Exploring Patient Satisfaction Before and After Electronic Health Record (EHR) Implementation: The Kuwait Experience

by Eiman Al-Jafar, PhD

Abstract

Patient satisfaction has gained the focal position in well-planned healthcare delivery systems. The objective of this study was to investigate patient satisfaction with the quality of services provided before and after the implementation of electronic health records (EHRs) at Primary Health Care Centers (PHCCs) in Kuwait. A self-developed questionnaire was used. A random sampling was used to select 700 subjects. The response rate was 74 percent. The majority of participants (67 percent) were 19 to 34 years of age. Of the participants, 63 percent were female and 92 percent were Kuwaiti nationals. Before EHR implementation, respondents’ disagreement regarding the doctor’s carefulness in conducting the examination, uses of medical terminology, explanations for medication given, and time given for a patient was more than 30 percent. Disagreement regarding the rest of the questions related to the patient/physician relationship after EHR implementation was also higher (25 percent to 39 percent).

Keywords: electronic health records, patient satisfaction, primary healthcare

Background

“Empirical studies of the [electronic health record (EHR)] have increased”1 recently, but few studies have explored the impact of EHRs on patients’ satisfaction and the physician-patient relationship.

Patient satisfaction has gained the focal position in modern-day, well-planned healthcare delivery systems. Much attention within the healthcare industry is focused on patients’ satisfaction with the quality of healthcare services. Several lines of research have converged on the finding that care providers’ interactions with patients and their families have remarkably strong effects on clinical outcomes, functional status, and even physiologic measures of health.2,3 Measurement of such interactions is used as a key indicator of healthcare quality by many physicians and consumer groups. It gives useful feedback to clinicians and managers on perceived performance and satisfaction with care that may not be apparent through more traditional audit measures.4-7 However, patient satisfaction has not been widely studied with respect to implementation of EHRs.8

A study conducted by Menachemi and Collum indicated that the potential benefits of EHRs include improved clinical, organizational, and societal outcomes. Clinical outcomes include improving the quality of care provided to patients and reducing medical errors. Organizational outcomes include financial and operational benefits. Societal outcomes include the improved ability to conduct research, improved population health, and reduced costs.9

The Ministry of Health in Kuwait implemented various projects aimed at improving the quality of healthcare services. These comprehensive projects targeted primary, secondary, and tertiary levels of care. One project was the implementation of EHRs at the Primary Health Care Centers (PHCCs).10 The move toward implementing EHRs was a result of many factors and problems faced by the Ministry of Health. The Ministry of Health recognized the need for accurate, complete, and comprehensive patient information and data for providing quality healthcare, delivering accurate statistics, helping in the planning process, evaluating treatment effectiveness, and facilitating the decision-making process. In addition, EHRs have the potential to advance the quality of healthcare.11-17

Patients who get healthcare services from Kuwait’s PHCCs are often observed to complain about the quality of the services provided in general. A study was conducted in 2006 to investigate patients’ satisfaction with primary healthcare in Kuwait after the implementation of EHRs without considering patients’ satisfaction before the implementation.18 Although EHR implementation has several advantages, barriers to EHR adoption remain.19 Some of the barriers may include the effects on eye contact and time spent with patients.20,21 Therefore, this study sought to identify patients’ perception of and satisfaction with the quality of the services provided at the PHCCs before and after the implementation of EHRs. In particular, the level of satisfaction with physicians, administrative staff (receptionists), routine procedures and paperwork, waiting time before seeing the doctor, time spent at the doctor’s office, working hours, and appointment availability were analyzed.

The significance of this study lies in assessing the level of healthcare quality as perceived by patients, identifying gaps between patient expectations and actual process, providing an empirical base for changes to be made by policy makers, offering feedback to care providers, and, in the long run, indicating changes that should be made in the medical curriculum.

Method

Sample

The Kuwait Health Care Delivery System includes more than 78 PHCCs. For this study, the population consisted of all patients who visited the various PHCCs in Kuwait. The data were collected using a self-developed questionnaire. The questionnaires were distributed among patients at the time of their visits at PHCCs during morning and evening shifts from September 2004 to December 2004. A total of 700 questionnaires were distributed at various clinics. At each clinic, patients were selected randomly. The patient’s agreement to participate in the study was obtained before each questionnaire was completed.

