Health professionals' readiness to implement electronic medical recording system and associated factors in public general hospitals of Sidama region, Ethiopia.

BACKGROUND: Electronic medical recording system is one of the information technologies that has a proven benefit to improve the quality of health service. Readiness assessment is one of the recommended steps to be taken prior to implementing electronic medical recording system to reduce the probability of failure.
OBJECTIVE: To determine the level of health professional readiness to implement Electronic medical recording system and associated factors in public general hospitals of Sidama region, 2022.
METHODOLOGY: A cross-sectional study design complemented with qualitative study was employed at three public general hospitals in Sidama region on a sample of 306 participants. A pretested self-administered questionnaire was used to collect quantitative data and in-depth interview was used for the qualitative study. Bivariate and multivariate Binary logistics regression was performed to determine predictors of readiness at α = 0.05, using an odds ratio and 95% confidence interval. Thematic analysis was done for qualitative data collected through in-depth interview. RESULT: The overall readiness for health professionals was 36.5%. Of the study participants, 201 (73.4%) were computer literate, 176(64.23%) had good knowledge, and 204 (74.45%) had favorable attitude towards EMR. Only 31 participants had previous training (11.3%), while 64 (23%) had previous experience. EMR knowledge (AOR = 3.332; 95%CI: (1.662, 6.682)) and attitude towards electronic medical recording (AOR = 2.432; 95%CI: (1.146, 5.159)) were statistically significant predictors of readiness to implement electronic medical recording. Qualitative analysis has revealed lack of training, ease of use concerns, information security concerns, and perceived inadequacy of infrastructures including internet connectivity and electricity as common barriers for health professional readiness to implement EMR.
CONCLUSION: Health professionals' readiness in this study was low. Capacity building efforts to increase the awareness and skills of health professionals should be done before implementing the system.

Introduction

The demand for technologies that can accommodate for the large volume of information generated by the health care system has increased in the 21st century. This need had motivated countries to adopt an innovative way of handling medical records known as electronic medical recording (EMR). EMR system is a digital health technology utilized in the health sector to collect, generate and present health related data by the health professionals along with exchanging information with authorized personnel within the health care setting [1].

EMR has proven benefits to improve the quality of service by improving efficiency and productivity through timely decision-making, saving recurring costs, reducing medical errors, increasing patients’ safety, ensuring data confidentiality, and sharing medical information between authorized personnel [2-5]. These benefits are more pronounced in developing and low income areas like sub-Saharan countries which are constantly ravaged by pandemics and epidemics [6,7].

Globally, less than half of the world countries has adopted a national EMR system according to a 2016 WHO report, although there have been improvements over the past decade [1,8]. The report had also shown disparities in the adoption of the system among countries. Globally, Israel, Canada, Denmark, and Australia had notable achievements in the implementation of electronic health records [9]. However, the adoption of EMR system in developing countries was low. This low level of implementation is attributed to the high level of both budget and human resources required by the system which includes large financial investment, better infrastructures including electricity and internet connectivity, and skilled manpower [10,11].

For the same obvious reasons and exacerbated by poor infrastructures, African continent and the sub-Saharan countries in particular are lagging behind the world in implementing EMR, in spite of the high disease burden and health demand [6,10,12].

Although Health information system has been used for long period to generate aggregate data to be used at different administrative levels, the implementation of EMR in Ethiopia is still young. EMR with a name of smartcare, which was later called Tenacare, was first piloted in Ethiopia in 2009 by the Ministry of Health (MOH) with a support from Tulane University technical assistance project in Ethiopia (TUTAPE) [13,14]. Currently, the role of digital technologies is given great emphasis after the MOH acknowledged benefits of digitization and the ministry set out to change the culture of information generation and utilization for evidence based decision making at all levels[14]. The quality and availability of health information would significantly impact the quality of health care provision. Individual level data including but not limited to demographic, clinical, laboratory investigation, imaging, and medication history and billing were targeted [14,15].

