PLOS ONE
RESEARCH ARTICLE
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Citation: Faris N, Saliba M, Tamim H, Jabbour R,
Fakih A, Sadek Z, et al. (2024) Electronic medical
record implementation in the emergency
department in a low-resource country: Lessons
learned. PLoS ONE 19(3): e0298027. https://doi.
org/10.1371/journal.pone.0298027
Editor: Asli Suner Karakulah, Ege University,
Faculty of Medicine, TURKEY
Received: November 14, 2022
Accepted: January 17, 2024
Published: March 1, 2024
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https://doi.org/10.1371/journal.pone.0298027
Copyright: © 2024 Faris et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper.
Funding: The author(s) received no specific
funding for this work.
PLOS ONE | https://doi.org/10.1371/journal.pone.0298027 March 1, 2024
Electronic medical record implementation in
the emergency department in a low-resource
country: Lessons learned
Nagham Faris ID1, Miriam Saliba1, Hani Tamim2,3, Rima Jabbour1, Ahmad Fakih4,
Zouhair Sadek4, Rula Antoun4, Mazen El Sayed1*, Eveline Hitti ID1*
1 Emergency Department, American University of Beirut Medical Center, Beirut, Lebanon, 2 Department of
Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon, 3 College of Medicine,
Alfaisal University, Riyadh, Saudi Arabia, 4 Department of Information Technology, American University of
Beirut Medical Center, Beirut, Lebanon
* eh16@aub.edu.lb (EH); melsayed@aub.edu.lb (MES)
Abstract
Objective
There is paucity of information regarding electronic medical record (EMR) implementation in
emergency departments in countries outside the United States especially in low-resource
settings. The objective of this study is to describe strategies for a successful implementation
of an EMR in the emergency department and to examine the impact of this implementation
on the department’s operations and patient-related metrics.
Methods
We performed an observational retrospective study at the emergency department of a ter-
tiary care center in Beirut, Lebanon. We assessed the effect of EMR implementation by
tracking emergency departments’ quality metrics during a one-year baseline period and one
year after implementation. End-user satisfaction and patient satisfaction were also
assessed.
Results
Our evaluation of the implementation of EMR in a low resource setting showed a transient
increase in LOS and visit-to-admission decision, however this returned to baseline after
around 6 months. The bounce-back rate also increased. End-users were satisfied with the
new EMR and patient satisfaction did not show a significant change.
Conclusions
Lessons learned from this successful EMR implementation include a mix of strategies rec-
ommended by the EMR vendor as well as specific strategies used at our institution. These
can be used in future implementation projects in low-resource settings to avoid disruption of
workflows.
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PLOS ONE Electronic medical record implementation in a lebanese emergency department

Competing interests: The authors have declared Introduction

that no competing interests exist.
Electronic Medical Records (EMRs) adoption in hospitals and emergency departments (EDs)
is increasing, especially in high-resource countries where healthcare digitization is often incen-
tivized by governments and policymakers [1, 2].
The adoption of these EMRs in hospitals often entails challenges including high cost, end-
users resistance, and complex implementation processes [3]. A failed EMR implementation
incurs significant financial losses to healthcare organizations [4]. An extensive preparedness
plan is therefore required for a successful implementation especially in the busy and complex
ED setting [5].
EMRs have been shown to improve clinical practice and patient safety in hospitals and EDs,
where timely clinical information is needed to manage patients with life threatening emer-
gency medical conditions [1]. Additional benefits include a decrease in medical errors [6–8]
and unnecessary testing [9], reduction in length of stay (LOS) [10–12], and improved docu-
mentation with less illegible, misplaced, or lost documents [5].
There is paucity of information regarding EMR implementation in EDs in countries outside
the United States, especially in low-resource settings. The objective of this study is to describe
strategies for a successful implementation of an EMR in the ED and examine the impact of this
implementation on this department’s operations and patient-related metrics at a tertiary care
center in Beirut, Lebanon.

