Taibah University

Journal of Taibah University Medical Sciences (2014) 9(3), 213e218

Journal of Taibah University Medical Sciences

www.sciencedirect.com

Original Article

Physician satisfaction with electronic medical records in a major

Saudi Government hospital

Hana Alharthi, PhD, Adel Youssef, PhD *, Salma Radwan, BS,Sukainah Al-Muallim, BS and Al-Tuwaileb Zainab, BS

Department of Health Information Management & Technology, College of Applied Medical Science,

University of Dammam, Dammam, Kingdom of Saudi Arabia

Received 20 November 2013; revised 2 January 2014; accepted 5 January 2014Available online 10 July 2014

*

Ma

Un

of

Pee

165

Pro

htt

صخلملا

ماظننعبيبطلااضرىوتسمسايقلةساردلاهذهفدهت:ثحبلافادهأةصاخلاةيدرفلاةفصلاديدحتلًاضيأفدهتو،ةينورتكلالاةيبطلاتالجسلا.ماظنلانعبيبطلااضرىوتسمبةلصلاتاذةينورتكلإلاةيبطلاتالجسلاب

لماعممادختسامتو.ةيتاذةنابتساةئبعتميونتلامسقءابطأنمبِلُط:ثحبلاقرطاضرلاعمةيوقةقالعتاذةيدرفلاماظنلاتافصنميأديدحتلنوسريبطابترانيبةقالعلاةساردليطخلارادحنالارابتخاقيبطتمتكلذدعب.ماظنلانعماعلاطبضلاةاعارمعمماظنلانعماعلااضرلاوةنابتساللةسيئرلاتالاجمثالثلا.بيبطللةيصخشلاصئاصخلل

ماظنببيبطلااضرفلاخو.ةنابتسالاىلعابيبط115باجأ:جئاتنلاطقفءابطألانم%40ناكثيح.تاعقوتلاةينورتكلإلاةيبطلاتالجسلااضرنعؤبنتللصئاصخلامهأتناكو.ماعلكشبماظنلانعنيضارلمعلاريسعمجامدنإلايهو،ةعرسلاةيحاننمماظنلاءادأماظنللبيبطلا.ضيرملاتامولعمبةصاخلاتقولاو،لامكلاو،ةقدلاكماظنلاتامولعمو

نأيغبني.تبثملاماظنلانعنيضارريغماعلكشبءابطألاناك:تاجاتنتسالارايتخالاماظنلايمدختسمنمتاظحالملاوةتبثملاةمظنأللرمتسملامييقتلاهجوي.ةينورتكلإلاةيبطلاتالجسلاةمظنأذيفنتوايلبقتسم

تايفشتسملا;اضرلا;ءابطألا;ةينورتكلإلاةيبطلاتالجسلا:ةيحاتفملاتاملكلاةيدوعسلاةيبرعلاةكلممملا;ةيموكحلا

Corresponding address: Department of Health Information

nagement & Technology, College of Applied Medical Science,

iversity of Dammam, PO Box 2435, Dammam 31441, Kingdom

Saudi Arabia.

E-mail: aayoussef@ud.edu.sa (A. Youssef)

r review under responsibility of Taibah University.

8-3612 � 2014 Taibah University.

duction and hosting by Elsevier Ltd. All rights reserved.

p://dx.doi.org/10.1016/j.jtumed.2014.01.004

Abstract

Objectives: The objectives of this study were to measure

physician satisfaction with a recently introduced elec-

tronic medical record (EMR) system and to determine

which of the individual attributes of EMR were related to

physician satisfaction.

Methods: One year after introduction of an EMR system,

physicians in an inpatient department were asked to answer

a self-administered survey. Pearson’s correlation coefficient

was used to determine which attributes were significantly

related to overall satisfaction with the system. Linear

regression analysis was then performed to examine the as-

sociation between the three main domains of the question-

naire and overall satisfaction with the system, with

adjustment for physician demographic characteristics.

Results: A total of 115 physicians answered the survey.

Only 40% were satisfied with the system overall. The best

predictors of overall satisfaction were performance in the

form of speed, integration with workflow, and patient in-

formation, such as accuracy, completeness and timeliness.