Readiness assesses the level of preparedness and how welcoming a given institution and its professionals will be to the changes brought by adopting a new technology [16,17]. The need for this pre-implementation assessment emanates mainly from the resource intensive nature of the process and its dependence on human and organizational factors for its success; equally to the technical aspect. The probability of failure of EMR system could be minimized if an appropriate pre-implementation assessment of readiness is done and the concerns and gaps of practitioners are addressed properly [18]. A readiness assessment is paramount to save the unnecessary expenditure of energy, time, and money.

There are few published studies done in Ethiopia to assess health professional readiness and there was no study conducted in the region to best of the investigators knowledge [13,15]. Thus, this study aims to determine the level of health professional readiness to implement Electronic medical recording system and associated factors in public general hospitals of Sidama region.

Methods and materials

Study setting and study design

Sidama region is one of the 11 regions in Ethiopia. Based on up to date information there are four general hospitals in the region namely Adare, Yirgalem, Bona, and Leku which are found 275 km, 325km, 392km, and 306 km away from the capital Addis Ababa respectively. Adare hospital was excluded from the study since EMR system is already implemented. Institution based cross-sectional study complemented with qualitative study was conducted from April 15 –May 10, 2022.

Study population and inclusion criteria

Health professionals working at the three selected general hospitals of Sidama region were the study population. Professionals who have worked for six months or more at their respective hospitals were included to ensure adequate exposure has occurred to medical record keeping.

Sample size and sampling procedure

Sample size was determined using Epi info version 7 using the following assumptions: 80% power, proportion of readiness among those with favorable attitude 0.75 [15], AOR = 1.63 [15], 95% confidence interval. Final sample size of 306 was achieved after accounting for finite population correction and 10% non-response. After allocating proportional sample size to each hospital, Stratified random sampling was utilized to reach the final sample using a sampling frame containing the list of professionals in each professional category of each hospital. For the qualitative study 4 key informants from each hospital were purposively selected and data was collected until saturation of information was achieved.

Data collection technique and quality control

A structured self-administered questionnaire adapted after reviewing literatures and translating in to Amharic language was utilized for data collection. The tool was pretested on 5% of the final sample size (16 professionals) at Tula primary hospital, which has a near similar setup to the study area. The reliability of the tool that was used to assess readiness was tested and Cronbach alpha for core readiness was 0.763 and for engagement readiness it was 0.712. The tool was declared reliable as the result was > 0.7. Data collection was done by three trained nurses and supervision was done by a Masters student with previous experience of research. In-depth interview with medical directors, nurse matrons, quality unit heads and health management information system focal person through Amharic language was conducted to collect qualitative data. Among the interviewees, 8 of them were male while 4 of them were females. Interviewees were consisted of 6 medical doctors, 3 nurses, and 3 health information technology professionals. The supervision of data collection and quality control was done by the supervisor and the primary investigator at each hospital.

Operational definition

Computer literacy was measured using a set of self-assessment questions regarding the responders’ ability to perform routine tasks on a computer [19]. Professionals who scored ≥ 50% on literacy questions were classified as computer literate.

Knowledge is measured as a latent variable of a set of five questions which assessed whether the individual has the basic knowledge about EMR. professionals that scored 50% or more for the knowledge questions were said to have good knowledge [15].

Attitude was measured as a latent variable of a set of six questions that assesses the individual perception of EMR measured on a five point Likert scale. A score of median or above was used to classify as having a favorable attitude [15].

Core readiness was measured as a latent variable of a set of four questions measured on five point Likert scale based on Li Et al. [17] that addressed satisfaction with the current paper based system and the desire for change. A professional who scored above or equal to the median were labeled to have core readiness [13,15]. Meanwhile, Engagement readiness was measured as a latent variable of a set of nine questions measured on five point Likert scale based on Li Et al. [17] that addressed the willingness to use EMR and the professionals perceived benefits and harms of EMR. A professional who scored above or equal to the median were labeled to have engagement readiness [13,15]. Health professionals who have both core readiness and engagement readiness were labeled to have an overall readiness [17].

