Challenges and Opportunities of Using the National Electronic Health Record from the Perspective of Iranian Nursing Staff

Abstract

Purpose: EHRs are being implemented into healthcare systems around the world. In Iran, an integrated national health information system – SIB System (NEHR) was implemented in 2015. This research aimed to study Iranian nurses’ attitudes about challenges and opportunities in the utilization of this system.

Methods: This descriptive cross-sectional study was conducted in 2020. Linear Regression analysis was utilized to show the connection between the scores of the questionnaire and the inspected attributes.

Results: The mean score of the participants' attitudes toward technical, organizational, and individual challenges of the NEHR was 4.06 (± 0.77), 4.9 (± 0.62), and 4.09 (± 0.29), respectively. As well, the average score towards the impact of the NEHR on nursing documentation was 4.04, on nursing interventions, education & research was 4.02 and 3.87 for timesaving.

Conclusion: Although the use of the NEHR improves the quality of the nursing process by making healthcare data accessible and available at the point of care, several barriers may impact the successful implementation and administration of the NEHR.

Keywords: National Electronic Health Records (NEHR), Challenges, Nurse, Opportunity, SIB System, policymakers, prospective, nursing staff, healthcare, health professional.

Introduction

Electronic health records (EHRs) are being implemented in healthcare systems around the world (Melnick et al., 2020). These systems are introduced to support health care organizations through expected benefits, for example, support patient safety (Overhage & McCallie, 2020), improve documentation (Fazio et al., 2020), and improve quality of care (Plantier et al., 2017). To understand the opportunities of EHRs, health professionals must use the technology in a trustworthy and competent ways (Pagulayan et al., 2018). Furthermore, they need high levels of technology adoption by users if EHRs benefits are to be obtained (Castillo et al., 2019). A sociotechnical hypothesis suggests that EHRs can not be planned or administered effectively without precise thought of the "fit" of the technology with the users providing care and the current workplace setting (AlJarullah et al., 2018). Indeed, a review of EHRs studies regularly refers to this deficiency of fit as one of the main barriers during EHR implementation (Schenk et al., 2018).
Nurses who are among the biggest group of professionals in health care institutions utilize EHRs for documentation, management of medications, clinical checklists and decision-making, and coordination of patient care (Kutney-Lee et al., 2019). The nurses’ use of EHRs may influence whether the anticipated benefits of utilizing the technology are achieved (Strudwick et al., 2018). A nurses' point of view has been analyzed for ease of use of EHRs and attitudes toward use in several types of research, in addition to how EHRs impact care practices and patient outcomes (Rosenberg, 2019). Whereas some nursing staff recognized positive elements of EHRs (Higgins et al., 2017; McBride et al., 2017), several expressed disappointment with their utilization, found them difficult and time-wasting to use and distrusted the capacity of EHRs to improve patient care (Schenk et al., 2016; Topaz et al., 2016). These mixed responses from nurse end-users raise questions about the method of EHR implementation, and differences in the organizational and clinical situations into which the EHRs are integrated.

The National Electronic Health Record (NEHR) is a patient data exchange system that enables physicians and other healthcare professionals to view patient health records across the National healthcare network and supports them in clinical decision making and planning patient treatments and care. The NEHR includes data elements such as admissions and visits history data, hospital inpatient discharge summaries, laboratory and radiology results, medications, allergies, and adverse drug reactions, past operations history, and immunization records data (Takian et al., 2014).

Some studies show that health care organizations with better workplace practices (such as Magnet hospitals) are more likely to accept EHRs despite their complexity (Lippincott et al., 2017). It is critical to better realize how different barriers and facilitators influence nurses’ utilization of NEHR. By accepting these factors, training, tasks and policies can be shaped to more readily reinforce nurses’ utilization of the NEHR. This research aimed to study Iranian nurses’ attitudes about the challenges and opportunities in the utilization of the NEHR in health care organizations.

