured to make the computers assist in fulfilling these requirements (Shortliffe et al., 2014).

Moreover, EHRs has many benefits as: reduce errors, increase speed of care, accuracy and also lower health costs by coordinating services and improving quality of care while traditional paper based medical records are bulky and harder to maintain, so these problems can be easily solved by implementing e-HIS (Jha et al., 2018).

However, the target of EHRs involves increased efficiencies, improved accuracy, timeliness, availability, and productivity. Clinicians in environments with EHRs spend less time updating static data, such as demographic and health history, because these data are populated throughout the record and generally remain constant. Clinicians also have better access to other automated information, improved organization tools, and alert screens. Alerts are a significant capacity of EHRs because they identify medication allergies and other needed notices (Department of Health & Human Services, 2014).

Furthermore, EHRs can help the nurse to monitor the usage of drugs effectively which leads to better utilization of medicines and better cost control. Also, provide facilitation of the information sharing, mass archives, security, high reliability, standardization of work processes in the hospital, improving the patient care through standardization of performance and support of medical information format of images, and figures (Rose et al., 2014).

 Electronic documentation systems improve the worth of EHRs by providing electronic release of clinical notes; patient assessments; and clinical reports, such as medication administration records. Examples of clinical documentation that include: physician, nurse, and other clinician notes, flow sheets (vital signs, input and output, problem lists), per-operative notes, discharge summaries, consents (procedural) and medical record (Coffman et al., 2012).

In other words, EHR is principally focused on the patient, as well as on medical and nursing care, and the administrative issues needed to support these kinds of care. Therefore, EHR frees the medical staff from data management tasks so that they can concentrate more on patient care improved efficiency: Also they will never have to face adversities such as missing records, delays, duplicate records and the data is to be well-organized (Khalifa, 2014).

Nursing Information System (NIS) is “a part of health care information system that deals with nursing aspects, particularly the maintenance of the nursing record”.  Nursing Record System is the record of care planned given to individual patients by qualified nurses or other caregivers, to assess patient acuity, prepare a plan of care, and document care. Nursing information systems help nurses plan support activities, and communicate with related services (Cohen, 2016).

                The main utility for EHRs it provides a platform which electronic media are used to facilitate and enhance quality assurance of the public consumers’ healthcare service delivery. Moreover, the systems support new methods to create, keep and maintain records for hospitals as well as improve management, accountability and security in processes, improve the handling of information by healthcare providers (Middleton, et al; 2013).

Significance of the study

Introduction of e-HIS considered initiatives to transform existing paper-based systems in most teaching healthcare institutions in developing countries has usually been a difficult process of change, often faces with several challenges and problems such as lack of adequate resources (poor financial resources) and poor infrastructural development, inadequate skills and knowledge at a local level to handle new systems and technologies. The success of the system is achieved through user acceptance with the system (Ojo and Popoola, 2015).

Al-Rajhy University Hospital has a fully automated e-HIS since its opening in (2012). The implementation of e-HIS to a hospital is consider a new system in Assuit University Hospitals as a whole, in an attempts to convert the paper-based health record system to a fully automated electronic record systems which is very problematic for nurses and some employees and faced with resistance at the beginning and hospital administration overcome this resistance by providing support and training for all health care providers involved in the system of e-HIS. It was felt necessary to evaluate to what extent the e-HIS was effective.

Aims of the study

The aim of the current study was to   evaluate the effectiveness of using EHRs at Al-Rajhy Assiut University Hospital for Liver.

Research Question

Does the usage of electronic health records are effective for health care providers?

Subjects & Method

Study Design

Descriptive comparative research design was used in the present study.

Study Setting

The present study carried out - at Al-Rajhy Assiut University Hospital for Liver at the following units: general ward, intensive care unit, critical care unit, endoscopic unit, operating room, outpatient clinics, laboratory, and X- ray.

Study Subjects

The study subjects included all users of the e-HIS, (n= 250) categorized as follows; physicians (n=20), staff nurses (n=200), and employees (n=30) from admission office, human resources personnel, and financial department.

Tool of data collection

One tool was used to collect data through self- administered questionnaire consists of three parts.

Part (1): Personal and characteristics data sheet.

 Designed to collect data about study participants personal characteristics as; age, gender, marital status, educational qualification, current job title, years of experience, duration of using electronic records system by each categories in hospital.

Part (2): Evaluation of electronic health records scale.

It developed by Cortes, (2008) and consists of 23 items comprised of 4 main domains; general evaluation of operation of the electronic system (6 items), evaluation of the information made available by electronic system (5 items), and evaluation of the screens of the system (5 items). And general evaluation of electronic records (7 items).Asking respondents to indicate their agreement or disagreement with the statement measured on five point likert- scale;(1)Completely disagree, (2) disagree, (3) indifferent, (4) agree, and (5) completely agree.

Part (3): Utility of electronic hospital information system scale.

