An electronic medical record (EMR) is a digital version of a patient’s paper medical chart and personal information. It includes the patient’s medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, laboratory test results, and more. EMRs adhere to nationally recognized interoperability standards and enable the secure use and sharing of information across networks [1].

The adoption of EMRs is a high priority in many countries because of their potential to enhance the security, effectiveness, and efficiency of healthcare delivery [2]. EMRs facilitate healthcare delivery at various stages by allowing clinicians access to previous laboratory and radiology investigations, medication orders, and comprehensive patient histories, including comorbidities [3,4]. Additionally, EMRs improve clinical performance by supporting clinical decision-making. This support includes access to updated clinical guidelines, alerts for abnormal test results, and notifications of drug allergies and interactions [5]. Implementing EMRs has been shown to reduce medical errors, enable more effective communication and information sharing among clinicians, decrease national healthcare costs, and improve the quality of healthcare [2]. The adoption of EMRs in hospitals is increasing globally [6]. In the Gulf Cooperation countries region, the adoption of EMRs has begun, though progress has been slow [3,4].

In healthcare, digital maturity refers to the extent to which digital systems are utilized to deliver high-quality care, thereby enhancing services and improving the patient experience [7]. Assessing digital maturity is especially critical in hospital settings due to the complexity and cost associated with delivering multidisciplinary healthcare for both acute and chronic cases [8]. To evaluate digital maturity, organizations can use a maturity model that assesses their current digital status across various dimensions [9]. However, current methods for assessing digital maturity in hospitals face challenges due to a lack of consensus on which capabilities should be evaluated [10]. Several adoption and maturity models exist to measure the level of health information exchange (HIE) implementation [11,12]. We have employed the Healthcare Information and Management Systems Society (HIMSS) maturity model, which defines various stages of EMR adoption by healthcare providers. These stages are rated on a scale from 0 to 7, with 0 representing the least mature stage and 7 the most mature. The EMR Adoption Model (EMRAM) uses over 100 indicators across several focus areas, including software applications, software consumption, IT security, and closed-loop administration procedures [13].

EMRs have been in use at the Dubai Health Authority (DHA) since 1998. However, in January 2021, a policy was introduced that required the implementation of EMR in all healthcare facilities, including hospitals, outpatient clinics, dental clinics, pharmacies, labs, and rehabilitation facilities. One of the primary motivations for this initiative was the coronavirus disease 2019 (COVID-19) pandemic [14]. The United Arab Emirates (UAE) health sector faced significant challenges in managing COVID-19 patient data, which involved tracking cases, admissions, treatments, transfers, and ultimately, discharges or deaths [15]. The pandemic placed an enormous burden on already overstretched healthcare systems, especially in managing patients with chronic conditions [14]. It also impacted doctors’ ability to access information timely and make accurate diagnoses.

Another key reason for this push was the implementation of the HIE in Dubai, known as Nabidh. The Nabidh HIE is a healthcare platform designed to securely exchange trusted healthcare information across both public and private facilities in Dubai. The goal of Nabidh is to facilitate the seamless and secure sharing of patient health information and EMR across various healthcare sectors. It utilizes International Classification of Diseases (ICD) and Current Procedural Terminology codes along with HL7 Standards. The rollout of Nabidh faced several hurdles, primarily because many healthcare facilities either lacked an EMR system or had EMRs that did not meet the standards required by Nabidh.

The purpose of this paper was to evaluate the implementation of EMRs in healthcare facilities within the Emirate of Dubai, focusing on the challenges, milestones, and achievements. We believe that our experiences can provide valuable insights to other neighboring countries that are considering the adoption of EMR systems in their health sectors.

A situation analysis was conducted to explore the current state of health informatics records management in healthcare facilities. The DHA contacted approximately 2089 healthcare facilities in Dubai to determine whether they had implemented EMRs in their medical practices and to identify any challenges they faced during this process. Additionally, a benchmark analysis of the current EMR situation in major hospitals was performed. The primary aim of this methodology was to assess the readiness of healthcare facilities to adopt the Nabidh HIE in Dubai. There were a total of 3,670 healthcare facilities actively operating in Dubai, of which 1,581 were facilities without a physician, such as drugstores and school clinics. The study included the remaining 2,089 healthcare facilities, spanning both governmental and private sectors and regulated by the DHA (Table 1).

Since 2011, the EMRAM has been utilized to assess the maturity level of healthcare facilities in terms of EMR adoption among hospitals in Dubai. This includes inquiries about current EMR systems, requirements, provider names, and applications. The EMRAM survey is conducted annually from September to November via email and telephone calls. In-person meetings are also held to verify the survey results with the facilities. According to institutional policies, no ethics committee approval was required to conduct the survey, as it was not a human research study and all data were handled confidentially. All hospitals (healthcare facilities that include an inpatient setup) were included. HIMSS uses proprietary software with a survey tool to collect, validate, and assess responses from the hospitals. The survey includes criteria corresponding to seven stages as detailed in Table 2.

If the hospital successfully completes stage 6 according to the EMRAM scoring system, further validation measures, such as onsite visits, will be undertaken. The reliability and precision of the data presented, along with the findings in this evaluation, were primarily the responsibility of representatives from the participating hospitals.

