Barriers to the implementation of large-scale electronic health record systems in Primary Healthcare centers

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Hutchings This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4461961/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The incorporation of data Over the past two decades, policy-makers in healthcare organizations have placed significant emphasis on technology as a top priority. This is because of the potential advantages that technology offers in enhancing healthcare services and improving their quality. Nevertheless, approximately half of those projects did not succeed in attaining their planned objectives. This outcome was a consequence of multiple variables, which encompassed the expenses associated with these initiatives. The Saudi ministry of health intended to deploy an electronic health record system in approximately 2200 basic healthcare clinics across the country. It was recognized that this project could encounter obstacles, perhaps leading to project failure, if implementation facilitators were not identified beforehand. The Saudi Ministry of Health (MoH) states that the earlier adoption of Electronic Health Record Systems (EHRS) at Primary Health Centers (PHCs) failed due to various obstacles, including inadequate infrastructure, limited connectivity, and lack of interoperability. Aim: To determine the barriers that may that could potentially contribute of failure the implementation of the EHRS in the PHCs Method: A mixed methods approach was employed, incorporating both qualitative and quantitative methodologies. The qualitative aspect involved conducting semi-structured interviews, while the quantitative component utilized a closed survey. The objective of employing exploratory mixed-methods was to find a diverse array of facilitators that could potentially impact the implementation of EHRS. The data were collected from two distinct viewpoints: PHCs practitioners and project team members. A total of 351 practitioners from 21 PHCs participated in the online-based survey, while 14 key informants at the Saudi Ministry of Health (MoH) who were directly involved in the implementation of the Electronic Health Record System (EHRS) in the PHCs agreed to be interviewed in person. Results: The results from both investigations identified multiple obstacles. The constraints include the project's extensive scope, the need to adapt individuals to change, insufficient training, inadequate technical assistance, lack of compatibility between systems, geographical obstacles, software selection issues, and insufficient user engagement. However, this study offers many suggestions to decision-makers and the EHRS implementation project team to streamline the adoption of a widespread EHRS. These ideas include collaborating with telecom providers and splitting the state into clusters. Conclusion: The primary factors contributing to the failure of the previous initiative were insufficient connectivity, inadequate technical assistance, and significant turnover in high-level posts within the Saudi Ministry of Health. Training and support were identified as a significant obstacle, whereas confidentiality and privacy were determined to be less of a hindrance to the introduction of EHRS. Hence, authorities must allocate a enough budget to ensure seamless execution, especially when making choices about software selection and the provision of training and support. • This study provides insights into the procedures and steps of implementing EHRs. • The findings will enhance our understanding of how to overcome impediments that impact the success of EHRS deployment. •This study aims to address the research gaps by specifically identifying and analyzing the implementation methods in primary healthcare centers (PHCs) in Saudi Arabia and other Arab Gulf Countries (GCCs). This study makes a methodological addition by combining qualitative and quantitative research designs to investigate the obstacles to the implementation of EHRS. Electronic health records Barriers Primary Healthcare centres Large-scale IT projects Saudi Arabia Introduction Information Technology (IT) has played a crucial role in enhancing and improving healthcare services since the 1960s [ 1 – 4 ]. The IT in the final decades of the 20th century has completely transformed the methods of classifying and recording information. The rapid and accurate implementation of the IT revolution prompted the governments of industrialized countries (where this revolution originated) to promptly embrace these sophisticated, swift, and effective technologies [ 4 , 5 ]. Consequently, the use of EHRS has gained significant importance in both developed and developing nations [ 5 , 6 ]. Several academics have contended that the deployment of EHRS is highly intricate as a result of the scarcity of implementation expertise and the related challenges. [ 7 – 12 ]. Although, the barriers to EHRS implementation have been described, many of them remain unresolved [ 13 ]. Therefore, it has been suggested that further research and investigation is necessary to overcome these barriers [ 12 , 13 ]. Around 50% of EHRS implementation projects around the world have failed or fail to be properly implemented [ 14 – 18 ]. Other studies have approximated that the percentage of failing IT initiatives in the hospital sector may reach up to 70%. [ 19 ]. In addition, The introduction of Electronic Health Record Systems (EHRS) in Primary Healthcare Centres (PHCs) poses a more significant barrier compared to its implementation in secondary care settings, such as hospitals [ 20 – 22 ]. Urban hospitals exhibit a higher propensity to use EHRs in comparison to rural hospitals and PHCs [ 21 – 23 ]. Furthermore, according to Xierali, Phillips [ 21 ], and Wittie, Ngo-Metzger [ 23 ], electronic health record systems are more commonly adopted in affluent communities as opposed to lower-income areas. Information regarding the utility and advantages of EHRS, along with the expenses associated with implementation and other obstacles, is limited in developing nations [ 24 ]. Although study on the effects of EHRS and its potential advantages has been carried out in industrialized nations, there is still conflicting information regarding the system's influence [ 24 ]. Furthermore, the implementation process in poor nations necessitates more extensive exertion compared to developed countries, due to the inferior preparedness of healthcare organizations in terms of IT and infrastructure [ 25 , 26 ]. The main barriers identified in previous studies include insufficient technical support, and decreased productivity [ 12 , 27 ], user resistance, interoperability issues, high implementation cost [ 12 , 27 , 28 ], inadequate training, lack of awareness regarding the importance of EHRS, usability issues, concerns about patient privacy and confidentiality, unsuitable hardware [ 27 ] and finally privacy, confidentiality and security issues [ 29 ]. The impact of system usability on EHRS implementation has been recognized [ 30 – 32 ]. Usability concerns can limit the use of information technology in healthcare organizations [ 12 , 31 – 35 ]. Conversely, studies have shown that there is a direct correlation between system usability and adoption rate. A higher level of system usability leads to an increased adoption rate [ 36 ]. Furthermore, according to Khajouei, Wierenga [ 31 ], and Gagnon, Payne-Gagnon [ 37 ], the usability of EHRS is a key determinant of end-user satisfaction with the system. Finally, unsuccessful interoperability can arise from the misconnection or discoordination between healthcare providers from different organizations, as these organizations employ different standards [ 28 , 33 , 36 – 42 ]. Study Aim To discover the hurdles that influence the effectiveness of the deployment of the EHRS in the PHCs in SA Methods Research design and data collection The study employed a mixed methods approach, namely an exploratory sequential design, which involved conducting qualitative semi-structured interviews and a quantitative close-ended survey [ 43 ]. The initial semi-structured interviews were conducted to investigate and identify potential obstacles that could impact the deployment of EHRS. The information gathered from these interviews was then utilized to develop a more targeted questionnaire for the quantitative survey study. In order to accomplish the objective of this study, we considered the primary elements that influence the deployment of Electronic Health Record Systems (EHRS) as identified in prior research. These aspects were taken into consideration when developing the questionnaire, as well as the insights gained from the semi-structured interviews. The data collection instruments utilized in this investigation, both qualitative and quantitative, were previously created and employed by Alzghaibi and Hutchings [ 44 ]. Study questionnaire validity and radiality We performed multiple initial procedures to evaluate and, if needed, enhance the questionnaire. The questionnaire was developed in two phases. The initial instrument underwent evaluation by a panel comprising external specialists, including: two information technology experts from the central office of the Saudi Ministry of Health, the directors of the information technology departments of two distinct hospitals, one scholar from King Saudi University (holding a doctorate in Health Informatics), one radiologist, and one pharmacist (holding a master's degree in Health Informatics). After undergoing a review and receiving input from expert panels, the questionnaire was administered as a pilot study to a small group (n = 5) of the project team. This was done to verify the clarity, comprehensibility, and reliability of the questionnaire. The data collection questionnaire was tested at the Saudi Ministry of Health's main office with project team members who willingly consented to participate. Various factors were considered, including distinct position tiers (e.g. supervisors, directors, and senior managers), diverse divisions, and varied ethnicities. Table 1 demonstrates that the dependability of all scales is satisfactory. The obstacles scale exhibits the highest level of dependability, with a coefficient of 0.83, followed by negative attitudes with a coefficient of 0.70. The overall reliability of the data collection device in the study is high, with a coefficient of .81. Table 1 Cronbach’s Alpha Test Scale Number of Items Cronbach’s Alpha Negative attitude 7 0.70 Barriers 16 0.83 Entire questionnaire 23 0.81 The qualitative data were analyzed using a thematic analysis technique with the assistance of NVivo10 software developed by QSRInternational.com. The quantitative data were subjected to statistical analysis using IBM SPSS V.22. At first, descriptive statistics were conducted utilizing measures such as the median, rank, and overall agreement. Subsequently, non-parametric tests were employed to ascertain the presence of any disparities among the groups. Specifically, the Mann-Whitney U test was utilized for comparisons involving two groups, while the Kruskal-Wallis test was employed for comparisons involving three or more groups. Population and sampling In order to select the most suitable participants for this study, who were actively involved in the project execution and possessed information about the deployment of Electronic Health Record Systems (EHRS) in Primary Health Care (PHC) centers in South Africa, a non-probability, purposive, snowball sampling method was employed [ 43 , 45 ]. In order to gather qualitative data, all 53 members of the project team were invited to participate in semi-structured interviews. However, only 14 individuals agreed to take part. The quantitative analysis employed a multi-stage cluster sampling technique [ 46 , 47 ]. Thus, in Stage One, we employed the same categorization as the Saudi Ministry of Health, where areas were transformed into clusters [ 48 ]. For the second phase, a method called simple random sampling was employed, which involved selecting participants based on the geographical location of each province [ 43 ]. During Stage Three, a sample of 21 PHCs was picked randomly from a total of 2259 PHCs among the five specified clusters. The sample (n = 491) was picked from 21 specific centers, spanning across five designated areas. The utilization of the multi-stage cluster sampling technique has been proven to be highly beneficial for conducting statewide studies and surveys with bigger populations. In addition, multi-stage cluster sampling helps to address the difficulties associated with random sampling [ 43 ] Data collection process Qualitative Fourteen semi-structured interviews were conducted with the chosen participants. The interviews were carried out within a span of two months. We allocated a maximum of two hours for each interview, but there were no restrictions on the duration of the session. The participants were notified that they had the option to terminate the interview at any given moment. Furthermore, to provide maximum convenience for the interviewees, I personally visited the participants' locations to conduct the interviews. In order to optimize the participants' time, I diligently prepared for the interviews ahead of time and ensured the provision of a concise and meticulously structured interview guide. I obtained consent to record the interviews and ensured that the recording devices were well charged and had ample storage capacity for the interviews. Furthermore, cell phones were set to airplane mode to preempt any phone calls or other notifications from disrupting the interviews. I came at least thirty minutes before the scheduled interview to ensure the suitability of the interview venue. All interviews, save for one, were done at the same place. All participants were administered identical questions, adhering to the criteria for conducting interviews. The interviews were recorded digitally using an iPad and an iPhone. Field notes were recorded during the interview to prevent any disruption caused by the emergence of additional questions. This enabled me to produce additional inquiries to address any omissions and also to elucidate any remarks given. This feature also provided adaptability during the interview and facilitated the interviewer in recognizing any remarks that might prompt additional inquiries and areas of investigation. Furthermore, the interviewer made field notes during the interview to document nonverbal cues and participants' responses that may not have been discernible in the audio recording. The interview commenced with a self-introduction and a concise overview of the research's essence. Subsequently, we elucidated the rationale behind the participant's invitation to participate. Prior to commencing the interview and posing inquiries, we allocated a enough amount of time for the participants to peruse the consent document. We obtained explicit confirmation from the participants regarding their willingness to participate in the study and thereafter requested their signature on the consent form. Following each interview, participants were explicitly urged to voice any comments or concerns that were not discussed during the interview. The duration of the interviews ranged from 35 to 130 minutes, with an average duration of approximately 65 minutes [ 49 ]. Quantitative After the completion of the data gathering instrument, I began contemplating the most suitable approach to disseminate it. The initial concern were around enhancing the response rate and motivating individuals to actively engage in this study. Initially, we opted for the electronic questionnaire due to its proven efficacy in evaluating the preparedness of many PHCs in comparison to alternative methods like observation. In the present study, twenty-one PHCs were chosen specifically for the goal of assessing their generalizability. However, the decision on how to distribute the questionnaire for this study was determined by three primary considerations. Firstly, Saudi Arabia faces significant geographical obstacles due to its vast size. Physically disseminating a paper-based questionnaire to all the chosen PHCs was unfeasible due to the relatively insufficient postal services in South Africa. Furthermore, the study had a substantial sample size, making the utilization of a paper-based questionnaire prohibitively costly. Ultimately, due to our location in the UK, it was not feasible to physically disseminate the questionnaire. Thus, we opted to employ an online self-administered questionnaire through Survey Monkey to gather the data [ 49 ]. The dissemination of the questionnaire for this study took place over a duration of 10 weeks. Following the dissemination of the original questionnaire, two reminder e-mails were sent to the participants. The initial email was dispatched in the second week, while the subsequent email was transmitted in the fourth week. The official staff emails were not utilized efficiently, since most of the selected PHCs staff continued to use their personal email addresses at work, which I did not have access to. Consequently, we had a direct connection with delegates from the twenty-one chosen PHCs. Each representative received a copy of the ethical permission letter and was then invited to join a 'WhatsApp' group that I developed specifically for this purpose. Every single one of the twenty-one representatives agreed to the invitation. After all the individuals had joined the group, we distributed a singular link acquired from surveymonkey.com to the group. We instructed them to complete the questionnaire and thereafter share it with all other staff members in the chosen Primary Health Centers (PHCs) through their personal email accounts or other available communication channels, such as other WhatsApp groups. Data analysis Qualitative Thematic analysis was used to analyze the qualitative data obtained from the semi-structured interviews [ 43 ]. Thematic analysis was chosen due to its versatility and lack of limitations to a particular framework or theory. Furthermore, the choice was taken to do theme analysis to discern patterns in highly abundant information from various viewpoints [ 43 ]. After concluding the interviews, I transcribed the audio recording into a textual format and subsequently saved it as a Microsoft Word document. The recordings were transcribed word for word to ensure the response context and information substance are easily understood. Hence, the data analysis commenced promptly after the transcription of the interviews, followed by their translation into English (for interviews done in Arabic). The transcripts were Microsoft Word files that were put into the NVivo program. Quantitative The data were analyzed utilizing SPSS V.27. To confirm the consistency of the data collection instrument, the reliability of the study's scales was assessed using a Cronbach's alpha test. Subsequently, a descriptive analysis was used to present the data collected from the participants. This analysis involved calculating the median, percentages, total agreement, and rank. However, it is important to note that the barriers scale did not contain the measurement of total agreement. The replies were utilized to compute a cumulative agreement score for each question. The questions were graded according to the degree of consensus, ranging from the highest to the lowest. The cumulative agreement was aggregated by combining the responses of "agree" and "strongly agree" in order to discern the relative levels of agreement among different items, hence facilitating their ranking [ 49 ]. After presenting the descriptive data, inferential statistical tests were employed to examine any correlations or disparities. All tests are non-parametric and were selected due to the data being categorized as ordinal and nominal. To assess the disparities among groups, we conducted Mann-Whitney U tests for two groups and Kruskal Wallis tests for three or more groups [ 49 ]. Results Fourteen individuals from the Saudi Ministry of Health's project team who were instrumental in implementing electronic health records in primary healthcare facilities consented to an in-person interview. However, a total of 351 professionals from 21 Primary Health Centers (PHCs) took part in the online survey. Interview results The participants held various positions, including three General Managers (GM), three Heads of Department (GM), one Deputy Head of Department (DHD), one Software Developer (SD), and five Data Analysts (DA). This section encompasses all the themes and codes that have been established to signify the obstacles to the installation of EHRS in PHC facilities in South Africa. The participants identified multiple obstacles. In addition, many measures to overcome the obstacles that can result in the failure of implementation were documented. At first, the participants acknowledged that there are multiple obstacles to establishing EHRS in PHCs. “The obstacles are too many.” (SD1) During the interviews, the participants cited numerous challenges they faced while participating in the deployment of EHRS in PHCs. The barriers to EHRS implementation encompassed various factors, including personnel turnover, a dearth of expertise in EHRS implementation, inadequate training, a high number of primary healthcare centers, limited implementation time, challenges associated with vendors, insufficient connectivity, subpar infrastructure, geographical obstacles, EHRS interoperability, software selection, and a shortage of suitable computers (see Table 4 )[ 49 ]. Table 4 themes and sub-themes No. of themes Themes No of sub-themes Sub-themes 1. Turnover Rate and Lack of Manpower 1. Changing people 2. Shortage of expertise in EHRS implementation 3. Lack of training 4. Logistical Issue 4. Scale of the project 5. Timeframe for implementing EHRS in PHCs 6. Geographical challenges 7. Technologically Challenged 7. Inadequate infrastructure and lack of connectivity 8. Software selection 9. Lack of EHRS interoperability 10. Overcoming barriers 10. Continuous Development 11. Compartmentalization 12. Piloting the system 13. Cooperation with TelCo Theme one: Turnover Rate and Lack of Manpower Changing people Projects to deploy EHRS are negatively affected by personnel changes, particularly those involving politicians or top administrators. Every incoming minister brings a fresh plan that completely eradicates all past efforts, including both planned and implemented strategies. Modifications extended beyond plans and tactics, encompassing the alteration of administrative personnel and decision-makers. “Every minister cancels the previous plan and develops new plans and strategies.” (GM 2) “Unfortunately, we have a problem in SA in that new ministers remove the plans and decisions of the former minister.” (DHD 1). As a result of these modifications, obstacles and interruptions have negatively impacted the progress of numerous EHRS installation initiatives. “Some obstructions, delays and execution of works are also affected by constant changes that happen in the Ministry, including replacement of the Minister and some seniors in the MoH.” (GM 1) “Unfortunately, frequent changes at the ministerial level and the subsequent changes at the departmental level had a negative effect on the completion of the projects.” ( GM 2) The ramifications of these alterations encompass not only the prolongation and disturbances to the projects, but also the cessation of ongoing projects (such as the adoption of EHRS in Primary Health Centers in South Africa). “Unfortunately, with new seniors and a new Minister, the work on the current project stopped.” (HD 3) Likewise, alterations in the personnel composition of Primary Health Centers (PHCs) were discovered to have an adverse effect on the adoption of Electronic Health Record Systems (EHRS), specifically in regards to the delivery of training. “Another problem that has been encountered is that of staff change. Many times, after three or four months of training one employee, another employee comes instead of that one.” (SD1) Shortage of expertise in EHRS implementation The Ministry of Health in Saudi Arabia faces a deficiency of skilled personnel, including IT technologists and health informatics professionals. “One of biggest challenges is finding talented people in specific areas, especially in SA.” (GM1) “Finding efficiencies is a very difficult task; we also have a very big problem with labour availability.” (HD1) Lack of training The Saudi Ministry of Health (MoH) encounters the additional obstacle of training, specifically in relation to the utilization and execution of Electronic Health Record Systems (EHRS) at Primary Health Care Centers (PHCs). A significant proportion of the survey participants concurred that training posed a substantial obstacle to the implementation of Electronic Health Record Systems (EHRS). As an illustration: “The lack of training is among the problems.” (HD 1) “Of the main obstacles is training.” (Analyst 1) Theme two: Logistical Issue Scale of the project The abundance of Primary Health Centers (PHCs) is a significant hindrance to the successful implementation of Electronic Health Record Systems (EHRS). The magnitude of the project has a detrimental impact on the provision of training and technical assistance. “The biggest problem is how to install the EHRS into more than 2,000 PHCs, so it is a huge issue because it is equally important as the hospitals.” (Analyst 3) “The main obstacles are training and technical support in particular; with regards to the PHCs, problems arise due to the large number of the PHCs.” (Analyst 1) Timeframe for implementing EHRS in PHCs The project team encountered the difficulty of time constraints when implementing a large-scale project, as such projects necessitate a greater amount of time and have the potential to result in delays. “Our problems are often associated with time, as the implementation of such large projects requires a lot of time.” (HD3) Geographical challenges The Saudi Ministry of Health considers the size and geographical characteristics of Saudi Arabia to be a significant problem. “The geographical nature of the Kingdom is considered to be a big challenge to EHRS implementation.” (HD 3) The geographical distribution of certain PHCs poses a significant challenge to the introduction of EHRS across the Kingdom. Especially those situated in rural or isolated regions. “The most influential obstacles to the MoH are PHCs which are located in remote areas.” (GM 3) Theme three: Technologically Challenged Inadequate infrastructure and lack of connectivity The aforementioned geographical challenges are directly correlated with infrastructure. Therefore, the establishment of infrastructure and the establishment of connectivity are two significant obstacles to the introduction of EHRS in PHCs in Saudi Arabia. The Saudi MoH considers the issue of connectivity between PHCs to be a challenging problem, which has resulted in the postponement of numerous projects. The absence of connectivity among PHCs is a consequence of inadequate infrastructure. “Also, we faced other difficulties related to the infrastructure such as connectivity, especially with PHCs in remote areas.” (GM 1) “The technical side is a very important factor regarding the development of the infrastructure and networks, it is possible to choose the best system in the world, but when it comes to implementation, the surprise is that the infrastructure may not be suitable for implementation.” (Analyst 1) Establishing a suitable infrastructure might incur significant costs, particularly due to the utilization of rented facilities for certain PHCs that are not conducive to IT initiatives. “Infrastructure involves a very expensive process of communication between the health centres, especially since some of the PHCs are in rented buildings.” (GM 3) Another infrastructure-related obstacle is that not all PHCs have computers and other necessary devices. “Lack of computers is one of the obstacles we faced at the beginning, especially in non-developed PHCs.” (Analyst 2) Software selection Another obstacle to implementing EHRS in Saudi PHCs is the absence of a suitable EHRS that aligns with the project team's goals and aspirations. Most of the EHRS offered to the Saudi MoH, especially those from outside the country, do not align with the features and operations of primary healthcare facilities in SA. “We also face a big challenge, we cannot find either a local or global EHRS that meets the requirements of PHCs in SA, and the most important reason is that there are not many options for PHCs because all global companies focus on hospitals and making systems that fit into hospitals.” (HD 3) The characteristics of PHC facilities in South Africa differ from those in other nations including the United Kingdom, United States, and Australia. The disparities have impeded the process of choosing software because there is a scarcity of a supremely effective and internationally renowned EHRS that aligns with the existing functionalities of PHCs in SA. “…and what made it even more difficult is the differences in the characteristics of PHCs and business workflow in SA compared to that of large countries such as America, Britain and Australia. They apply so-called ‘GPs’ rather than PHCs.” (HD 3) “We did not find an EHRS that is compatible with the workflow of the PHCs in SA.” (GM 3) Vendor selection is a hindrance to the implementation of EHRS due to many factors, such as suppliers' inefficiency, price escalation, and lack of adequate experience in the Saudi healthcare system. These three criteria hinder the identification of appropriate vendors for EHRS installation initiatives. The project team hesitated to make a conclusion in this area due to a deficiency in experience. In addition, inflated costs posed a challenge for the Saudi MoH in pursuing an arrangement with vendors. Some vendors could not meet the project team's ambitions at the MoH, as evidenced by the quotations below: “International companies have never implemented EHRS Saudi PHCs; this has made us hesitant to select international companies.” (GM 3) “The main obstacles are contracting with a qualified vendor.” (SD 1) Lack of EHRS interoperability The lack of interoperability in EHRS has been identified as a significant obstacle to the successful adoption of EHRS programs in primary healthcare centers in SA. “One of the big challenges here is EHRS interoperability.” (Analyst 3) “We should take EHRS interoperability issues seriously.” (SD 1) Theme four: Overcoming barriers The Saudi MoH has implemented several measures to overcome the aforementioned obstacles and improve the effectiveness of EHRS implementation. Measures taken to address the aforementioned barriers and difficulties involve establishing the essential infrastructure and protocols, carrying out extensive research and studies, collaborating with Telecommunication Companies (TCs), engaging multiple vendors, dividing the Kingdom into distinct regions, and actively involving all relevant stakeholders. Continuous Development The Saudi MoH successfully addressed difficulties and problems in implementing EHRS by focusing on developing the existing infrastructure, standards, and other technical factors. “The key success, of course, is the development of standards and infrastructure.” (Analyst 3) The MoH also intends to enhance the current EHRS to align with the goals of the MoH and meet the needs of its users. “The Ministry is currently studying the possibility of the development of the previous EHRS to be generalised and implemented in all PHCs.” (HD 1) Compartmentalization Due to its extensive scope, the implementation of the EHRS in PHCs is highly complex. To address this challenge, the MoH has implemented a strategy to divide the country into five zones. As part of this strategy, a data center will be established in each of these regions. Through these data centers, all PHCs and hospitals within each region will be interconnected. “As I mentioned to you earlier, the plan was to set up a data centre in each region after the division of the Kingdom into five regions (zones), to link the PHCs with these data centres, and then connect the PHCs with the hospitals.” (HD 3) “We divided the Kingdom into five zones; each zone will have one data centre.” (GM 1) Multiple vendors will be chosen to implement the EHRS in order to decrease the burden and minimize the risks. “We will be contracting with at least three providers to reduces the pressure on the provider. If it is one vendor, the number to cope with is huge, and one company alone cannot implement the EHRS in all PHCs in SA.” (GM 1) Piloting the system The Saudi MoH will conduct a trial of the chosen system by introducing the EHRS in a limited number of PHCs. Subsequently, the MoH will assess the system to identify any potential usability or technical difficulties before proceeding with the real installation. “First, we will select a system and try to implement it in some PHCs for the evaluation of several aspects to measure the system’s usability and determine any problems; then we will collect and analyse the problems and solve them. We will work on this more than once until we achieve 100% user satisfaction.” (GM 3) Cooperation with TelCo Collaborating with communications and information technology firms is another potential strategy that could help overcome the constraints. The Saudi MoH has entered into agreements with multiple communication and IT firms. The objective of this collaboration is to address the geographical issues and accompanying obstacles related to infrastructure. “The geographical challenges will be addressed through co-ordination with the TCs and connection to the Internet for all PHCs; then linking them to the data centres in each region.” (HD 1) “Working in co-ordination with the TCs on the development of infrastructure.” (Analyst 1) Questionnaire results Data from the questionnaire were gathered from 351 participants in five distinct locations of the Kingdom of Saudi Arabia. Out of all the respondents, the highest number, 103 (29.3%), lived in the capital city, Riyadh (refer to Table 4 ). All participants were employed in healthcare and administrative positions. Table 4 , displays the distribution of job roles among the participants. Out of the total, 149 individuals (42.4%) held administrative positions, such as managers, secretaries, and receptionists. 