Healthcare Information System (HIS): Challenges And Recommendations For Management

Utility of HIS in Healthcare Systems

It is well recognized that the healthcare sector is rapidly undergoing transformation, posing key challenges to healthcare practitioners, healthcare systems, governments and healthcare entities. This is more evident for the countries where the economic burden of healthcare costs is increasingly high owing to an aging population and high prevalence of chronic diseases. The complexity of delivering adapted and modified care services that meet the person-centered concerns is well reported across research. Health researchers have time and again sought answer for the increasing cost of proliferation of treatments that can address the concern of catering to the needs of a large patient population. It is critical for health care systems to optimize the nature of services provided and re-design different aspects of care provision (Callen, 2016).Constant efforts are being given to entrench innovation into the technologies used for articulating healthcare services at the present time (Paul, Ezz, & Kuljis, 2012). The researchers further state that healthcare authorities are have given their best efforts to integrate latest technologies into the healthcare system for advancement of services, starting from planning of care to evaluation of outcomes. The focus is on improving health through valuable contributions from different levels of healthcare system. A culture change has therefore been witnessed that promotes a shift towards optimal use of superior and highly developed technologies.

The implementation of healthcare technology had brought about a significant transformation in the healthcare system over the past few years. Key insights from research into the healthcare domain have led to a better understanding of how patient information can be managed, analyzed, shared and used for better outcomes. Various technologies are in use at present for augmenting the level of care provided and making it easier for service providers to do so. The purpose of integration of technology into healthcare system is to provide better care for patients and help them achieve health equality (Lau, Kuziemsky, Price, & Gardner, 2010). Further, technology has helped care professionals to increase patient safety, decreases rate of medical errors and strengthens the active interaction between healthcare providers and patients.

Healthcare Information System (HIS) refers to the wide range of technology based applications that are useful for capturing, storing, managing and transmitting health related information across the care continuum. This definition includes different systems such as routine information system, laboratory information system, hospital administration system, and human resource management system. Overall, HIS is an integrated effort for collecting, processing, reporting, and using health information and advanced knowledge for influencing decision-making and policy at different levels (Awang Kalong & Yusof, 2017). (Jardim, 2013) suggests reliable and sound information is the key to appropriate decision making in a healthcare system, and is crucial for policy implementation, regulation and governance, human resource development, health research, health education and service financing. The health information system enables the underpinnings for decision making in healthcare sector and comprises of four distinct functions; data generation, compilation, analysis and synthesis, and communication and use. The distinct feature is that the HIS is responsible for collecting data from relevant healthcare sector, analyzing the same and ensuring overall quality, timeliness and relevance, and converting the data into valuable information that can aid in health related decision making.

Benefits of Implementing HIS in Patient Care

Health information systems function to serve a broader end, supporting health facility management, ensuring accurate planning and stimulating research, enabling trends analysis and underpinning effective communication. Health related information is not of much value when the same is not available in a format that is of use of multiple users such as managers, planners, individuals and communities. Communication and dissemination are important attributes of the health information system (Lovelace & Shah, 2016). It is opined that a suitable HIS is elementary for enabling professionals gain access to authoritative, useable, reliable, comprehensive and understandable data. HIS aims to manage the paperless workflow of a patient and it is to be noted that this process is less complex and easier than the volatile medical records previously used. Healthcare providers benefit at large as accurate information is present on time for informed decision making. HIS is to be considered as an independent as well as self-contained system that runs in a seamless integrated process, covering a wide array of functionalities (Than, 2017).

The benefits of implementing HIS to the patient as well as to the healthcare setting are copious and have been well established across literature. Some of the key advantages for the patients include reduction in waiting times for admission, registration and examination; increased quality time for clinical examinations, improved treatment quality, and regular treatment monitoring. The advantages for the healthcare system are more profound and implies to professionals at different levels of practice. Reduction in manual data entry at multiple locations within the same system for the same patient is the most striking benefit. Secondly, HIS ensures that professionals can incorporate standards treatment guidelines for treating patients with diverse needs. Further, reduction in retrieval time of patient data is also highly appreciated. Faster referral of patients within a particular care setting is also an advantage (Lovelace & Shah, 2016).

As pointed out by healthcare experts there is a need to understand the challenges and concerns arising related to the implementation and utilization of HIS for optimizing its use across the care gamut. The rationale would be to understand the strategies through which transformation can be brought about in the improvement of quality of services provided at different levels (Weaver et al. 2016). New approaches in the HIS are emerging at the present time, increasing the complexity of implementing the same in a suitable manner. Professionals have been looking for solutions to problems arising due to the speedy change in practice (Kisekka & Giboney, 2018).

Challenges Faced in Implementing HIS

A deep look into the research carried out on the implementation of HIS in the recent years would indicate that a number of challenges have been faced in achieving desired outcomes. Successful implementation of the system has been restricted to certain countries, while the others are still struggling to accomplish the same. A key issue that has been acknowledged in this regard is the set of challenges at the management level. Such challenges include lack of skill and competency of the healthcare professionals and lack of awareness regarding the best application of the same. Though the use of HIS in the form of electronic medical record system has increased from 21% in 2005 to 86% in 2015, the risks of faulty treatment processes has increases as a result of the lack of adaptation capability. This concern has been found to be due to poor healthcare management system (Kaur & Rani, 2015). There is therefore a need to carry out a thorough analysis of the structural processes of implementation of HIS that are aimed at providing advanced forms of medical care.

The present research was carried out with the agenda of coming up with key recommendation for HIS implementation practice at management level. A key insight into the challenges faced at management level to implement HIS would help in coming up with recommendations that guide future use of HIS in a more effective manner. The healthcare industry would be highly benefited from such form of research in that they can consider policy changes within the healthcare settings. Concerned stakeholders would be armed with proper recommendations that would support the need of process changes across settings. It is also to be mentioned that leadership and accountability would be essential for promoting the changes based on a rich pool of evidences (Kisekka & Giboney, 2018).

Research aims are the broad statement regarding the outcomes of the study that outlines the expected accomplishments to be made. The aims give a clear picture of the overall purpose of the research (Chatburn, 2011). The aim of the present research was to identify the management issues that lead to poor implementation of HIS. Simultaneously, the research also aimed at providing recommendations for enhancement of skills and development of awareness among the respective stakeholders.

Research objectives are subsidiary to the research aims and are highly focused on the purpose of the research. It is crucial that the research objectives are precisely outlined (Chatburn, 2011). For the present research the objectives of the study were as follows-

To identify the management issues that are encountered by HIS
To identify the cause of medical errors that occur due to poor implementation of HIS
To provide proper recommendations for the management plan that can be incorporated to improve the usage of HIS.

Management Issues in HIS Implementation

The research question in a study is the answerable inquiry related to a particular topic or concern, acting as the first step in a research project. It is therefore the key active step for commencing with the research (Chatburn, 2011). The research question that was considered for the present research was as follows-

What recommendations can be provided for improving the management plan for HIS?

The present dissertation is structured in a systematic manner with logical flow of information across the chapters. The first provided an insight into the rationale for conducting the present study. The second chapter would provide a comprehensive literature review on the chosen research arena. The following chapter would be the methodology that outlines the key research steps. The successive chapter would describe the results of the research undertaken. The fifth chapter would provide a comprehensive discussion based on the study results. A logical conclusion and recommendations for future practice are mentioned in the next chapter. The last chapter evaluates the study and discusses scope for future research.

