Effect of electronic health records on doctor-patient relationship in Arabian gulf countries: a systematic review

Background The electronic health record (EHR) has been widely implemented internationally as a tool to improve health and healthcare delivery. However, EHR implementation has been comparatively slow amongst hospitals in the Arabian Gulf countries. This gradual uptake may be linked to prevailing opinions amongst medical practitioners. Until now, no systematic review has been conducted to identify the impact of EHRs on doctor-patient relationships and attitudes in the Arabian Gulf countries. Objective To understand the impact of EHR use on patient-doctor relationships and communication in the Arabian Gulf countries. Design A systematic review of English language publications was performed using PRISMA chart guidelines between 1990 and 2023. Methods Electronic database search (Ovid MEDLINE, Global Health, HMIC, EMRIM, and PsycINFO) and reference searching restricted to the six Arabian Gulf countries only. MeSH terms and keywords related to electronic health records, doctor-patient communication, and relationship were used. Newcastle-Ottawa Scale (NOS) quality assessment was performed. Results 18 studies fulfilled the criteria to be included in the systematic review. They were published between 1992 and 2023. Overall, a positive impact of EHR uptake was reported within the Gulf countries studied. This included improvement in the quality and performance of physicians, as well as improved accuracy in monitoring patient health. On the other hand, a notable negative impact was a general perception of physician attention shifted away from the patients themselves and towards data entry tasks (e.g., details of the patients and their education at the time of the consultation). Conclusion The implementation of EHR systems is beneficial for effective care delivery by doctors in Gulf countries despite some patients' perception of decreased attention. The use of EHR assists doctors with recording patient details, including medication and treatment procedures, as well as their outcomes. Based on this study, the authors conclude that widespread EHR implementation is highly recommended, yet specific training should be provided, and the subsequent effect on adoption rates by all users must be evaluated (particularly physicians). The COVID-19 Pandemic showed the great value of EHR in accessing information and consulting patients remotely.


Background
Continuity of patient care and overall healthcare safety are strongly associated with reliable medical records.Traditionally, medical records have used paper-based systems to record relevant details such as treatment and outcomes.However, in recent years, medical organisations are increasingly turning to computerisation for managing the plethora of data surrounding each patient entering the health system.The electronic health record (EHR) is a promising tool for enhancing national and international healthcare, particularly primary care delivery (1).An EHR can be defined as an application environment that captures the individual clinical data of patients, is linked to a clinical decision support system, and allows computerised order entry and clinical documentation applications (2).Electronic health records were initially developed and used at academic medical facilities, but many leading providers in the health industry are implementing computerised clinical record systems to manage the huge volume of clinical, administrative, and regulatory information that occurs in contemporary health care (3).The COVID-19 Pandemic and the need for virtual care demonstrated how essential EHRs are in delivering effective care remotely in both primary and hospital care settings.
Introducing any new information technology system into an organisation leads to changes in processes and workflows, which can lead to user dissatisfaction as they encounter teething problems in the system, bugs, or even simple annoyance at the requirement to learn a new way of doing things (4).Although EHRs are gradually entering widespread use within the Arabian Gulf, their impact on physician attitudes and the patient-doctor relationship remains to be determined.A previous systematic review has examined the impact of EHRs on patient-physician communication, finding no significant change in patient satisfaction or patient-doctor communication (5).However, this work focused on Western (Europe, United States, Australia) medical facilities; thus, the relevance to the culturally differing healthcare systems of the Gulf countries is still to be seen.
To shed light on this field, this systematic literature review seeks to understand the impact of EHR use on patient-doctor relationships and communication in the Gulf Cooperation Council (GCC) countries.

Search strategy
A systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards.
It was performed based on the methods of Alkureishi et al. (5).This study conducted a systematic electronic search of the English literature in Ovid MEDLINE, HMIC (Health Management Information Consortium), Eastern Mediterranean Index Medicus (IMEMR), Global Health, and APA PsycINFO between December 2021 and Sep 2023, with no date limit.Moreover, cited references searching of prior reviews and a manual search were performed with Scopus, Google Scholar, PubMed and The Cochrane Library.
The systematic search included all relevant studies by exploring Medical Subject Heading (MeSH) terms and keywords related to electronic health records and doctor-patient communication and relationship.The selection of search terms was performed in consultation with a biomedical librarian.
To explore publication bias and mirror Alkureishi et al. ( 5), unpublished studies were searched for in past meeting abstracts of the Society of General Internal Medicine, the American Academy of Family Physicians, the International Conference on Communication in Healthcare and the European Association of Communication in Healthcare.
Only studies related to EHR use, and face-to-face patientdoctor communication or relationship were included; editorials and commentaries were excluded.All study designs, and all patient populations were included, but the search was restricted to studies on the six Gulf countries (Bahrain, Kuwait, Oman, Saudi Arabia, United Arab Emirates).Studies exclusively reported physician attitudes, perceptions, and other interactions, but faceto-face patient-doctor relations (i.e., remote online access) were discarded.

