The National Alliance for Health Information Technology (NAHIT) defined an electronic health record (EHR) as “the aggregate electronic record of health-related information on an individual that is created and gathered cumulatively across more than one healthcare organization and is managed and consulted by licensed clinicians and staff involved in the individual’s health and care” [1]. EHRs are known by several synonyms in the literature, such as electronic medical records (EMRs) and computer-based patient records [2]. Among these, EMR is most often used synonymously; however, NAHIT recognized the difference and defined an EMR as “the electronic record of health-related information on an individual that is created, gathered, managed, and consulted by licensed clinicians and staff from a single organization who are involved in the individual’s health and care” [1].

When designed for dental practices, an EHR is called an electronic dental record (EDR) [3] or electronic oral health record (EOHR) and is used “with a greater focus in oral and maxillofacial region with the ability to store, manage the patient details, and follow the progress of treatment in dental care” [4,5]. The EDR concept includes the electronic dental record application, imaging, prescription management, appointment schedule, and so forth [4]. Hence, EDRs can be considered a dental information technology (DIT) tool that serves the purpose of EHRs in dental practice context [5].

An EHR is a form of health information system or health information technology (HIT) that supports comprehensive and efficient healthcare management by integrating healthcare information and communication technology (ICT) that improves hospital efficiency and the quality of patient care [6]. An integrated medical-dental record (IMDR) allows both medical and dental healthcare providers to view full patient information, which supports well-informed care and treatment planning. Not only does it allow comprehensive analysis of patient data, but the data may also be used for quality-improvement processes and population health. An IMDR enables coordination of the scheduling and billing of patient visits at the national level, and cross-border patient information sharing is possible, as demonstrated by several EU member states [7]. Studies have reported that patient data in dental school EDRs not only facilitates high-quality patient care, it also improves students’ professionalism and is a rich source of research data [8]. Policy-makers in developed countries have recommended the adoption of EHRs, which has led to the implementation of such initiatives as Health Information Technology for Economic and Clinical Health (USA), Smart Open Services (EU), and the Community eHealth Action Plan (EU) as a recommendation for cross-border interoperability [7].

Consequent to major progress in the healthcare infrastructure of the Kingdom of Saudi Arabia (SA), EHR adoption was undertaken to improve the quality of its citizens’ healthcare. A task team was formed in 2002 to build a national EHR program. To strengthen ICT in the healthcare sector, King Saud bin Abdul Aziz University for Health Sciences was founded in 2004. In 2005, the Saudi Association for Health Informatics was established to facilitate the implementation of health informatics training and education across SA [9]. In 2010, the SA Ministry of Health (MOH), inspired by the Vision 2030 plan, launched several initiatives to enhance citizens’ care outcomes, decrease medication errors, boost healthcare efficiency, and reduce unnecessary costs. One such initiative is the national eHealth strategy [10]. As part of this strategy, the MOH developed a “digital health journey” framework, which is intended to measure the digital capabilities of SA [11]. Although progress has been impeded, the MOH recognizes the importance of adopting an information system that will ultimately link all hospitals within SA [12]. In early 2011, the MOH launched the 2010–2020 national eHealth strategy roadmap in two 5-year phases [10,11], which led to the implementation of a medical records improvement program, a referral system (Ehalty), a unified portal of health services, a health electronic surveillance network, a poison control system (Awtar), a neonatal protection system, a registration system for hospitals’ serious incidents, and a premarital screening system [10]. Standards for manual and electronic medical records and patient information management were developed by the Central Board for Accreditation of Healthcare Institutions (CBAHI), a national accrediting authority in SA [13].

The prioritization of eHealth development and ICT implementation by the MOH made the transition from paper-based health records to EHRs imminent to achieve the mission of “a safe quality healthcare system based on patient-centric care guided by standards, enabled by eHealth.” The MOH’s national efforts towards eHealth initiatives have played an important role in how HIT use has developed, and EHR adoption has gained tremendous momentum in SA during the last decade. Among the diverse eHealth applications, EMRs have been increasingly adopted by SA organizations [14]. Despite the prioritization of eHealth and efforts over recent decades to encourage EHR adoption, EHR adoption in SA has encountered a variety of challenges to organizational and technical implementation [15,16], and paper-based medical record systems are still widely used in the healthcare industry. Whereas studies have reported an EHR adoption rate of 81% by US hospitals [17], only 50% of hospitals in Riyadh had fully functioning EHR systems; 36% had EHR systems in the development stage, and 14% were still using paper-based records [14]. Though EHR is considered a significant HIT innovation with substantial improvements in the effectiveness and efficiency of healthcare delivery, the EHR adoption rate still remains slow in many countries, as is evident from the few studies reporting the adoption rates of EHR at the national level not only in SA, but also globally [18]. Published research also discusses other aspects of EHRs in medical practice [19]. Furthermore, dental practitioners and researchers agree that DIT adoption in dental practices has been sluggish compared to the medical field, and the adoption of EDRs in dental office settings has received relatively little attention in studies, with insufficient research focusing on aspects that may contribute to adoption [5,20,21]. Because there have been no clear studies in SA that provide credible estimates of adoption by dentists, this study aimed to record the EDR adoption rate in dental offices in Jeddah and to investigate the organizational and environmental aspects related to adoption.