104 participants (29.6%) worked in nursing roles, while 32 (9.1%) were physicians and 30 (8.5%) were pharmacists. Four individuals, accounting for 1.1% of the total, did not disclose their occupation. Age was quantified using six distinct categories, as depicted in Table 4 . Out of the total participants, 192 individuals, accounting for 54.7% of the sample, fell between the age range of twenty-five to thirty-four years. Table 4 provides a comprehensive analysis of the age groups. Four individuals, accounting for 1.1% of the total, did not disclose their age. Participants were additionally requested to indicate their gender. The majority of participants were male, with a total of 261 individuals, accounting for 74.4% of the sample. Among the 351 participants, the number of females was only eighty-one, accounting for 23.1% of the total. Nine individuals, accounting for 2.6% of the total, did not disclose their gender. The participants' usage of a personal computer at home exhibited variation, with the majority of participants (36.8%) reporting experience spanning from ten to fifteen years. Table 5 shows that a mere eighteen participants, accounting for only 5.1% of the total, had less than one year of experience using a personal computer. Four participants, accounting for 1.1% of the total, did not disclose their level of experience in using a personal computer at home. The duration of the participants' engagement in their present work position was assessed using five distinct categories. Out of all the participants, a majority of 105 individuals, accounting for 29.9% of the total, had a professional experience ranging from one to five years. Table 4 provides a comprehensive analysis of the amount of time participants have spent in their current position. Five participants, or 1.4% of the total, did not disclose their level of experience in using a personal computer at home [ 49 ]. Table 5 Participant demographic distribution Geographical location Experience with using a personal computer Region Frequency Percent Length of experience Frequency Percent Riyadh 103 29.3 Less than 1 year 18 5.1 Gassim 61 17.4 1 to 5 years 29 8.3 Aljouf 69 19.7 5 to 10 years 109 31.1 Albaha 30 8.5 10–15 years 129 36.8 Makkah 88 25.1 More than 20 years 62 17.7 Total 351 100.0 Total 347 98.9 Occupation Age Occupation Frequency Percent Age Group Frequency Percent Administrator 149 42.4 18 to 24 3 .9 Physician 32 9.1 25 to 34 192 54.7 Nurse 104 29.6 35 to 44 123 35.0 Lab technician 11 3.1 45 to 54 23 6.6 Pharmacist 30 8.5 55 to 64 4 1.1 Radiologist 9 2.6 65 to 74 2 .6 Dentist 12 3.4 Total 347 98.9 Total 347 98.9 Experience in their current position No. % Less than 1 year 19 5.4% 1 to 5 years 105 29.9% 5 to 10 years 100 28.5% 10 to 15 years 82 23.4% More than 20 years 40 11.4% Total 346 98.6% Negative attitudes toward the EHRS: Table 4 includes elements that indicate several characteristics that impact the deployment of EHRS, such as user engagement and system effectiveness. These factors were determined based on the replies to seven questions on the negative attitude scale. The negative attitude scale collects participant responses to items that describe issues affecting the implementation of EHRS, such as the involvement of EHRS end-users. Consequently, the utmost level of support was generated for user engagement.: 1) “ End-users should have been considered in the system design ” (85.8%). The second level of agreement was generated for 2) “ It takes too much time to help others who don’t know how to use the system” (63.4%). However, lower agreement was generated for items: 5) “ Using EHRS raises stress levels among practitioners ” (12.8%); 6) “ The system makes me feel like I am no longer functioning as part of a team ” (12.3%); and 7) “ The EHR system is considered to be an extra load at work ” (9.7%) [ 49 ]. Table 4 Negative attitudes toward the implementation of EHRS Items Strongly Disagree Disagree Neutral Agree Strongly Agree Median Total agreement Rank End-users should have been considered in the system design N 2 6 21 56 120 5 176 1 % 1.0 2.9 10.2 27.3 58.5 85.8 It takes too much time to help others who don’t know how to use the system N 9 29 37 87 43 4 130 2 % 4.4 14.1 18.0 42.4 21.0 63.4 I am aware that problems with the EHR system have a direct impact on patient care N 16 36 27 78 48 4 126 3 % 7.8 17.6 13.2 38.0 23.4 61.4 Using the EHR system takes longer than the paper-based system N 75 81 13 18 18 2 36 4 % 36.6 39.5 6.3 8.8 8.8 17.6 Using EHRS raises stress levels among practitioners N 94 65 18 19 7 2 26 5 % 46.3 32.0 8.9 9.4 3.4 12.8 The system makes me feel like I am no longer functioning as part of a team N 73 85 21 15 10 2 25 6 % 35.8 41.7 10.3 7.4 4.9 12.3 The EHRS is considered to be an extra load at work N 99 66 20 13 7 2 20 7 % 48.3 32.2 9.8 6.3 3.4 9.7 Barriers to EHRS implementation As seen in Table 5 certain elements are perceived as less inhibitory compared to others. The question that received the least amount of positive endorsement were: 1) “ Lack of training ” (83.8%); 2) “ Inadequate infrastructure and the absence of connectivity ” (78.5%); 3) “ Lack of technical support ” (75.5%) and ;4) “ The absence of end-user involvement in EHR implementation and software design ” (74.6%). The items that were given the highest level of positive endorsement and reflected lesser barriers were: 13) “ The time spent using the EHR system ” (34%); 14) “ Confidentiality and privacy concerns ” (28.3%); 15) “ Concerns about loss of personal attention given to patients as entering patient information into the computer ” (28.3%) and; 16) “ Concern about a decrease in productivity during the use of the EHR system ” (25.4%). As seen in the below table, all listed items in the barrier scale were considered to be major or minor barriers [ 49 ]. Table 5 Barriers to implementation of EHRS in the PHCs Items Not a barrier Minor barrier Major barrier Median Rank Lack of training N 4 29 171 3 1 % 2.0 14.2 83.8 Inadequate infrastructure and the absence of connectivity N 4 40 161 3 2 % 2.0 19.5 78.5 Lack of technical support N 7 43 154 3 3 % 3.4 21.1 75.5 The absence of end-user involvement in the EHR system implementation and software design N 9 43 153 3 4 % 4.4 21.0 74.6 Ignoring end-user feedback and issue reports N 9 44 152 3 5 % 4.4 21.5 74.1 The lack of awareness of end-user requirements N 14 73 118 3 6 % 6.8 35.6 57.6 Difficulties using the system N 31 93 80 2 7 % 15.2 45.6 39.2 Inadequate resources and materials within the centre N 12 113 79 2 8 % 5.9 55.4 38.7 Lack of computer literacy N 25 103 77 2 9 % 12.2 50.2 37.6 Lack of perceived EHR system usefulness N 37 92 76 2 10 % 18.0 44.9 37.1 Lack of awareness of EHRS N 32 99 74 2 11 % 15.6 48.3 36.1 Resistance to new technology N 29 105 71 2 12 % 14.1 51.2 34.6 The time spent using the EHR system N 36 98 69 2 13 % 17.7 48.3 34.0 Confidentiality and privacy concerns N 51 96 58 2 14 % 24.9 46.8 28.3 Concerns about loss of personal attention given to patients as entering patient information into the computer N 45 102 58 2 15 % 22.0 49.8 28.3 Concern about a decrease in productivity during the use of the EHR system N 38 115 52 2 16 % 18.5 56.1 25.4 The association between the key scales was determined using a Spearman's correlation test. The association analysis revealed a significant negative correlation between impediments and a negative attitude towards the installation of EHRS (see Table 6 ). Nevertheless, all notable relationships are regarded as feeble. However, neither the Mann-Whitney U test nor the Kruskal Wallis test identified any significant differences between the groups (see Appendix S1). Table 6 Spearman’s correlation coefficient for correlations between barriers and negative attitude. Barriers Negative Attitude Barriers Correlation Coefficient 1.000 − .176 * Sig. (2-tailed) . .012 Negative Attitude Correlation Coefficient − .176 * 1.000 Sig. (2-tailed) .012 . Discussion Only 150 out of 2259 PHCs have successfully implemented an EHRS. However, the project has failed due to several impediments and challenges. Hence, it is worthwhile to delve into the underlying factors contributing to this failure. The identification of barriers was predicated on the Saudi Ministry of Health's prior and forthcoming project experience. Data regarding the obstacles to the implementation of EHRS were gathered through research that involved the use of questionnaires and semi-structured interviews. This research was conducted with two distinct groups: the project team responsible for the implementation, and the end-users of EHRS. The investigation revealed a conspicuous observation: the number of obstacles to implementing a widespread EHRS outweighed the number of factors that aided its deployment. As a result, there are certain obstacles that are specific to this project, such as its extensive magnitude. Additional obstacles that were identified include individual resistance to change, insufficient training, inadequate technical assistance, limited compatibility between systems, geographical limitations, software selection issues, and insufficient user engagement. Even though the PHCs' requirements, including size, were supposed to be a facilitator, this study is one of the few that has found that establishing a large-scale EHRS is a big hassle. In order to surmount this obstacle, it has been proposed that these extensive endeavors should be subdivided into more manageable undertakings. To streamline project management, the implementation of the EHRS should be carried out in various locations and at varied time intervals. Furthermore, it is advisable to establish agreements with many vendors in order to mitigate the risk of project failure caused by factors such as a vendor's incapacity to successfully execute a large-scale EHRS project while ensuring system compatibility and meeting specific requirements. The study results align with the findings of Ludwick and Doucette [ 36 ], and Lennon, Bouamrane [ 40 ], who also discovered that industrialized nations like the UK had a scarcity of specialists throughout the adoption of EHRS. Therefore, the lack of specialists is regarded as an obstacle for both developed and emerging nations. Nonetheless, our research strongly advocates for the recruitment of proficient professionals in Health Informatics (HI) and Information Technology (IT) from external organizations or other nations, particularly when considering the implementation of extensive EHRS. The presence of proficient individuals in the fields of Health Informatics (HI) and IT might serve as an indicator of a healthcare organization's preparedness for implementing new EHRS. An other intriguing discovery was the obstacle created by the turnover of executives and team members in the project team, namely those who held crucial roles. This impediment may present a more significant risk to large-scale initiatives that have implemented Centralized Management (CM), which can be characterized as the distinctiveness of a small group in making critical choices. Nevertheless, the replacement of executives or other policy makers has also been recognized as an obstacle in small enterprises [ 17 ]. While CM was observed to have a highly favorable effect on EHRS deployment, it could also have adverse consequences. Modifications in the executive and leadership hierarchy frequently result in subsequent alterations to previously implemented policies and plans, potentially resulting in project postponement or even collapse. Both technical support and training were identified as hindrances. Furthermore, the research revealed a detrimental correlation between the magnitude of the project and the availability of training and technical assistance. While training and technical assistance have been identified as obstacles in small initiatives [e.g. 50, 51], they can pose even greater challenges in large-scale projects. 83.8% of EHRS end-users saw lack of training as a significant obstacle, while 75.5% identified lack of technical support as a serious hindrance. A study conducted in primary healthcare centers (PHCs) in the United States found that fewer than 50% of the staff considered their training to be sufficient (Singh et al., 2013). The satisfaction level with the training provided to EHRS end users in SA is inconsistent. Alasmary, El Metwally [ 52 ] conducted a study in Saudi Arabia to investigate the effect of training on end-user satisfaction with electronic health record systems (EHRS) in secondary care. The results indicated that the end-users expressed satisfaction with the training they received. Nevertheless, additional research conducted in secondary healthcare settings in South Africa uncovered that users of electronic health record systems (EHRS) reported discontentment with the training and technical assistance provided [ 53 , 54 ]. The most significant result from this study's analysis is the correlation between the absence of technical support and the failure of the EHRS that were introduced in the Saudi PHCs. Moreover, the findings of this study demonstrated that problems related to training and technical assistance can have a detrimental impact on the acceptance of EHRS by end-users. These findings are consistent with the results of other research conducted in SA such as studies [e.g. 53, 54]. Nevertheless, these two trials were carried out in a secondary care setting. Conversely, prior studies have discovered that technological support had a role in enabling the introduction of EHRS [ 55 , 56 ]. However, Heyworth, Zhang [ 57 ] argued that there was no correlation between the provision of technical support and end-user satisfaction. Nevertheless, Heyworth and Zhang [ 56 ] contended that there was no discernible association between the provision of technical help and the level of pleasure experienced by end-users. An inverse relationship was observed between geographical obstacles, inadequate infrastructure, and absence of connectivity. The presence of this negative connection was identified as a primary factor contributing to the unsuccessful implementation of the previously utilized EHRS. This is attributed to the variations in topography among the several parts of the Kingdom, along with the vast expanse of the country. The results indicated that the primary healthcare centers that were most impacted were those situated in remote and rural regions. Within this particular context, the research findings indicate that the task of ensuring continuous connectivity among Primary Health Centers (PHCs) is perceived as difficult due to factors such as challenging terrain, inadequate infrastructure, and the positioning of certain PHCs. These findings are consistent with previously published research, who also identified inadequate infrastructure in remote and rural regions [ 40 , 58 – 60 ]. Our research, along with other related studies, indicates that infrastructural challenges pose a significant risk to the success of projects implementing Electronic Health Record Systems (EHRS), especially in developing countries [ 60 – 64 ]. Hence, it is imperative to incorporate infrastructure development at both the planning and pre-implementation stages, as stated in the literature. In order to address the obstacles posed by geographical factors and provide universal access for all primary healthcare centers (PHCs), our research strongly advises collaborating with other entities, such as local telecoms companies, who can