It was developed by Cortes (2008) it consists of 20 items comprised 3 main domains as follows; utility of electronic records (6 items), utility of the electronic system for medical and nursing work (8 items).And utility of the electronic system for the processes of billing and auditing (6 items). Asking respondents to indicate agreement or disagreement with the statement measured on a five point likert- scale; (1) completely disagree, (2) disagree, (3) indifferent, (4) agree, and (5) completely agree.

Scoring system:

The scores of the items were summed-up and divided by the number of items, giving the mean score. These scores were converted into a percent. Then the mean and standard deviations of the scores were computed. If the mean scores percent of responses were ≥ 60 % means high level but if ≤ 60% means low level.

Administration design

An official permission had been obtained from the medical director of Rajhy hospital to collect the necessary data from all users of hospital information system; also oral agreement permission was obtained from all users of EHIS to participate in the study.

Validity and reliability

To achieve the criteria of trustworthiness of the tools of data collection in this study, validity of tool were revised and validated for their face validity by five experts in the field of study. They were three assistant professors of Nursing Administration – Faculty of Nursing – Assuit University and one lecturer of Nursing Administration – Faculty of Nursing –Minia University, and one professor of IT unit-Faculty of Information Technology- Assuit University. Accordingly the modifications required already done by the researcher.

The reliability of the data collection tools was assessed through measuring their internal consistency by Cronbach Alpha Coefficient test, and it was proven test (0.832).

Pilot study:

A pilot was done to investigate and ensure the feasibility, applicability, clarity and reliability of the study tools. The pilot study included 10% of total number as follows (2 physicians, 3 employees, and 20 staff nurses) and the necessary modifications were done.

Ethical Considerations

Approvals were taken from Ethical Committee of Faculty of Nursing of Minia University,The purpose of this study was explained to all participants and oral consent taken from the participants in the present study, and  Confidentiality of data, voluntary participation and right to refuse to participate in the study was emphasized to subjects.

Operational design

This phase took about 3 months from January to March 2018 for reviewing the available literatures concerning the topic of the study; translation of the study tools from English to Arabic was done. Accordingly, modifications were done and the final form was developed. This phase took about 2 month from April to May 2018.

Data collection phase:

The data collected through self- administered questionnaire from participants for collection necessary data, this took about 15 minutes for each participant. The whole duration for data collection took about 4 months from May to August 2018.

Statistical design:

The data were reviewed, prepared for computer entry, coded, analyzed and tabulated. Descriptive statistics (i.e., frequencies, percentage, mean and standard deviation etc.) was done using computer program SPSS version 11. ANOVA test, used to compare differences in the distribution of frequencies among different groups. It is considered * significant when P- value were less than 0.05 or (P< 0.05). 

Results

Table (1): Percentage distribution of personal characteristics of studied subjects (n=250)

Personal data of studied subjects (physicians, nurses, and employees) depicted at table (1). Regarding to physicians nearly two thirds of physicians (60%) was male, married. Their mean age was (30.25) years old, while the mean year of experience was (9.25) and duration of electronic system used in hospital from 2-4 years. Regards to the nurses, the majority of them were female, married and graduated from technical institute,(95.5%, 69.0% and 60.5%) respectively. Their mean age was (27.11) years old, while the mean year of experience was (8.76) and duration of electronic system used in hospital from 2-4 and >4 (59.5%, 27.5%).Regarding to employees, the highest percent of them were married, male, and had bachelor degree or higher (90.0%, 73.3%) and (66.7%) respectively. Their mean age was (36.37), the mean years of experience was (15.20) and duration of electronic system used in hospital more than 4 years.

Table (2): Percentage distribution of physicians evaluation of electronic records system used in AL-Rajhy hospital (n=20)

Table (2) describes physicians evaluation of  electronic records system usage; regarding to general evaluation of electronic health records operation; the vast majority ofphysicians(95%)  completely agreed that the system works well, speed is good, it is easy to input information into electronic records and(90%) agreed that the records easy to use. While about two thirds of them agreed that it facilitates the implementation of internal protocol. Regarding to evaluation of information made available, majority of them  completely agreed that the system provides clear, useful, complete, and provides reliable information (95%, 85%,and 70%) respectively. Regarding to evaluation of the screens of the system, more than two thirds of them completely agreed that the screens has the ability to retrieve faster and reliable data for specific research, has the ability to see & analyze the patient data as a whole and easy access to the records ( 85%, 75%,and 70%) respectively. For general evaluation of electronicrecords system, the majority of physicians (85%) completely agreed that the records are useful, present updated information, in an appropriate format, and are easily configured, while (75%)of them agreed on the system has enough records for its activity.