Instrument

The questionnaire aimed to collect data on participants’ demographic characteristics. In addition, general questions on the clinics’ location, cleanliness, and decoration were included. Moreover, three separate sections addressed the patient/physician relationship before and after implementation of EHRs and the attitudes of other professionals at the clinics. At the end of the questionnaire, three open-ended questions were included. Before the data collection, the questionnaire was pretested for construct validity and reliability. The questionnaires were piloted with 20 patients, and a few adjustments were made regarding the wording of some questions.

Statistical Analysis

Data were analyzed using SPSS software. For reporting, descriptive statistics were used. In addition, factor analysis was used to identify the common significant factors regarding the patients’ satisfaction with the services of the clinics.

Results

The response rate was 74 percent, with 518 patients participating out of 700 surveys distributed. The patients who visited the PHCCs included 344 (67 percent) who were 19 to 34 years of age, followed by 81 (16 percent) between 35 to 49 years and 80 (15 percent) who were 18 years of age or below. Only 12 (2 percent) of the patients were 50 years or older. Among the patients, 325 (63 percent) were female and 189 (37 percent) were male. Regarding nationalities of the patients, 465 (92 percent) were Kuwaiti and 42 (8 percent) were non-Kuwaiti. (See Table 1.)

Table 1
Distribution of Respondents’ Demographic Characteristics

Characteristic Frequency Percentage
Age (in years)
18 or below 80 15
19–34 344 67
35–49 81 16
50+ 12 2
Sex
Male 189 37
Female 325 63
Nationality
Kuwaiti 465 92
Non-Kuwaiti 42 8

Regarding visits to PHCCs, 475 (93 percent) had previous visits, while only 38 (7 percent) of the patients had never visited the PHCCs previously. Among the patients, 335 (65 percent) had a visit during the last 3 months, 99 (19 percent) during the last 6 months, and 81 (16 percent) during the last year or earlier. Among the patients, 83 percent had a waiting time of 20 minutes or less to see a doctor, while 17 percent had to wait more than 20 minutes. Among patients who had to wait more than 15 minutes, 18 percent were given an explanation for the delay.

General characteristics related to the clinics include the greeting on arrival, which 25 percent of the patients reported as poor, followed by the waiting room decor (reported as poor by 23 percent), waiting time (reported as poor by 19 percent), promptness of attention (18 percent poor), waiting room comfort (16 percent poor), and courtesy of the receptionist (14 percent poor). Regarding the convenience of the clinic’s location, only 6 percent reported it as poor and 7 percent reported it as fair; the rest of the respondents reported it as good, very good, or excellent. (See Table 2.)

Table 2
Distribution of General Clinic-related Characteristics

Characteristics Excellent Very Good Good Fair Poor
N % N % N % N % N %
Convenience of clinic's location 182 36 139 27 127 25 36 7 29 6
Clear directions within clinic 99 19 170 33 132 26 77 15 34 7
Clinic's working hours 105 21 133 26 147 29 73 14 50 10
Cleanliness 150 29 146 29 137 27 44 9 35 7
Greeting on arrival 37 7 71 14 135 26 141 28 128 25
Promptness of attention 43 8 93 18 134 26 151 30 92 18
Courtesy of receptionist 54 11 88 17 155 30 141 28 72 14
Waiting time for appointment 29 6 101 20 170 33 115 23 96 19
Waiting room decor 37 7 73 14 154 30 132 26 116 23

Waiting room comfort 32 6 81 16 168 33 148 29 83 16

Overall impression 50 10 104 20 184 36 122 24 53 10

The distribution of characteristics of the patient/physician relationship before the implementation of EHRs is presented in Table 3. More than 30 percent of respondents disagreed or strongly disagreed with items regarding the doctor’s carefulness about the examination, use of medical terminology, explanations provided for prescribed medication, and time allotted for the patient. The percentage of respondents disagreeing or strongly disagreeing with the other items related to the patient/physician relationship varied from 23 percent to 29 percent.

Table 3
Distribution of Characteristics of the Patient/Physician Relationship before Implementation of Electronic Health Records (EHRs)

Characteristics Strongly Agree Agree Uncertain Disagree Strongly Disagree
N % N % N % N % N %
Doctor gives needed attention 60 12 168 33 137 27 114 22 32 6
Doctor explains reasons for medical tests 67 13 184 37 113 21 106 21 32 6
Doctor spends enough time with patient 58 11 165 33 108 21 139 27 38 8
Doctor listens carefully to my complaints 56 11 186 38 133 27 90 18 25 5
Doctor explains reason for prescribed medication 70 14 176 35 106 21 120 24 36 7
Sometimes I am not confident about the doctor's diagnosis 83 17 178 37 106 22 80 17 38 8
During visit, doctor performs complete physical check 52 10 108 21 119 23 157 31 72 14
At the visit, I am allowed to discuss my case 69 14 165 33 140 28 105 21 27 5
Sometimes doctor uses unclear medical terms 46 9 120 23 152 30 150 29 44 9