Conclusion: Physicians were generally not satisfied with

the system. Continued evaluation of such systems and

feedback from users should guide future selection and

implementation.

Keywords: Electronic medical records; Governmental hospi-

tal; Kingdom of Saudi Arabia; Physicians; Satisfaction

� 2014 Taibah University. Production and hosting by

Elsevier Ltd. All rights reserved.

H. Alharthi et al.214

Introduction

Hospitals around the world are using electronic medical

records (EMRs) to help health care providers to deliver safer,better care to patients.1,2 EMR systems offer automatedelectronic information processing for physicians in their

day-to-day work.3 The extent to which these systems aresuccessful depends strongly on the acceptance of thephysicians regarding the performance of such systems.4,5

Generally speaking, physicians prefer EMRs and considerthat these systems eliminate much paperwork and enhancethe methods by which they monitor their patients’ progress.6

Furthermore, EMR technology offers many benefits, such as

legibility and completeness of medical information anddocumentation, immediate access to information anywhereat any time, a large clinical database and decision-support

techniques.7 The introduction of new informationtechnology systems into an organization is certain to changethe workflow,8 and sometimes users are dissatisfied because

of problems in using the system that result in delays inordering and disturb the workflow.9 Several studies indicatefailure of EMR systems due to lack of user input and lack

of evaluation of feedback on use of the system.10e12

Despite the drive by the Saudi Government to expand theinformation technology infrastructure in the health caresystem, particularly the nationwide transition from paper-

based medical records to EMRs, to the best of our knowl-edge the level and extent of use of EMRs has been addressedin only two studies.2,13 Neither specifically described

physicians’ views on EMRs. The objective of the studyreported here was to gain a better understanding ofphysicians’ satisfaction with EMRs. We therefore report

the results of a survey conducted in a local Governmenthospital in Kingdom of Saudi Arabia to identify theattributes of EMRs that are related to physiciansatisfaction. The results are expected to help decision-

makers improve subsequent deployment of EMRs.

Materials and Methods

Study site and setting

This cross-sectional analytical observational study was

conducted in a 360-bed Government hospital in the EasternProvince, Kingdom of Saudi Arabia. The hospital has acommercially available EMR system provided by the Min-

istry of Health, use of which is mandatory in all departmentsof the hospital. The system integrates updated patient in-formation from EMRs and contains clinical decision supportalgorithms, allowing physicians to use it as central source for

ordering and reviewing laboratory results. The study wasconducted 1 year after introduction of the system in thehospital. The physicians eligible for inclusion in the study

were specialists and general practitioners working in aninpatient department during introduction of the system andwho used the system routinely.

Survey preparation and data collection

The tool used to collect the data was a self-administered

survey based on the DeLone and McLean model,14e16

borrowed from the business world to measure the successof information technology systems and used extensively to

measure physician satisfaction with EMRs. The survey wasbased on a previously validated survey,17 supplementedwith items selected after a thorough review of the relevant

literature. The survey consists of 31 questions that coverthe user’s sociodemographic characteristics and satisfactionwith the system. It is divided into four domains: the first

(seven items) addresses overall satisfaction with the system,with questions about its performance, preference for paperrecords and preference for a different system; the second(eight items) addresses system performance quality, with

questions about the ease of use of the system, speed andintegration with the workflow; the third domain (sevenitems) addresses the quality of the information, with

questions about the completeness, accuracy and availabilityof information at the right time; and the fourth domain(three items) addresses service quality, with questions

about introduction of the system and training.The responses were given on a five-point Likert scale,

ranging from “strongly disagree” (1) to “strongly agree” (5).The reliability of the items was evaluated with Cronbach’s

alpha, and the valueswere all above 0.82, indicating satisfactoryreliability. The face validity of each item was assessed by theresearch team, a practising physician and experts in infor-

matics. After a pilot test of the survey conducted with 10 phy-sicians, some of the questions were reworded and rearranged.

The survey was distributed directly to 220 physicians be-

tween 30 March and 25 May 2010 under the guidance of theMedical Director and the head of the information technol-ogy department. Participation was voluntary, and re-

spondents were assured that their responses would remainconfidential. Approval for the study protocol was receivedfrom institutional review boards of both the hospital and theUniversity of Dammam.