Table (3): Percentage distribution of nurse’s evaluation of electronic records system used in AL-Rajhy hospital (n=200)

Nurses evaluation of electronic records system usage; Table (3): illustrated that more than half of them agreed that the system easy to input information into electronic records, has few interruption and works well (58%, 55%, and 54.5%) respectively. For evaluation of information made available; (56%) of nurses agreed that the system provides clear, useful information, (53%) agreed that it divided in a consistent manner. While (46.5%) agreed that the system provides complete information. Regarding to evaluation of the screens of system; more than half of nurses agreed that it has the ability to retrieve faster and reliable data for scientific research, restricting is possible for the necessities and has the ability to see & analyze the patient data as a whole (59%, 56.5%,and 54%) respectively. And (54.5%) completely agreed that it is easy access to the records. For general evaluation of electronic records system; more than half of nurses completely  agreed that the generation of records is fast, records present updated information and it are useful (55%, 54%,and 53%) respectively. While nearly to half (49%) agreed that it present an appropriate format and present good organization. And (43.5%) agreed that it has enough records for its activity.

Table (4): Percentage distribution of employees evaluation of electronic records system used in AL-Rajhy hospital (n=30)

Employees evaluation of electronic records system usage: Regarding to general evaluation of system operation; Table (4): depicted that the majority of them completely agreed that it is easy to input information into electronic records, easy to use, and system works well (90%, 86.7%, and 80%) respectively. While (76.7%) of employees completely agreed that the system’s speed is good and facilitates the implementation of internal protocol.  Regarding to evaluation of information madeavailable; high percent of them (83.3%) completely agreed that the system provides clear information, and (80%) completely agreed that it is divided in a consistent manner and provides useful information. And (70%) completely agreed that it provides complete and reliable information. Concerning evaluation of screens of thesystem; the majority of them completely agreed that it is easy access to the records, disappearance of paper records, and the system has the ability to see & analyze the patient data as a whole (86.7%, 76.7%, and73.3%) respectively. For general evaluationof electronic records system; the vast majority of them completely agreed that the records are useful, present updated information, and the generation of records is fast (93.3%, 86.7%, and 83.3%) respectively. And (80%) of employees completely agreed that the records are easily configured, present an appropriate format, and present good organization.

Table (5): Percentage distribution of physicians evaluation of the utility of electronic records system used in AL-Rajhy hospital (n=20)

General utility of electronic records system as evaluated by physicians;Regarding 3 dimensions of utility of electronic system, utility of electronic system for medical & nursing work and utility of electronic system for the process of billing and auditing; Table (5) demonstrated that;   more than half of them (55%) agreed that the records offer reliability, and about half of them completely agreed that it facilitate coordination of tasks, increase level of control over operation and facilitates the decision process. While the majority of them agreed  that the electronic records facilitate nursing work in the evolution of the patient, facilitate work in the medical evolution of patient, and facilitate work in the sector of guidelines & authorization (90%, 85%,and 75%) respectively.Also; (70%) of them agreed that the records facilitate auditing and release of procedures,(60%) agreed that it facilitates analysis of hospital bills, facilitates verification of the materials & medications used in units, facilitates hospital billing, and provides better control over the consumption of medications.

Table (6): Percentage distribution of nurses evaluation of the utility of electronic records system used in AL-Rajhy hospital (n=200)

General utility of electronic records system as evaluated by nurses; Table (6) described that more than two third of them agreed that it facilitate the coordination of tasks, decision process and improve the reliability of decision process (64%, 60.5%, and 56%) respectively. While about (42, 5%) of them agreed that the records reduce the need for control, surveillance and conferencing. Regarding utility of electronic system fornursing work; it was shown that more than half of them (59.5%, and 56%) agreed that it facilitate patient care, and presents a good level of integration with the other units. Also (55.5% and 54%) agreed that it facilitate nursing work in the evolution of patients, and facilitates work in the medical prescriptions for patients.  Similarly; about two third of them (60.5%) agreed that it facilitates auditing in the authorization and release of procedures, and more than half of them agreed that it facilitate verification of materials and medications used in the units and provides better control over the consumption of medications (54.5%,and 54%) respectively.

Table (7): Percentage distribution of employees evaluation of the utility of electronic records system used in AL-Rajhy hospital (n=30)

General utility of electronic records system as evaluated by employees; Table (7), described employees opinion regarding utility of electronic records system; it showed that more than two thirds of them (66.7%) completely agreed   that it facilitate decision process, offer reliability, increase level of control over operation, and(60%) agreed that it reduce the need for control, surveillance and conferencing. For utility of electronic health records for medical and nursing work; more than two third of employees agreed that it facilitates work in medical prescription for patients, presents a good level of integration with the other units, and facilitates patients care.  As regarding to utilityof electronic system for the process of billing and auditing; the majority of them (86.7%, and 83.3%) completely agreed that it facilitates hospital billing, reduce the occurrence of frauds, and facilitates analysis of hospital bills .while (76.7%, and 73.3%) completely agreed that it facilitates auditing in the authorization & release of procedures and facilitates verification of the materials & medications used in the units.

Table (8): Mean scores of evaluation of electronic records system and general utility of electronic records system by study subjects (n=250)   at AL-Rajhy hospital

Table (8) demonstrated the mean scores of evaluation of electronic records system and general utility of electronic records system. There were high statistical significant difference among (physicians, nurses, and employees) regarding general evaluation of electronic system and utility of the electronic system (p=0.000*).