The NEHR

In line with the reform of health system in Iran (Esmailzadeh et al., 2013), a comprehensive integrated National health information system (SIB; an abbreviation for the Persian equivalent of "integrated health system”) (NEHR) was implemented in 2015  to provide integrated public health services, provide the requirements for the implementation of the referral system, increase the accessibility of public health reports, and ultimately improve the quality of health services. (Figure 1).

Figure 1:  The NEHR of Iran

SIB was implemented and used in health centers in Iran. These settings have close contact with the Iranian people and provide the first level of health services for the entire population. All health-related information of the population gathered during the provision of primary healthcare services is registered in SIB. In subsequent referrals for care recipients, this past information is available for providers through SIB. Since the inception of this reform up to June 2018, EHRs have been created for over 75 million people in Iran (more than 90 percent of the population). The users of this system are about 100,000 healthcare providers from more than 30,000 settings across the country.

Setting

This descriptive cross-sectional study was conducted in Iran in 2020. The study population consisted of all SIB end-users (n=183) in health centers affiliated with Semnan University of Medical Sciences, Semnan, Iran. These centers cover a population of 350,000 people in Semnan city. At the time of the study, SIB had already been implemented in 10 health centers in the city of Semnan. All the end-users had the same experience with SIB from its implementation date. Initially, the user interface of different parts of the system was inspected. Although users were different based on their position and field of education, the overall design of the user interface and the method of interaction with the different modules of the system were mostly the same. The researcher was present at healthcare institutions and distributed the questionnaire among the study subjects. An aggregate of 183 questionnaires was distributed among the investigation subjects; 135 were returned, showing a response rate of 73.7%.

Questionnaire and Measures

In this study, Gorzin et al.’s (2016) study questionnaire was used. Gorzin et al. believed that the implementation of an integrated EHR has potential benefits, such as increased organizational efficiency, improved communication, improved practitioner performance, better quality of care, and improved outcomes. In their questionnaire, the authors initially sought to examine how effective the EHR was in improving the performance and process of nursing. Then they wanted to know what nurses were concerned about and what problems they experienced when using the technology.
This questionnaire has three sections and 64 questions.

• The first section collects demographic information with six questions that measure the individual characteristics of the participants; 
• The second section was related to the opportunities that the NEHR provides for the nurses and is made up of five parts. The first part includes 16 questions related to documentation to evaluate the nurses’ perceptions of the impact of the NEHRs on documentation quality to provide an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver high quality care; the second part contains 11 questions related to nursing interventions to measure the impact of the NEHRs on the actual treatments and actions that are performed by the nurses when caring for patients; the third part has six questions related to access to information to measure the effect of the NEHRs on the storage, retrieval and display of clinical information and the level of nurses’ access to confidential information; the fourth part includes four questions related to education and research that measures the effect of the NEHR on increasing and sharing nursing knowledge and developing research in the field of nursing;  and the fifth part consists of three questions related to timesaving  to assess the impact of the NEHRs on minimizing time wastage in nursing care.

 The third section is related to the challenges of using the NEHR and has three parts.

• The first part contains seven questions related to technical challenges to measure where the use of the EHR is perceived as not being adequate to perform nursing tasks or accomplish the objectives for which the EHR was initially utilized.
• The second part includes seven questions related to organizational challenges such as rules and policies, status or hierarchical positions, or complex organizational structure among nursing staff that might impact the use of EHRs.
• The third part consists of four questions related to individual challenges such as limitations in skills, experience, and knowledge that hinder the ability of the nursing staff to significantly use the EHR.

The attitude score was estimated for each item on a 5-point Likert-type scale, where ‘completely disagree’ =1, 'disagree' =2, 'no agree and no disagree =3, 'agree' =4, and ' completely agree' =5. Gorzin et al.(2016) used Cronbach's alpha coefficients to test the reliability of the questionnaire (Cronbach, 1951). The correlation coefficient was 0.86.  In our investigation, the survey was again pilot tested on 22 nurses who had been arbitrarily chosen from the health care centers. The members of the pilot study were not included in the actual study. The Cronbach's alpha coefficients of each noted section were evaluated as 0.897 and 0.858, separately and the total survey was 0.944. The final survey was dispersed among the study subjects to completed and returned back to the researcher.