Data processing and analysis

Data entry, coding, and verification were done using epi-data 3.1. After exporting the data analysis was done using SPSS version 20. Categorical data were summarized using frequency and percentages. Simple binary logistic regression was performed to assess predictors of readiness and those variables with a p-value of <0.25 were considered as candidate for multivariable Logistic regression to determine predictors of readiness, using α = 0.05 as the significance level. Association was measured using Odds ratio with the corresponding 95% confidence interval. Qualitative data from audio recording was transcribed into Amharic and translated to English. After importing the text file, coding was done supported by Atlas.ti version 7.5.7 software. The codes were further categorized into themes and subthemes after which Thematic analysis was done.

Ethical statement

Ethical approval (approval number IRB/059/14) was obtained from Hawassa University, College of medicine and health science institution review board. A formal letter from the university addressed to the participating hospitals was taken and submitted. Informed written consent was obtained from the participants after thoroughly discussing the idea behind the study, and study participant rights. Participants were also assured that the confidentiality of the information they provided would be maintained.

Result and discussion

Of the total 306 participants 274 returned the questionnaire with a response rate of 89.5%.

Sociodemographic characteristics

In this study, more than half of the participants (53.3%) were within the age category 25–29 and 177 (64.6%) of the participants were male professionals. About 121 (44.2%) respondents were nurses, 40(14.6%) were doctors, 27(9.9%) were midwives, 27(9.9%) were pharmacists and 26(9.5%) were laboratory technicians. Of the respondents 192 (70.1%) have a bachelor degree while 21(7.7%) health professionals had a Masters degree and above. Moreover, 176(64.2%) of respondents have served at the hospital where they are currently working (Table 1).

Table 1

Sociodemographic characteristics of health professionals working in general hospitals, Sidama region 2022.

Variables		Frequency (N = 274)	Percentage
Age group
	20–24	37	13.5
	25–29	146	53.3
	30–34	75	27.4
	≥35	16	5.8
Sex
	Male	177	64.6
	Female	97	35.4
Profession
	Nurses	121	44.2
	Midwife	27	9.9
	Pharmacists	27	9.9
	Laboratory	26	9.5
	Doctors	40	14.6
	Health officer	10	3.6
	Health information technologists	8	2.9
	Others	15	5.5
Education status
	Diploma	61	22.3
	Degree	192	70.1
	Second degree and above	21	7.7
Duration of service at current hospital
	6–12 months	43	15.7
	13–18 months	26	9.5
	19–24 months	29	10.6
	More than 24 months	176	64.2

Others; anesthetists, radiographers, integrated emergency surgery officers, environmental health.

Organizational and technical factors

It was found that 126 (46%) of respondents have a personal computer at home. It was also found that 201 (73.4%) of the participants were computer literate. With regard to computer use, 158 (70.2%) of the participating professionals used computers for both work and entertainment purposes. among the study participants, only 31 (11.3%) had previous EMR training while only 63 (23%) had previous experience using EMR system. Of the 274 health professionals, 110 (40.1%) of them said they have computer access at workplace while 161 (58.8%) of the respondents also said they don’t have internet access at workplace. In addition, Only 92 (33.6%) health professionals believe that their hospital has adequate infrastructure. Moreover, only 91 (33.2%) health professionals think there would be strong managerial support if EMR is implemented at their hospitals (Table 2).

Table 2

Technical and organizational factors for health professional readiness in Sidama region.

Variables		Frequency	Percentage
Have Personal computer at home
	Yes	126	46
	No	148	54
Ever used computer
	Yes	225	82.1
	No	49	17.9
Duration of computer use
	Less than 6months	32	14.2
	6–12 months	37	16.4
	13–24 months	24	10.7
	More than 24 months	132	58.7
Purpose of computer use
	Work purpose only	54	24
	Entertainment purpose only	13	5.8
	Work and entertainment	158	70.2
Computer Literacy
	Literate	201	73.4
	Illiterate	73	26.6
Previous EMR training
	Yes	31	11.3
	No	243	88.7
Previous EMR experience
	Yes	63	23
	No	211	77
Workplace computer access
	Yes	110	40.1
	No	164	59.9
Workplace internet access
	Yes	161	58.8
	No	113	41.2
Adequate infrastructures
	Yes	92	33.6
	No	182	66.4
Adequate management support
	Yes	91	33.2
	No	183	66.8

Health professionals knowledge and attitude towards EMR system

Regarding knowledge about EMR, 176 (64.2%) of respondents had good knowledge. Meanwhile, 204 (74.5%) respondents had favorable attitude toward the EMR system (Fig 1).

