The Roles and Competencies of Nurse Managers in Enhancing Benefits and Lowering Barriers to the Implementation of Electronic Medical Records: A Mixed Methods Approach

Abstract

Background

The role and competencies of a manager are crucial to the success of an electronic medical record (EMR) implementation. A manager must possess a clear vision, a strong sense of commitment, and the capacity to spearhead organizational and technological change. This study aims to assess the benefits and difficulties of implementing EMRs and explore the competencies and roles of managers in adapting to the implementation of EMR.

Methods

A mixed method using cross-sectional analysis and a descriptive qualitative method using Focus Group Discussion (FGD). The quantitative study sample included 101 nurse managers, and the quantitative data analysis used the mean, standard deviation, minimum, and maximum. The roles of the manager were explored in eleven participants with FGD. Analysis of themes and word patterns related to digital use, thematic role leader using the Mintzberg approach. Finally, the results of quantitative and qualitative research are combined to determine the role and competencies of managers.

Results

The mean digital literacy competencies for the basic EMR implementation were 65 out of 100. It means that the digital competencies of the manager need to be improved. The results of the qualitative study show that EMR has many benefits and obstacles; in addition, the leader’s role, including interpersonal, informational, and decisional roles, is needed for successful EMR implementation.

Implications

Recommendations are proposed to improve competencies and the role of management.

Introduction

The development of technology and the digitalization of healthcare require the availability of electronic medical record facilities, which are essential for patients. EMR is an information system used to document patient progress and report the care provided to patients. EMR enhances patient outcomes and care coordination by enabling medical personnel to quickly access and update patient data.^1–3 The importance of electronic medical records (EMRs) in improving patient safety and documentation quality can be overstated.⁴ EMRs reduce medical errors, unnecessary treatments, and unnecessary testing.⁵ EMRs also make it easier for medical staff to communicate with one another, which reduces the likelihood of miscommunication and improves patient safety overall.^2,6 Additionally, EMRs enable healthcare providers to provide patients with tailored care and make informed decisions.^1,7,8 EMRs greatly improve the legal aspects of healthcare by ensuring accurate and timely documentation of patient treatment.⁶ In conclusion, EMRs are critical for enhancing patient safety and the standard of care in healthcare environments. The integration of EMRs has improved patient outcomes and fundamentally altered how healthcare is managed and delivered.^9,10

EMR is now being implemented in Indonesia, however it has not yet been a complete success.¹¹ Lack of leadership for EMR implementation is a barrier issue. Digital literacy results are still below 80% of the maximum value of 100%, according to a prior study on nurses.¹² According to earlier research, a period of adjustment and training is necessary during the initial shift from a traditional system to electronic medical records. Additionally, prior research has shown a significant correlation between education level and nursing position, suggesting that more educated nurses have better levels of informatics proficiency than less educated nurses.¹⁰.

In addition to the success and benefits, obstacles in the development and implementation of EMR can come from various sources. Previous research has reported failures of EMR systems in terms of human resources and facilities.¹³ According to research, human resources are the most frequently mentioned word when discussing the elements that influence the effectiveness of electronic medical records. According to some studies, EMR literacy training is necessary in healthcare professions. Education influences how people adapt to changes in EMR.^12,14 Electronic medical record competency consists of three components: information literacy, computer skills, and information and data management expertise.⁶ Beside general skills, human resources are also influenced by motivation. The absence of a leader to guide the EMR system change has led to decreased staff motivation.¹⁵ Managers not only have the role of increasing motivation but also of setting an example, providing information, and making innovations that facilitate the implementation of EMR.¹⁶ Mintzberg stated that the manager’s role is a key strategy for organizational success. Referring to Mintzberg’s opinion, the manager’s role in any change requires a specific role. A change, such as changing the system from conventional patient documentation to an EMR, also requires the role of a manager. Mintzberg’s role approach can be used as an approach to EMR success. Therefore, it is necessary to study the benefits and difficulties in EMR implementation, as well as how the manager’s role can be increased, and difficulties curbed or mitigated.¹⁷ Referring to Mintzberg’s opinion, the role of managers in the success of EMR needs to be studied so that EMR can be implemented effectively.