assume the responsibility of providing telecommunications and information technology services. The resolution of issues in this domain necessitates the collaborative efforts of all parties involved and cannot be achieved through unilateral actions. This technology has the potential to aid in the development of suitable infrastructure that enables the connecting of all Primary Health Centers (PHCs) in South Africa. Furthermore, this connectivity will also facilitate the resolution of other obstacles, such as technical assistance. Earlier studies have also revealed alternative approaches for addressing such geographical obstacles. For example, the utilization of mobile phone connections in situations where the technological infrastructure is insufficient or non-existent [ 65 , 66 ]. One additional technological challenge identified in this research was the absence of interoperability among EHRS. This issue has also been highlighted in prior studies. [ 27 , 28 , 60 – 62 , 67 , 68 ]. The complexity of EHRS interoperability difficulties may be exacerbated in large-scale projects, owing to the multitude of EHRS systems involved. As previously stated in this study, the EHRS in PHCs in SA will be implemented by three distinct suppliers. The presence of multiple elements may result in interoperability challenges that impede the project's success. Hence, as depicted in the literature, the problems related to EHRS interoperability can be prevented by taking them into account throughout the software selection process and other preparatory steps before implementation, including as planning and readiness assessments. [ 14 , 54 ]. By standardizing software selection criteria, healthcare companies may tackle interoperability issues and ensure system compatibility. The MoH is selecting three vendors, so CM implements standardized systems to ensure interoperability. When the project is competitive, a Request for Proposal (RFP) must be issued to potential vendors during the pre-implementation phase. EHRS implementation research shows that this standard facilitates technical communication between two or more systems [ 69 , 70 ]. Furthermore, previous study has discovered that commercial EHRS provide the advantageous quality of flexibility, allowing for seamless integration with other systems. [ 30 ]. An interesting finding from this study is that PHCs in SA differ in process and structure from those in the UK, US, and Australia. These differences hinder global system selection. Most international EHRS are designed to fit current workflows. The findings showed a link between PHC process and software choice. Thus, firms with unique workflows must reform or build their own systems. Limitation and recommendation for future work Initially, the data gathering tool used in this study did not incorporate items to assess the accessibility of professionals who could facilitate the achievement of the EHRS deployment, particularly for extensive undertakings. Hence, it is advisable for future researchers to include additional elements in order to evaluate the preparedness of healthcare organizations in terms of the availability of highly skilled health informatics experts. Furthermore, this study did not analyze the notable disparity between rural and urban PHCs. Identifying the rural and urban PHCs proved to be challenging. Conclusion This study is the first to examine a wide range of obstacles to implementing large-scale EHRS in PHCs. Hence, this study offers multiple suggestions to decision-makers and the entire EHRS implementation project team to streamline the deployment of a comprehensive EHRS on a broad scale. Policymakers should allocate adequate funding to ensure seamless implementation, especially when making decisions related to software selection. The study identified training and support as a significant obstacle, whereas confidentiality and privacy were deemed to be less problematic in the introduction of EHRS. Upon analyzing the factors that could potentially affect EHRS end-user satisfaction, it was found that demographic characteristics, except for participants' occupation, did not have a significant influence on EHRS end-user attitudes and satisfaction regarding the implementation and utilization of the system. The assessment indicated that it was implemented in 150 PHCs and was regarded as a pilot for the preceding initiative. The assessment also uncovered that the primary factors contributing to the previous project's failure were insufficient connectivity, inadequate technical assistance, and personnel turnover, notably among high-ranking positions within the Saudi Ministry of Health. Abbreviations EHRS Electronic Health Record System PHC Primary Health Care MoH Ministry of Health SA Saudi Arabia GM General Manager HD Head of Department DHD Deputy Head of Department SD Software Developer DA Data Analyst FR Financial Recourses SPSS Statistical Package for the Social Sciences Declarations Ethical approval and consent to participate All methods in this study were performed in accordance with the declaration of Helsinki and was approved by the Institutional Review Board (IRB) of King Fahad Medical City (KFMC) at the Saudi MoH (IRB Log No. 14-189E). All the participants provided informed consent to participate. In the case of the questionnaire-based study, all participants were informed of the voluntary nature, confidentiality, and aim of the study and the nature of their participation before they participated in the study. For the interview purposes, all participants provided written informed consent prior to enrolment in the study. Consent for publication Not applicable as no identifiable information is published in this manuscript. Availability of data and material (ADM) The datasets generated and/or analysed during the current study are not publicly available due copyright and ownership. All primary data collected for this research belong to the researchers. The dataset includes other data that will be used for another manuscript but are available from the corresponding author on reasonable request. Acknowledgements Researchers would like to thank the Deanship of Scientific Research, Qassim University for funding publication of this project. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4461961","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":319152746,"identity":"5ed8dcbb-b9da-4f20-991c-7acf0c318486","order_by":0,"name":"Haitham Alzghaibi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBACAwbmBgbGBgYeA2bmY2ARNnaCWhhhWtjSGBgSgFqYidQCZPCYgbUwENJizn6w+ePXHXYy5uw83x58/LFNno+ZgfHDxxzcWix7EhuMZc8k81g28243nJFw27CNmYFZcuY2PA47kNiQLNnGzGNwmHebNE/CbUagFjZmXnxazj9sOCzZVg/UwvMMpMWesJYbiY2NH9sOg7SwgbQkEqHlYTMzY9txoF/YzCRnpN1ObmNmbMbvl/PJhz/+bKu2N+c//Ezig81t2/ntzQc/fMSjBQSYeVD5oGgiABh/EFQyCkbBKBgFIxoAAHeWTh1EbFHCAAAAAElFTkSuQmCC","orcid":"","institution":"Qassim University","correspondingAuthor":true,"prefix":"","firstName":"Haitham","middleName":"","lastName":"Alzghaibi","suffix":""},{"id":319152747,"identity":"1b4febff-4fc0-4ce0-861b-226adcc32664","order_by":1,"name":"Hayley A. Hutchings","email":"","orcid":"","institution":"Swansea University","correspondingAuthor":false,"prefix":"","firstName":"Hayley","middleName":"A.","lastName":"Hutchings","suffix":""}],"badges":[],"createdAt":"2024-05-22 15:30:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4461961/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4461961/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67092676,"identity":"d0bff1d3-f88a-4ca7-b383-5af329634106","added_by":"auto","created_at":"2024-10-21 07:02:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1017392,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4461961/v1/3c45f73e-f85c-46b3-84c7-02ce33bb3ac8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers to the implementation of large-scale electronic health record systems in Primary Healthcare centers","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInformation Technology (IT) has played a crucial role in enhancing and improving healthcare services since the 1960s [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e–\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The IT in the final decades of the 20th century has completely transformed the methods of classifying and recording information. The rapid and accurate implementation of the IT revolution prompted the governments of industrialized countries (where this revolution originated) to promptly embrace these sophisticated, swift, and effective technologies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Consequently, the use of EHRS has gained significant importance in both developed and developing nations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral academics have contended that the deployment of EHRS is highly intricate as a result of the scarcity of implementation expertise and the related challenges. [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although, the barriers to EHRS implementation have been described, many of them remain unresolved [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, it has been suggested that further research and investigation is necessary to overcome these barriers [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Around 50% of EHRS implementation projects around the world have failed or fail to be properly implemented [\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Other studies have approximated that the percentage of failing IT initiatives in the hospital sector may reach up to 70%. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In addition, The introduction of Electronic Health Record Systems (EHRS) in Primary Healthcare Centres (PHCs) poses a more significant barrier compared to its implementation in secondary care settings, such as hospitals [\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e–\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Urban hospitals exhibit a higher propensity to use EHRs in comparison to rural hospitals and PHCs [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e–\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, according to Xierali, Phillips [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and Wittie, Ngo-Metzger [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], electronic health record systems are more commonly adopted in affluent communities as opposed to lower-income areas.\u003c/p\u003e \u003cp\u003eInformation regarding the utility and advantages of EHRS, along with the expenses associated with implementation and other obstacles, is limited in developing nations [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Although study on the effects of EHRS and its potential advantages has been carried out in industrialized nations, there is still conflicting information regarding the system's influence [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Furthermore, the implementation process in poor nations necessitates more extensive exertion compared to developed countries, due to the inferior preparedness of healthcare organizations in terms of IT and infrastructure [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main barriers identified in previous studies include insufficient technical support, and decreased productivity [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], user resistance, interoperability issues, high implementation cost [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], inadequate training, lack of awareness regarding the importance of EHRS, usability issues, concerns about patient privacy and confidentiality, unsuitable hardware [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and finally privacy, confidentiality and security issues [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe impact of system usability on EHRS implementation has been recognized [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e–\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Usability concerns can limit the use of information technology in healthcare organizations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR32 CR33 CR34\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e–\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Conversely, studies have shown that there is a direct correlation between system usability and adoption rate. A higher level of system usability leads to an increased adoption rate [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Furthermore, according to Khajouei, Wierenga [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], and Gagnon, Payne-Gagnon [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], the usability of EHRS is a key determinant of end-user satisfaction with the system. Finally, unsuccessful interoperability can arise from the misconnection or discoordination between healthcare providers from different organizations, as these organizations employ different standards [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37 CR38 CR39 CR40 CR41\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e–\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy Aim\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eTo discover the hurdles that influence the effectiveness of the deployment of the EHRS in the PHCs in SA\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eResearch design and data collection\u003c/p\u003e\u003cp\u003eThe study employed a mixed methods approach, namely an exploratory sequential design, which involved conducting qualitative semi-structured interviews and a quantitative close-ended survey [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The initial semi-structured interviews were conducted to investigate and identify potential obstacles that could impact the deployment of EHRS. The information gathered from these interviews was then utilized to develop a more targeted questionnaire for the quantitative survey study. In order to accomplish the objective of this study, we considered the primary elements that influence the deployment of Electronic Health Record Systems (EHRS) as identified in prior research. These aspects were taken into consideration when developing the questionnaire, as well as the insights gained from the semi-structured interviews. The data collection instruments utilized in this investigation, both qualitative and quantitative, were previously created and employed by Alzghaibi and Hutchings [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudy questionnaire validity and radiality\u003c/p\u003e\u003cp\u003eWe performed multiple initial procedures to evaluate and, if needed, enhance the questionnaire. The questionnaire was developed in two phases. The initial instrument underwent evaluation by a panel comprising external specialists, including: two information technology experts from the central office of the Saudi Ministry of Health, the directors of the information technology departments of two distinct hospitals, one scholar from King Saudi University (holding a doctorate in Health Informatics), one radiologist, and one pharmacist (holding a master's degree in Health Informatics).\u003c/p\u003e\u003cp\u003eAfter undergoing a review and receiving input from expert panels, the questionnaire was administered as a pilot study to a small group (n = 5) of the project team. This was done to verify the clarity, comprehensibility, and reliability of the questionnaire. The data collection questionnaire was tested at the Saudi Ministry of Health's main office with project team members who willingly consented to participate. Various factors were considered, including distinct position tiers (e.g. supervisors, directors, and senior managers), diverse divisions, and varied ethnicities.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e demonstrates that the dependability of all scales is satisfactory. The obstacles scale exhibits the highest level of dependability, with a coefficient of 0.83, followed by negative attitudes with a coefficient of 0.70. The overall reliability of the data collection device in the study is high, with a coefficient of .81.