To explore the large-scale implementation of EHRS in PHCs in SA
3.4 Study Two: Assessing PHC readiness for EHRS implementation in SA from a PHC staff perspective SA from a PHC staff perspective
This study complements Study One, which was conducted to address the objective, “To assess PHC readiness for EHRS implementation from a project team perspective”.
Although, this study had the same objective, it was directed to a different population and utilised a different data collection instrument to comply with the addressed population.
Therefore, the objective of this study was “To assess PHC readiness for EHRS implementation in SA from a PHC staff perspective”. According to Negash et al. (2018), employee perspectives are important when assessing organisation readiness to change.
Although organisation readiness assessment documented to be influential factor to the EHRS implementation (see Section 3.3), some previous evaluation studies have failed to include aspects related to readiness at an individual level, such as individual attitude, awareness and knowledge about the EHRS (Biruk et al., 2014). This study therefore aimed to demonstrate the level of individual readiness to the EHRS implementation.
3.4.1 Population and sampling technique
The study population were all clinical staff such as physicians and administrative staff, such as receptionists, working in PHCs in SA that had not yet implemented EHRS (n=38514) (MoH, 2012). These staff were from various backgrounds, age groups, and occupations as well as genders.
The sampling strategy applied in this study was a multi-stage cluster sampling technique (Daniel, 2011; Levy & Lemeshow, 2013). The Saudi MoH divided SA into thirteen regions (MoH, 2012). Therefore, at Stage One, I utilised the same division adopted by the Saudi MoH, with regions converted to clusters (see Table 3.4.1) (MoH, 2012). In the second stage, simple random sampling based on the geographical location of each province was used (Bryman, 2012; Thompson, 2012), PHCs in SA are similar to each other (see Chapter One), geographical location is the only difference between them. For instance, Makkah province was selected to represent the west side of the country, and Albaha selected to represent the south side of the country (see Table 3.4.1). As a result, five of thirteen regions were selected for this study (see Table 3.4.1). Simple random sampling is very useful in reducing sampling bias, as it allows the selection of a more
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representative sample (Bryman, 2012; Thompson, 2012). At Stage Three, a total of 21 out of 2259 PHCs were randomly selected within the five chosen clusters. The sample (n= 491) was drawn from the selected 21 PHCs, across the five selected regions.
Table 3.4.1 Main regions in Saudi Arabia and the number of PHCs in each province NO Region Geographical
location
Number of PHCs
Selected in this study
Number of selected PHCs
1 Riyadh East 435 Yes 6
2 Gassim Centre 159 Yes 4
3 Makkah West 355 Yes 5
4 Almadinah West 154 No
5 Alsharqiah East 248 No
6 Albaha South 101 Yes 3
7 Asir South 317 No
8 Najran South 65 No
9 Hail North 100 No
10 Alshamaliyah North 45 No
11 Jazan South 155 No
12 Tabuk North 73 No
13 Aljouf North 52 Yes 3
Total 13 2259 21
3.4.2 Data collection instrument
Although methods such as the questionnaire have been frequently used in similar previous literature (see Section 3.3.4), this study used a modified data collection instrument to comply with the study objective and match the population background. The utilised questionnaire-based method was also used for the first time to assess implementation of an EHRS in SA PHCs. Initially, the questionnaire was presented in two languages (English and Arabic) for two main reasons (see Appendix A). The main language used in Saudi healthcare organisations is English, but the majority of employees in these organisations are Arabic native speakers (MoH, 2012). Therefore, for the sake of
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convenience and for the purposes of clarity and readability, the questionnaire was developed in both English and Arabic.
