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A territory-wide Internet-based electronic patient record allows better patient care in different sectors. The engagement of private physicians is one of the major facilitators for implementation, but there is limited information about the current adoption level of electronic medical record (eMR) among private primary care physicians.
This survey measured the adoption level, enabling factors, and hindering factors of eMR, among private physicians in Hong Kong. It also evaluated the key functions and the popularity of electronic systems and vendors used by these private practitioners.
A central registry consisting of 4324 private practitioners was set up. Invitations for self-administered surveys and the completed questionnaires were sent and returned via fax, email, postal mail, and on-site clinic visits. Current users and non-users of eMR system were compared according to their demographic and practice characteristics. Student’s
A total of 524 completed surveys (response rate 524/4405 11.90%) were collected. The proportion of using eMR in private clinics was 79.6% (417/524). When compared with non-users, the eMR users were younger (users: 48.4 years SD 10.6 years vs non-users: 61.7 years SD 10.2 years,
These findings identified several physician groups who should be targeted for more assistance on eMR installation and its adoption. Future studies should address the barriers of using Internet-based eMR to enhance its adoption.
The introduction of Internet-based information technology (IT) into the health care system is widely perceived as a significant step to improve the quality of services provided by health care institutions [
Hong Kong is one of the most densely populated cities in the world. In order to meet the rising demand for high quality health care, the clinical management system (CMS) developed by the Hospital Authority (HA) was implemented in the public hospitals to allow clinicians timely access to electronic clinical information. It relied exclusively on the Internet as a significant conduit to medical data access. Since 1999, the electronic patient record (HA ePR) was developed to bring information from different modules of CMS into one standardized repository, offering a clinician-friendly interface to access a longitudinal, lifelong patient record [
The objectives of this study were (1) to measure the level of, and factors associated with, the adoption of the eMR system among physicians working in the private sector of Hong Kong, (2) to explore the enabling and hindering factors of the use of eMR, and (3) to evaluate the key functions of eMR and the popularity of electronic systems and vendors used by these private practitioners.
A questionnaire was designed and drafted by an academic family physician (MCS) with reference to literature tailor-made to the local context of primary health care in Hong Kong. These questions were face-validated by a panel of epidemiologists, family physicians, informaticians, and academic professors in public health. The questionnaires were then pilot-tested among 15 private practitioners randomly selected from the registry of private practitioners who were honorary tutors of the School of Public Health and Primary Care, Chinese University of Hong Kong (CUHK), and subsequent amendments made according to their recommendations. This study was approved by the Survey and Behavioral Research Ethics Committee of CUHK.
The target population consists of all registered practitioners in Hong Kong working in the private sector. We identified the following sources to trace the contact information of these private practitioners: (1) the Hong Kong Doctors’ website of the Hong Kong Medical Association (HKMA) for the public (n=2464), (2) a list of clinical tutors working in the private sector, carrying an honorary teaching appointment in the School of Public Health and Primary Care of the Chinese University of Hong Kong (n=149), (3) a research database containing the contact details of previous collaborating private practitioners who consented to disclose their contact information for future research (n=247), (4) private doctors’ list from a medical insurance company (Bupa) and members of the Association of Private Medical Specialist (APMS) (n=760), (5) Hong Kong Doctors’ networks in different districts (n=86), and (6) site visits to clinics of various buildings with high concentration of doctors (n=618). We established a central practitioner registry consisting of all registered doctors currently practicing in the private sector from the above sources (N=4405).
We assumed a desired precision level of 5% and the proportion of private practitioners having computerized systems in their clinics being 86% according to a survey conducted by the HKMA in 2006 [
Invitations were sent via faxlines, emails, post with return postage included, site visits, and visits to CME seminars. All surveys were self-administered. Survey invitations were conducted through all these contact channels for each registered doctor identified in our central registry. Hence there may exist multiple invitations to one single practitioner and we checked each returned survey for potential duplication. Up to three telephone or email reminders were sent to the participant physicians to encourage more responses. In addition, we conducted 618 clinic visits to buildings with high concentration of medical doctors and visited two CME seminars (on April 15th-16th, 2010).
For each survey returned, we checked for the presence of consent signature, full name of the doctor as appeared in the first page of the invitation letter, as well as the completeness of the questionnaires. To ensure confidentiality and anonymity, the first page with doctors’ identity was detached from the survey and each questionnaire was assigned a survey number as a unique identifier by one researcher. Another researcher who collected and entered the data was therefore blinded to the identities of the participant physicians.
