Implication Of Health Informatics on the Healthcare Workers’ Activities in Saudi German Hospital in Jeddah, Saudi Arabia

ABSTRACT

. Of notable interest to this research is the application of technology in healthcare for storage and sharing of patient information and data. The health information system played critical role in managing patients' information in many countries including Saudi Arabia (Hassounah, Raheel & Alhefzi, 2020;Alghamdi, Alqahtani & Aldhahir, 2020;Alghamdi et al., 2021). Scholars trace the development and testing of health informatics in healthcare to over 70 years back (Cesnik & Kidd, 2010). In the recent times, technology around health informatics has greatly improved, and is effectively applied in many areas of patient care, including clinical decision making, reduce risks of information loss, decrease costs of operation, data analysis, and improve nature of healthcare service delivery for patients' convenience (Siedlecki & Hixson, 2015;Persell et al., 2011;Kutney-Lee & Kelly, 2011;Salmond & Echevarria, 2017;Nguyen, Wang & Jack Li, 2018). Some of the relatively recent research also document the potential role of health informatics in promoting cancer care (Meropol, 2018). Indeed, the application of tools, such as the electronic health records have a vast impact in healthcare (Bae & Encinosa, 2016;Nijhawan et al., 2013). Schoener et al. (2018) indicates that the data storage by the electronic health system, notably health informatics, could help to inform future decisions to improve patient care. Reid et al. (2021,) refers to health informatics as the integration of information and communication technologies with the available health knowledge to enhance patient care service delivery. Health informatics also encompasses the "clinical supportive network that is arranged and executed by high normalized measures and of incredible reproducibility" (Curtis et al., 2018). Empirical evidence shows that health informatics in nursing practices significantly enhance patients' wellbeing and helps to evaluate staff requirements (Silow-Carroll et al., 2012). As such, nursing informatics give a reliable clue on how information technology can improve patient care practices. Another research done by Sayed (2021) showed that the electronic health records are important in collecting patients' data faster. While there is vast evidence supporting the positive impact of health informatics in nursing care practices, some studies have also reported some challenges experienced in the course of health informatics. One of the recent investigations in Saudi Arabia, by AlSadrah (2020) reported that negative attitudes of the healthcare workers negatively affect the application of electronic medical records. At the same time, literature evidence has noted that the application of health informatics may face many significant barriers such as "loss of access to medical records transiently if computer crashes or power fails" (El Mahalli, 2015). Despite the documented evidence in many parts of the world, little research has been done in Saudi Arabia regarding the role of health informatics in relation to patients' safety, competency of healthcare workers, and quality of patient care. Moreover, based on the extent of the investigations already presented in the literature, this study noted that there are still knowledge gaps in the role of health informatics in improving quality of patient care, health workers' competencies, and patients' safety in Saudi Arabia, and hence the need for this investigation.

METHODS
This study applied the cross-sectional quantitative study design. The survey questionnaires were administered to 123 healthcare workers in Saudi German Hospital in Jeddah. These participants were identified from the hospital records of employees at the human resources office. The ethical approval was sought from the research and ethics committee of the university and the hospital. Data was then collected by using a pencil and paper technique due to the proximity of the research participants. The research questionnaire was designed to cover four main concepts, which were derived from the variables in the literature. The questionnaire had two main sections. The first section was designed to collect data about the study participants' sociodemographic factors, including age, gender, level of education, department of work, and duration (years) of using health informatics. The other section was designed to collect data about the three discrete outcome features of applying health informatics. These outcome features included health workers competencies, patients' safety, and quality of patient care. However, before the actual data collection, the research questionnaire was piloted among a volunteer sample of 10 participants to check the reliability statistics based on the internal consistencies of the items. Accordingly, the study reported a Cronbach's alpha of 0.89, which justified that the tool was reliable for collecting data regarding the named variables and for the stated constructs. Further, the construct validity was also assessed to examine whether the questionnaire items were relevant to the variables and constructs against which they targeted. This was done with the aid of an expert researcher within the university. It was found out that the questionnaire items adequately met the requirement feature of addressing the named variables, and suitable for the named research participants. The collected data was analyzed using the SPSS version 26 by utilizing three statistical tests, including the descriptive statistics, Multiple Analysis of Variance (MANOVA), multiple linear regression, and Spearman's rho correlation. The Spearman's rho correlation was used over the use of Pearson's correlation since the instrument presented both ordinal scale data.