Chapter 2Literature review

The present chapter aims to highlight the existing literature on healthcare information system (HIS) to understand the relevancy and significance of implementing the system in modern day healthcare facilities. The utility of the healthcare information system can be recognized and apprehended on the basis of examining the present pool of literature on the topic. The literature reviews aims to set the stage for the present research project and justify the need of conducting the research. The main themes in literature have been discussed under different headings for having a proper flow of information. At the very beginning of the literature review the definition and purpose of HIS have been presented. Focus is then given to understand the types of healthcare information system and the process of implementing the same. The purpose and benefits gained to all relevant stakeholders are next discussed. The consecutive section throws light on the challenges faced in implementation of HIS. The last section brings into limelight thee future prospect of implementing HIS. The literature review ends by commenting on the key insight gained from the literature review, the gaps in existing literature and the implications for the research project carried out.

The healthcare sector is rapidly growing at the contemporary era, and a shift from reactive model of care to the one that is more patient-centric has been evident in the recent past. There is a mounting pressure on healthcare sector to constantly deliver high quality, safe and accessible care to a wide patient population. The number of preventable deaths in healthcare settings on the global basis is alarming. Novice strategies are therefore being identified that can hail as the methods of reducing the figures of preventable poor outcomes of healthcare through enhancement of safety and quality of care. In the past few years much interest has been generated to migrate from traditional care delivery systems to more advanced forms of processes that can address the evolving need of the healthcare sector. The interest, in part, is due to the growing recognition that only a stronger healthcare service management system can address national concerns of improving quality and safety of car and rising healthcare costs (Chaudhry, et al., 2006). According to (Buntin, Burke, & Hoaglin, 2011) the application of information system in the field of healthcare has emerged against this context and has been successful in receiving much attention. The advancements gained in the process of patient care delivery might be enriched through the introduction of information systems that support decision making in a robust manner.

Research Aims

Healthcare Information System (HIS) refers to the information system responsible for capturing, storing, managing and transmitting information related to the healthcare system and the activities of the healthcare settings carried out within the health sector. The definition of HIS includes aspects of information system such as routine information system, laboratory information system, disease surveillance system and hospital patient administration system. On the whole, HIS that functions well in a healthcare setting is the consolidated effort to carry out an accurate collection, processing, reporting and usage of health knowledge for influencing decision making, care actions and individual health outcomes (Wager, Lee, & Glaser, 2017). Rodrigues (2009) identified the prospects of thriving implementation of healthcare information systems has been commendable. HIS refers to any such system used in the healthcare sectors that are used for processing knowledge, information and data in care environment. The term Healthcare Information System can be considered as analogous to different primitive forms of the concept like hospital information system. At present, healthcare information system encompasses different systems including administrative systems, patient information systems, pharmacy information systems, radiology information systems and telemedicine. Healthcare professionals, policy makers and researchers have set high expectations from HIS that there is a growing interest to exploit the potential HIS holds.

The Health Metrics Network (HMN) had put forward the Framework and Standards for Country Health Information Systems in which Health Information System has been defined as the amalgamation of six components; health information system resources, indicators, data sources, data management, information products, dissemination and use. Health information system resources includes regulatory, legislative, and planning frameworks needed for a definite health information system, along with the resources needed for the system to be functional. Indicators are the basis of a HIS plan and strategy that require to focus on determinants of health. The data sources can be classified under two categories; institution based data and population based approaches. Data management encompasses diverse aspects of handling of health data starting from collection and storage to analysis. Information products refer to the transformation of data into information that forms the foundation for knowledge for shaping health action. The value of applying information system is augmented when the information is readily accessible for decision making (Balgrosky, 2014).

Ngafeeson (2015) suggested that health information system is consisting of a diverse range of networking technologies, electronic medical records, clinical databases, and other financial and administrative technologies. A generic model of information flow acting as a representation of health information system infrastructure is highlighted below.

Research Objectives

It is well known that Health information system is the advanced information management system used in the healthcare sector that is responsible for capturing and disseminating data relevant to delivery of comprehensive healthcare services. One must note that HIS is not merely a system of electronic applications; rather it encompasses interfaces for different clinical decision making tools and information databases. HIS can be classified broadly into four categories depending on the task carried out.

Subject based information systems are the most commonly used form of information system across settings. Electronic medical record (EMR) or electronic heath record (EHR) is the well known form of such systems that act as the equivalent of paper data records. The EHR can capture huge volumes of patient information and store the same in a safe and secured manner. Another subject-based system is the Master Patient Index (MPI) that helps in listing the details of the entire patient population being treated in a particular healthcare setting. Ideally, this system acts as the basic database for different patient-related systems. Those systems can be administrative as well as clinical, such as medical records, patient scheduling and billing. Task-based information systems are responsible for capturing and reporting information related to particular healthcare associated tasks. This encompasses diagnostic imaging, laboratory imaging, as well as medication management systems. It is to be remembered that the systems are primarily driven through MPI system wherein information is captured and stored for later use.

Administrative healthcare service systems are the third type of health information system that is used for managing daily managerial functioning within a healthcare system. These include scheduling of appointments and billing insurance carriers. The system is into functioning when decision support systems consider extraction of data from diverse administrative systems for compilation of information. The fourth type of health information system is care access internet systems. While electronic health records enable proper storage of health information, care access systems ensure that the same is accessible by healthcare service users. Through such systems, patients are able to request refilling of prescription, update the respective demographic information, and communicate in real-time with the healthcare professionals (Tan, 2010).

Implementation of HIS, as pointed out by (Sligo, Gauld, Roberts, & Villa, 2017) is not to be perceived as a simple or straight-forward linear approach. It is to be mentioned at the beginning of the discussion on the implementation of HIS that the concepts of implementation and adoption of HIS are different from each other. Though HIS might be adopted, it is not necessary that the same is being used in a manner intended. Proper implementation of HIS entails a lengthy procedure that encompasses planning, designing, and piloting prior to its use in a consistent manner. With a wider span of technology the implementation becomes difficult. A healthcare organization is supposed to consider a complex network of technical, cultural and clinical issues, highly interrelated to each other, for setting the base for successful implementation of HIS.

Research Question

Cresswell (2013) pinpointed that implementation of HIS is not inexpensive and a number of countries are considering dedicating a substantial portion of the health budget for information system application. Scholars suggest that technological change is a key reason why there is a rapid increase in the share of health sector in GDP in the past one decade. The implications for implementing HIS are huge, and disruptions might be caused for care organizations as the process can be an insightful change agent. Sicotte (2010) put forward contradictory ideas and stated that though there has been evidence that HIS has a positive effect on the whole, no regulatory frameworks are being diligently used for evaluating implementation of HIS. Some of the HIS are not developed in a rigorous manner, making the implementation difficult. Therefore, implementation of HIS might be involved with high risks. In summary, delivery of care services through HIS might be highly complex under certain conditions, and would therefore require rigorous administrative approaches. Implementation levels might be low owing to such complexity of the underlying process of HIS.

Healthcare information system has faced immense critical appraisal for the potential it holds to increase the legibility and of care, shrink healthcare resource utilization costs, reduce chances of medical errors, and enhancement of quality of services provided. Murthy (2014) identified reasons in support of implementing HIS primarily involve cost, safety, quality, and efficiency. There is an urgent need of addressing the increasing costs of providing optimal quality healthcare services to the rapidly aging population while not making any comprises with the access, quality or equity. Scientific evidence points out that HIS can ensure that the return on investment in positive. Some of the noted benefits are reduced clinical errors, better monitoring of care, constant diagnosis support, and better accessibility of patient information.