The questionnaire consisted of four main sections (see Appendix A). The first section contained a letter of assurance (for more details see Section 3.2). As illustrated in Chapter Two, individual readiness assessments can be conducted by including seven criteria:
computer skills, gender, attitudes toward the implementation of the EHRS, knowledge about the EHRS implementation (Biruk et al., 2014; Yusif et al., 2017), experience at work, age (Yusif et al., 2017), Therefore, the second section was designed to obtain the participants’ demographic data. Moreover, as revealed in Chapter Two, awareness about the perceived usefulness of the system found to be core predictor to the level of individual readiness to the introduction of new EHRS (Biruk et al., 2014; Kuo et al., 2013; Simon et al., 2008; Yusif et al., 2017). Therefore, the first set of questions in the third section assessed whether practitioners in PHCs were fully aware of the benefits of an EHRS. This scale contains thirteen items, which represent the benefits of the EHRS (see Section 3.5.3). Moreover, the third section comprised specific questions that were designed to assess PHCs readiness for the implementation of the system. Therefore, the second set of questions (n=13) in the third section measured the PHCs readiness for implementation from the PHCs staff perspective. The questions used in this section were taken from the OITIRS questionnaire (see Section 3.3.4). Both scales are designed to gather responses on a 5-point Likert scale that ranged from Strongly disagree to Strongly agree, as follows:
Strongly disagree (1); Disagree (2); Agree (3); Strongly agree (4); and No opinion (5).
Five-point Likert scale was found to be less confusion especially for non-experts and those who have less knowledge about the studied context. In addition, 5-point Likert scale can increase the response rate (Buttle, 1996). Hence, the panel of experts who reviewed this questionnaire suggested to reduce the Likert scale from 7-points to 5-points (see next section for more details)
To achieve a better understanding of organisational readiness, user resistance and willingness should be measured (Lennon et al., 2017; Yusif et al., 2017). Therefore, the fourth section included two closed-ended questions. The first closed-ended question asked whether participants were enthusiastic about the implementation of the EHRS. The second closed-ended question asked participants whether they would resist the implementation of the EHRS in their workplace. Part of readiness evaluation is to
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determine the specific requirements of individuals who will use the EHRS, so the system can be designed with consideration of their specific needs (see Chapter Two). Therefore, an additional open-ended question asked participants to list any personal requirements related to the implementation of the EHRS and any recommendations they could suggest for improving it.
3.4.3 Questionnaire development
Similar to the development procedures adopted in Study One, due to modifications and additional items, the questionnaire of this study was also developed in two phases. In Phase One, the preliminary data collection instrument was reviewed by the same expert panels, however, additional experts joined the second panel. This consisted of three IT engineers from the headquarters of the Saudi MoH, the general manager of the PHC department at the MoH, five heads of IT departments from five different hospitals, three academics from a Saudi university who held a PhD in Health Informatics, three radiologists, and one pharmacist who held a Master’s degree in Health Informatics. As a member of the Health Informatics Club (HIC) in SA, I benefited from the experience of other members. The HIC in SA created a WhatsApp group, which currently has more than 200 active members from different healthcare organisations and backgrounds in HI.
I selectively invited some of the members to review the preliminary instrument to ensure that all included items were relevant to the target population and that they addressed the study objectives.
One of the main comments, by the panel of experts, was the recommendation to distribute the questionnaire in two languages (Arabic and English). Once the questionnaire was developed in both languages, it was sent to two Saudi PhD students of translation at Swansea University, who reviewed the questionnaire before the final draft was distributed to the participants. They also suggested removing all items that were not relevant to the target population (n=35). The deleted items were concerned with factors related to the organisation, such as project team selection, software selection, and planning (see section 3.3.4). The panel of experts believed that the current study population may not be able to accurately respond to these items, due to lack of awareness caused by the type of project management utilised (see Chapter One).
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In the second phase, sixteen volunteers agreed to take part in the pilot study. The aim of the pilot study was to gather feedback regarding the questionnaire design before the research was undertaken on the required population. Certain criteria were taken into consideration, such as differences in gender, occupation and nationality of the participants, to ensure all items were relevant and that both languages were clear and readable for all participants. Similar to Study One, the pre-test draft of the questionnaire also included questions at the end to gain feedback about the questionnaire (see Section 3.3.5).
Each volunteer completed a first draft of the questionnaire and provided comments and feedback about the process and the measures, the questionnaire administration time, and the clarity of the questions. None of them asked to include or exclude any question.