The Statistical Package for Social Sciences version 16.0 (Chicago, Illinois) was used for all data entry and analyses. The major outcome variable was the proportion of private practitioners who used computers in their clinics. We performed descriptive analyses for all survey items. The eMR users and non-users were compared according to their demographic characteristics and practice information using chi-square tests of independence and student’s
We received a total of 524 completed surveys via fax, email, postal returns, and on-site collections in clinics and CME seminar venues, giving a response rate of 11.90% (524/4405). The mean age of the study participants was 51.11 years (SD 11.8). Approximately 80.3% (421/524) were male physicians (
We analyzed the difference in the characteristics between eMR users (ie, those private practitioners who adopted any electronic computer system for medical consultations in their clinics) and the non-users. Among these private doctors, 417 (79.6%) used computerized systems in their clinics for consultations (
Participant characteristics (N=524).a
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Overall |
eMRb users |
Non-users |
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n (%) | n (%) | n (%) | n (%) | |
Age in years, mean (SD) | 51.11 (11.8) | 48.44 (10.6) | 61.72 (10.2) | <.001 | |
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Male | 421 (80.3) | 333 (79.9) | 88 (82.2) | .013 |
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Female | 94 (17.9) | 80 (19.2) | 14 (13.1) |
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Male, practice experience 0-20 yrs | 125 (24.3) | 119 (28.5) | 6 (5.6) | <.001 |
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Male, practice experience >20 yrs | 294 (57.2) | 213 (51.1) | 81 (75.7) |
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Female, practice experience 0-20 yrs | 33 (6.4) | 32 (7.7) | 1 (0.1) | .024 |
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Female, practice experience >20 yrs | 60 (11.7) | 48 (11.5) | 12 (11.2) |
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Practice Setting: Health Maintenance Organization | 444 (84.7) | 347 (83.2) | 97 (90.7) | <.001 | |
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Solo | 379 (72.3) | 283 (67.9) | 96 (89.7) | <.001 |
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With partners | 130 (24.8) | 126 (30.2) | 4 (3.7) |
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None | 150 (28.6) | 111 (26.6) | 39 (36.4) | .105 |
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Current or completed Basic training | 29 (5.5) | 25 (6.0) | 4 (3.7) |
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Current or completed higher training | 24 (4.6) | 22 (5.3) | 2 (1.9) |
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Academy Fellow | 318 (60.7) | 257 (61.6) | 61 (57.0) |
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Emergency medicine | 3 (0.6) | 3 (0.7) | 0 (0.0) | .617 |
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Community Medicine | 2 (0.4) | 2 (0.5) | 0 (0.0) |
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Otorhinolaryngology | 9 (1.7) | 7 (1.7) | 2 (1.9) |
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Family Medicine (specialist) | 73 (13.9) | 61 (14.6) | 12 (11.2) |
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General Practice (non-specialist) | 145 (27.7) | 111 (26.6) | 34 (31.8) |
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Obstetrics and Gynaecology | 37 (7.1) | 28 (6.7) | 9 (8.4) |
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Anaesthesiology | 4 (0.8) | 2 (0.5) | 2 (1.9) |
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Ophthalmology | 19 (3.6) | 19 (4.6) | 0 (0.0) |
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General Medicine | 68 (13.0) | 53 (12.7) | 15 (14.0) |
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Orthopedics | 31 (5.9) | 23 (5.5) | 8 (7.5) |
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Pediatrics | 39 (7.4) | 34 (8.2) | 5 (4.7) |
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Psychiatry | 9 (1.7) | 7 (1.7) | 2 (1.9) |
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Radiology | 8 (1.5) | 8 (1.9) | 0 (0.0) |
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Surgery | 67 (12.8) | 55 (13.2) | 12 (11.2) |
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aSome figures did not add up to 100% due to missing values for some variables.