EMR was implemented in Indonesia, but sadly, there has not been much research done on the viewpoint of manager roles and competencies to use EMR. Some studies describe quantitative approaches, such as EMR usability, but qualitative perspectives on roles are scarce. Mixed-method quantitative and qualitative data regarding role managers and competencies in EMR implementation were needed. This study is crucial because it serves as a foundation for reducing the likelihood that the health sector’s EMR efforts would fail. Even though there have been numerous prior studies, measures and planning for the effective use of EMR in the health sector will go more easily if genuine data from Indonesian conditions are understood. Other nations going through an EMR revolution can learn from our research.

Method

This study aims to assess the benefits and difficulties of implementing EMRs and explore the competencies and roles of managers in adapting to the implementation of EMR (Electronic Medical Record). A mixed method using cross-sectional analysis and a descriptive qualitative method using FGD. The first stage involved a cross-sectional study aimed at identifying the digital literacy competencies of nurse managers, which are essential for EMR implementation. The questionnaire used was one previously used in a previous study, containing 96 questions with a reliability value of Cronbach’s Alpha 0.95.¹¹ The questions covered basic computer literacy, information literacy, and digital literacy in the implementation of patient care services. Sample 101 nurse managers are patient coordinators, head nurses, middle and top managers. The sample selection was based on the criteria of being a manager, using EMR in patient care, and being willing to participate in the study. The collected data were analyzed descriptively using mean, median, standard deviation, and percentage.

The second stage involved a Focus Group Discussion (FGD). Focus Group Discussions (FGDs) in qualitative studies are structured, interactive sessions with 6–10 participants, guided by a moderator to generate in-depth insights into specific topics.¹⁸ The FGD was conducted to further explore the experiences of managers and their roles in implementing EMR. In the final stage, quantitative and qualitative data were combined, and recommendations were made based on the Mintzberg manager role approach. The questions of FGD are: 1. Could you describe an implementation of EMR? 2. Could you share the role of manager in EMR development and implementation (interpersonal, informational, and decisional roles)? 3. What is the expectation of manager roles in the EMR implementation?

In this study, eleven focus group discussion (FGD) participants were chosen using purposive sampling. The identification of participants, including nurses, midwives, doctors, and other health care professionals, entailed the use of EMR in health services. Care professionals with more than 5 years of direct patient care experience and a role in workplace EMR implementation were eligible. To recruit people, a request for research volunteers was sent to key informants at the institution, and the institution then submitted potential individuals. After reviewing the needs of the participants supplied by the organization, the researcher accepted the potential participants using a convenient method. All individuals who submitted met the inclusion criteria to continue participating in the study. The study included eleven (11) healthcare professionals from Jakarta, Depok, and Bogor, Indonesia, representing hospitals, clinics, community health centres, and private practices. The researcher’s online Zoom media was used to conduct the FGD, and a 90-minute discussion was recorded. Participants who are not speaking are placed in the muted mode to reduce noise during speech. Participants are invited to repeat what was said when the signal is clear again if signal interference is present. The atmosphere can be managed during focus group talks, and there are no issues with internet connectivity.

Focus group saturation occurs when no new information or topics emerge, indicating that the data collection process has hit its limit. Data saturation is tried by inquiring whether there are any outstanding issues from the focus group. This guarantees that the issue has been thoroughly understood and that the data obtained can be analyzed meaningfully.

The data were acquired through focus group conversations; therefore, there is a possibility of response bias, which occurs when participants change their views based on the opinions of others in the group. To decrease prejudice, the facilitator offered information at the outset, allowing each participant to express their viewpoint without being swayed by others’ experiences. At the conclusion of the discussion, all participants were given the opportunity to share material that had not been covered throughout the discussion based on their own experiences. Several members of the study team took part in the data analysis, ensuring trustworthiness. Using quotes to illustrate ideas, involving the research team in discussions about how to interpret and analyse data, and keeping detailed field notes.^18,19