Methods
Study setting and design
This observational retrospective study took place at the largest academic tertiary care center in
Lebanon, in an ED that is divided into three sections (High Acuity, Low Acuity, and Pediat-
rics), with over 55,000 patient visits per year. The ED has an associated residency program in
emergency medicine and is staffed by a mix of American board-certified/eligible Emergency
Medicine physicians as well as non-Emergency Medicine physicians with extensive experience
in emergency care. The study was approved by the institutional review board of the American
University of Beirut, and requirement for informed consent was waived. De-identified data
regarding all variables was obtained from ED leadership.
This EMR implementation was the first of its kind in Lebanon, a low-middle income coun-
try. In this low-resource setting, financial resources were limited. There is an absence of gov-
ernment funding for healthcare infrastructure, and healthcare institutions rely on internal
funding. Moreover, there was a lack of trained personnel to implement and maintain the
EMR. Budget to hire external consultants and to pay faculty and staff additional compensation
for roles performed during Go-Live was limited.
Before implementation of the EMR, an electronic dashboard provided real-time informa-
tion about active ED patients. This dashboard was used to access the patient’s records through
a homegrown HIS (Health Information System). It was also used for the CPOE (Computerized
Physician Order Entry), admission orders, charges, and discharge orders. Laboratory and radi-
ology orders were electronically placed but some orders still required paper forms (including
medications, cytology, and echocardiography). Paper-based documents were used for triage,
physician notes, nursing notes, and orders. The paper charts were then scanned by the medical
records department and uploaded to the homegrown HIS that displays previous patient
encounters and diagnostic test results. Different applications were also present including
Admission, Discharge and Transfer (ADT), registration and Master Patient Index, material
management, and billing. Lab information system and PACS had also been installed in prior

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years. For pharmacy, a plan was to install an automated medication dispensing system (BD
Pyxis™ MedStation™ ES) during the implementation of the new EMR. The projected imple-
mentation plan of the EMR (EPIC Systems Corporation) was over 2 years, which was proposed
and agreed on by the EMR vendor. For ED staff, the plan consisted of extensive workflow anal-
ysis sessions, adoption sessions, training, and preparation. On November 3, 2018, the new
EHR system (EPIC) went live across all clinical areas including the ED.

Emergency department and organizational strategies

Pre-implementation: ED leadership engagement and operational strategies. ED leader-
ship was engaged fully in all implementation phases. Extensive sessions over several months
were dedicated to workflow analysis, ED processes, staffing and hardware requirements, and
issues with interfaces. All clinical and non-clinical risks were reviewed, and corresponding
mitigation plans were prepared. Paper-based order sets and protocols were modified and
transferred to the EMR.
Pre-implementation: Staff training and engagement strategies. All ED physicians,
nurses, and staff underwent extensive training that included: online training, hands-on train-
ing, and practice through the EMR ‘playground’. Prerequisite online introductory videos were
sent to end-users through the institution’s online platform for easy access and tracking. End-
users then registered for small group training sessions and were able to choose times and dates
that suit their schedules.
Each physician attended a four-hour class in which the basic EMR functions were pre-
sented, another two-hour class in which personalization of physician notes and orders were
introduced, and a third two-hour refresher course. Also, physicians were divided in groups,
each led by one physician super-user, to practice personalization functions and tips. This
occurred over a period of two months.
In our ED, a physician champion was chosen to act as the link between the ED leadership,
ED physicians, and Information Technology (IT) staff. Super-users were also selected from the
ED. These included physicians, residents, medical students, and nurses who underwent
advanced training which included troubleshooting strategies that could be used during and
after Go-Live. Each super-user was assigned a group of 4 to 5 trainees for one-on-one support
as needed.
Physicians who needed additional sessions, including those who were less computer savvy,
had visual problems, or had infrequent ED shifts, were identified in advance and received
additional personalized training from super-user physicians.
With the involvement of all stakeholders, several simulations and drills took place reflecting
the new EMR workflows, with special focus on high-risk areas. All possible technical glitches
were addressed and minimized prior to Go-Live. Implementation teams from the EMR vendor
were also available on-site. A cut-over team was created and included a physician, two nurses,
patient access staff, cashiers and IT staff. A cut-over drill took place, problems were identified,
and the drill was repeated three times until all problems were solved and the process occurred
smoothly.
Moreover, multiple new computers with wide screens were installed. A workstation was
allocated for every person working in the ED. Staff were instructed to use their designated
workstation even before Go-Live. Workstations on wheels (WOWs) and wall-mounted sta-
tions were also installed. New printers were installed to ensure adequate printing capabilities.
Post-implementation: EMR Go-Live strategies. Go-Live occurred on November 3, 2018,
which was a Saturday. Patient load in the hospital during the weekend is usually lower than
weekdays because of clinic closure and lack of scheduling of elective cases. Adequate IT