beMR: electronic medical record
Among the 417 eMR users, the majority perceived efficiency of computerized systems (379/417, 90.9%) as the reason of using computers in their clinics (
Turning to the reasons of not using computers among the other 107 physicians, the most frequently chosen responses included “not patient-friendly during consultations” (58/107, 54.2%) and “computer use is more time-consuming” (54/107, 50.5%) (
Among the eMR users, electronic patient registration system (376/417, 90.2%) was the most common key functions of the computerized systems (
SoftLink Clinic Solution (160/417, 38.4%) followed by HKMA Clinical Management System 3.0 (CMS 3.0) (46/417, 11.1%) were the most popular computer systems (
SoftLink (121/417, 29.0%) represented the most frequently chosen vendors among the physicians (
The mean duration of vendor use was 53.9 months (SD 44.0 months) (
Participants were divided into two groups based on the approach method, where group 1 used clinic site visits and invitations via practice or network chairmen and group 2 used faxline /email/ postal invitations. These groups were tested for heterogeneity with regard to the participants’ demographic and practice characteristics. When group 1 was compared with group 2, there were no differences in age (group 1: mean 55.21 years, SD 15.73 years vs group 2: mean 52.75 years, SD 14.74 years,
Reasons for using computerized systems in clinics. x-axis: 1=Offer more efficient service; 2=Ability to share patient information in public sector; 3=Reduce medical errors; 4=Eliminate need to store paper records; 5=Eliminate illegibility of my practice partners; 6=Others.
Reasons for not using computerized systems in clinics. x-axis: 1=Cost concerns (Setup/ maintenance); 2=Computer use is more time-consuming; 3=Not supported by the practice partners/ practice organization; 4=Concerns on data migration from paper to system; 5=Insufficient space for computer installation; 6=System not support Chinese language; 7=Not patient-friendly during consultations. 8. Inconvenience caused during down-time 9. Lack of technical support 10. Concerns on computer hackers 11. Others.
Key functions included by the computerized system. x-axis: 1=Electronic patient registration system; 2=Appointment booking system (e.g. arrangement of next patient visit); 3=Electronic clinical notes (eg, recording of patient history); 4=Dispensing system (eg, printing of prescriptions); 5=Order Entry functions (eg, laboratory, radiological exam order); 6=Picture Archiving and Communication System (PACS); 7=Electronic Health Care Voucher System (eHS); 8=Electronic Drug labels; 9=Public Private Interface-electronic Patient Record (PPI-ePR).
Names of computer system currently in use. Invalid response was defined as naming of computerized systems as Operation Systems (eg, Microsoft Vista) or computer hardware. HKMA: Hong Kong Medical Association.
The proportion of participants adopting various vendors. HKMA: Hong Kong Medical Association.
Study participants’ reasons for choosing the current vendors for eMR (N=524).a
Reasons for choosing the current vendor | n | % |
Cost concerns (setup/maintenance) | 125 | 30.0 |
Reputation | 125 | 30.0 |
Introduction by friends | 172 | 41.2 |
Chosen by practice management | 31 | 7.4 |
At random | 18 | 4.3 |
Others | 85 | 20.4 |
aDuration of vendor services: mean 53.85, SD 44.00
This study found that among 524 private physicians, 79.6% (417/524) adopted computerized systems in their clinics. The computer users were significantly younger, more were female, possessed less clinical experience, and less worked under an HMO. The major reasons of using computers in their clinics included perceived computer efficiency, reduction of medical errors, elimination of need to store paper records as well as issues related to case note illegibility. The high and similar prevalence of using eMR in the clinical practice of both specialists and non-specialists indicated that a communication culture on sharing patient records through extensive computer network has been established between these 2 groups of physicians as this brings convenience of extracting updated information of patients through eMR during consultation. This was also reflected from their heavy use of electronic patient registration system, dispensing system, and electronic drug labels printing system, which are part of the eMR system. Among the users, the key functions of computerized systems included electronic patient registration and drug dispensing. Among the non-users, the use of computers was regarded by most as patient-unfriendly and time-consuming during clinical consultations and it was quite surprising that the impression of eMR system between eMR and non-eMR users was quite different. Therefore, there may probably be a misunderstanding on the eMR system and further efforts should be made, especially tackling the opinions from the non-users, in order to increase the overall prevalence of using eMR system. SoftLink Clinic Solution was the most frequently used computer system and also vendor. It is a comprehensive software system allowing physicians an easy documentation of electronic medical notes and access to clinical images and laboratory reports of patients. Drug label printout system is also integrated into the system. The preference of the computer system was found to be diversified and this might lead to more adoption of SoftLink Clinic solution over other current choices in the market. The choice of vendors was mostly influenced by friends, setup and maintenance costs, and their reputation.