Qualitative data analysis began with verbatim transcripts from the Focus Group Discussion (FGD), progressing systematically toward the detection of significant patterns and themes, which were then analyzed and synthesized. Various coding techniques were employed to guarantee the integrity, trustworthiness, and rigor of the data. During the sessions, the facilitator wrote detailed memos, recorded audio, and generated transcripts afterwards. All information was kept anonymous, and any identifying details were changed during transcription. To establish inter-coder reliability and multiple coding, the facilitator’s notes and initial codes were cross-verified with a secondary researcher. This rigorous, iterative process ensured that all aspects of the data were adequately evaluated and digested, resulting in comprehensive and credible findings.¹⁸

Because there were so few participants, coding in this study was done manually rather than using software. The first stage was to break down the data into smaller sections (words, phrases, sentences) and assign descriptive codes to each one. Inductive open coding was employed, with the participants’ exact statements used as in-vivo codes. This preserved the intricacy and uniqueness of their language, capturing the individuals’ fundamental values, beliefs, and assumptions. All codes were recorded and arranged, and analytical memos were continuously updated to track decision-making. Some codes were subsequently modified especially those dealing with barriers and perceived deficiencies to achieve greater clarity. The goal of this revision was data refinement, from which overarching patterns and themes were ultimately identified.

To confirm the validity and credibility of the findings, a member checking process was conducted. The researchers returned synthesized summaries, emerging themes, and selected representative quotes to the FGD participants. Participants were asked to review these findings, evaluate whether the interpretations accurately reflected their perspectives, and provide feedback. Adjustments were made to the thematic frameworks based on their responses, ensuring the final representation authentically aligned with the participants’ original intentions and lived experiences.¹⁹

To aid easy visualisation and comparison, all of the topics were depicted in the main map figure, allowing for a more thorough understanding of the relationships between different data points. This organised technique of analysis also aids in the identification of data gaps or discrepancies, resulting in a robust and accurate final report. Finally, the Standards for Reporting Qualitative Research (SRQR) checklist was utilized to increase transparency in all stages of qualitative research.

The third stage is the final stage, where the researcher conducts a combined analysis of the FGD theme results and the qualitative results in a table of recommendations for the interpersonal, informational, and decisional roles of managers using Mintzberg’s approach, as well as the improvement needs for the competencies. At this stage, a cross-table has been constructed between managerial roles based on digital competencies.

Ethical Consideration

This study was approved by the Ethical Board of the Faculty of Nursing at Universitas Indonesia. KET-153/UN2.F12, D1.2.1/PPM.00.02.2023. All about the study complies with the Declaration of Helsinki. Participants were told about the study’s objectives, advantages, and methodology. The researcher-maintained anonymity throughout the questions and kept the data secret, and participants already signed an informed consent that included publication of anonymized responses/direct quotes.

Results

Table 1. Details the respondents’ characteristics in the quantitative study, showing that the majority were women who possess a bachelor’s degree, a majority position as a nurse coordinator and a nursing unit manager.

Table 1.

Characteristics of Nurse Manager in the Competencies Survey (N = 101)

Variable	Frequency	%
Gender
Male	16	15.8
Female	85	84.2
Education
Diploma	13	12.9
BSN	70	69.3
MSN and Master	12	11.9
Specialist Nurse	6	5.9
Position
Top Manager	1	1
Nursing Unit Manager	44	43.6
Clinical Care Manager	3	3
Nurse Coordinator	53	52.5

Table 2 presents an overview of the informatics competencies of nurse managers as a basis for EMR implementation. All grades were in the range 64–67%, and the average of competencies was 65% of the total value of 100%. The least competency is information literacy (64%), while categories such as basic computer, service application, ethical, and decision-based on data were 67%.

Table 2.