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PLOS ONE Electronic medical record implementation in a lebanese emergency department

support was available for the ED. The cut-over team was present during Go-Live. Physician
and nurses involved in cut-over did not have clinical responsibilities and focused on ensuring
a smooth cut-over process.
Super-users had no clinical responsibilities during super-user shifts and were available at all
times for the first three days of Go-Live. In addition, the ED attending staffing model included
at least one physician at all times who had also undergone super-user training. This staffing
model was maintained for two weeks post implementation. Super-user coverage was modified
according to the need. Staffing was also increased with an extra attending present in the high
turnover low-acuity area of our ED during the first 3 weeks after implementation.
A structured troubleshooting system was created. All super-users were also trained on how
to place tickets for issues that could not be solved real-time. Tickets were placed online, and
the super-users included the priority of the problem (low, medium, high, or critical) as well as
important details needed to facilitate troubleshooting including screenshots of alerts, worksta-
tions involved, and user information. IT response was effective in addressing and resolving
tickets immediately after Go-Live.
Daily huddles post Go-Live took place to discuss issues, updates and plans. A list of tips was
provided daily and disseminated by super-users to end-users. Moreover, multidisciplinary
teams had regular meetings to discuss issues and propose solutions. A close follow-up and col-
laboration occurred between the ED leadership, ED staff, and the IT staff.
Knowing that operational data and metrics can be inaccurate after Go-Live [13], emphasis
was placed on report validation. The top ten key operational metrics were prioritized and
report validation started immediately after Go-Live. Observations were made, compared and
benchmarked to historical metrics and live observations. This ensured reliable data regarding
key ED metrics after Go-Live.

Outcomes and intervention results

The main outcomes assessed reflected the priority ED operational quality metrics including
LOS, door to admission request, and rate of return visits or bounce-backs. The bounce-back
rate captures the percentage of ED patients who return to the ED within 72 hours after being
discharged from the ED. The high-risk bounce-back rate shows the percentage of patients who
return within 72 hours and require admission, are dead, or get transferred to another hospital.
Secondary outcomes included end-user satisfaction and patient satisfaction.

Data collection
Data was collected for the period of one year before EMR implementation (Nov. 2, 2017 until
Nov. 2, 2018) and one year after (Nov. 3, 2018 until Nov. 3, 2019). For the pre-intervention
period, data regarding ED quality metrics was collected from a business intelligence solution
that was adopted as well as from electronic reports reading from e-forms. For the post inter-
vention period, reports were obtained from the new EMR and were validated.
After implementation, three online surveys were used to assess end-users’ satisfaction with
the newly-implemented EMR. The surveys were sent at one month, three months, and one
year after implementation. End-users included physicians, nurses, and other ED staff. End-
users’ answers were on a scale from 1 to 6 where 1 corresponds to “Strongly Disagree” and 6
corresponds to “Strongly agree”. A satisfaction score was created.
A representative from the patient affairs office regularly conducted phone surveys with a
random selection of patients who presented to the ED as part of a routine quality initiative.
Phone calls took place one to two days after patient discharge. Surveys consisted of 30

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PLOS ONE Electronic medical record implementation in a lebanese emergency department

questions divided according to 6 domains. These surveys were conducted before and after
implementation, except for the first two weeks after implementation.