Statistical analysis

Summary statistics for the study population were calcu-lated as frequencies and proportions for categorical vari-ables, and means and standard deviations for continuous

variables. Negative statements were reversed. To simplify thepresentation of level of satisfaction, the scale was collapsed,such that responses 4 and 5 were combined into “satisfied”

and 1, 2 and 3 into “not satisfied”. Pearson’s correlationcoefficient was used to determine which individual attributesof the system were significantly related to overall satisfaction

with the system.Mean overall satisfaction was determined byaveraging the answers to the seven questions. The remainingitems on the questionnaire were then correlated with themean overall satisfaction score. Linear regression analysis

was performed to examine the association between the threemain domains of the questionnaire and overall satisfaction,with adjustment for physicians’ demographic characteristics.

An alpha of <0.05 was considered to be statistically signifi-cant. Stata 12 was used for the analyses.

Results

Of 220 physicians who used the system daily in inpatient

departments, 115 were included in the final analysis,

Table 2: Mean responses and agreement with statements on

overall satisfaction with the system.

Mean

score (SD)

Agreement with

the statement

% (No.)

Satisfaction with electronic medical records 215

representing a 52.3% response rate. Table 1 shows thephysician characteristics; 71% were male, 64% were Saudi,

and the average age was 39.8 years. Of the respondents,70% worked in medical departments and 30% in surgicaldepartments. General practitioners and specialists were

fairly evenly distributed.

Positively worded statements:

Overall satisfaction with

system performance

3.2 (0.92) 40.0 (46)

Overall satisfaction with

system information

3.4 (0.87) 50.0 (57)

Overall satisfaction with

technical support

3.3 (0.88) 46.5 (53)

Overall satisfaction with

the system

3.4 (0.89) 48.7 (56)

Overall mean of positive

statements

3.3a(0.74) 46.3

b

Negatively worded statements:

Prefer to go back to paper

records

3.3 (1.15) 61.4 (70)

Prefer to use a different

system

3.7 (0.92) 90.3 (102)

Benefit to quality of care is

less than expected

3.6 (0.88) 85.1 (97)

Overall mean of negative

statements

3.5a(0.68) 78.9

b

Overall satisfaction

Table 2 shows physician satisfaction with the system.Only 40% were satisfied with the system; furthermore,

61% were willing to totally abandon the system and goback to paper records. Of the physicians surveyed, 90%wanted to change the system, and 70% of those who did

not want to go back to a paper system wanted to changethis particular system. The mean of negatively stated itemson overall satisfaction with the system (such as going back

to paper records, prefer to use a different system) wasgenerally higher than that for positively stated statements(overall satisfaction with the system performance andsystem information) (3.5 vs 3.3, p ¼ 0.01). Also, the mean

percentage agreement with negatively stated statementswere higher than that with positively stated statements(78.9% vs 46.3%, p < 0.001).

Likert scale: 1 ¼ strongly disagree, 2 ¼ disagree, 3 ¼ neutral,

4 ¼ agree, and 5 ¼ strongly agree.a Difference between overall means, p ¼ 0.01.b Difference between mean proportions, p < 0.001.

Satisfaction with the quality of the system

As shown in Table 3, physician satisfaction with theperformance and quality of information in the system was

moderate at best. Of the six items on quality ofperformance, only two items, “system easy to use” and“security is acceptable”, were satisfactory to about 65% ofthe respondents. About 50% agreed with the statements

“features allow me to perform my work well” and “theperformance of the system is reliable”. Fewer than half ofthe respondents agreed that “the system is fast” and “the

system is integrated with my workflow”.

Table 1: Survey response rate and demographic characteristics

of participants.

Frequency (%)

Number contacted 220

Responses 115 (52.3%)

Age (years) (mean, SD) 39.8 (9.9)

Sex

Female 33 (28.7)

Male 82 (71.3)

Nationality

Saudi 73 (63.5)

Non-Saudi 42 (36.5)

Years of practice (years) (mean, SD) 12.3 (9.8)

Profession

General 52 (45.2)

Specialist 63 (54.8)

Department

Medical 81 (70.4)

Surgical 34 (29.6)

Satisfaction with the quality of information and service

For the seven items assessing information quality(Table 3), just above 60% of the physicians agreed with only

three items, “the information is accurate”, “relevant” and“in acceptable format”. Less than half the physiciansagreed that “the information is complete” or “available

when needed”.About half of the responding physicians agreed that the

level of training and level of on-going support were accept-

able (Table 3).