Study selection
After duplicate removal, title and abstract screening were performed by the author and an independent reviewer.When titles or abstracts were unclear, they were included in full-text screening, followed by a second independent review.Quality assessment of the final selection was performed using the Newcastle-Ottawa Scale (NOS).

Data synthesis and analysis
Studies were compared by the study population, design and outcomes and sorted according to the data collection method.They were then organised in a data extraction table.Initial codes relating to the research question were generated to capture the ideas from the studies.Themes were defined from recurring patterns that provided insights into the effects of EHR implementation on patient-doctor interactions.
The data collected did not allow for a meta-analysis due to the heterogeneity in interventions, methodology, and outcomes of the studies included.Thus, a narrative synthesis was conducted.
The initial search provided a total of 94 studies.From these, 93 studies remained for screening following the removal of duplicates.
Manual search and backward reference screening produced a further 7 items.Seventy studies were excluded in an initial assessment (e.g., references lacking an abstract or unrelated to health).A detailed analysis of the remaining 30 studies was performed.As part of this detailed analysis, 15 studies were excluded as irrelevant to electronic health records or not presenting a doctor-patient relationship outcome.The 18 remaining studies were then included.An overview of this process is shown in Figure 1.

Data availability
The data supporting this systematic review are from previously reported studies and datasets.Details of the publications used in this systematic review are included in Table 1.

Results
Figure 1 shows the number of studies identified, excluded (duplication, not EHR-focused), and selected with the criteria for the systematic review.This process generated 18 eligible articles.

Study characteristics
A summary of the results found for each of the 18 articles is provided in Table 1 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24).The articles that met the inclusion criteria were assessed to determine the characteristics and effect of EHR implementation in GCC countries, including a summary of the study features such as information on doctor communication, quality of care, medication error, data retrieval and waiting time.The Newcastle-Ottawa Scale (NOS) was applied for quality assessment, as shown in Table 2. Publication dates ranged from 1992 to 2021.The number of participants in each study varied from 23 to 700, including male and female healthcare workers.

Effect of EMR on quality of care
Almost two-thirds of the studies (72%) found that EHR improves the quality of care for patients, noting that retrieval and entry of patient information is more straightforward and more accurate, access to the system is efficient, and the presence of an EHR reduces medical errors and enhances work productivity (6,7,10,14,16,(18)(19)(20)(21)(22)(23)(24) and comfort while entering the data through typing instead of writing (14).This general finding supports the previously shown positive impact of advanced technology in the healthcare sector and supports the desire of GCC healthcare providers to adopt paperless systems (10,17).Nevertheless, lack of reliability or completeness of data (13,15) and gaps in users' computer skills (15, 17) are also reported.