Muennig (2016) highlighted the cost savings healthcare organizations can achieve as a result of successful implementation of HIS. As per the researchers, HIS can promisingly save a substantial proportion of healthcare costs when considered on the long run. This is related to the generation of organizational profitability through cost-effectiveness, efficiencies and safety of all the medical deliveries. When speaking on a practical term, much can be expected that HIS would attempt to reduce the expenses that are incurred for record keeping while maintaining focus on adhering to privacy regulations and standards for improvement of workflow. It is also to be highlighted that HIS can permit a speedy and accurate sharing of information on an automated manner among the service providers. This reduces the need of office visits and subsequent admissions to the hospital. Even risks of mal-practicing law suits are reduced. Waterson (2014) found that investments made in the healthcare sector have been leading to high profitability. The healthcare system of UK is a highly efficient enterprise on the global scale. Billions of dollars can be saved through implementation of electronic medical record in a sufficient manner.

Chapter 2 – Literature Review

Oinas-Kukkonen (2018) reported that a large number of patient population die due to medical errors that are preventable. Around 50% of the medical errors can be reduced over three to five years under circumstances where the technological know-how in relation to health information system is implemented. The Institute of Medicine (IOM) had reported that millions of adverse drugs events come into highlight which is preventable on the first place. As a solution to this problem, the IOM had recommended the implementation of HIS. As a key resolution to the prevalence of medical errors, HIS brings about distinct benefits.

Apart from reduction in medical errors, HIS has other general beneficial implications for the healthcare sector. While explaining the association between implementation of HIS and overall improvement in quality of care, (Wager, Lee, & Glaser, 2017) mentioned that more accurate, complete and structured documentation of clinical data is a key advantage. Further, information can be generated through automatic sorting. Remote access to records of patients is another major benefit (Burke, 2018) also provided insights into how improvement of overall quality of care can be gained for a patient population. The researchers stated that decision support can be increased when predictive data management tools are used. Further, clinical decision can be made better when there is exchange of health information between professionals within a particular healthcare setting. In short, through the diverse capabilities of HIS, mistakes can be kept at bay, response times for treatment can be improved, quality of information can be enhanced and optimal clinical decision making can be attained (Refer to Appendix VI).

Extensive literature review indicates that a number of benefits can be gained through implementation of HIS. This is more evident for bigger healthcare organizations that face difficulties in implementing the system at the basic level. Nevertheless, the conceptualization, implementation, and maintenance of HIS are a complex and time consuming process. Other issues related to the successful implementation are related to administrative and managerial activities that have time and again being highlighted in research. Strategic context and organizational approaches for implementation of HIS have been discussed in literature. Kuperman (2013) the opportunities and potential held by HIS to bring about a radical transformation have been acknowledged, a number of challenges are imminent and evident. A number of healthcare organizations have not been able to adequately adopt the changes and are therefore lagging behind in bringing about a required transformation in their care delivery processes. The problem has been aggravated by the immense resistance of healthcare employees to adopt the changes needed for successful implementation of HIS. The challenges cover a diverse range of concerns starting from regulatory environment to the healthcare setting itself.

Abdelhak & Grostick (2014) commented that concerns in implementation of HIS stem from organizational, human and technical factors. A combination of all these factors leads to the failure in achieving the set target. However, organizational and management issues are to be given more focus in this regard since such issues are the key contributors to inhibition of successful implementation of HIS. The failure or success of HIS implementation might be considered as dependent on the existing gap between present realities and management concepts. The supporters of this concept argue that the stakeholders involved in usage of the systems have different version of the utility of the same that is highly subjective. Since the stakeholders have different viewpoints regarding how and to what extent the information systems, the challenges emerging are distinct. For the implementation of HIS in healthcare organizations, strategic approach is required at the managerial level which might not be straightforward. Managers at care settings might find radical changes as necessary for implementation within the care setting environment. As teams come together to deliver care, hospital staffs are to learn certain different ways to work with them. This might be difficult for staffs to manage, leading to extreme dissatisfaction. For instance, a risk lies that processes in the organization are automated, in contrast to redesign. This leads to a lack of sense of gaining benefits from it. In addition, negligible appreciation is there since the perception of the staff is that the benefits would need much time to become evident since the success depends, to a considerable extent, on the communication of care providers and consumers.

Different theoretical models are known to be present for explaining the management issues revolving around acceptance of HIS from the perspective of users. Among these, the most prominent one among the different models of user acceptance is technology acceptance model. As per this model, the attitude of a user toward a newly implemented technology in highly reliant on the usefulness of the technology as perceived by the users as well as the ease of use of the same technology. Perceived usefulness and attitude are then responsible for jointly predicting the intention of the user to consider utilization of the particular technology. Since healthcare workers are presented with professional autonomy which is evident at almost all stages, they can take decisions regarding technology acceptance in an independent manner. The technology acceptance model can be further extended by including the facilitating conditions and social influences that act as key predictors of accepting technology change. Social influence refers to the different norms emerging from the social environment related to the use of advanced technology. On the other hand, the facilitating conditions are the wide range of objective factors promoting the embracement of technology (Ketikidis, Dimitrovski, & Lazuras, 2012).

At this juncture it would be essential to highlight another significant model of management issue, namely Information system success model proposed by DeLone and McLean. The scholars had added user satisfaction as an element in user acceptance model, the rationale being the fact that user satisfaction needs to be considered as a measure of system value when use of alternative systems in obligatory. As per the model, success measure of information system can be divided into six different categories; system quality, information quality; usage; user satisfaction; individual impact and organizational impact. In the view of the scholars, information quality and system quality jointly make an effect on user satisfaction. The impact of the information system on the behavior of the individuals is known as individual impact. Further, organizational impact is the influence the system has on the performance of the organization. Since user training and user support are essential for influencing acceptance of users, there is a need of more studies for understanding how such management issues can be resolved (Petter & DeLone, 2013).

Choi, Rho, Park, Kim & Kwon (2013) stated that with the evolution of technology, new approaches have come up in relation to healthcare information systems. As new information systems are being constantly introduced into the system, the management issues also are subjected to change. Surveys are to be conducted for understanding the management issues that are coming into limelight in the recent times. HIS managers can identify the key challenges through such research and interpret the trends in adoption of HIS. Policy makers are constantly encouraging professionals from the field of healthcare management to explore the diverse and intense management challenges faced in implementation of HIS and the strategies through which they can be resolved.

Okpokoro (2013) pointed out that a key management issues in the context of implementation of HIS in primary health care system is related to the absence of proper understanding of the systems and the lack of proper information being cascaded to them regarding usage. As a result, healthcare staffs face immense challenges in maintaining a stable channel of communication with the stakeholders. Key insights are needed from care facilities to understand how the management challenges can be dealt with in a robust manner. Sulaiman & Wickramsinghe (2014) mentioned that organizational culture has a key role in taking important decisions regarding the HIS infrastructure provision. It is necessary to increase the level of awareness regarding the latest management issues faced in healthcare centers and how the same can be resolved. It is also pivotal to give focus on the demographic elements since they can reflect on the accurate management issues faced in the sector. Privacy is another concern in the healthcare sector (Wager, Lee, & Glaser, 2017). The risk of patient information being leaked to the public acts as a security issue. Optimization of the large volume of information can also be considered as a concern of the management (Carvalho, Rocha, & Abreu, 2016).

Weaver, Ball & Kim (2016) reported on the challenges faced while conducting studies for understanding the issues pertaining to implementation of HIS. While some studies exploring management issues in HIS implementation of HIS had unclear goals, others gave rise to contradictory results. Controversy regarding whether the results generated from the studies might be appropriately generalized to different environments were also noted. A certain section of the existing studies also had non-systemic research design. Healthcare information system has so far faced much criticism for not being able to be appreciated by healthcare workers as promised. Nevertheless, there is a mounting need of understanding the management challenges faced in implementation of HIS for paving the path of future success of HIS in an appropriate manner. Further research is therefore necessary at the grass-root level to highlight the challenges that employees of healthcare organizations face in terms of management aspects. Research on issues of HIS implementation, such as management issues must focus on the perceptions and viewpoints of the professionals involved with the processes. There is a need of conducting research with users of HIS so that their concerns can be reviewed in an apt manner (Sligo, Gauld, Roberts, & Villa, 2017).