Fig 1

EMR knowledge and attitude towards EMR among health professionals working in public general hospitals, Sidama, Ethiopia, 2022.

Readiness to implement EMR system

The core readiness to implement EMR in this study was 55.8% and the engagement readiness was 54%. Of the study participants, only 100 (36.5%) had overall readiness and were ready to use EMR (Fig 2). This is significantly lower than what studies conducted in other parts of Ethiopia 62.3% [15], Ghana 54.9% [20], and Myanmar 54.2% [19] reported. However, this difference could also be due to method used to classify the readiness of professionals, differences in sample size or differences in sociodemographic characteristics.

Fig 2

Health professional readiness to implement EMR in public general hospitals of Sidama region, Ethiopia, 2022.

Factors associated with readiness to implement EMR system

In this study, duration of employment, knowledge about EMR, and attitude towards EMR were found to be statistically significant predictors of health professional readiness after adjusting for other variables. It was found that those health professionals who have worked for 13 to 18 months at the hospital where they are currently working had 3.85 times higher odds of being ready than those who have worked for more than 24 months (AOR = 3.848, 95% CI; (1.428,10.371)). This result differs from a study done in Ghana which showed old employees to be more likely to be ready than new employees [20]. The finding could be explained by the fact that early level employees are young professionals who can easily utilize technologies while also being sufficiently exposed to medical recording system [21].

Among health professionals, those who had good EMR knowledge had 3.33 times higher odds of being ready than those with poor knowledge (AOR = 3.332, 95% CI; (1.662, 6.682)). This finding is supported by studies done in other parts of Ethiopia [13,15], Ghana [20], and Myanmar [19]. This can be explained by the fact that a professional having good knowledge about EMR could have higher chance of understanding about the potential benefits that the system would bring to the professionals, the patients, and the overall service. This finding is also supported by qualitative study results.

A 35 year old participant said “I didn’t have any training or previous experience working with EMR. While I was attending a relative, I have seen it being practiced in private healthcare settings and I was able to see its benefits. It had made me eager to know more about the system”

It was also noted that those professionals with favorable attitude had 2.43 times higher odds of being ready than professionals with unfavorable attitude (AOR = 2.432, 95% CI; (1.146, 5.159)) (Table 3). This could be explained by the fact that professionals could likely be willing to use the system if they have a favorable and positive image with good interest towards the system. Previous studies had also shown that health professional’s attitude affects not only their readiness but also the actual utilization of the system [22]. The finding is also supported by qualitative study results.

Table 3

Bivariable and multivariable analysis of factors associated with health professional readiness to implement EMR in public general hospitals of Sidama region, 2022.

Variables		Not ready(174, 63.5%)	Ready(100, 36.5%)	COR (95% C.I)	AOR(95% CI)	P-value
Duration of employment
	6–12 months	32(74.4%)	11(25.6%)	0.573 (0.27,1.21)	0.797 (0.321, 1.977)	0.624
	13–18 months	11(42.3%)	15(57.7%)	2.273 (0.985,5.242)	3.848 (1.428, 10.371)	0.008*
	19–24 months	21(72.4%)	8(27.6%)	0.635 (0.266,1.515)	0.931 (0.339, 2.557)	0.89
	> 24 months	110(62.5%)	66(37.5%)	1.00	1.00
EMR Knowledge
	good	94(53.4%)	82(46.6%)	3.877 (2.147,7.0)	3.332 (1.662,6.682)	0.001*
	poor	80(81.6%)	18(18.4%)	1.00	1.00
Attitude towards EMR
	Favorable	116(56.9%)	88(43.1%)	3.667 (1.857,7.241)	2.432 (1.146,5.159)	0.021*
	Unfavorable	58(82.9%)	12(17.1%)	1.00	1.00

Variables accounted for: Age category, profession category, previous EMR experience, ownership of personal computer, workplace computer access, perceived adequacy of infrastructure, and perceived management support.