Analysis
The Statistical Package for Social Sciences (SPSS), version 24.0 was used for data cleaning,
management, and analyses. Categorical variables were summarized using numbers and per-
centages while continuous variables were summarized by means ± standard deviation (SD).
The association between pre-implementation/post-implementation, and other categorical var-
iables was carried out by using the Chi-square test. Student’s t-test was used for the association
with continuous variables. Moreover, Cochran-Mantel-Haenszel Statistics was used to evaluate
the p for trend for categorical variables over time. P-value < 0.05 was used to indicate statisti-
cal significance.

Results
Table 1 shows the baseline and demographic characteristics of the ED patient population 1
year pre- and 1 year post-implementation.

Operational outcomes
Mean ED LOS increased in the post-implementation period, as shown in Fig 1; however mean
LOS returned to its baseline at around 6 months post-implementation. A similar trend was
observed for the mean ED visit to admission decision time (Fig 2). Fig 3 presents the bounce-
back rate, the results show an increase from 3.4% to 3.7% after implementation. The high-risk
bounce-back rate also increased from 1.1% to 1.2%.

Table 1. Baseline and demographic characteristics.

Pre N = 54893 (%) Post N = 56417 (%) p-value
Age (years) Mean (±SD) 35.7 ± 24.8 25.3 ± 24.8 <0.0001
Gender Male 27456 (50.0) 28584 (50.7) 0.03
Female 27437 (50.0) 27833 (49.3)
Country Lebanon 48220 (87.8) 55250 (97.9) <0.0001
Others 6673 (12.2) 1167 (2.1)
Guarantor Self-payer 10201 (18.6) 9331 (16.5) <0.0001
Insured 44692 (81.4) 47073 (83.5)
ESI Mean (±SD) 3.01 ± 0.35 2.95 ± 0.37 <0.0001
1–2 2647 (4.8) 4929 (8.7) <0.0001
3 49340 (89.9) 49104 (87.0)
4–5 2906 (5.3) 2384 (4.2)
ED visit to admission decision (minutes) Mean (±SD) 138.80 ± 103.80 151.43 ± 111.10 <0.0001
ED disposition Admitted 11074 (20.2) 11698 (20.7) <0.0001
AMA 2582 (4.7) 2650 (4.7)
Dead 94 (0.2) 105 (0.2)
Home 40783 (74.3) 41531 (73.6)
Transfer to other hospital 360 (0.7) 433 (0.8)
LOS (hours) Mean (±SD) 2.84 ± 3.33 3.26 ± 5.25 <0.0001
Bounce-back Yes 1873 (3.4) 2109 (3.7) 0.003
High-risk bounce-back Yes 583 (1.1) 699 (1.2) 0.01
https://doi.org/10.1371/journal.pone.0298027.t001

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PLOS ONE Electronic medical record implementation in a lebanese emergency department

Fig 1. Mean length of stay (LOS) for the post-implementation period with the mean of the pre-implementation
value as baseline.
https://doi.org/10.1371/journal.pone.0298027.g001

End-user satisfaction
Table 2 shows the result of the three conducted online surveys. End-users were satisfied with
the newly implemented EMR. After implementation, and with time, end-users experienced a
significant improvement in patient care (4.12 ± 1.49 vs5.14 ± 1.35, p-value = 0.01) and
reported a better efficiency in their day-to-day jobs (4.80 ± 1.17 vs 5.47 ± 0.83, p-value = 0.04).

Patient satisfaction
Table 3 shows the results of the patient satisfaction interviews that were conducted. No signifi-
cant difference was found in the overall patient satisfaction pre- and post-implementation;
only three variables scored significantly higher when comparing post to pre-implementation:
the courtesy of the staff in registration (4.60 ± 0.57 vs 4.66 ± 0.57, p-value = 0.02), waiting time
at registration area (4.43 ± 0.74 vs 4.58 ± 0.67, p-value <0.0001) and LOS before triage
(4.53 ± 0.69 vs 4.63 ± 0.63, p-value = 0.001).