It can be summarized from the review of literature that healthcare information system brings about immense benefits for both the service users as well as the healthcare organizations. With the highly felt shift from centralized to decentralized care, restructuring of HIS can be essential. The underuse of HIS can be a key concern in the near future since the optimal benefits might not be gained. It is therefore elementary to conduct research and understand how healthcare workers perceive implementation of HIS at different levels. Consequently, existing studies are to be reviewed for validating and comparing the findings across a wide continuum of care service provisions.

The section on research methodology is responsible for providing a blueprint of the steps that are followed for carrying out the research. Research methodology is to be perceived as the particular technique or set of procedure that are used for the identification, selection and analysis of information related to the chosen research question. In any research paper, the section on methodology permits the reader to undertake a critical evaluation of the overall reliability and validity of the study. The prime aim of the section is to provide the readers with answers to two questions; how the data was generated and how the analysis process was carried out (Silverman, 2016).

The essence of research philosophy is to be first explained while discussing the type of investigation carried out for the present research. Research philosophy is related to the nature, source and development of knowledge. It is therefore the belief regarding the manner in which the data is to be collected and subsequently analyzed for future use. The four main forms of research philosophies are pragmatism, positivism, realism and interpretivism. For the present research, the underpinning research philosophy was pragmatism. Taylor, Bogdan & DeVault (2015) pragmatism research philosophy recognizes that there might be multiple ways of undertaking an interpretation of the world for carrying out a research. The viewpoint is that there might not be a particular notion that can bring into focus a clear picture of what is being studied and multiple realities might exist. As per this philosophy, the most crucial and significant determinant of the research idea is the research question. The pragmatic paradigm is a perceived as an intuitive permission to study the area of interest through embracing methods seemed appropriate and in harmony with the belief system of the researcher.

Research approach is the procedure and plan consisting of the steps of assumptions for detailing data collection and analysis method, and interpretation process. Hence, it is based on the nature of the particular research problem. The approach can be divided into two particular categories; approach for data collection and approach for data reasoning. The two primary forms of research approach are deductive and inductive. The significant difference between deductive and inductive approaches is that while the deductive approach aims at testing existing theory, the inductive approach relates to the generation of new ideas and theories emerging from the research. For the present research, the inductive approach was used that starts with the key observations made throughout the data collection process and ends with theories proposed at the end of the research. Such a research is known to involve a search for patterns from observations and generation of explanations through those patterns (Silverman, 2016).

The research design is the particular set of methods used for collection and analysis of variables specified for the research problem. The design specifies the study type, subtype, research problem, and data collection and data analysis method. For the present research a descriptive study design was referred to that is usually used for describing the characteristics of the phenomena being studied that is management issues in implementation of health information system in healthcare settings. The aim was to understand the characteristics of the challenges faced while implementing the health information systems speaking in terms of management aspects. While accurate predictions might not be possible under all circumstances, a potential relationship between two variables can be easily established. Descriptive research might not be fitting exactly into the requirement for qualitative or quantitative research as the elements of both the research forms can be used in such a study. The form of research question decided upon determines the approach taken. However, descriptive studies are concerned about finding out ‘what is’ as applied to the research question (Flick, 2015).

Two forms of data collection process have been identified in the research arena, namely primary and secondary data collection process that is aligned with the investigation being carried out. While primary data collection revolves around collecting data by the research himself, secondary data pertains to analysis of already existing data on the concerned research domain (Taylor, Bogdan, & DeVault, 2015). In the present research, both primary and secondary data had been collected and analyzed for addressing the research question.

The advantage of primary data collection is that the researcher can collect data specific to the problem being studied. Further, the quality of data collected is more reliable. In addition, the researcher might obtain additional data during the research period (Panneerselvam, 2014). Primary data collection had been undertaken for the present research from important stakeholders of the healthcare sector. Two reputed healthcare centers had been selected for undertaking the primary data collection. The participants for the study were four technicians, two from each setting, and fifty other healthcare workers from different levels of the two organizations. Random sampling method had been used for selection of the participants. Taylor, Bogdan & DeVault (2015) noted that random sampling is the form of sampling in which each potential participant has an equal chance of getting selected for the study. It is noted that such as sample chosen is an unbiased representation of the broader population. The four technicians were considered for undertaking interviews and fifty healthcare workers were considered for undertaking survey. The participants were required to work in the respective organization for a minimum of three years.

Surveys are easy to administer and can be completed in less time. Further, they are highly cost-effective and can be undertaken remotely. Another advantage is that a number of questions can be answered that gives extensive flexibility regarding data analysis. A broad range of data might be collected such as beliefs, values, attitudes and opinions of the respondents (Silverman, 2016). Interviews are useful data collection instrument when investigation demands in-depth analysis. Such a data collection method is used for discovering how individuals perceive about a topic, which in the present case was managerial issue in HIS implementation. Interviews can achieve a high response rate and detailed information can be gathered (Panneerselvam, 2014).

Secondary data collection had been undertaken by searching for relevant literature from healthcare databases corresponding to the topic of and challenges that are faced while implementing the primary healthcare information system. The aim was to support the findings of the primary data collection with the previous studies conducted in the same arena. The advantages of such data collection are that it is less expensive and the research does not hold accountability for the quality of data.

Primary data collection had been undertaken for the present research from important stakeholders of the healthcare sector. Two reputed healthcare centers had been selected for undertaking the primary data collection. This includes the Manchester Institute of Health & Performance (MIHP) and the North Manchester General Hospital (NMGH) in UK. These two hospitals were selected as they were large hospitals with 800-100 bed and the hospitals are equipped with latest technology. Hence, finding out the experience of technicians and staffs working in the hospital related to use of HIS and challenges faced in implementation would be useful.

All health care staffs working in both the hospitals were recruited for the participation in survey. Before starting the recruitment process, ethical approval for research was taken from relevant Research Ethics Committed. The managers of both the hospitals were also approached to provide information regarding the purpose of research and the need to include their staffs in the research process. After receiving the permission for research, informed consent criteria was fulfilled by informing all the health care professionals regarding the purpose of research, types of survey and interview and duration taken for each. In addition, only those staffs were included in the survey and interview process who gave consent for research and signed the informed consent form.

For the purpose of survey, 50 staffs including technicians, managers and administrative staffs were included. The survey questionnaire was developed using 10 questions and details regarding questionnaire for survey is provided in appendix 1. The survey questionnaire was distributed via mail and all participants had given online response within 1 day. For the purpose of interview, interview was taken in an enclosed room with audio recording and the duration for interview was 30 minutes. An experienced hospital administrator was involved in conducting the interview. The interview recording was transcribed verbatim and analyzed. Random sampling method had been used for selection of the participants. (Taylor, et al., 2015) noted that random sampling is the form of sampling in which each potential participant has an equal chance of getting selected for the study. It is noted that such as sample chosen is an unbiased representation of the broader population. The four technicians were considered for undertaking interviews and fifty healthcare workers were considered for undertaking survey.

Secondary data collection had been undertaken by searching for relevant literature from healthcare database like CINAHL, MEDLINE and search engines like Google Scholars corresponding to the topic of and challenges that are faced while implementing the primary healthcare information system. The aim was to support the findings of the primary data collection with the previous studies conducted in the same arena. The advantages of such data collection are that it is less expensive and the research does not hold accountability for the quality of data.