*P<0.05.

A 30 year old participant said “I do not think there would be a problem for me to use the system effectively. If I am instructed on a few things and if I am provided with the software, I think I would build upon what I know and be better able to use it.”

Perceived barriers for readiness to implement EMR

Qualitative analysis from the in-depth interview conducted on participants with mean age of 28 to explore barriers for readiness to implement EMR had shown that majority of participants had concerns pertaining to lack of training, concerns related EMR system ease of use, patients information security concerns, and perceived inadequacy of infrastructures including internet connectivity and electricity as common barriers for health professional readiness to implement EMR.

Training related

Among the participating hospitals, Leku hospital has already done facility assessment and installed servers needed, although professionals hadn’t been trained. Most of the participants predominantly raised their concern about lack of training regarding EMR system and computer related skills. They also discussed the need for continuous on job orientations, monitoring, and follow up. Furthermore, one participant discussed the need to avail manuals by the professional’s side. A 32 year old participant explained the need for a skill laboratory for professionals to improve their skills.

He stated “If professionals who are not familiar with computers want to use the system, it would be difficult for them. Once the system is implemented, we need to have skill labs where professionals could develop their computer skills to better understand the system”.

System related

Four of the study participants expressed concerns regarding the EMR system itself. Issues related to security including hacking, the dependence of the system on stable connection and electricity, and issues of maintenance were some of the concerns raised. Furthermore, one participant explained the need for parallel documentation to better secure information. A 32 year old male interviewee explained

“The software can be attacked by different things. One thing is it can be corrupted or hacked and it can take away all patients data. I think it would be better if there is a printed hard copy of everyday records”.

Facility related

Respondent also raised their concerns regarding the adequacy of infrastructures in their institution. Issues of electricity, internet connectivity, and availability of computers at work stations were raised predominantly. It was also noted that those concerns were shared by all participants of the interview. Participants suggested this issue should be properly dealt with prior to implementation. A 28 year old female participant denoted

“The stability of the internet connection around here is concerning. If the system is implemented without addressing this, it can frustrate the professional and might eventually lead to prefer the paper based record system”

Strength and limitation

This study is the first study done in the region to assess the readiness of health professionals to implement EMR. The study utilized mixed method design which enabled to better explore the level of readiness and factors related with its implementation. However, the study was not without limitations. First, data was collected over a period of 3 days per institution. This might have led to information sharing among participants regarding the questions raised in the questionnaire and affected the assessment of knowledge level. Secondly, although the study utilized composite questions to assess computer literacy, the assessment of computer literacy was subjective. Thus, the high level of computer literacy reported in this study might not reflect the truth and needs objective assessment.

Conclusion

Overall, the readiness of health professionals to implement EMR in this study was low. Duration of employment, knowledge about EMR, and attitude towards EMR were found to be statistically significant predictors of readiness.

Recommendation

Capacity building and awareness creation efforts including training should be provided to health professionals prior to implementation to increase the level of knowledge about EMR among health professionals. Presumably, this could also change the attitude of health professionals as it would increase the skills of professionals and it would make them feel competent and willing to use the system. Furthermore, further study is recommended to assess the factors that affect the knowledge and attitude of health professional towards EMR system.

Minimal data.

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1 Aug 2022

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Reviewer #1: Abstract: The result doesn’t reflect anything from qualitative section. No need to mention the name of Software used in data analysis.

Introduction: Kindly reflect how EMR system could contribute to better data management and what kind of health data are mostly aimed to handle by EMR system in Ethiopia.

Methods: Provide justification why p value less than 0.25 was considered as candidate for multivariate Logistic regression to determine predictors of readiness. On what basis were the professionals who scored ≥ 50% on literacy questions classified as computer literate? Mention the process of qualitative data analysis. Focus on preconceptions and meta-positions for qualitative data analysis process.

