title: Comprehensive evaluation of electronic medical record system use and user satisfaction at five low-resource setting hospitals in ethiopia.
abstract: BACKGROUND
  Electronic medical record (EMR) systems are increasingly being implemented in hospitals of developing countries to improve patient care and clinical service. However, only limited evaluation studies are available concerning the level of adoption and determinant factors of success in those settings.
  
  
  OBJECTIVE
  The objective of this study was to assess the usage pattern, user satisfaction level, and determinants of health professional's satisfaction towards a comprehensive EMR system implemented in Ethiopia where parallel documentation using the EMR and the paper-based medical records is in practice.
  
  
  METHODS
  A quantitative, cross-sectional study design was used to assess the usage pattern, user satisfaction level, and determinant factors of an EMR system implemented in Ethiopia based on the DeLone and McLean model of information system success. Descriptive statistical methods were applied to analyze the data and a binary logistic regression model was used to identify determinant factors.
  
  
  RESULTS
  Health professionals (N=422) from five hospitals were approached and 406 responded to the survey (96.2% response rate). Out of the respondents, 76.1% (309/406) started to use the system immediately after implementation and user training, but only 31.7% (98/309) of the professionals reported using the EMR during the study (after 3 years of implementation). Of the 12 core EMR functions, 3 were never used by most respondents, and they were also unaware of 4 of the core EMR functions. It was found that 61.4% (190/309) of the health professionals reported over all dissatisfaction with the EMR (median=4, interquartile range (IQR)=1) on a 5-level Likert scale. Physicians were more dissatisfied (median=5, IQR=1) when compared to nurses (median=4, IQR=1) and the health management information system (HMIS) staff (median=2, IQR=1). Of all the participants, 64.4% (199/309) believed that the EMR had no positive impact on the quality of care. The participants indicated an agreement with the system and information quality (median=2, IQR=0.5) but strongly disagreed with the service quality (median=5, IQR=1). The logistic regression showed a strong correlation between system use and dissatisfaction (OR 7.99, 95% CI 5.62-9.10) and service quality and satisfaction (OR 8.23, 95% CI 3.23-17.01).
  
  
  CONCLUSIONS
  Health professionals' use of the EMR is low and they are generally dissatisfied with the service of the implemented system. The results of this study show that this dissatisfaction is caused mainly and strongly by the poor service quality, the current practice of double documentation (EMR and paper-based), and partial departmental use of the system in the hospitals. Thus, future interventions to improve the current use or future deployment projects should focus on improving the service quality such as power infrastructure, user support, trainings, and more computers in the wards. After service quality improvement, other departments (especially inter-dependent departments) should be motivated and supported to use the EMR to avoid the dependency deadlock.
authors.affiliation: Institute of Medical Informatics, University of Münster, Münster, Germany. Binyam.Tilahun@uni-muenster.de.
authors.forename: Binyam
authors.identifier: http://orcid.org/0000-0002-1813-167X
authors.initials: B
authors.lastname: Tilahun
authors.forename: Fleur
authors.identifier: http://orcid.org/0000-0002-9005-6766
authors.initials: F
authors.lastname: Fritz
keywords: DeLone and MacLean model; Ethiopia; electronic medical record; evaluation; low-resource settings