A mixed research approach was referred to for the data analysis process that involves collection and analysis of quantitative as well as qualitative research. Such an approach was used for the integration of the two methods to provide a deeper understanding of the research problem. As noted by (Flick, 2015) through mixing of quantitative and qualitative research, the research is able to gain in depth understanding of the phenomena. Such a method was used for validating the results obtained from each of the two methods, primary and secondary. While quantitative data analysis was done for the surveys, the interviews referred to a qualitative analysis method. Regression analysis was done for the analysis of survey data. In addition, while analyzing interview data, the focus was to highlight responses which were similar or different for each interview question. Different colors were given to response with different meanings or concept. In this wide, different types of challenges and all possible solutions were analyzed. As it was appreciable to continuously look at the research question on the managerial issues regarding implementation of the HIS, a mixed method could clarify any unexpected findings from the primary research and the potential contradictions arising from the research. While quantitative data provides a suitable way of testing existing theories, qualitative research is ideal for building theories.

Primary research entails strict ethical principles to be adhered to since there is an involvement of human participants. Research ethics is viewed as a crucial component of research that is to be considered throughout the entire data collection and analysis process. Ethical principles, when followed by researchers, ensure that a trusted research environment is created. Data fabrication and falsification can be avoided when research is done in an ethical manner. Participants can be supported with a secured environment wherein they can provide with optimal information related to research question. This is known to enhance the data reliability. The core ethical principles are informed consent, anonymity, confidentiality and transparency (Panneerselvam, 2014).

The research was carried out after receiving ethical approval from the local Research Ethics committee and the respective healthcare settings. Informed consent was taken from the participants before taking part in the study. This allowed the participants to understand the research aim, purpose, scope and implications for practice. The participation was voluntary and the participants had the freedom not to continue with the research as per their convenience (Artal & Rubenfeld, 2017). The identity of the participants was protected through anonymity as the personal information was not disclosed. The information generated was preserved in a confidential manner so as to avoid reach of external agencies. The reports generated were stored in a safe and secured manner so that the researchers could only access them.

This chapter illustrates the analysis and findings of the data collected for the purpose of the study on ‘Management issues that are faced while implementation of Healthcare Information system and the ways to deal with the same’. This is majorly an exploratory research, in which the researcher aims to find out the management issues and their impact on the efficiency of the HIS. To conduct the study, both primary and secondary data was collected and analyzed using qualitative and quantitative method. Various management issues were identified through literature review and the primary data was collected from two major hospitals in the UK, namely, MIHP and NMGH. Primary data was gathered using two methods, survey and interview. 25 employees from both the hospitals were chosen for the survey using simple random sampling technique and two officials were selected for the interview. The survey questionnaire contained two sections, demographic and non-demographic. The findings and its explanations are as follows.

These factors aim to focus on the socio economic background of the survey participants. In this survey, the age group, gender profile, designation in the hospitals and tenure were considered to get an idea about the people working in the hospitals and their ideas about the implementation of health information system (HIS), managements issues in the hospitals and their impact.

It is seen that in both the hospitals, equal number of male and female employees participated in the survey and among them, number of males is greater than the male employees. Male respondents comprised 56% of total sample and female respondents consisted of 44% (See appendix IV). Regarding the age group, it is seen that, majority, that is, 40% of the respondents in MIHP belong to the age group of 31 to 40 years, followed by 24% in each the age group of 41 to 50 years and 51 to 60 years. Only 12% fell in the category of 25 to 30 years. On the other hand, in NMGH, maximum number of employees, that is, 36% belonged to the category of 41 to 50 years, followed by 28% in the age group of 31 to 40 years, 20% in 51 to 60 years and very few, that is, 16% in 25 to 30 years (See appendix V). Thus, the sample populations in both the hospitals majorly consist of younger people, assumed to have idea about the HIS and its challenges (See Appendix VII).

In MIHP, 32% of the participants were administrative workers, 28% were technicians, 24% healthcare workers, such as, nurse and physicians, and 16% were managers. In NMGH, majority, that is, 40% were managers, 32% (28% + 4%) were healthcare workers, 16% were administrative executive and only 12% were technicians. These designated employees were chosen for the sampling as these employees are assumed to use the health information system as that is an administrative tool for efficient management of the information of the patients (See Appendix VIII).

52% of the survey respondents in MIHP were working for 6 to 10 years, followed by 24% working for 1 to 5 years, and equal number of respondents, 12% working for less than 1 year and more than 10 years. On the other hand, 32% of the respondents were working for 1 to 5 years, followed by 28% for 6 to 10 years and an equal number for more than 10 years. 12% were working for less than 1 year. From this profile, it can be inferred that majority of the respondents in both hospitals were working for less than 10 years and technology of HIS is familiar to them.

These factors were chosen based on the information obtained through literature reviews. These were framed to highlight the awareness of the respondents regarding the systems, effectiveness of different aspects of management, efficiency of the system in their hospitals, existence of management issues and their impact on the efficiency of the systems and potential data security issues of these information systems. The response rates have been presented through pie charts to reflect the percentage of people aware about those factors and relative influence of those on the efficiency of the systems (See Appendix IX).

The list of different types of health information system (HIS) was made from the information gathered from the literatures. It is possible that the hospitals use any one type of system or more than one in different departments. It is found that majority of the respondents (48%) in MIHP reported that Electronic Medical Records (EMR) or Electronic Health Record (EHR) was being used, while 20% reported that they did not know which system was being used. 16% said it was Patient Administration Systems (PAS) and another 16% reported that it was Clinical Information Systems (CIS). Thus, it can be said that, MIHP uses EMR or EHR for record keeping and it may also use any the other or both of those in different departments or they used those prior to using the EMR. Since, it is possible to use multiple systems, hence, it is quite natural that not all respondents know the name of the particular system being used or if the systems have changed recently (See Appendix IX).

In NMGH, 56% reported that the hospital uses Patient Administration System (PAS). 24% voted for EMR/EHR , 16% reported that they do not know and only 4% voted for Clinical Information System (CIS). Thus, it can be said that NMGH mostly use PAS in majority of their departments, and they also use EMR and CIS (See Appendix IX).

Regarding the question on the efficiency of HIS in the hospitals, it is found that majority respondents in the both the hospitals agreed to this, indicating that the hospitals are getting benefitted from the implementation of HIS as that makes the record keeping and managing easier (See Appendix X).

In the above question, the respondents were asked to rate 6 factors that affect the efficient working of HIS in the hospitals. System quality, information quality, user level, user satisfaction, individual impact and organizational impact were listed to find their effectiveness. Based on the perceptions and knowledge of the respondents on the HIS and influencing factors, this rating was created.

It is found that, in MIHP, the respondents rated system quality and information quality as the most effective factors, while usage level and user satisfaction were rated as moderately effective or just effective, while the individual and organizational impact were mostly considered as ineffective. A similar pattern of response was found in NMGH also. Majority found system and information quality as the most effective factors for influencing the efficiency of HIS. They rated user level, satisfaction, were rated as moderately effectively, and individual and organizational impact as ineffective and negatively effective. Thus, from this observation, it can be said that, according to the employees and users of HIS in the hospitals, the system and information quality are the two most important factors that affects the efficiency of the systems (See Appendix XI).

According to maximum number of participants (64%) in MIHP, the management issues of the hospitals affect the efficiency of the HIS, while 28% answered neutral. On the other hand, majority (44%) answered neutral in NMGH, followed by 28% disagreed and 24% agreed. Thus, it can be inferred that the survey participants in two hospitals have different perspectives regarding the impact of management issues on the effectiveness of the HIS (See Appendix XII).

