Far East Journal of Psychology and Business

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HOSPITAL INFORMATION SYSTEM (HIS) IMPLEMENTATION IN A PUBLIC HOSPITAL: A CASE STUDY FROM MALAYSIA
Noor Fadzlina Mohd Fadhil Lecturer, Faculty of Business Management and Accountancy Universiti Sultan Zainal Abidin, Malaysia Email: noorfadzlina@unisza.edu.my Mariana Jusop Lecturer, Faculty of Business Management and Accountancy, Universiti Sultan Zainal Abidin, Malaysia Email: marianajusop@unisza.edu.my Dr. Abdul Aziz Abdullah Lecturer, Faculty of Business Management and Accountancy, Universiti Sultan Zainal Abidin, Malaysia Email: abdulaziz@unisza.edu.my ABSTRACT In this competitive global information system (IS) environment, an integrative system is crucial for the highly demanding of information needs. This is evident in the fact that the greater majority of hospitals both in Asia Pacific and Southeast Asian are in the process of implementing or planning to implement the Hospital Information System (HIS). This research aims to investigate users acceptance towards the implementation of HIS in one of the public hospitals in Malaysia. The research main objective is to identify the acceptance and awareness level of the system users in early system implementation. Furthermore, findings from a few past studies have shown that resistance in the early stages of the introduction of a new information system is quite common before users could evident its benefits in terms of minimizing costs and helping them to perform their tasks better. A case study method is used in this study for more thorough information in this stage of the system implementation. This research then is planned to contribute to the identification of major factors which can influence the users acceptance or resistance. Thus, it will be a guidance for the researchers to overcome the gap. Keywords: Implementation, Acceptance, Information System Paper Type: Research Paper INTRODUCTION Healthcare aspect is vital in daily lives (Burke, Ng & Fiksenbaum 2009) where most people nowadays prefer to find a hospital that offers better healthcare services. Peoples demands for good-quality services provided by hospitals drive these organizations to improve their services by adopting information system (IS) (Burke 2009). In the context of hospital environment, the adoption of IS is quite tremendous since many hospitals are able to increase their services to high quality level for competing with other healthcare entities (Puay and Nelson 2000). This can be proven in many developed countries like United States of America (USA) (Smith and Swinehart
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2001; Trimmer, Pumphrey and Wiggins 2002; Ovretveit et al. 2007; Meinert and Peterson 2009; Caccia-Bava, Guimaraes and Guimaraes 2009; Lee and Meuter 2010), United Kingdom (UK) (Procter and Brown 1997), and other countries which have adopted IS in their organizations. In Malaysia not exceptionally, IS adoption has been increasing from year to year. Many healthcare entities are found to improve their hospital services by managing the quality of services delivered (Raduan et al. 2004). Nevertheless, adoption of IS in many local hospitals in Malaysia is still at an early stage. Therefore, this research helps to explain more about IS, consequently, able to give some understanding of its operations as well as its implementation. PROBLEM STATEMENT AND MOTIVATION HIS in Malaysia is still in the first phase of its implementation. According to Ovretveit, et al. (2007) early system implementation phase is very critical. During this phase, there are many changes occurred. Based on Stefanou and Revanaglou (2006) when a new system is introduced such as HIS, there will be changes in the way of the medical staff performing their tasks. Thus, bad management during the changes can cause users resistance towards the new system implemented. Besides, these researchers also found that the level of resistance towards new system implementation was quite high as they were familiar with manual practices. This is agreed by Darr et al. (2003) found that medical staffs, especially doctors negatively acted in response to new technology introduced. While a research done by Trimmer, Pumphrey and Wiggins (2002) supported that the medical staffs tend to resist and look at the new system as a threat that could affect their work and potential. Hence, users should be made aware to the importance of fully utilizing the system. Therefore, it is important to conduct a study at a very early level of system implementation to identify the major factors, which can influence the acceptance or resistance of the users towards HIS. As a result, this research is planned to; first, contribute to the identification of factors and will be a guidance for the researchers to overcome the gap, second, this research will provide input and equip all the necessary steps for the improvement of hospital management and third is to give early information to other hospitals that will implement HIS efficiently in the near future. LITERATURE REVIEW Hospital and IS Hospitals around the world have widely utilized IS for over 30 years. IS for many hospitals in US and UK have been automated since the emergence of IBM systems. For example, US government has made the adoption of the electronic medical records as mandatory to all healthcare providers by 2014 (RAND Health 2005). Besides that, the emergence of the technology evident the adoption of the systems has taken place across hospitals in most countries like USA (Smith and Swineheart 2001; Trimmer et al. 2002; Ovretveit et al. 2007; Meinert and Peterson 2009; Caccia-Bava et al. 2009; Lee and Meuter 2010), England (Procter and Brown 1997), Egypt and Jordan (Zineldin 2006; Hammad et al. 2010), Scotland (Walsh et al. 2010) and New Zealand (Lowe 1999). At the beginning of IS implementation, it focused only on improving efficiencies in accounting function such as billing and financial reporting (Trimmer et al. 2002).