Table 4 shows the data on the patient/physician relationship after EHR implementation. After implementation of EHRs, the percentage of patients agreeing or strongly agreeing with questions related to the patient/physician relationship after implementation of EHRs, (e.g., the doctor focuses on EHR screen rather than on patient, I believe EHR took doctor’s attention from me, at visit, doctor pays more attention to typing, and EHRs increase trust in physicians) varied from 36 to 50 percent.

Table 4
Distribution of Characteristics of the Patient/Physician Relationship after Implementation of Electronic Health Records (EHRs)

Characteristics Strongly Agree Agree Uncertain Disagree Strongly Disagree
N % N % N % N % N %
Doctor focuses on EHR screen rather than on patient 118 23 136 27 107 21 119 23 30 6
I believe EHR took doctor's attention from me 80 16 122 24 119 23 143 28 46 9
At visit, doctor pays more attention to typing 88 17 135 27 126 25 125 25 29 6
Doctor gives copies of medical information to patient 26 5 67 14 102 20 169 34 137 27
EHRs didn't affect relationship with doctors 66 13 151 30 149 30 95 19 42 8
EHRs improved relationship with doctors 44 9 111 22 175 35 112 23 56 11
EHRs increase trust in doctors 44 9 137 27 147 29 118 24 56 11
I support using EHRs at Primary Health Care Centers (PHCCs) 127 25 178 36 102 20 57 11 37 7
I gained no benefit from EHRs 63 13 89 18 136 27 124 25 88 18
No improvement seen with EHRs 72 15 90 18 136 27 135 27 63 13

Data on the behavior of the other professionals at the PHCCs shows the following: except for effective treatment and professionalism of staff at PHCCs, patients’ agreement on other questions were 50 percent or more. Slightly more than 50 percent of the patients did not agree regarding the effectiveness of treatment and other staff members’ professionalism at the PHCCs. This part of the survey is excluded from this study but will be addressed in a future study.

Discussion

The majority of Kuwait’s population use the PHCCs as the first step to access healthcare services. The initial implementation of EHRs by the Ministry of Health in Kuwait took place at the PHCCs in 2002. This study aimed to investigate patient satisfaction with the quality of services provided before and after the implementation of EHRs at the PHCCs in Kuwait.

Factor Analysis

The results of exploratory factor analysis are presented in Table 5 and Table 6. Factor analysis is used to identify the common factors that explain the patients’ relationship with the physician before and after implementation of EHRs and the relationships with other professionals working at the PHCCs. Using the factor loadings from factor analysis also helps to identify the construct validity of our questionnaire. Table 5 presents the factor analysis of items related to the patient/physician relationship before EHR implementation. Factor analysis identified two common factors on the basis of eigenvalues greater than 1, which explain 56 percent of total variations. The loadings of the two factors vary from 0.62 to 0.82, which showed that the construct validity of these items is very high. The first factor explains whether the physician is taking enough time to address patients’ questions, such as by explaining the patient’s medical problem, test, procedure, or prescribed medication, which makes a patient feel confident about the doctor. The second factor explains items that reduce the patient’s confidence in the doctor.

Table 5
Factor Analysis of Items Related to the Patient/Physician Relationship before Implementing Electronic Health Records (EHRs)

Items Factor Loadings
Factor 1 Factor 2
v26 Doctor gives needed attention .807
v25 Doctor explains reasons for medical tests .805
v24 Doctor explains tests and procedures in understandable terms .796
v23 Doctor explains problem clearly .793
v31 Doctor listens carefully to my complaints .788
v22 Doctor answers all questions .768
v35 During my medical care I am always allowed to say everything I think is important 735
v30 Doctor pays more attention to privacy during care .728
v32 Doctor explains reason for prescribed medication .726
v34 During visit, doctor performs complete physical check .712
v21 Doctor gives needed attention .689
v20 Personal manner of physician .616
v33 Sometimes I am not confident about the doctor's diagnosis .772
v29 Doctor sometimes ignores what I say .730
v36 Sometimes doctor uses unclear medical terms .657

 

Table 6
Factor Analysis of Items Related to the Patient/Physician Relationship after Implementing Electronic Health Records (EHRs)