Effect of EHR on doctor-patient relations
The disadvantages of EHRs listed in the assessed publications included concerns about confidentiality (6,11), general underutilisation of the system (6, 7), and a need for applicable or flexible disease coding (6).In Kuwait (7,9), the participants disliked the requirement for physicians to work with the Exported PRISMA data from covidence.EMR improves the communication between department in 95% Improves the quality care of patient (85%); Retrieval and entry of patient information is accurate and easy way (80%) Access to the system is easy and available (70%) Reduces medical errors (67%) Enhances the productivity (59%).
80% agreed the EMR system required increased confidentiality.
The EMR system is underutilized (75% of physicians agree); hospital is still using a paper system in some departments (74%); Disease coding represents a major problem (70%); The EMR system is time consuming (67% agree); Speed of the system is too slow (60%).Participants' feedback: Each doctor receives a specific access password that changes periodically.// Train and advise staff on the requirements of patient // Information privacy and encourage their input on how protection should be developed.Only 40% were satisfied with the system; furthermore, 61% were willing to totally abandon the system and go back 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 change this system.60%of the physicians agreed with Information is accurate", "relevant" About 50% agreed with the statements "features allow me to perform my work well" and "the performance of the system is reliable" "system easy to use" and "security is acceptable", were satisfactory to about 65% Fewer than half of the respondents agreed "the system is fast" and "the system is integrated with my workflow".
Only 48% of the system was integrated well with their workflow The physicians in our study might also have been experienced computer users but expected more sophisticated training.Additionally, only half found that the system support was acceptable.
The screen layout was acceptable to 62% of the physicians, who considered that information was presented in a suitable format.The physicians were not satisfied with the completeness or accuracy of the information: only 45% reported that the information was complete and 64% that it was accurate.
The system was considered easy to use by 64% of the physicians, a finding similar to those of other studies.58% of the physicians were dissatisfied with the speed of the system, reporting that it took a long time to move between screens and that the system was slow to start up.The participants rated the perceived usefulness of the new system at 6.4/10 for patient care and physicians' satisfaction levels were 5.2/10.The top indicator of HER usefulness was the system's ability to reduce errors and improve the quality of care [mean 3.31, SD 0.9, RII 82.8%]; The top indicator of satisfaction with the HER system was enhanced "individual performance" [mean 3.04, SD 1, RII 60.9%]; This study revealed that higher level of satisfaction was associated with the perceived positive effect of HER on individual performance and patient care.
The results of this study are provided a "pediatricformatics" insight to establish specialized children hospital and similar forms of integrated paediatric health care services.Academic centres might face other difficulties in implementing HER, due to the involvement of medical students, interns, and residents in the clinic care  More than 75%-100% agree that the given features are either very easy or at least easy to use.The small deviation from the 'near consensus' is seen in the answers about the continuity of care (67%) and analysis of care results (69%) which is not a bad result in general at least 67% agreement regarding the consistency of monitored and recorded clinical details and suitability of documentation features, while the screens and layouts of pages and other web-based tools found an agreement of 69%.
The above results show that the young generations of specialists (86%) are more adaptable to change and accept the EHRs even if the experience they have is less than three years.the need for integrating some EHRs related training in the curriculum of medical schools is of paramount importance 17-AlSadrah, Sana

Electronic Medical Records and Health Care Promotion in Saudi Arabia
In this literature review, the author focused on the benefits of widespread adoption of EMRs in Saudi Arabia, the perceptions of health care professionals, and the challenges and barriers toward improved implementation of this technology.
The ease of communication is another major advantage when health care professionals can communicate with patients through email, fax, and phone.18important for clinical investigations, but for evaluating health care policies and informing stakeholders about approaches to improve access to high-quality health care.25 Other advantages related to accessibility and management include management and records of patient referrals, allowing health care professionals, even when out of the hospital, to access patient health records, allowing patients to access parts of their health records and providing data backup and disaster recovery.2 Recommendations are related to improving the communication between different health care personnel as well as between physicians and their patients.Ensuring the possibility of short message service (SMS) or email communication is a must.This can be achieved by providing quality Internet connection to hospitals and other healthcare delivery facilities, improving patients' awareness about the value of online communication with their health care provider, and increasing physicians' computer literacy.39Physicians should also be able to customize their preferred, easy-to-use EMR interface and should be able to select the optimal tools to achieve effective communications with their patients.40A literature review summarized the barriers of EHRs by physicians and classified them into 8 main categories.These categories included technical, financial, psychological, social, legal, time, organizational, and change processes.In short, the main highlighted barriers across the eight categories were probable security breaches, loss of access to data upon computer crashes or power failures, the time needed to enter data and check their quality, the complexity of the technology (especially among personnel with poor English language and computer skills), the potential to disturb physician-patient communication, and the lack of system customization for all hospital needs.Other barriers were concerned about the lack of continuous support from IT staff in hospitals (Continued)  (11).Increasing difficulty with work performance after applying the EHR system has also been reported (8).For example, it has been mentioned that the system was inadequate (24), slow (6,19) or lacked a user guide during medication ordering (10).