Correlations with overall satisfaction

Although overall satisfaction with the system was statis-

tically significantly correlated with all the system attributes,the correlations were weak to moderate (range, 0.27e0.57).Two items, “speed of the system” and “information is up to

date”, were highly correlated with overall satisfaction withthe system (r ¼ 0.56, p < 0.001 and 0.57, p < 0.001 respec-tively). Items that showed moderate correlations with overall

satisfaction were “reliable system performance” (r ¼ 0.5),“completeness of information” (r ¼ 0.53), “accuracy ofinformation”(r ¼ 0.52) and “information available when

needed” (r ¼ 0.52) (Table 3).In the multiple linear regression analysis, the domains

system quality and information quality remained as signifi-cant predictors of overall satisfaction with the system

(b ¼ 0.19, 95% confidence interval, 0.01e0.36; and b ¼ 0.25,

Table 3: Perceptions of system, information quality and system

functionality and correlations to overall satisfaction.

Dimension Agreement

with statement

% (n)

Correlation

with overall

satisfactiona

(r)

System performance quality

Easy to use 64.4 (74) 0.32

Fast (minimal wait between

screen and start-up)

41.7 (48) 0.56

Integrated with the my workflow 47.8 (55) 0.47

Security is acceptable. 65.2 (75) 0.31

Features allow me to perform

my work well.

54.8 (63) 0.27

Reliable performance 51.3 (59) 0.50

System information quality

The information is complete. 45.2 (52) 0.53

The information is up to date. 54.8 (63) 0.57

The information is accurate. 63.5 (73) 0.52

The information is relevant. 63.5 (73) 0.43

Available when needed 49.6 (57) 0.52

The format is acceptable. 61.7 (71) 0.45

Service quality

Implementation process

was acceptable.

61.7 (71) 0.45

Level of training is acceptable. 49.6 (57) 0.31

Level of on-going support

is acceptable.

55.7 (64) 0.30

a p < 0.001.

H. Alharthi et al.216

95% confidence interval, 0.10e0.41, respectively) after

adjustment for confounding (Table 4).

Discussion

One of the most crucial findings of our study was lowoverall satisfaction with the system by the majority of thephysicians: 65% expressed general dissatisfaction withEMRs. Furthermore, 61% wished to abandon the system

and go back to paper records, and 90% asked for anotherEMR system. The overall satisfaction of the physicians wassignificantly associated with the quality of information and

performance of the system. Despite their overall negativeattitude to the system, the physicians acknowledged that thetechnology would probably improve the quality of care.

The system was considered easy to use by 64% of thephysicians, a finding similar to those of other studies.18,19

Nevertheless, 58% of the physicians were dissatisfied with

Table 4: Multivariate relations between system attributes and

overall satisfaction.

Quality attribute b (SE) p 95% CI

System performance

quality

0.19 (0.09) 0.03 0.01e0.36

System information

quality

0.25 (0.08) 0.004 0.10e0.41

Service quality �0.04 (0.06) 0.53 �0.15 to 0.08

Multivariate linear regression analysis with adjustment for phy-

sicians’ age, sex, nationality and speciality.

the speed of the system, reporting that it took a long timeto move between screens and that the system was slow to

start up. Clinicians in other studies had similar concerns.20,21

The literature reports conflicting views on the security ofsuch systems, some physicians considering that they protect

information well,22,23 while in another study only 30% ofphysicians had a positive view of the effect of computerson patient privacy.24 In our study, system security was the

attribute for which the physicians reported the greatestsatisfaction. They may have considered that individualhealth information in this country is generally not abused,whereas in other countries patients with certain diseases

may be denied jobs or health insurance coverage.Only 48% of the physicians considered that the system