There is a scarcity of local studies on the adoption levels of eMR in the private sector. To our knowledge, there was only one study conducted by Ho et al [
The level of computer adoption in this study is high (417/524, 79.6%). When a sub-analysis of Ho’s study [
The low proportion of eMR users whose reason to use computers in their clinics was to share patient information with the public sector might reflect their low intention to do so. This is echoed by the relatively low proportion of computer users having Public Private Interface-electronic Patient Record (PPI-ePR) Sharing Pilot Project, which is a pilot programme allowing sharing patients’ electronic records among the public and private sectors, as the key functions of their installed systems. Many of the motivators to use computers identified in this study were related to efficiency and convenience of clinical practice instead of information sharing between the public and private sector. The importance of sharing patients’ records between the two sectors should be more emphasized among private practitioners. Extra personal incentives could also be provided to encourage the use of the eMR system [
The friends of the private physicians, many might well be medical colleagues, were found to be more influential on the choice of vendors than the set-up and maintenance cost required for the eMR system and the reputation of vendors. This reflected that the costs of the eMR system might not be a heavy burden for the physicians and recommendations from other physicians will be a good initiation for the use of eMR system in the clinical practice. Seminars could be organized where colleagues of the same specialty share their positive experience of using eMR in their clinics tailor-made to their clientele for the eMR non-users. In addition, as free services including computer setup and ongoing system support have been raised as an important consideration by a number of physicians who were currently using eMR, initiatives on provision of such services at low costs could be considered for the non-users to incentivize their adoption of computerized systems in their clinics.
This study included more than 500 surveys and the precision achieved is higher than the traditionally used 5%. However, some of its limitations should be mentioned. First, the response rate was modest (524/4,405, 11.9%) although previous studies among physicians yielded even lower response rates at the levels of approximately 5% (398/6772). There existed non-response bias, and it is conceivable that those without computers might be less interested to participate in the survey. Second, we do not have the contact information of all private practitioners in Hong Kong. In addition, the sampling frame is a mix between the usual invitation group: by postal mailing, faxline, email, and the on-site visit group: clinic visits and survey invitations during CME seminar, thus introducing sampling bias. However, this sampling bias should be regarded as minimal as shown by our separate analysis where no differences in the demographic and practice characteristics between the two groups were detected. Last, the surveys received names of computers and vendors interpreted by the participant physicians differently. All programs or applications must run on an Operation System as a platform. For instance, Microsoft Vista is an Operation system. Clinic management system is a generic name for the software used for clinic management (including clinic solution, WinMed, HKMA CME 2.0 and HKMA CMS 3.0 etc) and the Clinic Solution is one of the Clinic management systems. The Clinic Solution is the CMS developed by the SoftLink, hence SoftLink is the name of the company but not a software. It is not expected that the participant physicians could provide details of computerized systems and vendors at these different levels in details, and hence a distinction could not be made here due to the lack of additional information.
In summary, this survey provided a cross-sectional description of the current adoption of eMR and their vendors in the private sector, and depicted the major reasons of their use and non-use. Based on the demographic characteristics of the non-users (more likely older, male physicians, more practice experience, work under HMO, and solo practice), knowledge of eMR installation and maintenance should be conveyed to these physician groups. The competitive advantages of eMR use in clinics, namely their efficiency and convenience favorable to the practice, should be shared with the non-users by the current users, preferably having similar clientele. The major reasons of not using eMR, among the non-users should be further addressed and tackled with. These include strategies to make computer use in clinics equally patient-friendly as compared to not using computers, as well as addressing the possible misperception that computer adoption is time-consuming. More technical supports, including lower cost computer setup and system support services, should be made readily available for the current non-users to remove barriers of eMR use. Future studies should be conducted to capture more data from practices not reachable due to absence of contact information. Site visits may lead to a high response rate and future research should consider further survey services by clinic visits.
the Association of Private Medical Specialist
Continuous Medical Education
clinical management system
Chinese University of Hong Kong
electronic Health Record
electronic medical record
electronic patient record
Hospital Authority
Hong Kong Medical Association
Health Maintenance Organizations
information technology
We wish to express our sincere gratitude to Dr Ho Chung Ping, MH, the chairman of the IT committee of the HKMA for his expert advice on this project. He also conducted clinic visits together with the principal investigator for survey invitations and collection in the Champion building, for which the team members are very appreciative. We are grateful for the invaluable opinions and networking of private practitioners from Dr Chiu Sik Ho, the chairman of the Taipo doctors’ network; Dr Eddie Chan Tat, the chairman of the New Territories West Private Practitioners’ Network; Dr Aaron Lee Fok Kei, the founding President of the CUHK SPHPC Alumni Association; Dr Pang Lai Sheung, chairman of the Human Health Medical Group; and Dr Lau, the chairman of the New Town Medical Group. We thank all the participant physicians in this survey study. This study was funded by the Hospital Authority, Hong Kong.
None declared.