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCronbach’s Alpha Test\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eScale\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Items\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCronbach’s Alpha\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNegative attitude\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBarriers\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEntire questionnaire\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.81\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eThe qualitative data were analyzed using a thematic analysis technique with the assistance of NVivo10 software developed by QSRInternational.com. The quantitative data were subjected to statistical analysis using IBM SPSS V.22. At first, descriptive statistics were conducted utilizing measures such as the median, rank, and overall agreement. Subsequently, non-parametric tests were employed to ascertain the presence of any disparities among the groups. Specifically, the Mann-Whitney U test was utilized for comparisons involving two groups, while the Kruskal-Wallis test was employed for comparisons involving three or more groups.\u003c/p\u003e\u003cp\u003ePopulation and sampling\u003c/p\u003e\u003cp\u003eIn order to select the most suitable participants for this study, who were actively involved in the project execution and possessed information about the deployment of Electronic Health Record Systems (EHRS) in Primary Health Care (PHC) centers in South Africa, a non-probability, purposive, snowball sampling method was employed [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. In order to gather qualitative data, all 53 members of the project team were invited to participate in semi-structured interviews. However, only 14 individuals agreed to take part. The quantitative analysis employed a multi-stage cluster sampling technique [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Thus, in Stage One, we employed the same categorization as the Saudi Ministry of Health, where areas were transformed into clusters [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. For the second phase, a method called simple random sampling was employed, which involved selecting participants based on the geographical location of each province [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. During Stage Three, a sample of 21 PHCs was picked randomly from a total of 2259 PHCs among the five specified clusters. The sample (n = 491) was picked from 21 specific centers, spanning across five designated areas. The utilization of the multi-stage cluster sampling technique has been proven to be highly beneficial for conducting statewide studies and surveys with bigger populations. In addition, multi-stage cluster sampling helps to address the difficulties associated with random sampling [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eData collection process\u003c/p\u003e\u003cp\u003eQualitative\u003c/p\u003e\u003cp\u003eFourteen semi-structured interviews were conducted with the chosen participants. The interviews were carried out within a span of two months. We allocated a maximum of two hours for each interview, but there were no restrictions on the duration of the session. The participants were notified that they had the option to terminate the interview at any given moment. Furthermore, to provide maximum convenience for the interviewees, I personally visited the participants' locations to conduct the interviews.\u003c/p\u003e\u003cp\u003e In order to optimize the participants' time, I diligently prepared for the interviews ahead of time and ensured the provision of a concise and meticulously structured interview guide. I obtained consent to record the interviews and ensured that the recording devices were well charged and had ample storage capacity for the interviews. Furthermore, cell phones were set to airplane mode to preempt any phone calls or other notifications from disrupting the interviews. I came at least thirty minutes before the scheduled interview to ensure the suitability of the interview venue. All interviews, save for one, were done at the same place.\u003c/p\u003e\u003cp\u003e All participants were administered identical questions, adhering to the criteria for conducting interviews. The interviews were recorded digitally using an iPad and an iPhone. Field notes were recorded during the interview to prevent any disruption caused by the emergence of additional questions. This enabled me to produce additional inquiries to address any omissions and also to elucidate any remarks given. This feature also provided adaptability during the interview and facilitated the interviewer in recognizing any remarks that might prompt additional inquiries and areas of investigation. Furthermore, the interviewer made field notes during the interview to document nonverbal cues and participants' responses that may not have been discernible in the audio recording.\u003c/p\u003e\u003cp\u003eThe interview commenced with a self-introduction and a concise overview of the research's essence. Subsequently, we elucidated the rationale behind the participant's invitation to participate. Prior to commencing the interview and posing inquiries, we allocated a enough amount of time for the participants to peruse the consent document. We obtained explicit confirmation from the participants regarding their willingness to participate in the study and thereafter requested their signature on the consent form. Following each interview, participants were explicitly urged to voice any comments or concerns that were not discussed during the interview. The duration of the interviews ranged from 35 to 130 minutes, with an average duration of approximately 65 minutes [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eQuantitative\u003c/p\u003e\u003cp\u003eAfter the completion of the data gathering instrument, I began contemplating the most suitable approach to disseminate it. The initial concern were around enhancing the response rate and motivating individuals to actively engage in this study. Initially, we opted for the electronic questionnaire due to its proven efficacy in evaluating the preparedness of many PHCs in comparison to alternative methods like observation. In the present study, twenty-one PHCs were chosen specifically for the goal of assessing their generalizability. However, the decision on how to distribute the questionnaire for this study was determined by three primary considerations. Firstly, Saudi Arabia faces significant geographical obstacles due to its vast size. Physically disseminating a paper-based questionnaire to all the chosen PHCs was unfeasible due to the relatively insufficient postal services in South Africa. Furthermore, the study had a substantial sample size, making the utilization of a paper-based questionnaire prohibitively costly. Ultimately, due to our location in the UK, it was not feasible to physically disseminate the questionnaire. Thus, we opted to employ an online self-administered questionnaire through Survey Monkey to gather the data [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe dissemination of the questionnaire for this study took place over a duration of 10 weeks. Following the dissemination of the original questionnaire, two reminder e-mails were sent to the participants. The initial email was dispatched in the second week, while the subsequent email was transmitted in the fourth week. The official staff emails were not utilized efficiently, since most of the selected PHCs staff continued to use their personal email addresses at work, which I did not have access to. Consequently, we had a direct connection with delegates from the twenty-one chosen PHCs. Each representative received a copy of the ethical permission letter and was then invited to join a 'WhatsApp' group that I developed specifically for this purpose. Every single one of the twenty-one representatives agreed to the invitation. After all the individuals had joined the group, we distributed a singular link acquired from surveymonkey.com to the group. We instructed them to complete the questionnaire and thereafter share it with all other staff members in the chosen Primary Health Centers (PHCs) through their personal email accounts or other available communication channels, such as other WhatsApp groups.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eQualitative\u003c/p\u003e\u003cp\u003eThematic analysis was used to analyze the qualitative data obtained from the semi-structured interviews [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Thematic analysis was chosen due to its versatility and lack of limitations to a particular framework or theory. Furthermore, the choice was taken to do theme analysis to discern patterns in highly abundant information from various viewpoints [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. After concluding the interviews, I transcribed the audio recording into a textual format and subsequently saved it as a Microsoft Word document. The recordings were transcribed word for word to ensure the response context and information substance are easily understood. Hence, the data analysis commenced promptly after the transcription of the interviews, followed by their translation into English (for interviews done in Arabic). The transcripts were Microsoft Word files that were put into the NVivo program.\u003c/p\u003e\u003cp\u003eQuantitative\u003c/p\u003e\u003cp\u003eThe data were analyzed utilizing SPSS V.27. To confirm the consistency of the data collection instrument, the reliability of the study's scales was assessed using a Cronbach's alpha test. Subsequently, a descriptive analysis was used to present the data collected from the participants. This analysis involved calculating the median, percentages, total agreement, and rank. However, it is important to note that the barriers scale did not contain the measurement of total agreement. The replies were utilized to compute a cumulative agreement score for each question. The questions were graded according to the degree of consensus, ranging from the highest to the lowest. The cumulative agreement was aggregated by combining the responses of \"agree\" and \"strongly agree\" in order to discern the relative levels of agreement among different items, hence facilitating their ranking [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAfter presenting the descriptive data, inferential statistical tests were employed to examine any correlations or disparities. All tests are non-parametric and were selected due to the data being categorized as ordinal and nominal. To assess the disparities among groups, we conducted Mann-Whitney U tests for two groups and Kruskal Wallis tests for three or more groups [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFourteen individuals from the Saudi Ministry of Health's project team who were instrumental in implementing electronic health records in primary healthcare facilities consented to an in-person interview. However, a total of 351 professionals from 21 Primary Health Centers (PHCs) took part in the online survey.\u003c/p\u003e \u003cp\u003eInterview results\u003c/p\u003e \u003cp\u003eThe participants held various positions, including three General Managers (GM), three Heads of Department (GM), one Deputy Head of Department (DHD), one Software Developer (SD), and five Data Analysts (DA).\u003c/p\u003e \u003cp\u003eThis section encompasses all the themes and codes that have been established to signify the obstacles to the installation of EHRS in PHC facilities in South Africa. The participants identified multiple obstacles. In addition, many measures to overcome the obstacles that can result in the failure of implementation were documented. At first, the participants acknowledged that there are multiple obstacles to establishing EHRS in PHCs.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The obstacles are too many.\u0026rdquo;\u003c/em\u003e (SD1)\u003c/p\u003e \u003cp\u003eDuring the interviews, the participants cited numerous challenges they faced while participating in the deployment of EHRS in PHCs. The barriers to EHRS implementation encompassed various factors, including personnel turnover, a dearth of expertise in EHRS implementation, inadequate training, a high number of primary healthcare centers, limited implementation time, challenges associated with vendors, insufficient connectivity, subpar infrastructure, geographical obstacles, EHRS interoperability, software selection, and a shortage of suitable computers (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ethemes and sub-themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo of sub-themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSub-themes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTurnover Rate and Lack of Manpower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChanging people\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShortage of expertise in EHRS implementation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLack of training\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eLogistical Issue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eScale of the project\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTimeframe for implementing EHRS in PHCs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeographical challenges\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e7.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTechnologically Challenged\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInadequate infrastructure and lack of connectivity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSoftware selection\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLack of EHRS interoperability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e10.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eOvercoming barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eContinuous Development\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCompartmentalization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePiloting the system\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCooperation with TelCo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTheme one: Turnover Rate and Lack of Manpower\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eChanging people\u003c/h2\u003e \u003cp\u003eProjects to deploy EHRS are negatively affected by personnel changes, particularly those involving politicians or top administrators. Every incoming minister brings a fresh plan that completely eradicates all past efforts, including both planned and implemented strategies. Modifications extended beyond plans and tactics, encompassing the alteration of administrative personnel and decision-makers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Every minister cancels the previous plan and develops new plans and strategies.\u0026rdquo; (GM 2)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Unfortunately, we have a problem in SA in that new ministers remove the plans and decisions of the former minister.\u0026rdquo;\u003c/em\u003e (DHD 1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs a result of these modifications, obstacles and interruptions have negatively impacted the progress of numerous EHRS installation initiatives.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Some obstructions, delays and execution of works are also affected by constant changes that happen in the Ministry, including replacement of the Minister and some seniors in the MoH.\u0026rdquo;\u003c/em\u003e (GM 1)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Unfortunately, frequent changes at the ministerial level and the subsequent changes at the departmental level had a negative effect on the completion of the projects.\u0026rdquo; (\u003c/em\u003eGM 2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe ramifications of these alterations encompass not only the prolongation and disturbances to the projects, but also the cessation of ongoing projects (such as the adoption of EHRS in Primary Health Centers in South Africa).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Unfortunately, with new seniors and a new Minister, the work on the current project stopped.\u0026rdquo;\u003c/em\u003e (HD 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLikewise, alterations in the personnel composition of Primary Health Centers (PHCs) were discovered to have an adverse effect on the adoption of Electronic Health Record Systems (EHRS), specifically in regards to the delivery of training.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Another problem that has been encountered is that of staff change. Many times, after three or four months of training one employee, another employee comes instead of that one.\u0026rdquo;\u003c/em\u003e (SD1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eShortage of expertise in EHRS implementation\u003c/h2\u003e \u003cp\u003eThe Ministry of Health in Saudi Arabia faces a deficiency of skilled personnel, including IT technologists and health informatics professionals.