was integrated well with their workflow, an important factor

in overall satisfaction with the system. Cheng et al.8

commented that EMR systems create new workflows,which may result in human error over time if not properly

integrated. Many complex technological and social issuesmust be addressed in introducing such systems,25 and amiddle ground must be reached between clinical workflowand software features while not compromising patients’

safety or the quality of care.26

Patient information is critical for delivering the best care;however, in our study, the physicians were not satisfied with

the completeness or accuracy of the information: only 45%reported that the information was complete and 64% that itwas accurate. This is surprising, as we would have expected

higher percentages of the clinicians to report more positiveviews on one of the main advances introduced byEMRs.24,27,28 Lack of accuracy and completeness of

information, as indicated in this study, should alert thehospital management to improve reporting fromdepartments that provide patient information, such aslaboratory and radiology departments. This includes both

conducting the requested tests without unnecessary delayand entering accurate, timely results into the system.

The screen layout was acceptable to 62% of the physi-

cians, who considered that information was presented in asuitable format. These results are similar to those reported byresearchers at hospitals in the USA.19 Others have found,

however, that the screen layout is confusing and difficult tofollow, hindering use of EMRs by physicians.7,22 A user-friendly screen layout for information not only improves

the efficiency and productivity of users but also increases thelevel of physician satisfaction and their desire to continue touse the system.

Less than half of the physicians considered that the level

of training was adequate, a percentage similar to those inother studies.21,29,30 Morton and Wiedenbeck pointed outthat younger users found the training adequate because of

their prior experience with computers.27 Although most ofour study population was young, they were dissatisfiedwith their training on EMRs. The physicians in our study

might also have been experienced computer users butexpected more sophisticated training. Additionally, onlyhalf found that the system support was acceptable.O’Connell et al.31 also found that only 50% of users

considered the level of support acceptable. Delayedsupport from the information technology department whenneeded can increase physicians’ frustration with the system.

Studies have shown that good support by information

Satisfaction with electronic medical records 217

technology departments and better collaboration withphysicians improves the success rate of already installed

systems.4,18

When we examined how the three main dimensions of thisstudy were related to overall satisfaction, we found that the

strongest predictor of overall satisfaction was the quality ofinformation, particularly when it was up-to-date, accurate,complete and available when needed. This was followed by

the quality of the system itself, particularly that it was fast,reliable and integrated well with the workflow. These find-ings confirm those of several previous studies that efficient,fast systems that provide useful patient information are

essential for physician satisfaction.9,32,33 A user-friendlydesign makes the system easy to use and increases the levelof acceptance and willingness to use it. We found a non-

significant association between system support and overallsatisfaction, which was not consistent with the results ofmost other studies.20,34 The need for information system

support depends on the sophistication of the system andthe number of functions. It is not clear if physiciandissatisfaction in our study with system support was due tothe fact that the system was not sophisticated and had only

basic functions, which did not require as much support asin other studies. Future studies of physician satisfactionwith EMRs should include the level of system

sophistication to allow for proper comparisons.The fact that this survey was conducted 1 year after

introduction of the system may partly explain the overall

dissatisfaction of the users, particularly as use of the system ismandatory. User satisfaction might, however, increase overtime as they become more experienced in use of the system.6

To address that issue, a new survey should be conducted. Assatisfaction tends to improve with regard to some aspects ofa system but not others,6 the best strategy for increasingacceptance would be to maximize positive perceptions of

all aspects of the system during its introduction.35

Satisfaction with the system in our study was not associ-ated with the demographic characteristics of the participants,

including age, sex, nationality, profession or department,which is consistent with several other studies.6,36e38 Thisconsistent finding among studies reaffirms the importance

of system attributes such as speed, quality of informationand compatibility with physician workflow in theiracceptance, irrespective of physician characteristics.

The two main limitations of this study were that it wasperformed in one Government hospital with one EMRsystem, and the results may not be generalizable to othertype of hospitals or hospitals with different EMR systems;

and only 52% of the eligible physicians participated in thesurvey. Although relatively low response rates are commonin satisfaction surveys, this may have introduced selection

bias. Voluntary respondents to satisfaction surveys gener-ally tend to have more positive or more negative perceptionsof issues.