Data Analysis

A frequency dissemination table was utilized for describing the categorical factors as attributes, including demographic characteristics of the sample. The mean and standard deviation were determined for every item on the attitude scale, which estimated the participants’ attitudes about the opportunities and challenges that the NEHR had created for nurses.  The cut-off point was set as 4 (score <4 considered disagree and score ≥4 considered agree) considering the two higher scores of the 5-point Likert scale ('agree' and ' completely agree'). A low score demonstrated a negative disposition, while a high score showed a positive attitude and general agreement. Linear Regression analysis was utilized to break down the information and show the connection between the scores of the questionnaire and the inspected attributes. IBM statistics SPSS 26 software was utilized to depict and examine the information at the significance level of 0.05.

Ethical considerations

Ethics approval was received from the Ethics Committee of Semnan University of Medical Sciences (IR.SEMUMS.REC.1398.152). An introductory consent letter was distributed with the survey that outlined the reasons for the study and disclosed that answering the survey demonstrated the respondents consented to participate in the study. It additionally guaranteed the study subjects that their answers would be kept private and confidential.

Results

The results indicated that the participants’ average age was 34 (± 8.1) years old. Work experience average was 7(± 5.9) years, 69.6% were female, 94.8% had an undergraduate degree, 65.7% had moderate computer skills, and 60.6 % worked with the computer for more than three hours per shift (Table I).

Table 1: Demographic Characteristics

The results showed that the average score of the participant's attitudes towards the impact of the NEHR on nursing documentation was 4.04, on nursing interventions and education and research was 4.02 and on timesaving was 3.87 (Figure 2).

Figure 2: Average scores of participants' attitudes towards the opportunities created by the NEHR

Regression analysis showed that there were significant relationships between the participants’ characteristics and their attitudes towards opportunities of the NEHR. (Table 2)

Table 2: Regression analysis between the participants’ characteristics and their attitudes towards opportunities of using the NEHR

The results showed that the mean score of participants' attitudes toward technical, organizational, and individual challenges of the NEHR was 4.06 (± 0.77), 4.9 (± 0.62), and 4.09 (± 0.29), respectively. There was a significant relationship between the participants’ computer skills and their attitudes towards individual challenges of using the NEHR (Beta=0.213, P=0.040). (Table 3)

Table 3: Regression analysis between the participants’ characteristics and their attitudes towards challenges of using the NEHR

Discussion

Our findings showed that the nursing staff agreed (Mean=4.04) that the NEHR positively impacted and improved nursing documentation. In other words, it seems that the healthcare centers implementing the NEHR ensured that there is a streamlined approach to documentation so that information can be documented efficiently with minimal requirements for duplicate documentation. While, other research studies have shown documentation workload challenges in both nurses and other health professionals (Bae & Encinosa, 2018; Strudwick et al., 2018), this was not the case with the NEHR. This difference suggests a potential link between system design, organizational expectations, and nurses’ documentation workload. Clear organizational expectations for nursing documentation during EHR training sessions must be reflected in organizational policies. The findings showed that there was a significant positive and direct relationship between the duration of working with the NEHR per shift and the nursing staff’s attitudes towards the impact of the NEHR on improving nursing documentation (Beta= 0.221, P=0.028). In other words, the more nurses worked with the system, the more they understood the positive impact of the system on improving documentation.