7 management issues were considered to conduct the study. The researcher selected these factors based on the paper by (Murthy B. K., 2014) that addressed the implementation challenges of HIS in the Super Specialty Hospital. From all the factors mentioned in the paper, the researcher selected the above mentioned factors, which are most relevant for the hospitals, and also easy to understand for the survey participants, holding different designations. It is found from the responses that, in MIHP, majority of the participants voted for lack of master database as one of the major issues affecting the HIS. Although the problem is technical, but the management of the hospital was not able to solve this problem and arrange facilities to introduce a master database for effective functioning of HIS. The other major factors highlighted in this hospital are the inadequate infrastructure in electronic delivery, lack of educated and trained staff and lack of awareness about the system and its functioning.

In NMGH, the participants highlighted that lack of educated and trained staff is one of the major issues, followed by lack of awareness, lack of master database and lack of data entry operators. Thus, it can be said that there are various issues, some are management issues and some are not, which affects the efficiency of the HIS. However, the management of both the hospitals was unable to solve the issues, such as, technical issues, infrastructural issues, lack of training and educated staff and dearth of data entry operators, creating the problems in the path of achieving the optimum effectiveness of HIS (See Appendix XIII).

Regarding the question of potential security threats to the data in HIS, maximum number of respondents (36%) agreed in MIHP, followed by disagreement from 32% of the employees, and neutral response from 24% and strong disagreement by 8%. In NMGH, majority (36%) disagreed to this question, followed by 28% answered neutral and 28% agreed. Only 8% strongly disagreed.

Two information technology technicians from each of the hospitals were selected for conducting the interview. Each of them was asked 5 questions that focused on the applications of HIS in the hospitals and the management issues that create hurdles for efficient working of the HIS. The details regarding the interview response is provided in appendix 3. In MIHP, the technicians highlighted the usage of EHR in majority of the departments and usage of PAS and CIS in some. They mentioned the benefits of the systems, such as, streamlining of billing and coding, database management and documentation process of patients’ records. This reduces time for treatment, especially in case of returning patients with chronic diseases. However, some of the management issues highlighted were the lack of support from vendors of the services, lack of adequate funds, complexity of the system, lack of trained staff as well as lack of training arrangements. Similar findings were obtained from NMGH also. The technicians reported that the medication errors have reduced significantly increasing patient safety. On the other hand, lack of flexible attitude to learn the new system is a problem in effectiveness of HIS, along with other issues, such as, complexity, inadequate funds, lack of awareness and shortage of educated staff. Thus, it can be said that, the hospitals face some common issues that affect the efficiency of the HIS systems.

To find out the impact of the managerial issues on the efficiency of HIS, the researcher has narrowed down the factors to focus on a specific aspect. Two research hypotheses were formulated with efficiency of HIS and specific management issues.

1H₀: System quality does not have any significant impact on efficiency of HIS.

1H₁: System quality has a significant impact on efficiency of HIS.

2H₀: influencing factors do not have any significant impact on information quality of HIS

2H₁: influencing factors have significant impact on information quality of HIS

It is to be noted that, since there are many factors under management issues, affecting the efficiency of the health information system in the hospital, the researcher computed medians of the 7 factors and transformed it to into a single variable for computation purpose. This was done for both the datasets.

Moreover, system quality and information quality depend on the management capacity of the hospitals. An efficient management will be able to deliver a best quality system and best quality information. Thus, due to the issues, the system and information quality get compromised or reduced, which in turn affects the efficiency and effectiveness of health information system in (HIS).

Two regression models were framed to test the hypotheses. The tests were performed twice to highlight the cases of both the hospitals.

In the first regression model, system quality was considered as independent variable and efficient HIS was considered as dependent variable.

Model Summary
Model	R	R Square	Adjusted R Square	Std. Error of the Estimate
1	.584^a	.341	.312	.560
a. Predictors: (Constant), 7.a) MIHP_System quality

ANOVA^a
Model	Sum of Squares	df	Mean Square	F	Sig.
1	Regression	3.736	1	3.736	11.893	.002^b
Residual	7.224	23	.314
Total	10.960	24
a. Dependent Variable: 6. MIHP_Efficient HIS
b. Predictors: (Constant), 7.a) MIHP_System quality

Coefficients^a
Model	Unstandardized Coefficients	Standardized Coefficients	t	Sig.
B	Std. Error	Beta
1	(Constant)	1.220	.263		4.641	.000
7.a) MIHP_System quality	.456	.132	.584	3.449	.002
a. Dependent Variable: 6. MIHP_Efficient HIS

In the second regression model, information quality was considered as dependent variable and the combined variable containing the factors, that is, influential factors was considered as dependent variable.

Manchester Institute of Health & Performance (MIHP)

Model Summary
Model	R	R Square	Adjusted R Square	Std. Error of the Estimate
1	.558^a	.312	.282	.761
a. Predictors: (Constant), MIHP_InfluencingFactors

As the adjusted R square value is 0.282, it explains 28% of the model.

ANOVA^a
Model	Sum of Squares	df	Mean Square	F	Sig.
1	Regression	6.038	1	6.038	10.423	.004^b
Residual	13.322	23	.579
Total	19.360	24
a. Dependent Variable: 7.b) MIHP_Information quality
b. Predictors: (Constant), MIHP_InfluencingFactors

Coefficients^a
Model	Unstandardized Coefficients	Standardized Coefficients	t	Sig.
B	Std. Error	Beta
1	(Constant)	-.138	.631		-.218	.829
MIHP_InfluencingFactors	.749	.232	.558	3.228	.004
a. Dependent Variable: 7.b) MIHP_Information quality

As the significance value is 0.004 in both the two tables, it is less than the 0.05. This indicates that the second null hypothesis is rejected for MIHP. In other words, the influencing factors all together have a significant impact on the information quality of the HIS, which in turn affects the efficiency of the system.

North Manchester General Hospital (NMGH)

Model Summary
Model	R	R Square	Adjusted R Square	Std. Error of the Estimate
1	.675^a	.456	.432	.744
a. Predictors: (Constant), NMGH_InfluencingFactors

The value of the adjusted R square value explains 43% of the model, which is again a moderate fit.

ANOVA^a
Model	Sum of Squares	df	Mean Square	F	Sig.
1	Regression	10.642	1	10.642	19.246	.000^b
Residual	12.718	23	.553
Total	23.360	24
a. Dependent Variable: 7.b) NMGH_Information quality
b. Predictors: (Constant), NMGH_InfluencingFactors

Coefficients^a
Model	Unstandardized Coefficients	Standardized Coefficients	t	Sig.
B	Std. Error	Beta
1	(Constant)	.038	.437		.088	.931
NMGH_InfluencingFactors	.763	.174	.675	4.387	.000
a. Dependent Variable: 7.b) NMGH_Information quality

The significance p-value is less than 0.05 in the above two tables, indicating the second null hypothesis to be rejected for NMGH, that is, information quality in the system is significantly affected by the combined impact of the influential factors.

The importance of HIS is realized in health care setting because of its ability to improve the quality of care and minimize the chances of medical errors. Health care managers aim to adopt updated HIS to stay competitive in the marketplace and improve efficiency in the care process. (Koulayev & Simeonova, 2010) argue that HIS technology like EMRs has the potential to improve patient care and reduce the work lives of health care professionals. Quality improvement in health care is dependent on health care professional’s ability to address complex patient needs and tools like EHR support primary care providers to be better informed while delivering care to patient. It also provides structured and legible formats for improving communication between family physician and team members. The importance of HIS is also realized in addressing patient safety issues and improving work flow. This is understood by a research which revealed that very few unfavorable outcomes is seen in hospitals were EHRs has been fully implemented. The rate of poor outcomes, medication errors and poor quality of care are significantly reduces due to full adoption of EHR tool in health care (Kutney-Lee & Kelly, 2011). Hence, it can be concluded that HIS promotes patient safety and enables maintaining continuity of patient care. However, for the success of such technology in health care, there is a need for health care leaders to support the growth of technology in clinical setting.