Fig 2. Mean visit to admission decision time for the post-implementation period by month with the mean of the
pre-implementation period as baseline.
https://doi.org/10.1371/journal.pone.0298027.g002

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PLOS ONE Electronic medical record implementation in a lebanese emergency department

Fig 3. Bounce-back and high-risk bounce-back rate in the pre- and post-implementation periods.
https://doi.org/10.1371/journal.pone.0298027.g003

Discussion
In this study, we describe the implementation of HIMSS stage 6 EMR in a setting that used a
hybrid model EMR and paper-based charting.
Results presented describe the operational and clinical impact of this EMR implementation.
This implementation was considered successful based on vendor and hospital assessment.
Main operational metrics including mean patient LOS and mean door to admission decision
returned to baseline values after around 6 months, end-user satisfaction in the ED was rela-
tively high, and patient satisfaction was not significantly affected.
Statistically significant differences are seen in the demographic characteristics between pre
and post groups. However, most of these differences are mainly due to the large sample size
and are not clinically significant. The pre-implementation patient group seems to be signifi-
cantly older than the post-implementation group, which might seem to bias the operational
metrics results such as LOS. For this reason, a month-by-month analysis was done, and the

Table 2. Results of the surveys assessing end-user satisfaction (on a scale from 1 to 6). The numbers shown represent the mean.
First survey N = 44 Second survey N = 15 Third survey N = 15 P-value
Adequate training 4.68 ± 1.25 5.20 ± 1.08 5.07 ± 1.39 0.31
Adequate super-user support 5.19 ± 1.33 5.79 ± 0.43 5.08 ± 1.12 0.20
Ease and accuracy of capturing charges 4.58 ± 1.55 5.20 ± 1.03 4.90 ± 0.74 0.42
Ease of EMR use 4.95 ± 1.13 5.47 ± 0.64 5.27 ± 1.03 0.21
Better efficiency 4.80 ± 1.17 5.40 ± 0.63 5.47 ± 0.83 0.04
Improved patient care 4.12 ± 1.49 5.07 ± 0.59 5.14 ± 1.35 0.01
Improved revenue cycle 4.60 ± 1.24 5.20 ± 0.63 5.11 ± 0.60 0.20
Satisfactory system response time 4.52 ± 1.19 4.53 ± 1.30 4.80 ± 1.01 0.73
Feeling supported in EMR use 4.86 ± 0.98 5.00 ± 0.85 5.13 ± 1.25 0.66
Ability to take appropriate actions from reports 4.68 ± 1.14 5.07 ± 0.80 4.53 ± 1.46 0.41
Overall Satisfaction 4.84 ± 1.16 5.27 ± 0.70 4.93 ± 1.34 0.45
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Table 3. Comparison of ED patients satisfaction score between pre-implementation and post-implementation (The scale score based on: 1 = very poor; 2 = poor;
3 = fair; 4 = good; 5 = very good).
Pre-N = 871 Post-1 year N = 1156 p-value
Admission Courtesy of staff in registration area 4.60 ± 0.57 4.66 ± 0.57 0.02
Explanations given by registration staff 4.57 ± 0.62 4.59 ± 0.59 0.44
Cooperation/helpfulness of registration staff 4.63 ± 0.56 4.68 ± 0.54 0.06
Waiting time at registration area 4.43 ± 0.74 4.58 ± 0.67 <0.0001
Nursing LOS before triage 4.53 ± 0.69 4.63 ± 0.63 0.001
Nurses introduced themselves 4.46 ± 0.81 4.50 ± 0.78 0.37
Courtesy of nurses 4.68 ± 0.57 4.70 ± 0.57 0.69
Listening to questions and concerns 4.69 ± 0.58 4.65 ± 0.61 0.15
Communication of progress and delays 4.37 ± 0.85 4.35 ± 0.87 0.72
Explanations given by nurses (e.g.: tests/procedures) 4.51 ± 0.71 4.52 ± 0.68 0.88
Responsiveness of nurses to requests and needs 4.56 ± 0.66 4.50 ± 0.74 0.07
Pain assessment by nurses 4.54 ± 0.69 4.53 ± 0.67 0.75
Medical Team LOS before being seen by ED physician 4.30 ± 0.88 4.30 ± 0.90 0.86
Physicians introduced themselves 4.59 ± 0.68 4.60 ± 0.64 0.89
Courtesy of attending physician 4.77 ± 0.52 4.77 ± 0.51 0.91
Explanations physician gave about condition 4.68 ± 0.60 4.67 ± 0.62 0.90
Communication of plan of care 4.67 ± 0.60 4.65 ± 0.62 0.43
Concern the physician showed for questions or worries 4.68 ± 0.58 4.66 ± 0.60 0.39
Instructions physician gave about follow up care 4.61 ± 0.62 4.58 ± 0.67 0.23
Amount of time physician spent with patient 4.54 ± 0.67 4.52 ± 0.65 0.50
Discharge Courtesy of cashiers 4.56 ± 0.65 4.57 ± 0.65 0.81
Explanations cashiers gave 4.55 ± 0.65 4.45 ± 0.77 0.13
Cooperation/helpfulness of cashiers 4.55 ± 0.70 4.56 ± 0.64 0.83
Waiting time at cashier’s station for payment 4.50 ± 0.74 4.52 ± 0.71 0.79
Overall Satisfaction Overall satisfaction with ED visit 4.54 ± 0.69 4.57 ± 0.73 0.45
Cleanliness 4.51 ± 0.76 4.54 ± 0.74 0.36
Overall level of noise 4.23 ± 0.85 4.26 ± 0.86 0.53
Respect to confidentiality and privacy 4.55 ± 0.71 4.59 ± 0.67 0.20
Likelihood of recommending our ED to others 4.68 ± 0.63 4.68 ± 0.63 0.93
Overall ED LOS 4.24 ± 0.96 4.24 ± 0.98 0.99
https://doi.org/10.1371/journal.pone.0298027.t003