The results also showed that nursing staff agreed (Mean=4.02) that the NEHR had a positive impact and improved the documentation and selection of nursing interventions. The results of the present study contradict the findings of Taylor et al’s (2014) study, which found the face-to-face communication between nurses and physicians decreased following the EHRs implementation. This finding suggests that having a strong culture of interprofessional teamwork becomes even more important with the introduction of EHRs. This result also provides empirical proof for the consideration of the healthcare environment as a critical factor in the implementation and utility of EHRs. The results indicated that there was a significant positive and direct relationship between the duration of working with the NEHR per shift and the nursing staffs’ attitudes towards the impact of the NEHR on improving nursing interventions (Beta= 0.267, P=0.010). In other words, the more nurses worked with the NEHR; the more they understood it contributes to the effectiveness of nursing interventions.

This study showed the participants doubted (Mean=3.91) that the EHRs impact on the improvement in data access in a beneficial way. Before the EHRs were adopted, issues such as access to health data, legal infrastructures, and access permission should be taken into account, and practical solutions should be considered (Ayatollahi et al., 2014). The participants’ attitudes may be related to ethical and legal issues about the security and privacy of computer systems and data confidentiality. The results of the study conducted by Thakkar and Davis (2006) showed that the concern of breaching the confidentiality of health data and a lack of control of unauthorized access were the main challenges in using EHRs. Other studies also emphasized the importance of the confidentiality of health data when computerized systems are used (Adeleke & Abdul, 2020; Bani Issa et al., 2020). In our study, there was a significant direct and positive relationship between the participants’ education level and their attitudes towards the impact of the system on improving data access (Beta= 0.225, P=0.041).

Also, this study finding showed that the participants were doubtful (Mean=3.87) about EHR impact on timesaving during care. Results of this study may be related to poor navigation of the NEHR, like Sockolow et al’s study (2012) which indicated that nurses in two community care settings were not able to maximally use the EHRS due to poor system navigation. The findings of this study showed that there was no significant relationship (P=0.435) between the nursing staffs’ length of work experience and their attitudes about the impact of the NEHR on timesaving.

The findings of Gomes et al’s study (2016) were contrary to our results.  They evaluated the nurses’ attitudes and beliefs about the effects of implementing an EHR on medical-surgical registered nurses' time spent in direct professional patient-centered nursing activities.  They found that nurses spent less time at the nurses' station, less time charting, significantly more time in patients' rooms and in purposeful interactions, and time spent in relationship-based caring behavior.  Gomes et al. found that there was a significant difference (P=0.01) in normative beliefs between nurses with less than 15 years’ experience and nurses with more than 15 years’ experience. Perhaps the reason for this difference between the results of the present study and Gomes et al's study is that we did not group the age of the participants and did not examine the attitudes of nurses in each age group.
The results indicated that there was no significant relationship (P>0.05) between the participants’ work experiences and their attitudes about the impact of the NEHRs. The findings of Raddaha et al.’ (2018) study confirmed the results of the present study. They evaluated opinions, perceptions, and attitudes toward an EHR system among practicing nurses in Oman country. They also found that there was not any significant relationship (P=0.68) between nursing career experience and their attitudes toward the EHR system.

The findings showed that there was no significant relationship (P>0.05) between the study subjects’ sex and their attitudes about the impact of the NEHR. The findings of other studies confirm these results (Raddaha, 2017; Raddaha et al., 2018).  Galimany-Masclans et al’s (2011) study investigated the use and perception of primary healthcare nurses about EHRs in Catalonia, Spain. They found that there was not any significant relationship (P=0.68) between the nursing staffs’ gender and their attitudes toward EHRs.