Items Factor Loadings
Factor 1 Factor 2 Factor 3
v44 Using the computer improved my relationship with my doctor .847
v45 Using the computer provides me with more trust in my doctor .807
v43 Implementation of electronic records did not affect my relationship with the doctor .712
v41 I receive adequate eye contact from doctor .702
v46 I support using a computer system in my clinic .648
v42 Doctor gives copies of medical information to patient .588
v38 At any time I visit the doctor, his attention is on the computer .903
v37 Doctor focuses more on computer screen than on me .877
v39 I believe EHRs took doctor's attention from me .848
v40 While I was receiving medical care, doctor paid more attention to typing .774
v48 I can't see any improvement in clinic system after computer implementation .822
v47 I gained no benefits from using computer system .816
v49 Consultation time increased after using computer system .574

The factor analysis of items related to the patient/physician relationship after EHR implementation identified three common factors on the basis of eigenvalues greater than 1, which explain 66 percent of total variations. The factor loadings vary from 0.57 to 0.90, which again showed that the construct validity of these items is very high. It was easy to name the three factors identified here. The first factor explained the patients’ perception regarding improvement in the quality of care due to the implementation of EHRs. For example, some patients indicated that using EHRs improved relations with the physician and increased trust in the physician’s performance. The second factor explained the patients’ feeling about the shift of the doctor’s attention from the patient to the computer screen, such that less eye contact was received. Finally, the third factor explained the patients’ perception of the negative impact due to the computerization. For example, some patients did not see improvement in the clinic’s system after EHR implementation. (See Table 6.)

One limitation of this study is the low participation of non-Kuwaitis in the study (8 percent) although they form the majority of Kuwait’s population.

As noted above, data on the behavior of other professionals on the healthcare team working at the PHCCs were excluded from this study but will be used in a future study. Another exclusion was the results of the three open-ended questions because of difficulty in categorizing participants’ answers into limited themes.

Conclusion

EHRs in healthcare settings pose challenges to medical practice.22 Therefore, more studies of EHR implementation and its effects on the medical practice in general and on physician-patient relationships are needed.

This study’s results show decreased physician attention toward patients during patient visits due to the use of EHRs. EHR implementation should support positive relationships with patients and improve the quality of care.23 Implementation of EHR systems in gradual phases in healthcare facilities will help the healthcare professionals adapt to the system as well as maintain good physician-patient relationships.24

The data were gathered during 2004, when technology use was not as common among Kuwait’s population as it is today. Hence, a similar study will be conducted in the near future to investigate further the impact of EHR systems on patients’ satisfaction. The new study will include a larger sample size to better represent the population in Kuwait.

More studies should be conducted related to EHRs and the improvement of patient care. EHR training should be introduced for the various health care professionals and in medical schools’ curricula.25 Other studies should be conducted after more years have passed since EHR implementation to investigate the cost-benefit factors.

Support

This research was supported by Kuwait University, grant no. ZN 03/04.

Eiman Al-Jafar, PhD, is a faculty member in the Department of Health Information Administration, Faculty of Allied Health Sciences at Kuwait University, Kuwait.

Notes

1 Shield, R. R., R. E. Goldman, D. A. Anthony, N. Wang, R. J. Doyle, and J. Borkan. “Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation.” Annals of Family Medicine 8, no. 4 (2010): 316–26.

2 Kenagy, J. W., D. M. Berwick, and M. F. Shore. “Service Quality in Health Care.” Journal of the American Medical Association 281, no. 7 (1999): 661–65.

3 Bolus, R., and J. Pitts. “Patient Satisfaction: The Indispensable Outcome.” Managed Care 8, no. 4 (1999): 24–28.

4 Thorne, L., and N. Kitchen. “Auditing Patient Experience and Satisfaction.” British Journal of Neurosurgery 16, no. 3 (2002): 243–55.

5 Garrison, G. M., M. E. Bernard, and N. H. Rasmussen. “21st-Century Health Care: The Effect of Computer Use by Physicians on Patient Satisfaction at a Family Medicine Clinic.” Family Medicine 34, no. 5 (2002): 362–68.

6 Goetz Goldberg, D., A. J. Kuzel, L. B. Feng, J. P. DeShazo, and L. E. Love. “EHRs in Primary Care Practices: Benefits, Challenges, and Successful Strategies.” American Journal of Managed Care 18, no. 2 (2012): e48–e54.