Competencies Literacy Digital as a Basis for Electronic Medical Record Implementation (N:101)

Variable	Median	SD	Min-Max	CI 95%
Basic Computer	67.00	18.18	19–100	62.94–70.16
Information Literacy	64.00	15.64	31–100	61.79–67.99
Services Application Literacy	67.00	13.86	33–100	65.53–71.03
Ethical Literacy	67.00	12.65	33–100	70.17–75.19
Decision based on data	67.00	14.73	33–100	61.61–64.47
Innovation Literacy	66.00	14.19	30–100	65.38–71.38
Total	65.00	14.00	33–100	64.03–69.59

Table 3 shows that the average age of the Focus Group Discussion participants was 34.37 years, and most of them were women. Participants included nurses, doctors, and midwives; the participants held a bachelor’s degree and a professional qualification. This study included eleven participants from diverse hospital facilities, health centers, clinics, and private practices in Jakarta, Depok, and Bogor, Indonesia (large cities).

Table 3.

Participant Characteristics of the Focus Group Discussion

Kode	Age	Gender	Organization	Education	Profession
P1	30	Male	Clinic	S1+Profession	Nurse
P2	34	Male	Hospital	S1+Profession	Nurse
P3	28	Male	Independence practical	S1+Profession	Nurse
P4	32	Female	Hospital	S1+Profession	Nurse
P5	39	Female	Primary Healthcare	S1+Profession	Midwife
P6	40	Female	Hospital	S1+Profession	Nurse
P7	33	Female	Ministry of Health	S2	Nurse
P8	39	Female	Primary Healthcare	S1+Profession	Midwife
P9	46	Female	Primary Health Care	S1+Profession	Doctor
P10	28	Female	Hospital	S1+Profession	Nurse
P11	47	Female	Primary Health Care	S2	Doctor

Table 4 demonstrates the crosstabulation between a manager’s competencies and roles for the successful implementation of EMR. It requires interpersonal, informational, and decisional roles for the success of EMR. Interpersonal roles include leadership and role modelling, which require proficiency in all digital competencies. Informational roles from a competency perspective may require basic computer skills and information literacy, which further elaborates on the ability to find current information and present it easily and attractively, as well as ethical competencies that serve to motivate and evaluate the implementation of EMR. Decisional roles are supported by data literacy for decision-making and the ability to create innovations for progress and success. Combining the results of cross-sectional studies and focus group discussions (FGDs), a recommendation was developed for enhancing managers’ competencies and roles in implementing EMRs.

Table 4.

Crosstabulation Competencies and Roles of Managers for EMR Successfully

Roles of the Managers	Competencies Literacy Digital as a Basis for EMR Implementation
	Basic Computer	Information Literacy	Services Application	Ethical Literacy	Data Decision	Innovation Literacy
Interpersonal Roles
Leadership Role model	V	V	V	V	V	V
Informational Roles
Informational resource. Provide ethical guidance. Support system. Evaluator	V	V		V		V
Decisional Roles
Resource allocator. Innovator. Risk management	V		V		V	V

The FGD conversation was transcribed verbatim, word-for-word. Here is a conversation grouped by the themes of implementation, EMR barriers, and the interpersonal, informational, and decisional roles of nurse managers.

The Experiences, Benefits and Barriers Using EMR

The first theme conveys the experiences, benefits and barriers using EMR that have been used for the documentation of patients. The theme conveys the many benefits that can be obtained from using EMRs, including expanding access, being faster, improving quality of care, being more efficient, reducing costs, increasing inter-collaboration, and becoming a marketing product health care. Human resources, policies and organisations, leadership, legislation, facilities, digital literacy, and a lack of rules, including risk mitigation, are all barriers to EMR deployment. Some participants felt irritated and worn out because of poor EMR facilities and leaders who did not fully grasp their needs. Statements about experiences, benefits and difficulties in implementing EMR can be shown in the following conversation.