Discussion
This review investigates the impact of EHR systems on the relationship between doctors and patients in the Gulf countries.Our results showed that the EHR facilitates the development of an environment in which all relevant patient clinical data is captured, which in turn helps doctors to make decisions that directly influence patient outcomes.Furthermore, in agreement with other literature, it has been observed that EHR facilitates communication between patients and doctors (5,25).The enhanced communication between patients and doctors improves the overall quality of care delivery in healthcare settings, especially in the physician-focused healthcare systems in Gulf countries.
However, it has been observed that some patients would like more satisfaction with respect to the implementation of EHR in the healthcare setting.There is a sense that doctors shift attention away from their patients and towards the recording of their entries.Therefore, patients feel dissatisfied, feeling doctors require more time for "data entry" than they do to assess the presenting patient.
Implementation of EHR was described as improving the transmission of accurate and reliable patient information, reducing chances of medication errors and "lost files".Furthermore, it was observed that the use of EHR improves the ability of physicians to note relevant information at the time of consultation rapidly.This, in turn, allows them to invest more time in decisions relating to medication and treatment, thereby improving the quality of care delivered to the patients.Despite this, it should also be noted that the implementation of EHR leads to large changes in physician workflow and processes, which may lead to increased errors during this transition period and thus adversely affect patient outcomes.As revealed in this study, the introduction of EHR systems brings about significant changes in the daily routines of healthcare professionals.These transitional challenges may contribute to a temporary increase in errors during the initial stages of implementation, necessitating the need for comprehensive change management strategies.It is imperative that healthcare organisations pay close attention to mitigating these disruptions to maintain the quality of patient care.
Furthermore, it is noteworthy that while EHRs are demonstrated to enhance healthcare delivery in the Gulf countries overall, there exists a divergence in perspectives between healthcare providers and patients.Physicians often perceive the benefits of EHRs, such as improved data accuracy and efficiency.However, patients may feel that these systems lead to reduced attention from their doctors, lack of eye contact, and extended waiting times.Addressing this disparity in perceptions through comprehensive education and transparent communication is pivotal to ensuring that the full potential of EHR systems is realised while simultaneously upholding patient satisfaction and trust in the healthcare system.
These behavioural outcomes are generally consistent with those previously observed in systematic Western healthcare facility reviews (5,(25)(26)(27)(28)(29). Similarities to this study include that effective communication of the benefits of EHRs to patients needed to be improved, leading to a general impression that physicians were spending more time on their computers than with the patients themselves.But that, nonetheless, led to enhanced surveillance and monitoring and decreased medication errors.Hence, it may Some believe that religion should be included in the patient's record to help understand the patient's habits and, possibly, culture that affect an individual's health condition while others find such an idea highly disputable, to say the least, pointing to the discrimination practices that it might lead to.Likewise, with the cases of a person's nationality, language, and religion; some find the idea of their inclusion to the EMR useful or even essential while others find it unacceptable.Category of 'eating habits' or 'life style'-MD could provide better health care to the patients and avoid mistakes that are related to the elimination of the effects of a medicine because of these behaviors.
The race, education level and the language are important because they may assist in communicating with the patient." The study suggests that: (1) The demographics of the EMR should be divided in categories, not all of them accessible and/or visible by all; (2) The EMR system should follow an open architecture so that more categories and subcategories can be added as needed and following a possible business plan (ERD is suggested); (3) The EMR should be implemented gradually bearing in mind both medical and financial concerns; (4) Sharing should be a patient's decision as the owner of the record.Reaching a certain level of maturity of its implementation and utilization, it is useful to seek the professionals' assessment on the structure and value of such a system.be generally agreed that the benefits of EHRs are not sufficiently communicated to all stakeholders.Even though all the studies were of good quality according to the NOS, limitations of this study included a lack of data and publications from all Gulf countries on this topic.Future studies should tackle the EHR and patient-healthcare provider relationship to further explore the impact of digital transformation in health systems.

Recommendations
Through this review, it has been noted that there needs to be more computer skills and trust in the EHR system, which leads to problems in effective implementation.This, in turn, hampers the potential relationship between doctors and patients in Gulf countries.The authors provide the following suggestions to ensure the effective implementation of EHR in healthcare settings of Gulf countries: • Physicians should be provided with specific training on the EHR system being implemented, preferably paired with general computer training in medical school and during the early years of the residency programmes.This is essential considering the huge surge of artificial intelligence and efforts to digitalise health systems.• Trust in the system itself should be built by openly communicating the objectives and advantages of an EHR system to physicians.In addition, the system implementation outcomes should also be communicated by doctors to patients.This will help to improve patient perspectives of the change and reduce overall dissatisfaction.

Conclusion
Implementing EHR systems is beneficial for effective care delivery by doctors in the Gulf countries.EHR assists doctors with recording patient details, including medication and treatment procedures, as well as their outcomes.Despite the patient's perception of decreased attention, EHR promotes and enhances healthcare delivery in the GCC.The EMR has the potential to be a key tool for improving continuity of care in the GCC by flagging up follow-up dates and tests, medications, and overall surveillance.Based on this study, the authors conclude that widespread EHR implementation is highly recommended.However, specific training should be provided, and all users' subsequent effects on adoption rates must be evaluated (particularly physicians).The COVID-19 pandemic showed the great value of EHR in accessing information and consulting patients remotely.

TABLE 1
Summary of the studies extracted that show the relationship between doctors and patients when using the EMRs.