7 Holanda, A. A., H. L. do Carmo E Sá, A. P. Vieira, and A. M. Catrib. “Use and Satisfaction with Electronic Health Record by Primary Care Physicians in a Health District in Brazil.” Journal of Medical Systems 36, no. 5 (2012): 3141–49.

8 Rosen, P., S. J. Spalding, M. J. Hannon, R. M. Boudreau, and C. K. Kwoh. “Parent Satisfaction with the Electronic Medical Record in an Academic Pediatric Rheumatology Practice.” Journal of Medical Internet Research 13, no. 2 (2011): e40.

9 Menachemi, N., and T. Collum. “Benefits and Drawbacks of Electronic Health Record Systems.” Journal of Risk Management and Healthcare Policy 4 (2011): 47–55.

10 Al-Azmi, S. F., A. M. Mohammed, and M. I. Hanafi. “Patients’ Satisfaction with Primary Health Care in Kuwait after Electronic Medical Record Implementation.” Journal of the Egyptian Public Health Association 81, nos. 5–6 (2006): 277–300.

11 Zhou, L., C. S. Soran, C. A. Jenter, L. A. Volk, E. J. Orav, D. W. Bates, and S. R. Simon. “The Relationship between Electronic Health Record Use and Quality of Care over Time.” Journal of the American Medical Informatics Association 16 (2009): 457–64.

12 Zastowny, T. R., W. C. Stratmann, E. H. Adams, and M. L. Fox. “Patient Satisfaction and Experience with Health Services and Quality of Care.” Quality Management in Health Care 3, no. 3 (1995): 60–61.

13 O’Connell, R. T., C. Cho, N. Shah, K. Brown, and R. N. Schiffman. “Take Note(s): Differential EHR Satisfaction with Two Implementations under One Roof.” Journal of the American Medical Informatics Association 11, no. 1 (2004): 43–49.

14 Weir, C. R., R. Crockett, S. Gohlinghorst, and C. McCarthy. “Does User Satisfaction Relate to Adoption Behavior? An Exploratory Analysis Using CPRS Implementation.” AMIA Annual Symposium Proceedings (2000): 913–17.

15 Robertson, A., K. Cresswell, A. Takian, D. Petrakaki, S. Crowe, T. Cornford, et al. “Implementation and Adoption of Nationwide Electronic Health Records in Secondary Care in England: Qualitative Analysis of Interim Results from a Prospective National Evaluation.” BMJ 341 (2010): c4564.

16 Jha, A. K., C. M. DesRoches, E. G. Campbell, K. Donelan, S. R. Rao, T. G. Ferris, et al. “Use of Electronic Health Records in U.S. Hospitals.” New England Journal of Medicine 360, no. 16 (2009): 1628–38.

17 El-Kareh, R., T. K. Gandhi, E. G. Poon, L. P. Newmark, J. Ungar, S. Lipsitz, and T. D. Sequist. “Trends in Primary Care Clinician Perceptions of a New Electronic Health Record.” Journal of General Internal Medicine 24, no. 4 (2009): 464–68.

18 Al-Azmi, S. F., A. M. Mohammed, and M. I. Hanafi. “Patients’ Satisfaction with Primary Health Care in Kuwait after Electronic Medical Record Implementation.”

19 Ash, J. S., and D. W. Bates. “Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion.” Journal of the American Medical Informatics Association 12 (2005): 8–12.

20 Linder, J. A., J. L. Schnipper, R. Tsurikova, A. J. Melnikas, L. A. Volk, and B. Middleton. “Barriers to Electronic Health Record Use During Patient Visits.” AMIA Annual Symposium Proceedings (2006): 499–503.

21 Chaudhry, B., J. Wang, S. Wu, M. Maglione, W. Mojica, E. Roth, et al. “Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care.” Annals of Internal Medicine 144 (2006): E12–E22.

22 Shield, R. R., R. E. Goldman, D. A. Anthony, N. Wang, R. J. Doyle, and J. Borkan. “Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation.”

23 Goetz Goldberg, D., A. J. Kuzel, L. B. Feng, J. P. DeShazo, and L. E. Love. “EHRs in Primary Care Practices: Benefits, Challenges, and Successful Strategies.”

24 Shield, R. R., R. E. Goldman, D. A. Anthony, N. Wang, R. J. Doyle, and J. Borkan. “Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation.”

25 Ibid.


Article citation:
AL-Jafar, Eiman. "Exploring Patient Satisfaction Before and After Electronic Health Record (EHR) Implementation: The Kuwait Experience" Perspectives in Health Information Management (Spring, April 2013).