The Experiences and Benefits of EMR

…with electronic medical records for documentation, records, and reports….(P1, P2, P3, P5, P8 and P11)

…with the advent of digital services, nursing services have become more accessible to users, customers, and individuals needing care. (P1, P7, P4, P3)

…digitalization is very helpful in this service, such as report and documentation (P4, P7)

…for example, online services, registration online (P1, P3, P5, P6, P7, P8, P9, P10)

…with the shift toward online health services like EMR and provide better care. “(P4, P8, P9)

…patient information, diagnosis, and medical conditions can be readily accessed to expedite the diagnostic process and enhance service efficiency. By using data from previous hospitals, the new healthcare facility can minimize the learning curve and associated costs. Consolidating patient data into a single source enables a faster and more streamlined approach. (P4)

…EMR has proven to be extremely beneficial for us in the field of public health. It has greatly contributed to enhancing our efficiency and reducing costs. (P4, P7)

… this collaboration and integration can be observed through the use of electronic medical records. (P11)

…by using EMR, we can enhance our communication and collaboration to provide comprehensive care and ensure high-quality service. (P1, P4, P11)

…It is possible to input all medical record information into a website for research. Considering the potential of patients and other factors, we can use these data to drive innovation. How can we best foster innovation for future services? (P7, P9)

…EMR can create a good marketing (P7)

The Barrier of EMR Implementation

… the issue was with human resources, low motivation …. (P5, P6, and P11)

… some leaders are unaware of the EMR direction…. (P11)

…the infrastructure and network can pose challenges, such as redundancy. (P2, P6, P11)

…introducing a system without proper training can be a challenge…. (P5, P-11)

…however, the problem with our system EMR is that it is a bit slow. (P5)

…the limitations are related to time constraints and the EMR application…” (P6)

Management plays a significant role in the success of EMR implementation. During the implementation of EMR, staff require a lot of information and training. Managers must be a leader, a liaison, source of information, provide motivation, and monitor the progress of EMR implementation. Various factors influence the implementation of EMR. Nurse managers must play a decision-making role in innovation to effectively utilize human resources and facilities and develop risk management to achieve goals. The following is a discussion of interpersonal, informational, and decisional roles obtained during the FGD.

The Interpersonal Role to Ensure the EMR Is Running Well

…as a role model, managers must protect personal data, including patient medical information. As a result, leaders must take the required efforts to develop their data security procedures to successfully preserve patient data. (P3)

…leadership plays a key role in successful EMR deployment. When I use the term literacy in this context, I mean understanding that data security begins with people, not with technology. (P9)

Informational Roles of Managers

…It is critical that managers provide knowledge regarding current rules, whether they are related to hospital standards or federal legislation, particularly those involving patient confidentiality. (P2)

it is essential to provide ethical guidance, including patient confidentiality. (P4)

…the issue was with human resources, such as low motivation, so managers must support and evaluate the progress…” (P1, P5, P6, P11)

Decisional Roles of the Managers

…. This leadership and organization play a key role in the success of EMR use in every.

health service… (P9)

… managers must provide adequate human resources. (P9)

… provide innovation for infrastructure and network.. (P2, P6, P11)

… therefore, there needs to be digital literacy education for health workers. (P4, P9)

… at times, in the event of system sluggishness, it is crucial to input important data.

promptly, as the system’s performance is compromised. (P4, P5)

…. therefore, risk management from the nurse manager is essential to ensure that the

The system can swiftly recover in the event of downtime. (P4, P5)

The main theme map was used to illustrate the categories and themes developed to integrate the participants’ discussions. The benefits and barriers related to EMR implementation are depicted in Figures 1 and 2.

Figure 1 .

The Benefits and Barriers of Electronic Medical Records in Healthcare.

Figure 2 .

The Roles of Managers in Electronic Medical Records Implementation.

Discussion

The findings in the FGD study indicated three main themes: the experiences, benefits, barriers of EMR, and the role of managers in EMR implementation. Understanding users’ experiences, benefits, and difficulties in implementing electronic medical record (EMR) systems is crucial for providing recommendations for improvement to the EMR. By examining users’ difficulties, we can identify areas that need improvement and optimize the design of the EMR tool. Previous research states that leaders must manage, set an example, and provide direction during EMR implementation.¹⁵ In Indonesia itself, there are already regulations that mandate all healthcare facilities to use EMR, but despite the national rules, many organizations are still not ready.^2,10,11 It is hoped that the experience gained in this research can serve as a learning opportunity for developing countries that are currently developing EMR.