The review of research studies from health care database like CINAHL and MEDLINE also gives an insight into management challenges faced by health care professionals while implementing HIS in hospital setting. One of the research literature used survey method to collect data from random sample of health care professionals working in two Saudi hospitals and the main objective was to analyze the barriers perceived by health care professionals in adopting EMR. The review of interview response revealed six main categories of barriers such as human barriers, professional barriers, technical barriers, organization barriers, financial barriers and legal barriers. Among them human and financial barriers were the most prevalence form of perceive barriers (Khalifa, Barriers to health information systems and electronic medical records implementation. A field study of Saudi Arabian hospitals. , 2013). However, the gap in the study was that it did not explored the barriers in detail and cause-analysis based evaluation was missing. Another research addressed the gap in the above findings by estimating the cost effectiveness of implementing EHR. High start-up cost, lack of capital, concerns related to the real benefit of the system and loss of productivity during implementation acted as the barrier to EHR adoption (Fleming, Culler, McCorkle, Becker, & Ballard, 2011). Hence, inadequate funding and lack of support for change in the hospital are some management challenges that impede the process of adopting EHR in health care setting.

The study by (Ajami & Arab-Chadegani, 2013)revealed that HIS systems like EHRs is not yet prevalently used by physicians because of perceptions related to major investments, lack of standardized applications, complexity of the system compared to paper records, disruptions in work flow and lack of any benefits for care providers. Another evidences reported lack of technical support and lack of skills to efficiently use the system as a management issue affecting implementation and adaptation of the technology. This is supported by another study which revealed system compatibility as one of the management issue affecting HIS implementation. Inter-operatability among different EHR system was highly desired to promote efficient health information exchange. Addressing technological barrier is considered important because it indirectly leads to loss of productivity because of longer time spent in EHR usage. Frustration has been highly reported by care providers and this is understood from statements like ‘hard to read and confusing’. Complex EHR interface increased the problem for providers and resulted in poor portal utilization (Hamamura, Withy, & Hughes, 2701). Hence, hardware and software concerns are some issues that hinder application of EHR.

Barriers to the adoption of technology in modern health care have been explored in research literature. Another study gave the insight that HIS technology like EMR id being adopted at a rapid rate. However, the main issue is that many physicians and clinicians have still not shifted from paper records. This has occurred because of economic barriers like time and cost burden. Many physicians and health care providers avoid using the EMR system because they cannot afford extra time on training (Christodoulakis, Asgarian, & Easterbrook, 2016). Furthermore, for small and medium sized health care organization, maintaining additional cost associated with the implementation of EMR, maintaining IT system and upgrading the system is difficult. Other forms of barrier reported in research studies included poor design and lack of customizability. Complex interfaces create challenges for physicians during recording information. Patient privacy issues and lack of reliability of the system has also been found as a barrier has been cited as reasons for health care staffs to distrust and avoid the technology (Kaipio, Reponen, Kushniruk, Borycki, & Vänskä, 2017). Therefore, in view of these barriers, there is a need to consider the new challenges occurring due to adoption of HIS technology and identify possible solutions to minimize management challenges for concerned staffs.

In response to the issues faced in implementing and adapting EHR, researchers have also focused on identifying possible solution to address those challenges. Human barriers related to poor perception about the use of HIS tools and lack of knowledge regarding its use hamper the utility of tools like EHR, CDS and PAS. The solution suggested by a study was to include importance of HIS and its application in medical education curriculum. This can raise some understanding regarding the benefits of HIS before entering medical practice (Khalifa, arriers to health information systems and electronic medical records implementation. A field study of Saudi Arabian hospitals., 2013). In addition, proper implementation of training program is crucial as many health care staffs lack he technical knowledge to successfully implement HIS. For health care managers, establishing good training strategies and engaging in technical follow-up is crucial to minimize resistance to use of HIS (Oliveira, Arroyo, Oliveira, & Ferreira, 2011). A literature review also gave an insight into the failure of many HIS because of inadequate training and the impact of training on changing attitude of users. Training was found to facilitate end user satisfaction which is successful indicator of successful information system implementation. Hence, the research evidence proves that training can inculcate positive attitude towards HIS and promote adoption of the system for health quality improvement.

To increase the uptake of HIS in health care system, addressing technical barrier to the usage of technology is important. The importance of the study by (Hasanain & Cooper, 2014) is that it looked to address the barriers as well as suggest possible solutions to address the barrier. One approach suggested by the researcher to address barriers related to the complexity of EHR software barriers include encouraging IT staffs to test the software performance and quality prior to the implementation process. Another possible solution was to take feedback from users regarding the ability of the software to meet their practice needs. As disruptions in care are reported because of sudden system breakdown during critical period, it was suggested to implement safeguarding process that could address such issues. For example, health care managers can arrange for a backup system where all the information are stored in the system. Presence of a strong and committed leadership is essential during the implementation process in order to effectively implement the system and create a welcoming environment for change. Hence, poor experience related to the use of HIS can be addressed if the above mentioned solutions are implemented. The evidence can be utilized to individually address barriers according to priority basis and needs of the organization.

As financial burden of implementing HIS is huge, the cost-effectiveness of the system can be improved by ensuring the sustainability of the process and reducing interoperability among systems. Standardized information channels and interoperability among the system is crucial for health data sharing. Taking the best approach to improve economic indicators is also essential to justify IT investment. The systematic review process gives the insight regarding economic analysis of the HIS tools to reduce cost of implementation and limit the barriers faced during the transition from paper-based to electronic systems (Becerra-Posada, Novillo-Ortiz, & Ribeiro, 2017). The clinical impact of semantic and synthetic interoperability needs to be determined in future research. Semantic interoperability is required to guarantee consistency of patient information.

Mixed methodology was chosen for this study to gain an in-depth knowledge about the issue and to find out the ways to solve those. Two hospitals were chosen as it was assumed that different systems would be used in two different hospitals and the knowledge of people would vary regarding the systems. This would be helpful to investigate about the awareness of the hospital staff regarding the health information system (HIS) as well as the existing and potential management issues. The issues were picked up from the literature review. From the paper of (Murthy, Srivastava, & Cheema, 2014), 7 management issues were chosen among many other issues, based on the diversity of the problems. For example, lack of infrastructure in electronic delivery system, dearth of master database, lack of training and educated staff, lack of awareness etc. belong to different categories of problems, such as, technical, human resource development, and management. However, if the management cannot solve the technical or human resource problems, then these create issues in efficient working of the information system. From all the factors mentioned in the paper, the researcher selected the above mentioned factors, which are most relevant for the hospitals, and also easy to understand for the survey participants, holding different designations. It is found from the responses that, in MIHP, majority of the participants voted for lack of master database as one of the major issues affecting the HIS. Although the problem is technical, but the management of the hospital was not able to solve this problem and arrange facilities to introduce a master database for effective functioning of HIS. The other major factors highlighted in this hospital are the inadequate infrastructure in electronic delivery, lack of educated and trained staff and lack of awareness about the system and its functioning. Primary data was collected using two types of method, survey and interview, as that was beneficial in understanding the topic in an in-depth manner. From the primary data analysis, it is found that the hospitals use more than one HIS and after implementation, the database management has improved significantly. However, there are some important issues in the management that affect the effectiveness of the systems. The results of regression analysis showed that, on one hand, the system quality has significant impact on the efficiency of the information systems; on the other hand, the management issues have a combined impact on the information quality of the system. The system quality represents technical aspects of the system, such as, simplicity, user friendliness, easy navigation etc. while information quality refers to the precise information of the patients along with the medical history. Thus, if system quality is improved, it will increase the efficiency of the system. Again, the management issues, such as, lack of improved infrastructural facilities, lack of training and educated employees, lack of awareness among the employees, shortage of data entry operators, etc. have a considerable impact on the information quality of the system. According to the participants in the survey, there might be data security issues in the system, but that needs to be addressed by the management of the hospitals. The interpretation of the interview responses yielded almost similar result. The technicians were associated with the hospitals for more than 1 year and hence, had a better knowledge about the systems than many other staff. The analysis showed that implementation of the information system has contributed in improving patient care. As the level and amount of the information has increased, the accuracy of the data has improved too. This has helped in reducing vital errors, such as, medication errors, wrong treatment etc. on the other hand, over time many crucial issues have emerged such as lack of educated or trained staff to handle the information system efficiently and flawlessly. Thus, the hospitals need more trained staff, who have knowledge on these information system; and the hospitals should also have the capacity to train the employees adequately so that there is no shortage of resources during any emergency situation. Moreover, the management should also take measures to address the issues of other departments, such as, technical, so that those specific problems could be solved and more efficiency is achieved. Thus, the hospitals need to focus on addressing these issues for achieving the desired efficiency of HIS.

