Documentation integrity: Authorship functionalities of EHR in a Saudi Arabian hospital

This paper aims to evaluate the authorship, privacy capabilities and functions of QuadraMed and BestCare systems, implemented at the Ministry of National Guard Health Affairs (MNGHA) in Riyadh, Saudi Arabia. A survey was conducted by interviewing back-end users of the EMR system in the KAMC hospital to check the aforementioned systems' authorship capabilities. Both the systems scored the same, with the overall result being 146/165 including the compliance level, which represents 88% availability of all authorship functions. The Quadra system's non-complying item was identified for only one entity, which is related to the lack of diagnosis documentation. It does not aid physicians in enhancing their ability to document diagnosis, which depends on coding and has not been implemented within the system so far. However, BestCare system provides documenting diagnosis depending on the coding part rather than free text, suggesting it is a promising system with enhanced functionalities. •Authentication of EMR system to verify the authenticity of the users' claimed identity is important because it assigns responsibility to the user for the created, modified, or viewed entries.•The study identified an overall compliance of the EMR system to the authorship functionalities. The compliance gap was identified in the QuadraMed system for only one item that was related to the lack of diagnosis documentation.