Conclusions

This study shows that physicians were generally dissatis-fied with the EMR system and that various aspects of thesystem require improvement. Hospital management and

stakeholders such as the Ministry of Health could benefit

from the views expressed by the physicians in this study.Continued evaluation of installed systems and feedback from

users should guide future selection and introduction of EMRsystems. Despite the huge investment in health informationsystems and the push by the Ministry of Health for wide

implementation of EMRs, the results of this study andothers13 indicate that the choice and introduction of EMRsystems in Saudi hospitals still needs to be improved.

Conflict of interest

The authors have no conflict of interest to declare.

References

1. Palm JM, Colombet I, Sicotte C, Degoulet P. Determinants of

user satisfaction with a clinical information system. AMIA Annu

Symp Proc 2006; 614e618.2. Bah S, Alharthi H, El Mahalli AA, Jabali A, Al-Qahtani M, Al-

kahtani N. Annual survey on the level and extent of usage of

electronic health records in government-related hospitals in

Eastern Province, Saudi Arabia. Perspect Health Inf Manag

2011; 8: 1b.

3. Cheriff AD, Kapur AG, Qiu M, Cole CL. Physician produc-

tivity and the ambulatory EHR in a large academic multi-

specialty physician group. Int J Med Inf 2010; 79: 492e500.

4. Yui BH, Jim WT, Chen M, Hsu JM, Liu CY, Lee TT. Evalu-

ation of computerized physician order entry systemda satis-

faction survey in Taiwan. J Med Syst 2012; 36: 3817e3824.

5. Van der Meijden MJ, Tange HJ, Troost J, Hasman A. De-

terminants of success of inpatient clinical information systems: a

literature review. J Am Med Inform Assoc 2003; 10: 235e243.

6. Chisolm DJ, Purnell TS, Cohen DM, McAlearney AS. Clinician

perceptions of an electronic medical record during the first year

of implementation in emergency services. Pediatr Emerg Care

2010; 26: 107e110.

7. Hier DB, Rothschild A, LeMaistre A, Keeler J. Differing fac-

ulty and housestaff acceptance of an electronic health record.

Int J Med Inf 2005; 74: 657e662.

8. Cheng CH, Goldstein MK, Geller E, Levitt RE. The Effects of

CPOE on ICU workflow: an observational study. AMIA Annu

Symp Proc; 2003: 150e154.

9. Khajouei R, Wierenga PC, Hasman A, Jaspers MW. Clinicians

satisfaction with CPOEdease of use and effect on clinicians’

workflow, efficiency and medication safety. Int J Med Inf 2011;

80: 297e309.

10. Menachemi N, Powers TL, Brooks RG. The role of informa-

tion technology usage in physician practice satisfaction. Health

Care Manage Rev 2009; 34: 364e371.

11. Zheng K, Padman R, Johnson MP, Diamond HS. Under-

standing technology adoption in clinical care: clinician adoption

behavior of a point-of-care reminder system. Int J Med Inf

2005; 74: 535e543.

12. Wakefield DS, Halbesleben JR, Ward MM, Qiu Q, Brokel J,

Crandall D. Development of a measure of clinical information

systems expectations and experiences. Med Care 2007; 45: 884e

890.

13. Nour El Din MM. Physicians’ use of and attitudes toward

electronic medical record system implemented at a teaching

hospital in Saudi Arabia. J Egypt Public Health Assoc 2007; 82:

347e364.

14. DeLone WH, McLean ER. Information systems success: the

quest for the dependent variable. Inf Syst Res 1993; 3: 60e95.15. DeLone WH, McLean ER. The DeLone & McLean model of

information systems success: a ten-year update. J Manag Inf

Syst 2003; 4: 9e30.

H. Alharthi et al.218

16. Pare G, Lepanto L, Aubry D, Sicotte C. Toward a multidimen-

sional assessment of picture archiving and communication sys-

tem success. Int J Technol Assess Health Care 2005; 21: 471e479.

17. Canada’s health infostructure. Ottawa, Ontario: Health Canada;

2013.www.hc-sc.gc.ca/hcs-sss/ehealth-esante/infostructure/

index-eng.php [accessed 30.09.13].