Results and discussions: Although the result fairly comply with the quantitative analysis, it seriously lacks the qualitative findings. There are only two sentences from the participants which does not show the strength of the qualitative data analysis. What theme was developed from the thematic analysis? The discussion should be more detailed and should focus on validity and reliability for quantitative findings and transferability for qualitative findings.

Recommendations and conclusions could be separate sections.

Reviewer #2: This study investigated the health professional readiness to implement electronic medical recording system and associated factors in public general hospitals in a region in Ethiopia. The idea was good, and the findings of this research could help the policymakers in future decision-making.

However, after carefully reading the whole manuscript, I feel that this manuscript needs a major revision to achieve the merit of publication in a high-quality journal.

Overall comments:

1. There are a few grammatical and punctuational errors in the manuscript. This should be addressed in the revised version.

Abstract:

2. “Electronic medical recording system is one of the information technologies that have a proven benefit to improve the quality of health service.” It will be “has a proven benefit”.

3. “A hospital based cross-sectional study design”; remove the term “hospital based”, as in the subsequent texts, it is mentioned that the data was collected from the hospital.

Introduction:

4. “Globally, less than half of the world countries has adopted a national EMR system according to a 2016 WHO report, although there have been improvements over the past decade [1, 8]. The report had also shown disparities in the adoption of the system among countries. A 2013 report indicated that more than 90% of primary care physicians in New Zealand, Netherlands, United Kingdom, Australia, Sweden, and Norway used EMR system [9].” These are old statistics. Please report the updated statistics.

5. MOH: use the full form of its first appearance.

6. “There are few published studies done in Ethiopia to assess health professional readiness and there was no study conducted in the region to best of the investigators knowledge.” Use citations.

7. Mention the objective of the study at the end of the introduction.

Methods and materials:

8. “Based on up to date information there are four general hospitals in the region namely Adare, Yirgalem, Bona, and Leku which are found 275 km, 325km, 392km, and 306 km away from the capital Addis Ababa respectively.” Use citations.

9. The authors mentioned G.C at the end of the date. What does it mean?

10. What are the types of health professionals included in the study? It should be mentioned in the study population section.

11. “12 key informants” from how many hospitals? From any single or from all hospitals?

12. In the logistic regression, it will multivariable analysis. Not multivariate analysis, as there is dichotomous dependent variable.

13. Operational definitions should be placed before data processing and analysis section.

Results:

14. “Of the respondents 192 (70.1%) have a first degree while 21(7.7%) health professionals had a second degree and above.” What are first degree and second degree? Not clear. Explain in the methods section or in the result interpretation.

15. In table 1, what is HIT profession?

16. In table 1, What does mean by degree and second degree professions?

17. “among the study participants, only 31 (11.3%) have previous training while only 63 (23%) had previous experience.” Write in the past tense.

18. In table 2, the variables ‘previous training’ and ‘previous experience’ are not clear. What training and what experience?

19. In table 3, p value placement of ‘duration of employment’ is not correct. The authors put value only for unadjusted analysis. Why not for adjusted analysis? Put p value for both the analyses, or indicate it using asterisk.

20. It is not clear how the authors adjusted the readiness of EMR use in the regression model. It should be adjusted by including some important demographic variables also, i.e. age, sex, educational status, profession etc.

References:

21. For most of the citations, there is no doi or url in the references.

22. There is no data as supplementary file.

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Reviewer #1: No

Reviewer #2: Yes: Saifur Rahman Chowdhury

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29 Aug 2022

We would like to take a moment to thank the Editor and the peer reviewers for the constructive evaluation of our paper. We have corrected the manuscript as per the comments provided and we hope the manuscript meets the requirement for publication.

Sincerely,

Kibruyisfaw Weldeab Abore

Response to Academic editor

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

We have edited authors contributorship as per the journal requirement. We have also edited the figure files using PACE and revised the file names to suit the journal.

2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

We have amended the information on both sections

3. Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter.

Thank you for the comments. We have availed the minimal data set as a supporting information.

Reviewer 1

Abstract: The result doesn’t reflect anything from qualitative section. No need to mention the name of Software used in data analysis

We amended abstract section to include results from the qualitative analysis and we have removed the name of the software used in data analysis from the abstract.