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;One of biggest challenges is finding talented people in specific areas, especially in SA.\u0026rdquo;\u003c/em\u003e (GM1)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Finding efficiencies is a very difficult task; we also have a very big problem with labour availability.\u0026rdquo;\u003c/em\u003e (HD1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eLack of training\u003c/h2\u003e \u003cp\u003eThe Saudi Ministry of Health (MoH) encounters the additional obstacle of training, specifically in relation to the utilization and execution of Electronic Health Record Systems (EHRS) at Primary Health Care Centers (PHCs). A significant proportion of the survey participants concurred that training posed a substantial obstacle to the implementation of Electronic Health Record Systems (EHRS). As an illustration:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The lack of training is among the problems.\u0026rdquo;\u003c/em\u003e (HD 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Of the main obstacles is training.\u0026rdquo; (Analyst 1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTheme two: Logistical Issue\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eScale of the project\u003c/h2\u003e \u003cp\u003eThe abundance of Primary Health Centers (PHCs) is a significant hindrance to the successful implementation of Electronic Health Record Systems (EHRS). The magnitude of the project has a detrimental impact on the provision of training and technical assistance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The biggest problem is how to install the EHRS into more than 2,000 PHCs, so it is a huge issue because it is equally important as the hospitals.\u0026rdquo;\u003c/em\u003e (Analyst 3)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The main obstacles are training and technical support in particular; with regards to the PHCs, problems arise due to the large number of the PHCs.\u0026rdquo;\u003c/em\u003e (Analyst 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTimeframe for implementing EHRS in PHCs\u003c/h2\u003e \u003cp\u003eThe project team encountered the difficulty of time constraints when implementing a large-scale project, as such projects necessitate a greater amount of time and have the potential to result in delays.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Our problems are often associated with time, as the implementation of such large projects requires a lot of time.\u0026rdquo;\u003c/em\u003e (HD3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eGeographical challenges\u003c/h2\u003e \u003cp\u003eThe Saudi Ministry of Health considers the size and geographical characteristics of Saudi Arabia to be a significant problem.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The geographical nature of the Kingdom is considered to be a big challenge to EHRS implementation.\u0026rdquo;\u003c/em\u003e (HD 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe geographical distribution of certain PHCs poses a significant challenge to the introduction of EHRS across the Kingdom. Especially those situated in rural or isolated regions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The most influential obstacles to the MoH are PHCs which are located in remote areas.\u0026rdquo;\u003c/em\u003e (GM 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTheme three: Technologically Challenged\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eInadequate infrastructure and lack of connectivity\u003c/h2\u003e \u003cp\u003eThe aforementioned geographical challenges are directly correlated with infrastructure. Therefore, the establishment of infrastructure and the establishment of connectivity are two significant obstacles to the introduction of EHRS in PHCs in Saudi Arabia. The Saudi MoH considers the issue of connectivity between PHCs to be a challenging problem, which has resulted in the postponement of numerous projects. The absence of connectivity among PHCs is a consequence of inadequate infrastructure.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Also, we faced other difficulties related to the infrastructure such as connectivity, especially with PHCs in remote areas.\u0026rdquo;\u003c/em\u003e (GM 1)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The technical side is a very important factor regarding the development of the infrastructure and networks, it is possible to choose the best system in the world, but when it comes to implementation, the surprise is that the infrastructure may not be suitable for implementation.\u0026rdquo;\u003c/em\u003e (Analyst 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEstablishing a suitable infrastructure might incur significant costs, particularly due to the utilization of rented facilities for certain PHCs that are not conducive to IT initiatives.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Infrastructure involves a very expensive process of communication between the health centres, especially since some of the PHCs are in rented buildings.\u0026rdquo;\u003c/em\u003e (GM 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother infrastructure-related obstacle is that not all PHCs have computers and other necessary devices.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Lack of computers is one of the obstacles we faced at the beginning, especially in non-developed PHCs.\u0026rdquo;\u003c/em\u003e (Analyst 2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSoftware selection\u003c/h2\u003e \u003cp\u003eAnother obstacle to implementing EHRS in Saudi PHCs is the absence of a suitable EHRS that aligns with the project team's goals and aspirations. Most of the EHRS offered to the Saudi MoH, especially those from outside the country, do not align with the features and operations of primary healthcare facilities in SA.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We also face a big challenge, we cannot find either a local or global EHRS that meets the requirements of PHCs in SA, and the most important reason is that there are not many options for PHCs because all global companies focus on hospitals and making systems that fit into hospitals.\u0026rdquo;\u003c/em\u003e (HD 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe characteristics of PHC facilities in South Africa differ from those in other nations including the United Kingdom, United States, and Australia. The disparities have impeded the process of choosing software because there is a scarcity of a supremely effective and internationally renowned EHRS that aligns with the existing functionalities of PHCs in SA.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;and what made it even more difficult is the differences in the characteristics of PHCs and business workflow in SA compared to that of large countries such as America, Britain and Australia. They apply so-called \u0026lsquo;GPs\u0026rsquo; rather than PHCs.\u0026rdquo;\u003c/em\u003e (HD 3)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We did not find an EHRS that is compatible with the workflow of the PHCs in SA.\u0026rdquo;\u003c/em\u003e (GM 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eVendor selection is a hindrance to the implementation of EHRS due to many factors, such as suppliers' inefficiency, price escalation, and lack of adequate experience in the Saudi healthcare system. These three criteria hinder the identification of appropriate vendors for EHRS installation initiatives. The project team hesitated to make a conclusion in this area due to a deficiency in experience. In addition, inflated costs posed a challenge for the Saudi MoH in pursuing an arrangement with vendors. Some vendors could not meet the project team's ambitions at the MoH, as evidenced by the quotations below:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;International companies have never implemented EHRS Saudi PHCs; this has made us hesitant to select international companies.\u0026rdquo;\u003c/em\u003e (GM 3)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The main obstacles are contracting with a qualified vendor.\u0026rdquo;\u003c/em\u003e (SD 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eLack of EHRS interoperability\u003c/h2\u003e \u003cp\u003eThe lack of interoperability in EHRS has been identified as a significant obstacle to the successful adoption of EHRS programs in primary healthcare centers in SA.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;One of the big challenges here is EHRS interoperability.\u0026rdquo;\u003c/em\u003e (Analyst 3)\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We should take EHRS interoperability issues seriously.\u0026rdquo;\u003c/em\u003e (SD 1)\u003c/p\u003e \u003cp\u003eTheme four: Overcoming barriers\u003c/p\u003e \u003cp\u003eThe Saudi MoH has implemented several measures to overcome the aforementioned obstacles and improve the effectiveness of EHRS implementation. Measures taken to address the aforementioned barriers and difficulties involve establishing the essential infrastructure and protocols, carrying out extensive research and studies, collaborating with Telecommunication Companies (TCs), engaging multiple vendors, dividing the Kingdom into distinct regions, and actively involving all relevant stakeholders.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eContinuous Development\u003c/h2\u003e \u003cp\u003eThe Saudi MoH successfully addressed difficulties and problems in implementing EHRS by focusing on developing the existing infrastructure, standards, and other technical factors.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The key success, of course, is the development of standards and infrastructure.\u0026rdquo;\u003c/em\u003e (Analyst 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe MoH also intends to enhance the current EHRS to align with the goals of the MoH and meet the needs of its users.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The Ministry is currently studying the possibility of the development of the previous EHRS to be generalised and implemented in all PHCs.\u0026rdquo;\u003c/em\u003e (HD 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCompartmentalization\u003c/p\u003e \u003cp\u003eDue to its extensive scope, the implementation of the EHRS in PHCs is highly complex. To address this challenge, the MoH has implemented a strategy to divide the country into five zones. As part of this strategy, a data center will be established in each of these regions. Through these data centers, all PHCs and hospitals within each region will be interconnected.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;As I mentioned to you earlier, the plan was to set up a data centre in each region after the division of the Kingdom into five regions (zones), to link the PHCs with these data centres, and then connect the PHCs with the hospitals.\u0026rdquo;\u003c/em\u003e (HD 3)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We divided the Kingdom into five zones; each zone will have one data centre.\u0026rdquo;\u003c/em\u003e (GM 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMultiple vendors will be chosen to implement the EHRS in order to decrease the burden and minimize the risks.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We will be contracting with at least three providers to reduces the pressure on the provider. If it is one vendor, the number to cope with is huge, and one company alone cannot implement the EHRS in all PHCs in SA.\u0026rdquo;\u003c/em\u003e (GM 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003ePiloting the system\u003c/h2\u003e \u003cp\u003eThe Saudi MoH will conduct a trial of the chosen system by introducing the EHRS in a limited number of PHCs. Subsequently, the MoH will assess the system to identify any potential usability or technical difficulties before proceeding with the real installation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;First, we will select a system and try to implement it in some PHCs for the evaluation of several aspects to measure the system\u0026rsquo;s usability and determine any problems; then we will collect and analyse the problems and solve them. We will work on this more than once until we achieve 100% user satisfaction.\u0026rdquo;\u003c/em\u003e (GM 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCooperation with TelCo\u003c/p\u003e \u003cp\u003eCollaborating with communications and information technology firms is another potential strategy that could help overcome the constraints. The Saudi MoH has entered into agreements with multiple communication and IT firms. The objective of this collaboration is to address the geographical issues and accompanying obstacles related to infrastructure.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The geographical challenges will be addressed through co-ordination with the TCs and connection to the Internet for all PHCs; then linking them to the data centres in each region.\u0026rdquo;\u003c/em\u003e (HD 1)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Working in co-ordination with the TCs on the development of infrastructure.\u0026rdquo;\u003c/em\u003e (Analyst 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eQuestionnaire results\u003c/p\u003e \u003cp\u003eData from the questionnaire were gathered from 351 participants in five distinct locations of the Kingdom of Saudi Arabia. Out of all the respondents, the highest number, 103 (29.3%), lived in the capital city, Riyadh (refer to Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAll participants were employed in healthcare and administrative positions. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, displays the distribution of job roles among the participants. Out of the total, 149 individuals (42.4%) held administrative positions, such as managers, secretaries, and receptionists. 104 participants (29.6%) worked in nursing roles, while 32 (9.1%) were physicians and 30 (8.5%) were pharmacists. Four individuals, accounting for 1.1% of the total, did not disclose their occupation.\u003c/p\u003e \u003cp\u003eAge was quantified using six distinct categories, as depicted in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Out of the total participants, 192 individuals, accounting for 54.7% of the sample, fell between the age range of twenty-five to thirty-four years. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e provides a comprehensive analysis of the age groups. Four individuals, accounting for 1.1% of the total, did not disclose their age. Participants were additionally requested to indicate their gender. The majority of participants were male, with a total of 261 individuals, accounting for 74.4% of the sample. Among the 351 participants, the number of females was only eighty-one, accounting for 23.1% of the total. Nine individuals, accounting for 2.6% of the total, did not disclose their gender.\u003c/p\u003e \u003cp\u003eThe participants' usage of a personal computer at home exhibited variation, with the majority of participants (36.8%) reporting experience spanning from ten to fifteen years. Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows that a mere eighteen participants, accounting for only 5.1% of the total, had less than one year of experience using a personal computer. Four participants, accounting for 1.1% of the total, did not disclose their level of experience in using a personal computer at home.\u003c/p\u003e \u003cp\u003eThe duration of the participants' engagement in their present work position was assessed using five distinct categories. Out of all the participants, a majority of 105 individuals, accounting for 29.9% of the total, had a professional experience ranging from one to five years. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e provides a comprehensive analysis of the amount of time participants have spent in their current position. Five participants, or 1.4% of the total, did not disclose their level of experience in using a personal computer at home [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant demographic distribution\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eGeographical location\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eExperience with using a personal computer\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFrequency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003ePercent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eLength of experience\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eFrequency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003ePercent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRiyadh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLess than 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGassim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 to 5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAljouf\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e19.