RESULTS
A total of 105 participants completed the survey. There were more males (60%) then females (40%). Most of the participants were between 31 and 40 years. Regarding level of education, 38.1% of the participants had diploma level and the least number (28.1%) had undergraduate level of education. Highest proportion of the participants (21%) worked in Pediatric unit while the least (5.7%) worked in the operation rooms. Fifty participants (40.9%) strongly agreed and 35 (33.3%) agreed that health informatics augments quality of healthcare services delivery. Also, majority of the participants indicated that health informatics enhances information quality as 35.2% agreed and 41.9% strongly agreed to the idea. However, when it came to the role of health informatics on enhancing job satisfaction, majority gave mixed responses as 43.8% remained neutral. Negative reactions were noted in the healthcare workers perception of the health informatics in enhancing teamwork and job satisfaction as majority of the participants disagreed and strongly disagreed ( Table 2). The MANOVA test was performed to examine whether health informatics had a statistically significant impact on the healthcare workers' competency, patient safety and quality of patient care. The Box's Test of Equality of Covariance Matrices (Table 3) shows that that the covariance matrices among the dependent variable are the same and having no significant differences (p>.005). Therefore, the assumptions of same covariance matrices were met. .013 Based on the Wilks' Lambda, it is evident that health informatics has a statistically significant and summative impact on the three outcome variables (p=.000) ( Table 4). As such, heath informatics explains a significance variance in the three outcome variables. Moreover, this study observed that health informatics has a statistically significant impact on the quality of patient care (p=.000), health workers competencies (p=.000), and patient safety (p=.000) ( Table 5). Health informatics has strongest impact on the health workers competencies (r=.522), which was followed by quality of patient care (r=.502), and finally patients' safety (r=.457).
Overall, health informatics had statistically significant impact on the three variables (p=.000) at 99% confidence interval (Table 6).  The coefficients of association show that age (p=.023) and level of education (p=.000) have a statistically significant effect on the role of healthcare informatics as perceived by the healthcare workers in Saudi German Hospital in Jeddah, Saudi Arabia (Table 8).

Role of Health Informatics
Health informatics has many significant roles, including augmenting the quality of healthcare service delivery, and improving information quality, and job satisfaction. Majority of the participants expressed a strong positive perception that health informatics improves healthcare service delivery. This outcome is, however, not unique to this study since the relationship between health informatics and quality of healthcare service delivery is highly explored in the literature  (2012), electronic health records help to improve quality of healthcare service delivery from different angles and perspectives including: "… the use of checklists, alerts, and predictive tools; embedded clinical guidelines that promote standardized, evidence-based practices; electronic prescribing and testordering that reduces errors and redundancy; and discrete data fields that foster use of performance dashboards and compliance reports… faster and accurate communication and streamlined processes…fewer duplicative tests, faster responses to patient inquiries, redeployment of transcription, and claims staff, more complete capture of charges, and federal incentive payments" (p. 40).
It was also noted that health informatics helps to improve quality of information in in Saudi German Hospital. Again, this outcome is not unique to this research. Previous studies have also noted that electronic health records help to improve the storage and retrieval of patients' clinical and medical information (Silow-Carroll, Edwards & Rodin, 2012; Atasoy, Greenwood & McCullough, 2019). Role of health informatics in improving quality of information can be closely tied to the use of electronic health records, which have taken shape in Saudi German Hospital, and many other hospitals in Saudi Arabia and beyond. On the same note, a review conducted by Ammenwerth, Schnell-Inderst and Hoerbst (2012) among the randomized controlled trials reported a significant improvement in many areas after using the electronic health record systems. One of the areas was a significant decrease in the office visit rates and slower increase in telephone contacts. These changes point However, a relatively smaller proportion of the health workers in Saudi German Hospital who reported that health informatics enhances their job satisfaction. In fact, most of the participants indicated that they were unsure if health informatics helped to improve satisfaction in their job. One of the reasons for the weak linkage between health informatics and job satisfaction among the healthcare workers in Saudi German Hospital are the reported barriers of effective adoption of health informatics in the literature. For instance, Ajami and Bagheri-Tadi (2013) noted many barriers, including malfunction, concerns over data security, negative attitude, and even high costs of installation and maintenance. Studies conducted in Saudi Arabia have also reported several barriers against the application of electronic health records, including legislative regulations, technical barriers, and employees' beliefs (Khalifa, 2013).
Most of the healthcare workers in in Saudi German Hospital indicted that health informatics does not enhance patients' safety. The negative perception could arise from the many negative challenges that face the use and adoption of health informatics, such as insecurity (Kruse et al., 2017). Information security is one the critical issues that affect the quality of trust of the information in electronic health records (Fernández-Alemán et al., 2013). The last issue focused on the role of health informatics in promoting teamwork among health workers, to which majority of the participants did not agree. Even though this study did not investigate the reasons why most healthcare workers feel that the health informatics does not promote teamwork, some previous literature reported otherwise (Iqbal, Syed-Abdul & Yu-Chuan Li, 2015).