difference in age between the two groups was not statistically significant for 9 out of the 11
months analyzed.
The ED followed recommendations from the EMR vendor and from other institutions that
previously successfully implemented the EMR. Additional measures were taken, knowing that
EMR implementation at our institution was the first in Lebanon and the area. The institution
had to rely on its own staff and resources since no other institutions in the country or in
nearby countries previously implemented this EMR, so a pool of experts and consultants was
not available. Table 4 summarizes the vendor recommendations and also lists the measures
that were followed in our low-resource setting.
Several EDs witnessed a prolonged patient LOS mainly in the immediate post-implementa-
tion period, but this effect was transient. LOS returned to baseline after a period of time that
varied among institutions [14, 15, 20, 21]. Some other EDs, however, did not show a prolonged
LOS after EMR implementation [2, 16]. An ED in Iowa reported a falsely elevated patient LOS
after EMR implementation because patients underwent quick-registration before triage,
whereas, prior to implementation, registration used to follow triage [22]. Similar to the

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Table 4. Vendor recommendations and specific recommendations for low-resource setting.

Category Recommendations from Vendor and Other Institutions
Training • Offering training classes as well as ‘playground’ for practice [5, • Initiating training early (4 months instead of 2 months prior to Go-Live)
11, 14–16]
• Sending tips and updates to end-users after Go-Live [15]
Super-users • Having super-users usually from within the department [5, 11, • Selecting super-users from every staff category (attending physicians, residents,
17]
Staffing • Having a physician champion [8, 18, 19]
• Increasing staffing to compensate for slowness that might
occur after Go-live [8, 15, 16]
Structural • Installing adequate hardware including new computers,
Readiness printers, and mobile workstations [5, 8, 15]
• Installing a dedicated workstation for every clinician [15]
Workflows • Creating order sets for common ED presentations [15]
Troubleshooting • Developing an efficient troubleshooting process
• Having a downtime plan [5, 8] and a SWAT team
Staff Engagement • Having frequent multidisciplinary meetings for optimization
[18]
• Leadership commitment and buy-in [5, 8, 15, 19]
• Involvement of all ED staff including physicians, nurses, IT
staff, administrative staff, and all other ED personnel [5]
Reporting • Creating and modifying the build for needed reports
https://doi.org/10.1371/journal.pone.0298027.t004
Specific Additional Measures in Low-Resource Setting
• Early super-user training
• Using shadow charts shortly after Go-Live (documentation on both paper
charts and EMR in order to ensure adequate documentation)
• Frequent simulation and drills with attending physicians’ involvement
nurses, students, clerks. . .)
• Selecting super-users to cover poorly staffed shifts (such as night shifts)
• Super-users offering one-to-one training to end-users
• Having a dedicated cut-over team
• Having a higher super-user to staff ratio
• Increasing staffing in high turnover areas (low-acuity and urgent care)
• Establishing a multidisciplinary team to assess hardware needs and locations of
stations
• Redesigning nursing station with predetermined assignments of workstations
to different staff categories (physicians, nurses, etc. . .)
• Assessing workflows in frequent meetings starting 2 years before Go-Live,
especially high risk workflows (such as registration) and involving all
stakeholders
• Identifying high risk areas early on in focus groups, and following up regularly
on implementation and modification
• Using online messaging systems where super-users discussed issues and