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 to 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e31.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbaha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u0026ndash;15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMakkah\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e25.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMore than 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e98.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFrequency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003ePercent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eAge Group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eFrequency\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003ePercent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdministrator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e42.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 to 24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25 to 34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e54.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e29.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35 to 44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLab technician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45 to 54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e55 to 64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65 to 74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDentist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e98.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e347\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e98.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003eExperience in their current position\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eLess than 1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e5.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e1 to 5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e29.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e5 to 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e28.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e10 to 15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e23.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMore than 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e11.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e \u003cp\u003e98.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNegative attitudes toward the EHRS:\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e includes elements that indicate several characteristics that impact the deployment of EHRS, such as user engagement and system effectiveness. These factors were determined based on the replies to seven questions on the negative attitude scale. The negative attitude scale collects participant responses to items that describe issues affecting the implementation of EHRS, such as the involvement of EHRS end-users. Consequently, the utmost level of support was generated for user engagement.: 1) \u0026ldquo;\u003cem\u003eEnd-users should have been considered in the system design\u003c/em\u003e\u0026rdquo; (85.8%). The second level of agreement was generated for 2) \u0026ldquo;\u003cem\u003eIt takes too much time to help others who don\u0026rsquo;t know how to use the system\u0026rdquo;\u003c/em\u003e (63.4%). However, lower agreement was generated for items: 5) \u0026ldquo;\u003cem\u003eUsing EHRS raises stress levels among practitioners\u003c/em\u003e\u0026rdquo; (12.8%); 6) \u0026ldquo;\u003cem\u003eThe system makes me feel like I am no longer functioning as part of a team\u003c/em\u003e\u0026rdquo; (12.3%); and 7) \u0026ldquo;\u003cem\u003eThe EHR system is considered to be an extra load at work\u003c/em\u003e\u0026rdquo; (9.7%) [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNegative attitudes toward the implementation of EHRS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eItems\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrongly Disagree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStrongly Agree\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTotal agreement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRank\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eEnd-users\u0026nbsp;should have been considered in the\u0026nbsp;system design\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e58.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e85.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eIt takes too much time to help others who don\u0026rsquo;t know how to use the system\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e63.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eI am aware that problems with the EHR system have a direct impact on patient care\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e61.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eUsing the EHR system takes longer than the paper-based system\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eUsing EHRS raises stress levels among practitioners\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eThe system makes me feel like I am no longer functioning as part of a team\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e12.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eThe EHRS is considered to be an extra load at work\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBarriers to EHRS implementation\u003c/p\u003e \u003cp\u003eAs seen in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e certain elements are perceived as less inhibitory compared to others. The question that received the least amount of positive endorsement were: 1) \u0026ldquo;\u003cem\u003eLack of training\u003c/em\u003e\u0026rdquo; (83.8%); 2) \u0026ldquo;\u003cem\u003eInadequate infrastructure and the absence of connectivity\u003c/em\u003e\u0026rdquo; (78.5%); 3) \u0026ldquo;\u003cem\u003eLack of technical support\u003c/em\u003e\u0026rdquo; (75.5%) and ;4) \u0026ldquo;\u003cem\u003eThe absence of end-user involvement in EHR implementation and software design\u003c/em\u003e\u0026rdquo; (74.6%).\u003c/p\u003e \u003cp\u003eThe items that were given the highest level of positive endorsement and reflected lesser barriers were: 13) \u0026ldquo;\u003cem\u003eThe time spent using the EHR system\u003c/em\u003e\u0026rdquo; (34%); 14) \u0026ldquo;\u003cem\u003eConfidentiality and privacy concerns\u003c/em\u003e\u0026rdquo; (28.3%); 15) \u0026ldquo;\u003cem\u003eConcerns about loss of personal attention given to patients as entering patient information into the computer\u003c/em\u003e\u0026rdquo; (28.3%) and; 16) \u0026ldquo;\u003cem\u003eConcern about a decrease in productivity during the use of the EHR system\u003c/em\u003e\u0026rdquo; (25.4%). As seen in the below table, all listed items in the barrier scale were considered to be major or minor barriers [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBarriers to implementation of EHRS in the PHCs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eItems\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNot a barrier\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMinor barrier\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMajor barrier\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eRank\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eLack of training\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e171\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e83.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eInadequate infrastructure and the absence of connectivity\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eLack of technical support\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eThe absence of end-user involvement in the EHR system implementation and software design\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eIgnoring end-user feedback and issue reports\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eThe lack of awareness of end-user requirements\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eDifficulties using the system\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eInadequate resources and materials\u0026nbsp;within the centre\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eLack of computer literacy\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eLack of perceived EHR system usefulness\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eLack of awareness of EHRS\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eResistance to new technology\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eThe time spent using the EHR system\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eConfidentiality and privacy concerns\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eConcerns about loss of personal attention given to patients as entering patient information into the computer\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eConcern about a decrease in productivity during the use of the EHR system\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe association between the key scales was determined using a Spearman's correlation test. The association analysis revealed a significant negative correlation between impediments and a negative attitude towards the installation of EHRS (see Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Nevertheless, all notable relationships are regarded as feeble. However, neither the Mann-Whitney U test nor the Kruskal Wallis test identified any significant differences between the groups (see Appendix S1).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSpearman\u0026rsquo;s correlation coefficient for correlations between barriers and negative attitude.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNegative Attitude\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation Coefficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.176\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSig. (2-tailed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNegative Attitude\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation Coefficient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.176\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSig. (2-tailed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOnly 150 out of 2259 PHCs have successfully implemented an EHRS. However, the project has failed due to several impediments and challenges. Hence, it is worthwhile to delve into the underlying factors contributing to this failure. The identification of barriers was predicated on the Saudi Ministry of Health's prior and forthcoming project experience. Data regarding the obstacles to the implementation of EHRS were gathered through research that involved the use of questionnaires and semi-structured interviews. This research was conducted with two distinct groups: the project team responsible for the implementation, and the end-users of EHRS. The investigation revealed a conspicuous observation: the number of obstacles to implementing a widespread EHRS outweighed the number of factors that aided its deployment. As a result, there are certain obstacles that are specific to this project, such as its extensive magnitude. Additional obstacles that were identified include individual resistance to change, insufficient training, inadequate technical assistance, limited compatibility between systems, geographical limitations, software selection issues, and insufficient user engagement.\u003c/p\u003e \u003cp\u003eEven though the PHCs' requirements, including size, were supposed to be a facilitator, this study is one of the few that has found that establishing a large-scale EHRS is a big hassle. In order to surmount this obstacle, it has been proposed that these extensive endeavors should be subdivided into more manageable undertakings. To streamline project management, the implementation of the EHRS should be carried out in various locations and at varied time intervals. Furthermore, it is advisable to establish agreements with many vendors in order to mitigate the risk of project failure caused by factors such as a vendor's incapacity to successfully execute a large-scale EHRS project while ensuring system compatibility and meeting specific requirements.\u003c/p\u003e \u003cp\u003eThe study results align with the findings of Ludwick and Doucette [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], and Lennon, Bouamrane [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], who also discovered that industrialized nations like the UK had a scarcity of specialists throughout the adoption of EHRS. Therefore, the lack of specialists is regarded as an obstacle for both developed and emerging nations. Nonetheless, our research strongly advocates for the recruitment of proficient professionals in Health Informatics (HI) and Information Technology (IT) from external organizations or other nations, particularly when considering the implementation of extensive EHRS. The presence of proficient individuals in the fields of Health Informatics (HI) and IT might serve as an indicator of a healthcare organization's preparedness for implementing new EHRS.\u003c/p\u003e \u003cp\u003eAn other intriguing discovery was the obstacle created by the turnover of executives and team members in the project team, namely those who held crucial roles. This impediment may present a more significant risk to large-scale initiatives that have implemented Centralized Management (CM), which can be characterized as the distinctiveness of a small group in making critical choices. Nevertheless, the replacement of executives or other policy makers has also been recognized as an obstacle in small enterprises [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. While CM was observed to have a highly favorable effect on EHRS deployment, it could also have adverse consequences. Modifications in the executive and leadership hierarchy frequently result in subsequent alterations to previously implemented policies and plans, potentially resulting in project postponement or even collapse. Both technical support and training were identified as hindrances. Furthermore, the research revealed a detrimental correlation between the magnitude of the project and the availability of training and technical assistance. While training and technical assistance have been identified as obstacles in small initiatives [e.g. 50, 51], they can pose even greater challenges in large-scale projects.\u003c/p\u003e \u003cp\u003e83.8% of EHRS end-users saw lack of training as a significant obstacle, while 75.5% identified lack of technical support as a serious hindrance. A study conducted in primary healthcare centers (PHCs) in the United States found that fewer than 50% of the staff considered their training to be sufficient (Singh et al., 2013). The satisfaction level with the training provided to EHRS end users in SA is inconsistent. Alasmary, El Metwally [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] conducted a study in Saudi Arabia to investigate the effect of training on end-user satisfaction with electronic health record systems (EHRS) in secondary care. The results indicated that the end-users expressed satisfaction with the training they received. Nevertheless, additional research conducted in secondary healthcare settings in South Africa uncovered that users of electronic health record systems (EHRS) reported discontentment with the training and technical assistance provided [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe most significant result from this study's analysis is the correlation between the absence of technical support and the failure of the EHRS that were introduced in the Saudi PHCs. Moreover, the findings of this study demonstrated that problems related to training and technical assistance can have a detrimental impact on the acceptance of EHRS by end-users. These findings are consistent with the results of other research conducted in SA such as studies [e.g. 53, 54]. Nevertheless, these two trials were carried out in a secondary care setting. Conversely, prior studies have discovered that technological support had a role in enabling the introduction of EHRS [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. However, Heyworth, Zhang [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] argued that there was no correlation between the provision of technical support and end-user satisfaction. Nevertheless, Heyworth and Zhang [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e] contended that there was no discernible association between the provision of technical help and the level of pleasure experienced by end-users.