Benefits and Barriers of EMR Implementation

According to the survey, many participants believe that EMRs improve communication between health personnel, inter-collaboration, and service quality. The outcomes of this study are consistent with prior findings showing EMRs have numerous benefits, including enhanced communication and collaboration.^15,20 EMRs can also help with paperwork completion, service quality, and clinical decision-making.²¹

EMRs are required because they can facilitate the interoperability and integration of both management and patient data.²² According to this blueprint, one healthy Indonesian EMR development is governed by digital transformation, which includes standardization efforts, data integration, and the building of a digital ecosystem.²³ A good EMR is expected to promote service continuity while also improving service quality and speed.^24,25 Previous research has also shown that the use of EMRs can make it easier to supervise and monitor medication safety.^5,23

EMR has also decreased paperwork time and facilitated inter-cooperation as well as intra and inter-health communication. EMR can also improve service quality by standardizing coding, which is supposed to be easier and more user-friendly, reducing misinterpretation owing to difficult-to-read writing elements. After using EMR, the completeness and quality of documents improve, allowing for the implementation of comprehensive and continuous services.⁴ This conclusion also supports prior studies indicating that EMR can improve service continuity by facilitating collaboration among the health team. Time efficiency can also be adopted because EMR provides checklist facilities, which are not all written.⁶ The use of codes is a crucial factor that must be regulated to enable the standardization of EMR.²⁶ When compared to a paper-based system, an EMR can save money by lowering the cost of printing forms.²⁷ In addition to quality enhancement, it provides the possibility to generate large amounts of EMR data as part of research and development. EMRs can be used as a source for clinical decisions, teaching, and research when analysed using big data.^4,5

The elements that influence and impede the adoption of digital health are nearly comparable. The recognized hurdles include the fact that only a minimum number of leaders may lead progress, and the EMR policy is not yet finalized. Human resources and facilities also pose a challenge. Inadequate staff training is another impediment to EMR implementation. The facilities mentioned are the minimum hardware, software, and connections required for EMR. Obstacles in the development and implementation of EMR come from facilities. Infrastructure is an aspect identified in the study as a barrier to digital health implementation. Networks, software, computers, and other tools contribute to success.^13,28,29 The slow connection aspect is still viewed as a barrier to EMR implementation, and the variety of systems that must be loaded and lack interoperability further complicates healthcare. The findings of this study support prior research that found technological barriers to integrating electronic health records, such as slow networks, non-integrated systems, and redundancy in paperwork.¹³

According to studies, human resources are the most stated word when addressing elements influencing EMR effectiveness. The human aspect consists of healthcare personnel who employ EMRs and information technology support.⁴ According to some research, EMR literacy training is required in the healthcare profession. Education influences how people adapt to changes in EMR.^14,30 Human resource failure is influenced by the competence of its leaders. In this study, it was found that the average leader competency in managing EMR implementation is still below 70%. The low digital competency of managers will affect the successful implementation of EMR. Computer skills of managers are required for EMR implementation; thus, managers must be trained in the usage of hardware and software, as well as computer capabilities.⁴

Information literacy refers to the ability to ensure data security and privacy. Managers must also be proficient in using technology in healthcare services, developing innovations, and making data-driven decisions. Previous research has demonstrated that literate digital training enhanced participants’ judgments of ethical behaviours, as well as their awareness of data security and confidentiality.³¹

Competencies and Role of the Leader

Leaders or managers play a vital role in shaping organizational outcomes, making leadership a core concept in organizational behaviour.¹⁶ The research questions were developed utilizing a prior research methodology for leadership roles based on Mintzberg’s managerial roles.¹⁷ Managers or leaders function are figureheads, leaders, informants, and decision makers in the context of EMR adoption. The role of a manager is essential to becoming a leader in leading change. New EMR technology can lead to unsatisfaction among nurses and health care providers and is both opulent and annoying when adjusting to new systems.¹⁵