Introduction: Kindly reflect how EMR system could contribute to better data management and what kind of health data are mostly aimed to handle by EMR system in Ethiopia

We have amended the manuscript to explain the kind of health data intended to be handled by EMR and the role of EMR for better data management.

Methods: Provide justification why p value less than 0.25 was considered as candidate for multivariate Logistic regression to determine predictors of readiness. On what basis were the professionals who scored ≥ 50% on literacy questions classified as computer literate? Mention the process of qualitative data analysis. Focus on preconceptions and meta-positions for qualitative data analysis process

Although different scholars use p-value < 0.2 for including predictors in to the multivariable logistic regression based on Hosmer and lemshow applied logistic regression recommendation, we used p-value< 0.25 to include as many predictor variables as possible in the multivariable model so as to ensure adjustment of confounders. Regarding computer literacy, we classified those participants with the average computer literacy score or above as literate. The questions were composed of questions which assessed basic computer skills of individuals. Pertaining to the process of qualitative analysis we have included details in the method and material section to meet reviewers comment.

Results and discussions: Although the result fairly complies with the quantitative analysis, it seriously lacks the qualitative findings. There are only two sentences from the participants which do not show the strength of the qualitative data analysis. What theme was developed from the thematic analysis? The discussion should be more detailed and should focus on validity and reliability for quantitative findings and transferability for qualitative findings

We have added a subsection labeled perceived barriers for readiness to implement EMR to address themes and subthemes that emerged during thematic analysis.

Recommendations and conclusions: could be separate sections.

We have amended this section in to two separate sections.

Reviewer 2.

Abstract:

1. There are a few grammatical and punctuation errors in the manuscript. This should be addressed in the revised version.

Thank you for the comments. We have amended the manuscript based on the comments.

2. “Electronic medical recording system is one of the information technologies that have a proven benefit to improve the quality of health service.” It will be “has a proven benefit”.

Thank you for the comment. We have addressed the comment

3.“A hospital based cross-sectional study design”; remove the term “hospital based”, as in the subsequent texts, it is mentioned that the data was collected from the hospital.

Thank you for the comment. We have addressed the comment

Introduction:

4.“Globally, less than half of the world countries has adopted a national EMR system according to a 2016 WHO report, although there have been improvements over the past decade [1, 8]. The report had also shown disparities in the adoption of the system among countries. A 2013 report indicated that more than 90% of primary care physicians in New Zealand, Netherlands, United Kingdom, Australia, Sweden, and Norway used EMR system [9].” These are old statistics.Please report the updated statistics.

Thank you for the comments. We have amended the section to include more updated information

5.MOH: use the full form of its first appearance.

Thank you for the comment. We have addressed the comment

6.“There are few published studies done in Ethiopia to assess health professional readiness and there was no study conducted in the region to best of the investigators knowledge.” Use citations.

Thank you for the comment. We have addressed the comment in the introduction section.

7.Mention the objective of the study at the end of the introduction.

Thank you for the comment. We have addressed the comment at the end of the introduction section.

Methods and materials:

8. “Based on up to date information there are four general hospitals in the region namely Adare, Yirgalem, Bona, and Leku which are found 275 km, 325km, 392km, and 306 km away from the capital Addis Ababa respectively.” Use citations.

Thank you for the comment.

9. The authors mentioned G.C at the end of the date. What does it mean?

Thank you for the comment. It means Gregorian calendar while in Ethiopia we use Ethiopian calendar ( E.C). we have removed all references of G.C from the manuscript.

10. What are the types of health professionals included in the study? It should be mentioned in the study population section.

Thank you for the comment. All health professionals working in the selected health facilities were considered the study population. Meanwhile, the details of the professional category were addressed in the sociodemographic part of the result.

11. “12 key informants” from how many hospitals? From any single or from all hospitals?

A total of 12 key informants were selected from all hospitals. We have amended the manuscript to address the concern.

12. In the logistic regression, it will multivariable analysis. Not multivariate analysis, as there is dichotomous dependent variable.