Overall, the pre-test showed that the questionnaire was relatively clear and easy to fill out. The pre-test was conducted over a period of two weeks, dating from 14th December 2015 to 7th January 2016. Since very minor modifications were made to the data collection instrument based on this pilot study, all responses obtained from pilot study were included with actual findings. Both SPSS files that included pilot study findings and final study findings were merged into one SPSS file. A Cronbach’s alpha test revealed that questionnaire used in this study was statistically reliable.
3.4.4 Data collection process
Similar to Study One, once the data collection instrument had been developed and was ready to be used, I started to think about the most appropriate method to distribute it. The first consideration was how to increase the response rate and encourage participants to take part in this study. Initially, I used the electronic questionnaire because it was found to be an effective tool to assess the readiness of numerous PHCs compared with other methods such as observation. As mentioned earlier, twenty-one PHCs were selected for assessment in the current study, for generalisability purposes (see Section 3.4.1). On the other hand, the decision regarding the method of distribution of the questionnaire for this study was based on three main factors. Firstly, the geographical challenges, the Kingdom of Saudi Arabia is a huge country. It was impossible to physically distribute a paper-based questionnaire to all the selected PHCs, as postal services in SA are relatively poor.
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Secondly, the sample size was large, and therefore, using a paper-based questionnaire would have been very expensive. Finally, I conducted this study from the UK, so it was impossible to physically distribute the questionnaire. Therefore, I decided to utilise an online self-administrated questionnaire via Survey Monkey to collect the data. The decision to select Survey Monkey over Google forms or other websites was that the Medical School at Swansea University has a premier account which allows researchers to create and design more flexible and advanced surveys and then export the responses to SPSS.
The questionnaire distribution of this study was conducted over a period of ten weeks, from 11th January 2016 to 31st March 2016. Two reminder e-mails were sent to the participants after distribution of the initial questionnaire. The first e-mail was sent during the week of 8th February 2016, and the second e-mail was sent during the week of 7th March 2016. The official staff emails were not effectively used, the majority of the selected PHCs staff were still using their personal e-mail address at work which was not accessible to me. Therefore, I was directly linked with representatives from the twenty-one selected PHCs. Each twenty-one of these representatives was provided a copy of the ethical approval letter and was then invited to join a ‘WhatsApp’ group which was created by me for this purpose. All twenty-one representatives accepted the invitation. Once all of them joined the group, I sent a unique link obtained from surveymonkey.com to the group and asked them to fill in the questionnaire and then forward it to all other staff in the selected PHCs via their personal emails or other possible communications such as other WhatsApp groups.
3.4.5 Data analysis
Similar to the data analysis procedures performed in Study One (see Section 3.3.7), the data were analysed using SPSS V.22. Firstly, the scales of the study were tested for reliability using a Cronbach’s alpha test to ensure the consistency of the data collection instrument (see Chapter Five for more details). Thereafter, descriptive analysis was applied to display the data obtained from the participants using median, percentages, total agreement and rank (except for the barriers scale, which didn’t include total agreement).
These responses were used to calculate a total agreement score for each question. Each question was ranked based on the level of agreement, from the highest agreement to the
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lowest. The total agreement was combined (agree + strongly agree) to enable me to distinguish between items, i.e. to see which of the items generated more agreement compared to the others (as ranked).
Following the presentation of descriptive data, inferential statistical tests were used to test any a priori hypotheses. All tests are non-parametric and were chosen as a result of the data being considered of an ordinal nature and nominal. Differences tests were performed using a Mann-Whitney U test for two groups and a Kruskal Wallis for three groups, or more, to examine the differences between groups and then determine if demographic differences influenced the level of readiness of those individuals (see Section 3.4.2).
Responses to open-ended questions
Responses to the open-ended questions were presented and organised using Microsoft Excel. All responses were exported as text from surveymonkey.com to a Microsoft Excel sheet. Arabic responses were translated to English by me and then checked by a professional translator. I read the responses obtained by the participants. The responses were then grouped into themes where similar responses were gathered under one theme.
All themes were then coded to label each response with the appropriate code to allow Excel to calculate the number of responses in each theme. Finally, all responses were presented in a table, which included the themes, an example of a response to each theme, and the number of responses to each theme.
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