This study explored the rate of EDR adoption by dental clinics and the organizational factors associated with its adoption. We investigated the relationships between the adoption of an EDR as a DIT tool and region, practice size, and practice type [5]. Our study attempted to identify the practice characteristics that predict EDR adoption; because the concept of EHRs is relatively new in SA [14,23] our findings could add valuable insights into developing effective strategies to encourage healthcare providers to adopt EDRs.

Based on earlier studies, we hypothesized that EDR adoption, region, practice size, and practice type would be associated [5]. Not only did our study reveal a high rate of EDR adoption among the dental practices we surveyed, but we also discovered that adoption rates in different regions of Jeddah were comparable, thus limiting the impact of region as a driving factor in EDR adoption decisions. Our findings are similar to those of other studies [5], that is, contrary to a study originating from the Gulf Cooperation Council (GCC), which reported that technical, social, managerial, and financial barriers inhibited EHR implementation and development [24] and a study of SA that reported low eHealth adoption rates nationally and described cultural, bureaucratic, and human resource issues as barriers to SA eHealth implementation [25]. This does not seem to be the case in our study, since we found a high rate (93%) of EDR/EHR adoption, which is consistent with other reported studies both within and outside SA [5,19,20]. This outcome could be attributed to the unbiased implementation of MOH regulations across the board with regard to patient data records and CBAHI’s requirement that institutional healthcare providers obtain accreditation [13].

Dental specialty-related workflow and information needs are said to drive the adoption of EDR [26]. This was not established in our study, and unlike other studies, ours did not find a statistically significant difference in EDR adoption between general and specialty practices [5,26]. We also found that large practices were more likely to adopt EDRs, an important predictor consistently found in earlier EDR/EHR adoption studies [21,27]. Additionally, we found that dental practices receiving patients with insurance coverage were more likely to adopt EDRs. These findings are in line with other published studies [5,27].

The odds of EDR adoption rate varied for three among the six dental practice predictors, namely public versus private, practice size regarding the number of patients seen per day, and whether the practice received patients with insurance. Other dental practice variables, namely general versus specialty practice and practice size regarding number of dentists, showed comparable odds. Public dental practices were more likely to adopt EDR was a significant finding in our study, consistent with other studies on EHR adoption in SA. This may be attributed to inherent characteristics of public dental practices, such as funding, management policies, and the IT landscape, which may constrain their ability to adopt EDRs [5].

The dental practices we surveyed used widely varied types of EDRs (not reported explicitly due to being out of scope). While some were capable of recording patients’ medical and dental information interoperably, others could record dental components only. These findings are consistent with other studies [5,12]. Both the oral and general health of an individual are vital components of optimum health. Therefore, EDR-EMR integration (IMDR) at the national level is important, because a DIT tool should be able to integrate with the HIT ecosystem to effectively implement eHealth in SA [28]. The potential of IMDR in SA extends beyond holistic care of patients within SA to cross-border data sharing with other GCC countries, similar to the European Commission initiative [7].

Our study’s findings indicate a high level of EDR adoption in the sample surveyed. Practice characteristics such as being public, being large, and receiving patients with insurance coverage have positively influenced EDR adoption among the participants. Based on our study findings, we deduce that the support of the MOH of SA and the mandatory EHR requirement by CBAHI have laid the foundation for the adoption of EHR/EDR systems by dental offices in Jeddah. However, because we studied only one city in SA, the results cannot be extrapolated to the entire Kingdom. We did not include educational institutions, though it may not impact our findings, since the number of educational institutions in the city of Jeddah is minimal compared to the number of dental practices we surveyed. Neither did we ascertain whether the EDRs currently in use were capable of communicating with EHRs and being integrated nationally, nor did we explore barriers such as IT readiness and availability of trained personnel. These shortcomings do not play a significant role in our findings because the high rate of adoption we observed suggests that the aforementioned barriers have been overcome by our study’s participants.