Thank you for the valuable comment. We have addressed the comment at the method and material section and result section.

13. Operational definitions should be placed before data processing and analysis section.

Thank you for the comment. We have placed operational definitions before data processing and analysis section.

Results

14. “Of the respondents 192 (70.1%) have a first degree while 21(7.7%) health professionals had a second degree and above.” What are first degree and second degree? Not clear. Explain in the methods section or in the result interpretation.

Thank you for the comment. We have addressed the issue in the result section. We have changed it to bachelor degree and Masters degree and above.

15. In table 1, what is HIT profession?

It means Health information technology professionals. We have amended it in the result section

16. In table 1, What does mean by degree and second degree professions?

Thank you for the comment. We have addressed the issue in the result section. We have changed it to bachelor degree and Masters degree and above.

17. “among the study participants, only 31 (11.3%) have previous training while only 63 (23%) had previous experience.” Write in the past tense.

Thank you for the comment. We have addressed the issue in the result section.

18. In table 2, the variables ‘previous training’ and ‘previous experience’ are not clear. What training and what experience?

Thank you for the comment. We have addressed the issue in the result section to previous EMR experience and previous EMR training.

19. In table 3, p value placement of ‘duration of employment’ is not correct. The authors put value only for unadjusted analysis. Why not for adjusted analysis? Put p value for both the analyses, or indicate it using asterisk.

Thank you for the comment. We have addressed the issue in the result section and we have indicated significant p-values using asterisk.

20. It is not clear how the authors adjusted the readiness of EMR use in the regression model. It should be adjusted by including some important demographic variables also, i.e. age, sex, educational status, profession etc.

Thank you for the comment. Although in the result section we have only displayed those with significant p-value on adjusted analysis, we did the multivariable logistic regression including variables from sociodemographic characteristics and organization and technical factors to adjust for confounders. If needed we can provide the detailed crude analysis and adjusted analysis results.

References

21. For most of the citations, there is no doi or url in the references.

Thank you for the comments. We have updated the references to include doi and url

22. There is no data as supplementary file.

Thank you for the comments. We have included minimal data as a supplementary file

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

29 Sep 2022

30 Sep 2022

We would like to take a moment to thank the Editor and the peer reviewers for the constructive evaluation of our paper. We have corrected the manuscript as per the comments provided and we hope the manuscript meets the requirement for publication.

Sincerely,

Kibruyisfaw Weldeab Abore

Response to academic editor

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice

Dear editor,

Thank you for taking the time to review our manuscript and for the constructive comment. After reviewing the reference list, although we have the booklet at hand, we noticed that one of the references booklets from ministry of health Ethiopia had no database to which readers could access the document. Therefore, we have removed this reference and updated it with a roadmap booklet that can be accessed from ministry of health E-library.

Reviewer 1: All the comments have been addressed. Therefore, I suggest to accept the manuscript. Furthermore, the underlying dataset could be checked, and probably a single excel sheet would be more aesthetic for the interested readers/researchers. If possible, provide the coded transcripts as the minimum underlying dataset for the qualitative part. The statistical issues could be re-checked by the expert before publication.

I would like to extend my sincere gratitude on behalf of all authors for the constructive review we received and for the support towards the publication.

Reviewer 2: I would like to make a suggestion to the authors that in Table 3, they should include a footnote stating for which variables they accounted for adjusting their analysis.

I would like to extend my sincere gratitude on behalf of all authors for the constructive review we received and for the support towards the publication. We have amended the manuscript to include a foot note on Table 3 for the variables accounted for in the multivariable logistic regression.

Submitted filename: response to reviewers.docx

Click here for additional data file.

6 Oct 2022

Health professionals’ readiness to implement electronic medical recording system and associated factors in public general hospitals of Sidama region, Ethiopia

PONE-D-22-16693R2

Dear Dr. Kibruyisfaw,

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Humayun Kabir, MSc in Epidemiology

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

10 Oct 2022

PONE-D-22-16693R2

Health professionals’ readiness to implement electronic medical recording system and associated factors in public general hospitals of Sidama region, Ethiopia

Dear Dr. abore:

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