suggested solutions
• Having multidisciplinary teams that combine leaders and front-liners
• Having regular town hall meetings to demonstrate workflows as early as 3
months prior to implementation
• Creating steering and executive committees to oversee implementation at all
stages
• Creating a clinical core owner group involved in end-user engagement to
facilitate implementation across all risk areas
• Focusing on reporting and early report validation plan (selecting key quality
metrics and predefining the top quality metrics to be validated)

experience of other EDs, our ED LOS increased in the post-implementation period, but
returned to its baseline values after around 6 months despite adding a new interval post-imple-
mentation to LOS (door and quick-registration to triage). In the pre-implementation period,
the patient was registered after triage.
Bounce-back rates slightly increased after EMR implementation. Several factors including
seasonal, clinical, and patient-related might have contributed to this observation in our setting.
In other institutions, these rates decreased [14] or remained unchanged [2].
Patient satisfaction is often cited to be negatively impacted by EMR implementation. Previ-
ous studies in EDs in the US reported that patient satisfaction was negatively affected by EMR
implementation [14, 15]. Data from our ED showed that patient satisfaction metrics remained
unchanged except for registration time before triage where a new step was introduced post
implementation. Before implementation, patients used to go immediately to triage before reg-
istration. The post-implementation workflow required patients to complete a quick registra-
tion process prior to triage which could have negatively impacted satisfaction with the intake
process.
This study has few limitations. Firstly, it was a retrospective study and therefore some data
might be missing, especially in the pre-implementation period when data required manual
cleaning. Secondly, patient satisfaction survey questions were kept the same despite EMR
implementation. These questions remain valid since EMR implementation caused major

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changes in ED workflows and new trends would have been detected in the survey results. Also,
some patient characteristics (country, guarantor, and ESI) showed significant differences
between the pre- and post-implementation groups even after the month-by-month analysis.
We believe these differences may be due to the changes in the way of entering information in
EMR. These differences are less likely to bias the results regarding the operational metrics such
as LOS.
Various metrics were used to assess the impact of EMR implementation in this study. There
are multiple other performance metrics that might have been affected by this EMR implemen-
tation, such as lab and radiology result turnaround time, financial metrics, and other opera-
tional metrics. However, this study was not intended to assess all aspects of implementation.
The study used data collected as part of regular ED operations and monitoring. Data is vali-
dated on a regular basis and used for reporting and compared to benchmarks identified by
Emergency Department Benchmarking Alliance (EDBA).
Different EDs have different processes and measuring time intervals can vary, but the pro-
posed clinical metrics and operational metrics can be adopted in other settings to assess
implementation.

Conclusion
Lessons learned from this successful initiative include the importance of following strategies
recommended by EMR vendor, previous approaches followed in other institutions as well as
specific and tailored strategies used in our institution. All those strategies can be integrated
into future implementation projects and used as part of the framework to ensure successful
implementation in a low resource setting.