In the present study, we chronicled the journey of EMR adoption and the transition from paper to electronic data in Dubai since 2011. The adoption of an EMR was evaluated based on its ability to support specific tasks, such as integrating clinical decision support into clinical platforms, automating the collection of patient-reported outcomes, and incorporating population health management initiatives as the adoption of a basic EMR became standard. Consequently, EMRAM was utilized to measure the maturity level of EMR implementation in the UAE. The average EMRAM score for Dubai hospitals was 2.6, slightly lower than the previous year’s score of 3.0. This decline can be attributed to model adjustments made between 2018 and 2022, as well as changes in the composition of the sample from 2021 to 2022. One of the significant challenges was that many hospitals in Dubai lacked EMRs. For those hospitals that did have EMRs, they were only at stage 0 or 1 according to the EMRAM assessment. Another issue was the lack of sufficient funds for hospitals without EMRs. Consequently, the experts in DHA health informatics decided to meet with the top executives and leaders of these healthcare facilities to encourage them to either purchase an EMR system or, if they already had one, to upgrade it to at least EMRAM stage 2. Additionally, there was a lack of awareness about vendors and interoperability standards. Therefore, DHA also decided to support these facilities by helping them identify suitable vendors and providing them with the necessary information and guidance on interoperability standards to employ.

The implementation of EMR systems was challenging, and their success heavily depended on healthcare providers’ willingness to integrate EMR into their daily practices. Another challenge involved finding qualified personnel to train medical professionals and clinicians in the use of EMR. This aligns with other studies that have reported similar obstacles and challenges in implementing EMR within the health sector [16,17]. DHA overcame this obstacle with the aid of training materials such as videos and virtual events. There were also technological challenges, including varying interoperability standards for data exchange. In 2017, different EMR vendors used different interoperability standards. Therefore, DHA worked to gradually unify these standards through various regulatory actions, initially offering options and eventually making it mandatory to use DHA-approved standards. In addition, to address this issue, DHA introduced the option of using cloud-based EMR. Cloud-based EMR is a software program that maintains health records data on remote servers, also known as the cloud, rather than on servers located within the premises of a medical clinic or facility [18]. It offers simplified operations, reduced costs, and enhanced data sharing with security for its users. Cloud EMR provides a comprehensive suite of essential features, facilitating easy storage, creation, sharing, and tracking of digital patient data for small clinics and practices. It is also accessible to both single-physician clinics and large, multi-location, multi-specialty practices. This approach enabled DHA to maintain EMR across various facilities in Dubai without incurring high costs.

Governmental hospitals in the Emirate of Dubai serve as an exemplary case of how healthcare providers can leverage technology to enhance patient care, minimize medical errors, and boost operational efficiency. These facilities have consistently advanced their digital maturity from 2012 to 2017, with further improvements following the introduction of new EMRAM criteria in 2018. One of the primary challenges in EMRAM stages 1 and 2 is the management of basic security and privacy requirements. Technological and functional deficiencies in EMRs, particularly in cardiology, along with inadequate annual reviews of physical access, acceptable use, and data destruction policies, prevent many hospitals in Dubai from advancing to EMRAM stage 2. While high levels of EMR maturity generally correlate with substantial IT investments, the amount of spending is less critical than its strategic application. It is often the strategic nature of the investment—allocating the right amount of funds to the right areas at the right time—that is crucial for achieving high levels of EMR maturity and adoption. This strategic approach complicates the implementation of investment projects.

Achieving EMRAM’s stage 2 or higher for EMRs was another significant milestone. This advancement promotes the uniformity of EMR interoperability among healthcare providers and supports the future integration of EMRs with local and regional HIEs. The DHA has actively encouraged healthcare providers to adopt interoperability by providing roadmaps and facilitating the development and adoption of new information exchange standards. However, achieving full interoperability will require more time. The ongoing lack of interoperability could negatively impact patient safety, clinical outcomes, and efforts in population health management [15]. Additionally, hospitals vary in their levels of capital assets, resources, and IT-oriented mindsets, which can result in different patterns of adopting EMR functionalities. Despite these challenges, our healthcare reform project has reached many milestones related to the use of information and technology standards, including the ICD, 10th Revision (ICD-10) [19], Health Level Seven International (HL7) [20], health insurance and claims management system, and telehealth systems.

In the Emirate of Dubai, the implementation of EMRs in healthcare facilities is advancing in maturity. The study explored the current state and challenges associated with EMR implementation. Several challenges were identified, including the absence of an EMR system in healthcare facilities, the presence of an EMR with a low EMRAM score, or an EMR that fails to meet the necessary standards for HIE due to a lack of awareness about available vendors and relevant interoperability standards. Funding, policymaking, and organizational resistance can significantly hinder the implementation of EMRs. However, evidence suggests that governmental support and national standards are the most critical factors influencing EMR adoption in hospitals [21]. Therefore, programs promoting interoperability and relevant policies and standards have been implemented in Dubai. Nevertheless, the lack of EMR incentives by the DHA may discourage hospitals from adopting EMRs and realizing their benefits. We believe that other Gulf countries can learn from our experience with EMR technologies and EMRAM to improve the maturity level of their health information systems.

This study has several limitations. Firstly, it was conducted in health facilities under the jurisdiction of the DHA, which is limited to the Emirate of Dubai. A more comprehensive study would include all health facilities across the UAE. Additionally, at the onset of the EMRAM assessment in 2011, only 23 hospitals participated; by 2022, this number had increased to 43. Furthermore, the period from 2011 to 2022 saw significant advancements in health informatics and technology. However, the impact of these technological advancements was not included in our assessment due to feasibility constraints.