The results showed that the nursing staff agreed that they faced technical challenges when using the system (Mean=4.06). The finding of the current study is consistent with the results of other studies that have emphasized the importance of technical barriers in the creation and adoption of EHRs (Niazkhani et al., 2020). A study done by Ni and colleagues (2019) showed that hardware infrastructure, networks, and information systems were the most important factors influencing the adoption of the EHRs. Therefore, it is essential to assess the technical infrastructure, equipment, and standards before the adoption of the system to prevent potential failures. Organizations also need to ensure that the appropriate technical infrastructure (e.g. number, type, location of devices) is in place so that system performance (e.g. application and network response) is not impeded (Ramya et al., 2018).
The findings also showed that organizational challenges in the creation and adoption of the EHRs had the least importance (Mean=3.96) compared to other challenges while insufficient senior management support of the creation and adoption of the EHRs is the most important factor (Felix et al., 2020). The complexity of activities with the use of the EHRs can also be important because healthcare providers expect that the use of EHRs facilitates organizational tasks and duties. Similarly, other studies have found the EHRs to be a workflow facilitator, not a hindrance (Ramya et al., 2018; Ravka, 2017).

According to the results of this study, the individual challenges were more important (Mean=4.09) than the technical or organizational challenges from the participants’ point of view. The results indicated that there was a significant direct and positive relationship between the participants’ computer skills and their attitudes towards the challenges of the NEHR (Beta= 0.213, P=0.040). At a glance, it seems that the nurses with little computer skills, agreed more with the individual challenges of working with the system. Of course, a lack of healthcare providers’ involvement in the steps of design, development, and adoption of the EHRs can be an important factor in creating individual challenges (Niazkhani et al., 2020).  Thakkar and Davis's study (2006) also showed that the lack of healthcare providers’ involvement is the most important barrier in the adoption of the EHRs.
It is worth noting that before the creation and adoption of the EHRs, organizational culture should be considered since it may prevent healthcare providers from participating in the process of system design. The readiness and teaching of employees should be assessed before system implementation, because they may not be ready to accept the changes to a new system within their existing workflow and way of doing things. In this case, organizational culture may work as the most important barrier to the adoption of the system (Felix et al., 2020). Figure 3 shows that participants agreed the EHRs created good opportunities in nursing activities, but they felt that several challenges reduced the effectiveness of the system.

Figure 3: Opportunities and Challenges of the Impact of the National Electronic Health Record on Nursing Activities

Implications

The findings have implications for healthcare organizations, policymakers, researchers, and EHR developers.

Implications for healthcare organizations

Healthcare organizations will be able to better understand whether a NEHR will adequately support the largest user group. It may need to redesign the NEHR to allow for the effective use of the various system functions that can be valuable to nurses.

Implications for policymakers

Policymakers are encouraged to expand nurses’ contributions regarding the NEHR modifications and customizations. Allowing nurses’ voices to be more heard would improve and streamline the NEHR support for nurses while they provided care for different recipients.

Implications for researchers

This study presents an opportunity for the researchers to determine if barriers to, and facilitators of nurses’ use of the NEHRs vary at different points in time (e.g. within the first year or several years after implementation)

Implications for EHR developers

EHR developers should create systems that minimize the number of issues identified in this study to enhance the NEHR’s ability to support nursing practice. Therefore, measures such as design considerations, and nurse engagement in the pre-market design of the EHR seem necessary.

Limitations and future research

This study had limitations that should be considered related to the results presented.

First, the study was done in a region; therefore, the study findings are not likely to be generalizable for other regions that are using the national EHR. Second, despite the efforts made by the researchers, only 74% of the participants completed the questionnaire. Because this survey was completed anonymously, it was difficult for us to follow the non-respondents; however, their interests or their workload might have prevented them from completing the questionnaire.

To eliminate current barriers, strategic planning for the creation and adoption of the NEHR in the country, creation of a team including experts to assess potential challenges and to develop strategies to eliminate the barriers, and clarifying the objectives and benefits of the NEHR for all senior managers, users, and healthcare providers are suggested.

Conclusion

Although the use of the NEHR improves the quality of the nursing process by making healthcare data accessible and available at the point of care, several barriers may impact the successful implementation and administration of the NEHR.  Future studies need to determine the challenges and opportunities related to the implementation of the NEHR and their impact on tasks and functioning of nurses and other healthcare providers.

Conflicts of interest/Competing interests

The authors declare that there is no conflict of interest regarding the publication of this article.