Clinical relevance statement

EMR implementation can be successful in low-resource countries. In addition to the EMR
vendor recommendations, additional strategies can be followed to ensure a successful EMR
implementation. These include the presence of a dedicated multidisciplinary team to optimize
workflows, a well-developed super-user strategy, and early initiation of training that includes
simulations and drills.
1. Multiple choice questions
1. What are some of the pre-implementation strategies adapted in our institution?

A. ED leadership engagement
B. Staff training and engagement
C. Giving physician super-users clinical shifts
D. Answer A & B
The correct answer is D. ED leadership engagement as well as staff training and engage-
ment were two of the pre-implementation strategies adopted in our institution. Having non-
clinical shifts for super-users was a post-implementation strategy.
ED leadership was engaged fully in all implementation phases. Extensive sessions over sev-
eral months were dedicated to workflow analysis, ED processes, staffing and hardware require-
ments and preparation, and issues with interfaces. All clinical and non-clinical risks were
reviewed, and corresponding mitigation plans were prepared. Paper-based order sets and pro-
tocols were modified and transferred to the EMR.

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PLOS ONE Electronic medical record implementation in a lebanese emergency department

All ED physicians, nurses, and staff received online training, hands-on training, and access
to the EMR ‘playground’ for practice. Super-users received advanced training mainly regard-
ing troubleshooting in order to help colleagues during and after Go-Live. Each super-user was
assigned a group of 4 to 5 trainees for one-to-one support as needed. Physicians who needed
additional sessions were identified in advance and received additional personalized training
from super-user physicians.
2. Super-users:

A. Included every staff category (attending physicians, residents, nurses, clerks)

B. Helped cover poorly staffed shifts
C. Offered one-to-one training to end-users
D. All of the above
The correct answer is D. Super-users, considered as advanced learners, were selected from
within the ED, and they included attending physicians, residents, medical students, nurses,
and other ED staff. They helped cover poorly staffed shift, such as night shifts. Super-users
were assigned a group of 4 to 5 end-users for one-to-one training and support as needed.

Acknowledgments
The authors acknowledge Layal Hamdar, Maha Makki, and Moustafa Al Hariri, PhD for their
contributions to this article.

Author Contributions
Conceptualization: Nagham Faris, Miriam Saliba, Hani Tamim, Mazen El Sayed, Eveline
Hitti.
Data curation: Nagham Faris, Rima Jabbour, Ahmad Fakih, Zouhair Sadek, Rula Antoun,
Mazen El Sayed, Eveline Hitti.
Formal analysis: Nagham Faris, Miriam Saliba, Hani Tamim, Mazen El Sayed, Eveline Hitti.
Investigation: Miriam Saliba, Rula Antoun, Mazen El Sayed, Eveline Hitti.
Methodology: Nagham Faris, Miriam Saliba, Rima Jabbour, Mazen El Sayed, Eveline Hitti.
Project administration: Nagham Faris, Rima Jabbour, Mazen El Sayed, Eveline Hitti.
Resources: Rula Antoun, Mazen El Sayed.
Software: Miriam Saliba, Rima Jabbour, Ahmad Fakih, Zouhair Sadek, Rula Antoun, Mazen
El Sayed, Eveline Hitti.
Supervision: Nagham Faris, Mazen El Sayed, Eveline Hitti.
Validation: Hani Tamim, Rima Jabbour, Ahmad Fakih, Zouhair Sadek, Rula Antoun, Mazen
El Sayed, Eveline Hitti.
Visualization: Miriam Saliba, Rima Jabbour, Ahmad Fakih, Zouhair Sadek, Rula Antoun,
Mazen El Sayed, Eveline Hitti.
Writing – original draft: Nagham Faris, Miriam Saliba, Zouhair Sadek, Mazen El Sayed, Eve-
line Hitti.

PLOS ONE | https://doi.org/10.1371/journal.pone.0298027 March 1, 2024 11 / 13

PLOS ONE Electronic medical record implementation in a lebanese emergency department

Writing – review & editing: Nagham Faris, Miriam Saliba, Hani Tamim, Rima Jabbour,
Ahmad Fakih, Mazen El Sayed, Eveline Hitti.

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