Conclusion and recommendation:

The main aim of the dissertation was to identify the management issues faced during the implementation of HIS and find possible solutions to reduce the barriers faced in HIS adoption in health care setting. The main rational for focus on the topic of improving management plan for HIS was the reduced uptake of HIS tools among all health care staffs and poor perceptions regarding the utility of HIS tool in health care. To achieve the objectives of research, primary and secondary research method was chosen to gain answer to the research question. The primary data was collected from four technicians working in two reputed hospitals or health care organizations from different level. The interview response was necessary to collect data related to management issues encountered during HIS adoption. In addition, survey with fifty health care workers was done to evaluation perception of staffs regarding the use of different HIS tools in health care setting. In addition, secondary method was also adopted for data collection to support the findings obtained from primary data collection process. The main advantage of using so many types of data collection process is that it enabled getting broad range of data related to management issues faced in implementing HIS. This section provides a discussion on the finding obtained and implication of the work for clinical setting.

The analysis of primary research data revealed that more than one HIS system are implemented in two chosen health care setting and the workers delivering care using the HIS systems are challenges by different types of barriers while implementing and adapting the health information technology. Some common HIS technology that were found to be used in the setting included EHR, EMR, CDSS, PAS, CPOE and CIS. Among them EMR or EHR was found to be most frequently used in research. The evaluation of survey and interview response also indicated about positive perceptions related to the application of HIS in health care setting as majority of respondents reported of getting benefits from the technology. Another significant aspect of the survey response was that it used six efficiency related factors to interpret the effectiveness of HIS in the two hospitals. The use of ranking to determine the benefits of HIS in terms of six parameters such as system quality, user level, user satisfaction, information quality, organizational impact and individual impact was useful in analysing knowledge and perception related to HIS. Information and system quality received more ranking in MIHP and NMGH and individual and organization factors received the least response. Hence, it can be said that HIS tools are effective resource to revitalize the health care system and promote effective use of HIS for efficient information exchange and quality improvement. CPOE and CDSS have the potential to support quality improvement in diverse patient setting.

Apart from evaluation of HIS system use in health care setting, the most important aim of the research was to identify the management issues that occur during the implementation of HIS and recommend strategies to improve the implementation process. The survey with health care workers in the two hospitals revealed different perspective regarding the impact of management issues on the efficiency of HIS. For example, 64% staffs in MIHP believed that management issues such as lack of training, lack of accountability, infrastructural issues and lack of master database affect efficiency of HIS. However, the same response was not achieved for NMGH staffs. Hence, it might be possible that the perception might differ because of variations in experience and organizational facilities of the two hospitals. Despite this variation, both the survey response and interview response revealed lack of facilities for proper training, infrastructural issues and technical issues as some major management challenges. These findings are consistent with the results obtained from secondary analysis of research data too. Two research evidence also reported about technical barriers, organizational barriers and lack of preparedness as the common management issues for hospitals implementing HIS. Hence, the response obtained from survey and interview response is regarded as credible as it is consistent with secondary analysis results too. The study findings can develop understanding regarding the management challenges that can be encountered during HIS implementation and health care managers can take the approach to learn from the challenges and prepare beforehand to make HIS implementation effective.

The analysis of the interview response of four technicians working in MIHP and NMGH established correlation between many management issues and the experience of staffs helped to collect possible solutions to address the problem too. The interview questionnaire started with questions on experience and benefits obtained and then proceeded to questions on management issues experiences and possible solution to address the issue. Some of the management issues identified included lack of appropriate support from vendors, user interface related issues and concerns, inappropriate training, financial constraints, poor acceptance of the technology, poor prior experience in using the HIS tools. These findings are consistent with the secondary analysis of research findings. For health care managers, recognizing user friendly technology and dealing with technical issues faced by health care workers in using EHR and CDSS is a challenging task. In response to the challenges identified, the study gives the implication to pay extra importance to the adaption of user friendly design and reducing complexity in HIS tools so that health care professionals embrace it wholeheartedly and effectively use it for health benefits and positive patient experience.

Based on the management issues identified and its impact on the efficiency of HIS tool, it is recommended that health care managers develop priorities to improve usability of the electronic health record. Collaboration between vendors regarding this priority is important so that usability elements are easily prepared. While planning EHR design, the IT leaders should focus on adding elements that promotes communication and engagement between patients and physicians. The EHR design and configuration should be such that facilitate physicians to effectively delegate work to other members of the care team. Reducing complexity in the HIS system is also necessary to reduce cognitive workload of staffs and provide concise and real time data related to information flow and user preferences. Hence, working with vendors and other stakeholders regarding the above mentioned priorities can facilitate feedback and improve the design of the product. This strategy would foster the development of user friendly HIS system and collaborating with other experts to increase the usability of health IT.

The study used mixed method study to identify management issues influencing EHR system and recommend solutions to address challenges experienced in using EHR technology. The research in this area is significant because of the increase in workload and patient flow in hospital setting and the need to integrate technology to provide high quality care. The focus on improving the efficiency of HIS is essential because of its ability to capture huge data, store information and maintain the continuum of care. The rationale for the research on the topic is also understood from the fact that HIS implementation process has not achieved that level of success because of improper training, poor infrastructure and lack of skills and competency required for best application of HIS tools. Hence, the main purpose of mixed method study was to develop thorough understanding regarding the management issue faced in implementing HIS and come up with key solutions to improve HIS implementation process at the management level. The strength of the study is the use of both primary and secondary data collection method for getting answer to the research question. The survey method helped to collect objective data related to the research question, whereas the interview method helped to identify subjective data related to use and adoption of HIS tools in health care setting. The survey questionnaire included both demographic elements and descriptive elements. This helped to gain in-depth idea regarding management issues and recommendations to complete HIS tools.

The secondary analysis of research evidence also enhanced the validity of the research data as it helped to find consistency in the result obtained from survey and interview method. It enhanced the reliability of work and highlighted about the common trend that is experience while adopting or applying HIS in the care delivery process. One limitation found in the research methodology is that all survey and interview questionnaires were self-developed and it did not used any validated tool to estimate the efficiency of HIS. However, the survey questionnaire used vital parameters to define factors influencing efficiency and the factors leading to management challenges. These were extracted based on common challenges faced in using EHR or CPOE in medical setting. The findings give the implication to consider technical issues and engage in proper collaboration with vendors to prioritise usability issues during adoption of HIS. Due to limited time, the effectiveness of various solutions proposed by the technicians could not be explored. Hence, future research can pay attention to identify important strategies to overcome challenges and conduct research to find out the effectiveness of each strategies implemented.

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