Impact of Health Informatics on the Quality of Patients' Care
Health informatics helps to improve quality of patients' care in many aspects, including timely diagnosis, convenient medical care, patient safety, assessment for adjustments, and speed of access to medical care. Similarly, previous research studies already established that health informatics has a positive association with the quality of patient care service delivery (Sadoughi, Nasiri & Ahmadi, 2018;Rozenblum et al., 2013). Indeed, there is a large body of evidence that links the use of health informatics in clinical decision-making due to the readily available information on patients' records (Kruse et al., 2017;Singh et al., 2018;Rothman, Leonard & Vigoda, 2012;Forrest et al., 2014). From a different angle,  explained that "providing patients with access to electronic health records (EHRs) has emerged as a promising solution to improve quality of care and safety" which is a key positive benefit that is realizable on the quality of patient care. Health informatics directly helps to improve the speed of information access on electronic avenues, such as the e-health systems, which helps to increase chances of patients' adherence to medication and recovery, and reduce chances of medication-associated errors (Han et al., 2016;Kharrazi et al., 2021). Faster access to healthcare service is likely to translate into faster positive outcome among patients. Other benefits of using health informatics on the quality of patient care can also be linked to the levels of patients' satisfaction as an indicator of the healthcare service quality delivery. many researchers have reported that health informatics helps to improve patients' satisfaction with the quality of healthcare service delivered (Rozenblum et al., 2013;van Der Vaart et al., 2014). Rozenblum et al. (2013) showed that out of the included 20 randomized control trial, 40% did had a positive impact on patients' satisfaction.

Impact Health Informatics on the Patients' Safety
Health informatics helps to improve patients' safety. The positive relationship between health informatics and patients' safety can be mirrored on many surfaces including the incidences of medication errors, patient safety predictors such as pressure ulcers, incidences of transfusion reaction count, faster to accurate patients' information and incidences of postoperative sepsis rate among patients who undergo surgical operations. The use of health informatics, such as electronic health records, help to ensure that patients' clinical and medication information are accurately saved so as to evade errors (Hess et al., 2020;Vaidotas et al., 2019;Agrawal, 2009;Alex et al., 2016). Many studies have examined the relationship between the use of health informatics and the incidence of medication errors, and the outcomes is concurrently positive (Alex et al., 2016;Jindal & Raziuddin, 2018). Notably, Jindal and Raziuddin (2018) showed a significant reduction in the incidences of medication errors, wrong site surgery, improper dosage delivery to a patient, and wrong medication, by 50-60 per cent due to health informatics. Researchers also reported that the use electronic health records significantly helped to reduce the cases of medication errors among the admitted adult patients ( (2016, p. 32) reported that "the percentage of patients without medication errors within 72 hours of discharge was 93.8% on the intervention team compared with 40.2% on the control team (P < .0001)."