In this study, it was found that the manager serves as a role model in the implementation of EMR. This is consistent with previous research stating that interpersonal roles include the sub-roles of figurehead, leader, and liaison. As a leader, a manager guides and motivates their staff to achieve organizational objectives. Building and maintaining connections with stakeholders both inside and outside the business is the responsibility of a leader acting as a liaison. In this research, managers should also inform regulations that can provide guidelines for staff, among other things related to how to write, report, and keep patient data confidential.^12,15,32 The manager acts as an informer for new regulations and conducts training for staff, which is an informational role. Research previously conducted by a manager should be a role model in the implementation of EMR. Regulations are also needed to regulate ethics, data security, and privacy, as well as how to download and repair incorrect data.³³ Triangulation of studies at hospitals that previously carried out EMR improvements also conveyed that the role of the head of the room is very important in directing, providing examples in the implementation of EMR in the health sector and carrying out controls, including in the field of ethics.¹¹

The ethical issue of digital use in health services was raised by participants. In addition, the role’s informational of manager is useful to educate related to ethical principle, confidentiality, and privacy of data. The participant hopes that there is an ethics of digital use to improve the quality of service and patient proximity, and not leave the essence of caring.^14,34,35 These results agree with Locsin’s finding that technological nursing is nursing care, which means that technology will improve patient care.³⁵ Harmonious coherence must exist between the nurse and the patient when using technology.¹ Managers must support staff so that EMRs do not distance them from patients. The benefit of EMR is time efficiency, so more time can be spent interacting with patients.

A problem with facilities in the implementation of EMR is the limitation of computers and connections. This condition requires managers to be able to use their innovative abilities in using resources.¹ In this study, participants stated that managers should take the initiative to manage and modify infrastructure. Additionally, how to empower human resources to actively participate in the change. The functions of innovation, resource allocation, and problem-solving are key points in the decisional role.^1,2 This aligns with previous research findings, which indicate that new behavioural changes require managers to be able to make quick decisions, be problem solvers, and manage minimal resources.³⁶

The results of this study indicate that nurse managers’ competencies are still within an adequate range. Information literacy, ethics, and care implementation are also inadequate. Managers’ competency in digital information is crucial for fulfilling their role in EMR implementation. These suboptimal results align with previous research that found gaps in digital competency among managers.¹⁰ Therefore, managers must continue to undergo training to improve their competencies.¹¹

Limitations

This was an initial study that investigated the benefits and barriers of EMR deployment and competencies, and the roles of managers in leading EMR implementation. The FGD included eleven health workers, and the FGD was only completed in one round; therefore, the results cannot yet be generalized. The cross-sectional study with 101 samples, and FGD only for nurse manager, doctor and midwives, so participants did not represent all professions. The weakness may lead to recommendations for additional investigation. However, this study might provide preliminary data on the prerequisites for EMR implementation and serve as a foundation for future development.

Conclusion

Exploration of experience in the use of EMR is necessary to understand EMR implementation. The expansion results are input to the advanced mining steps of the implementation of EMR. The mean digital literacy competencies of nurse managers were 65% from 100%. It means that the digital competencies of the manager need to improve. The results of the qualitative study show that EMR has many benefits and obstacles; in addition, the manager’s role, including interpersonal, informational and decisional, is needed for successful EMR implementation. The research results provide themes: the benefits, constraints perceived, and experiences using EMR; and the role of the manager in EMR implementation.

Many benefits are obtained, including ease of access, increased quality of service, reduced costs, and access to research sources. The barriers in the implementation of EMRs are human resources, facilities, policies, leadership, and literacy education. A manager is needed to improve digital competencies and roles in EMR implementation. Training for the manager is needed to develop digital literacy competencies and the roles of the manager. The role model interpersonal, informational and decisional as key success in the implementation of EMR. For future research can continue to examine the long-term impact of the roles of managers on adoption and outcome on EMR.

Funding Statement

This work was supported by Hibah PUTI HI_Impact th Anggaran 2024/2025 No NKB-09/UN2.RST/HKP.05.00/2024. from Universitas Indonesia.

Ethics Statement

Ethics approval and consent to participate: This study was approved by the Ethical Board of the Faculty of Nursing, Universitas Indonesia KET-153/UN2.F12.D1.2.1/PPM. 00.02/2024. Consent for publication. All the participants provided written informed consent, including the author, for publication.

Disclosure

The authors report no conflicts of interest in this work.