\u003c/p\u003e \u003cp\u003eAn inverse relationship was observed between geographical obstacles, inadequate infrastructure, and absence of connectivity. The presence of this negative connection was identified as a primary factor contributing to the unsuccessful implementation of the previously utilized EHRS. This is attributed to the variations in topography among the several parts of the Kingdom, along with the vast expanse of the country. The results indicated that the primary healthcare centers that were most impacted were those situated in remote and rural regions. Within this particular context, the research findings indicate that the task of ensuring continuous connectivity among Primary Health Centers (PHCs) is perceived as difficult due to factors such as challenging terrain, inadequate infrastructure, and the positioning of certain PHCs. These findings are consistent with previously published research, who also identified inadequate infrastructure in remote and rural regions [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan additionalcitationids=\"CR59\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Our research, along with other related studies, indicates that infrastructural challenges pose a significant risk to the success of projects implementing Electronic Health Record Systems (EHRS), especially in developing countries [\u003cspan additionalcitationids=\"CR61 CR62 CR63\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. Hence, it is imperative to incorporate infrastructure development at both the planning and pre-implementation stages, as stated in the literature.\u003c/p\u003e \u003cp\u003eIn order to address the obstacles posed by geographical factors and provide universal access for all primary healthcare centers (PHCs), our research strongly advises collaborating with other entities, such as local telecoms companies, who can assume the responsibility of providing telecommunications and information technology services. The resolution of issues in this domain necessitates the collaborative efforts of all parties involved and cannot be achieved through unilateral actions. This technology has the potential to aid in the development of suitable infrastructure that enables the connecting of all Primary Health Centers (PHCs) in South Africa. Furthermore, this connectivity will also facilitate the resolution of other obstacles, such as technical assistance. Earlier studies have also revealed alternative approaches for addressing such geographical obstacles. For example, the utilization of mobile phone connections in situations where the technological infrastructure is insufficient or non-existent [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne additional technological challenge identified in this research was the absence of interoperability among EHRS. This issue has also been highlighted in prior studies. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan additionalcitationids=\"CR61\" citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. The complexity of EHRS interoperability difficulties may be exacerbated in large-scale projects, owing to the multitude of EHRS systems involved. As previously stated in this study, the EHRS in PHCs in SA will be implemented by three distinct suppliers. The presence of multiple elements may result in interoperability challenges that impede the project's success. Hence, as depicted in the literature, the problems related to EHRS interoperability can be prevented by taking them into account throughout the software selection process and other preparatory steps before implementation, including as planning and readiness assessments. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBy standardizing software selection criteria, healthcare companies may tackle interoperability issues and ensure system compatibility. The MoH is selecting three vendors, so CM implements standardized systems to ensure interoperability. When the project is competitive, a Request for Proposal (RFP) must be issued to potential vendors during the pre-implementation phase. EHRS implementation research shows that this standard facilitates technical communication between two or more systems [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e]. Furthermore, previous study has discovered that commercial EHRS provide the advantageous quality of flexibility, allowing for seamless integration with other systems. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn interesting finding from this study is that PHCs in SA differ in process and structure from those in the UK, US, and Australia. These differences hinder global system selection. Most international EHRS are designed to fit current workflows. The findings showed a link between PHC process and software choice. Thus, firms with unique workflows must reform or build their own systems.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitation and recommendation for future work\u003c/h2\u003e \u003cp\u003eInitially, the data gathering tool used in this study did not incorporate items to assess the accessibility of professionals who could facilitate the achievement of the EHRS deployment, particularly for extensive undertakings. Hence, it is advisable for future researchers to include additional elements in order to evaluate the preparedness of healthcare organizations in terms of the availability of highly skilled health informatics experts. Furthermore, this study did not analyze the notable disparity between rural and urban PHCs. Identifying the rural and urban PHCs proved to be challenging.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study is the first to examine a wide range of obstacles to implementing large-scale EHRS in PHCs. Hence, this study offers multiple suggestions to decision-makers and the entire EHRS implementation project team to streamline the deployment of a comprehensive EHRS on a broad scale. Policymakers should allocate adequate funding to ensure seamless implementation, especially when making decisions related to software selection. The study identified training and support as a significant obstacle, whereas confidentiality and privacy were deemed to be less problematic in the introduction of EHRS. Upon analyzing the factors that could potentially affect EHRS end-user satisfaction, it was found that demographic characteristics, except for participants' occupation, did not have a significant influence on EHRS end-user attitudes and satisfaction regarding the implementation and utilization of the system. The assessment indicated that it was implemented in 150 PHCs and was regarded as a pilot for the preceding initiative. The assessment also uncovered that the primary factors contributing to the previous project's failure were insufficient connectivity, inadequate technical assistance, and personnel turnover, notably among high-ranking positions within the Saudi Ministry of Health.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEHRS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eElectronic Health Record System\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003ePrimary Health Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMoH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003eMinistry of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003eSaudi Arabia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003eGeneral Manager\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003eHead of Department\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDHD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003eDeputy Head of Department\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003eSoftware Developer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003eData Analyst\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003eFinancial Recourses\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"21.96339434276206%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSPSS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.03660565723794%\" valign=\"top\"\u003e\n \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eAll methods in this study were performed in accordance with the declaration of Helsinki and was approved by the Institutional Review Board (IRB) of King Fahad Medical City (KFMC) at the Saudi MoH (IRB Log No. 14-189E). All the participants provided informed consent to participate. In the case of the questionnaire-based study, all participants were informed of the voluntary nature, confidentiality, and aim of the study and the nature of their participation before they participated in the study. For the interview purposes, all participants provided written informed consent prior to enrolment in the study.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNot applicable as no identifiable information is published in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material (ADM)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due copyright and ownership. All primary data collected for this research belong to the researchers. The dataset includes other data that will be used for another manuscript but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eResearchers would like to thank the Deanship of Scientific Research, Qassim University for funding publication of this project. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis paper is based on the thesis of [Haitham Alzghaibi]. It has been published on the institutional website: https://ifind.swansea.ac.uk/permalink/44WHELF_SWA/14o5fp4/alma998613060602417\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eCompeting\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eof interest\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThis project fully funded by Qassim University. The funding body played no role in the design of the study and collection, analysis, interpretation of data, and in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCredit authorship contribution statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHAA\u003c/strong\u003e: Conceptualization, methodology, data collection, validation, analysis, writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHAH\u003c/strong\u003e\u003cstrong\u003e:\u0026nbsp;\u003c/strong\u003eConceptualization, supervision, reviewing and editing.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOrtiz E, Clancy CM, Ahrq. Use of information technology to improve the quality of health care in the United States. Health Serv Res. 2003;38(2):xi\u0026ndash;xxii.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtherton J. Development of the Electronic Health Record. 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Risks, barriers, and benefits of EHR systems: a comparative study based on size of hospital. Perspect Health Inf Manag. 2006;3:5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAjami S, Bagheri-Tadi T. Barriers for Adopting Electronic Health Records (EHRs) by Physicians. Acta Inf Med. 2013;21(2):129\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalra D. Electronic health record standards. Methods Inf Med. 2006;45:136\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBegoyan A. An overview of interoperability standards for electronic health records. USA: society for design and process science; 2007.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Electronic health records, Barriers, Primary Healthcare centres, Large-scale IT projects, Saudi Arabia","lastPublishedDoi":"10.21203/rs.3.rs-4461961/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4461961/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe incorporation of data Over the past two decades, policy-makers in healthcare organizations have placed significant emphasis on technology as a top priority. This is because of the potential advantages that technology offers in enhancing healthcare services and improving their quality. Nevertheless, approximately half of those projects did not succeed in attaining their planned objectives. This outcome was a consequence of multiple variables, which encompassed the expenses associated with these initiatives. The Saudi ministry of health intended to deploy an electronic health record system in approximately 2200 basic healthcare clinics across the country. It was recognized that this project could encounter obstacles, perhaps leading to project failure, if implementation facilitators were not identified beforehand. The Saudi Ministry of Health (MoH) states that the earlier adoption of Electronic Health Record Systems (EHRS) at Primary Health Centers (PHCs) failed due to various obstacles, including inadequate infrastructure, limited connectivity, and lack of interoperability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine the barriers that may that could potentially contribute of failure the implementation of the EHRS in the PHCs\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA mixed methods approach was employed, incorporating both qualitative and quantitative methodologies. The qualitative aspect involved conducting semi-structured interviews, while the quantitative component utilized a closed survey. The objective of employing exploratory mixed-methods was to find a diverse array of facilitators that could potentially impact the implementation of EHRS. The data were collected from two distinct viewpoints: PHCs practitioners and project team members. A total of 351 practitioners from 21 PHCs participated in the online-based survey, while 14 key informants at the Saudi Ministry of Health (MoH) who were directly involved in the implementation of the Electronic Health Record System (EHRS) in the PHCs agreed to be interviewed in person.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results from both investigations identified multiple obstacles. The constraints include the project's extensive scope, the need to adapt individuals to change, insufficient training, inadequate technical assistance, lack of compatibility between systems, geographical obstacles, software selection issues, and insufficient user engagement. However, this study offers many suggestions to decision-makers and the EHRS implementation project team to streamline the adoption of a widespread EHRS. These ideas include collaborating with telecom providers and splitting the state into clusters.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary factors contributing to the failure of the previous initiative were insufficient connectivity, inadequate technical assistance, and significant turnover in high-level posts within the Saudi Ministry of Health. Training and support were identified as a significant obstacle, whereas confidentiality and privacy were determined to be less of a hindrance to the introduction of EHRS. Hence, authorities must allocate a enough budget to ensure seamless execution, especially when making choices about software selection and the provision of training and support.\u003c/p\u003e\n\u003cp\u003e• This study provides insights into the procedures and steps of implementing EHRs.\u003c/p\u003e\n\u003cp\u003e• The findings will enhance our understanding of how to overcome impediments that impact the success of EHRS deployment.\u003c/p\u003e\n\u003cp\u003e•This study aims to address the research gaps by specifically identifying and analyzing the implementation methods in primary healthcare centers (PHCs) in Saudi Arabia and other Arab Gulf Countries (GCCs).\u003c/p\u003e\n\u003cp\u003eThis study makes a methodological addition by combining qualitative and quantitative research designs to investigate the obstacles to the implementation of EHRS.\u003c/p\u003e","manuscriptTitle":"Barriers to the implementation of large-scale electronic health record systems in Primary Healthcare centers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-15 03:31:23","doi":"10.21203/rs.3.rs-4461961/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"917c5fe3-4dda-42e6-aa5b-56f16c434cd1","owner":[],"postedDate":"July 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T06:54:22+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-15 03:31:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4461961","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4461961","identity":"rs-4461961","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}