Impact Health Informatics on Health Workers Competency
The competencies of health workers were considered using different concepts, including abilities to understand patients' critical needs, emotional skills, professional collaboration, clinical decision making, and overall professionalism. The study established a positive relationship between the use of health informatics and competencies of health workers, and literature outcomes uphold this observation (Zahabi, Kaber & Swangnetr, 2015;Dubovitskaya et al., 2017).
One of the widely reported ways of how electronic health records help to improve competency of the healthcare workers in Saudi German Hospital was noted in the clinical decision making. Sutton et al. (2020) also reported how the use of electronic health information technology helps in the management of clinical decision support systems. Many other studies have also noted a positive linkage between health information systems and professional work among the healthcare workers (Goldstein et al., 2017;Castaneda et al., 2015;Musen, Middleton & Greenes, 2021). Clinical decision making can also be done using data forecasting to provide reliable patients' treatment avenues. Moreover, the healthcare workers in Saudi German Hospital also noted that the time spent by the healthcare workers in documenting the healthcare services. Harris et al. (2018) reported that health informatics helps to reduce burnout and occupational stress among nurses by reducing the time they spend in making the manual data entry. In this design, these healthcare workers would experience a reduced burden of burnout and the result would be positive impact on patients' care practices. At the same time, using the electronic order entry approaches significantly helped to meet the standardized communication, which also has numerous benefits, including reduction in the medication errors. A case study by Rasmi et al. (2018) in Jordan also noted a positive association between the use of electronic health records and many features of the heath workers including, hedonic expectancy, competency, social influence and practice habit, which also have a critical niche in the healthcare workers' competencies.

Impact of Socio-Demographic and Work Factors on the Implication of Health Informatics
This study outcome showed that only age and level of education had impact on the healthcare workers perceptions on the role of health informatics. Theo other factors, including gender and department of work did not have any significant impact on the role of health informatics. Nevertheless, some previous studies have also noted the implication of socio-demographic factors on role of health informatics (Riordan et al., 2021;Schinasi et al., 2018). It was noted that older health workers had stronger perception on the role of health informatics in enhancing the quality of patients' care in Saudi German Hospital. This relationship can be linked to the duration of experience, whereby older employees could have experienced the negative features of the analogue system and can compare with the recent digital systems. Tubaishat (2018) and Kinnunen et al. (2019) noted that professional experience influenced the healthcare workers perceived roles electronic health records. However, Tubaishat (2018), also observed that gender, professional rank and computer skills influenced the workers perceptions. The healthcare workers with higher levels of education considered health informatics to be more effective than perceived by the younger healthcare workers and those with lower levels of education. In the same way, Kinnunen et al. (2019) reported that level of education and sufficiency of training had a positive impact on the perceived role of electronic health records. The relationship can be gauged from the idea that education and training improve the employees' knowledge on handling the electronic health records and hence the ease of use and positive regards.

LIMITATION
Two limitations should be noted. The first limitation is the use participants from a single hospital center. Even though the sample gave an adequate representation of the research population, the outcomes would have been slightly different if other research centers were included since different organizations have different cultures, and other difference regarding the use of healthcare information technology. The second limitation was the use of quantitative methods only. The study would have benefited more by using mixed methodology so as to establish the reasons behind the differences in the use of health informatics.

CONCLUSION
This study examined the implication of health informatics on the healthcare workers' practices in Saudi German Hospital, Jeddah in Saudi Arabia. The study become necessary to avail the most recent outcomes regarding the use of health informatics on three main areas that have not been fully explored in Saudi Arabia. The quantitative cross-sectional research design was applied. From the observed outcomes and discussions based on the literature evidence, it can be noted that health informatics plays significant roles in many aspects, notably in healthcare service delivery, information quality, quality of patient care, health workers competencies and patient safety. However, the perceived role of health informatics depends on the healthcare workers' level of education and age, which can be linked to experience and knowledge on information system.