18. Palm JM, Dart T, Dupuis I, Leneveut L, Degoulet P. Clinical

information system post-adoption evaluation at the Georges

Pompidou University Hospital. AMIA Annu Symp Proc 2010;

2010: 582e586.

19. Murff HJ, Kannry J. Physician satisfaction with two order

entry systems. J Am Med Inform Assoc 2001; 8: 499e509.

20. Shield RR, Goldman RE, Anthony DA, Wang N, Doyle RJ,

Borkan J. Gradual electronic health record implementation:

new insights on physician and patient adaptation. Ann Fam

Med 2010; 8: 316e326.

21. Joos D, Chen Q, Jirjis J, Johnson KB. An electronic medical

record in primary care: impact on satisfaction, work efficiency

and clinic processes. AMIA Annu Symp Proc; 2006: 394e398.

22. McAlearney AS, Chisolm DJ, Schweikhart S, Medow MA,

Kelleher K. The story behind the story: physician skepticism

about relying on clinical information technologies to reduce

medical errors. Int J Med Inf 2007; 76: 836e842.

23. Likourezos A, Chalfin DB, Murphy DG, Sommer B, Darcy K,

Davidson SJ. Physician and nurse satisfaction with an elec-

tronic medical record system. J Emerg Med 2004; 27: 419e424.

24. Simon SR, Soran CS, Kaushal R, Jenter CA, Volk LA,

Burdick E, et al. Physicians’ use of key functions in electronic

health records from 2005 to 2007: a statewide survey. J AmMed

Inform Assoc 2009; 16: 465e470.

25. Holden RJ. Physicians’ beliefs about using EMR and CPOE: in

pursuit of a contextualized understanding of health IT use

behavior. Int J Med Inf 2010; 79: 71e80.26. Christensen T, Faxvaag A, Loerum H, Grimsmo A. Norwegian

GPs’ use of electronic patient record systems. Int J Med Inf

2009; 78: 808e814.

27. Morton ME, Wiedenbeck S. EHR acceptance factors in

ambulatory care: a survey of physician perceptions. Perspect

Health Inf Manag 2010; 7: 1c.

28. Aaronson JW, Murphy-Cullen CL, Chop WM, Frey RD.

Electronic medical records: the family practice resident

perspective. Fam Med 2001; 33: 128e132.

29. Ghahramani N, Lendel I, Haque R, Sawruk K. User satisfac-

tion with computerized order entry system and its effect on

workplace level of stress. J Med Syst 2009; 33: 199e205.

30. Khajouei R, de Jongh D, Jaspers MW. Usability evaluation of a

computerized physician order entry for medication ordering.

Stud Health Technol Inform 2009; 150: 532e536.

31. O’Connell RT, Cho C, Shah N, Brown K, Shiffman RN. Take

note(s): differential EHR satisfaction with two implementations

under one roof. J Am Med Inform Assoc 2004; 11: 43e49.

32. Campbell EM, Guappone KP, Sittig DF, Dykstra RH, Ash JS.

Computerized provider order entry adoption: implications for

clinical workflow. J Gen Intern Med 2009; 24: 21e26.33. Khajouei R, Jaspers MW. The impact of CPOE medication

systems’ design aspects on usability, workflow and medication

orders: a systematic review. Methods Inf Med 2010; 49: 3e19.

34. Sicotte C, Pare G, Moreault MP, Lemay A, Valiquette L,

Barkun J. Replacing an inpatient electronic medical record.

Lessons learned from user satisfaction with the former system.

Methods Inf Med 2009; 48: 92e100.35. Menachemi N, Powers T, Au DW, Brooks RG. Predictors of

physician satisfaction among electronic health record system

users. J Healthc Qual 2010; 32: 35e41.

36. Weimar C. Electronic health care advances, physician frustra-

tion grows. Physician Exec 2009; 35: 8e15.

37. Morton ME, Wiedenbeck S. A framework for predicting EHR

adoption attitudes: a physician survey. Perspect Health Inf

Manag 2009; 6: 1a.

38. Laerum H, Ellingsen G, Faxvaag A. Doctors’ use of electronic

medical records systems in hospitals: cross sectional survey.

BMJ 2001; 323: 1344e1348.