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However, as the need to manage and integrate clinical, financial and operational information grows and evolves, HIS gives many benefits such as it could provide the best possible support of patient care and administration by electronic data processing (Ammenwerth, Kaiser, Wilhelmy and Hofer 2003). Realizing these benefits, MOH pioneered HIS project in hospitals around Malaysia, including Terengganu, Pahang and Sarawak. The adopted HIS is the systems that can help the selected hospitals to become the benchmark of modern, automated hospitals and realize the goals of becoming a model e-hospital in Malaysia. Hospital Information System (HIS) Hospitals are information-intensive organizations and pay a great attention on information management and processing, which have to be carried out using appropriate IS. HIS is a computer-based system designed to assist the management of the administrative and medical information within a hospital (Trimmer et al. 2002). It helps to improve operational efficiency, care quality and more informed decision making. According to N.ghosh (2010), the systems give comfortable access to patient data. The increasing customers expectations and regulatory requirements also lead to the need for clinical information and administrative tools that can be immediately accessible. It has been further stated by Lee and Meuter (2010), that efficiency is achieved through the use of the system that allows users to obtain patient critical information as soon as it is needed. Furthermore, by improving operation efficiency, the application of the systems could also reduce the costs (Spathis and Ananiadis 2005). As supported by Hegji et al. (2007) serving patients with quality of care would be worth for better return in the future. Additionally, by providing accurate and reliable information, the use of the system could enhance decision making (Spathis and Ananiadis 2005). It is also noted in the study conducted by Ashcroft (1998) found that users in healthcare services had clearly perceived the significant impact of the system on their decision making. Despite its widely accepted benefits, HIS adoption is still at a slow pace in certain countries due to lack of computer skills and training (Meinert and Peterson 2009). The inability of individual user to facilitate their knowledge in the systems application has caused significant barriers to wider adoption of HIS. This is argued by Caldeira and Dhillon (2010) by listing 17 facilitating competencies in delivering IS benefits, which is among all are, ability to ensure user application knowledge and provide ongoing IS training. Background of the public hospital For this research, the hospital is known as XYZ hospital. This public hospital is a non-profit government hospital which operates under the control of the Ministry of Health, Malaysia (MOH). It has covered land area of 21.09 hectares. It has 821 beds, 28 wards, 9 specialist clinic, 16 operation theatres, 13 delivery theatres and 1 delivery operational theatre as well as 19 clinical specialist. It has around 2,400 staffs. The hospitals services include prevention, diagnosis, treatment and rehabilitation. It is one of the largest hospitals in the east-coast region. Its mission is to provide a quality and innovative medical services to all, using appropriate technology, according to MOH corporate culture. Therefore, HIS has been introduced here. The trial of the implementation phase of the HIS took 2 years. The system serves for two major part
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of its modules; one for the whole hospitals and another for third party. Some of the modules include Patients Management System Mortuary, Electronic Medical Records (EMR), Medical Records, Pharmacy, Inventory, Orders, Laboratory Information System (LIS), Operation Theatre Management System (OTMS) and some other modules. This information is taken from the hospital documents. Users acceptance towards the system The role of IS has led to many changes, and it creates more opportunities for those who adopt and utilize it. Even though IS seems to provide many benefits, the increase of rate in its adoption is influenced significantly by its users (Stefanou and Revanoglou 2006). Therefore, users acceptance towards the systems is an important aspect. Since IS is usually adopted as a result of environmental changes, economic pressure, competition and organizational change, thus many unable to manage it appropriately in order to get the best output from it. Some rather prefer to stick to manual systems because of several factors such as strong resistance to adapt, effect on job practices, as well as training and skills. According to Aggelidis and Chatzoglou (2008), perceived usefulness and ease of use are two fundamental factors in evaluating technology acceptance by users. Basically, users are more open to a new system when they become familiar with the function and could witness benefits from it (Stefanou and Revanoglou 2006). It is further noted that the system should provide more managerial involvement in the implementation, facilitate research needs, act as a protection against future complaints, and as the measurement of professional hierarchy (Darr et al. 2003). METHODOLOGY Research on IS in hospital has been done in some of these countries like USA (Smith and Swinehart 2001; Trimmer, Pumphrey and Wiggins 2002; Ovretveit et al. 2007; Meinert and Peterson 2009; Caccia-Bava, Guimaraes and Guimaraes 2009; Lee and Meuter 2010), UK (Procter and Brown 1997), Egypt and Jordan (Zineldin 2006; Hammad, Jusoh and Onn 2010), Scotland (Walsh, Burns and Antony 2010) and New Zealand (Lowe 1999). However, in Malaysia researchers have performed very few studies because the implementation of HIS is still at introductory stage (Wan Mahani 2010). A case study method is used, combining the analysis from hospital records, government publications and relevant websites. Semi-structured interviews were conducted with the informants over a two-week period in early 2012. This research used purposeful sampling or theoretical sampling. According to Bailey (2007), under this sampling technique, criterion sampling strategy is appropriate for this qualitative research. Criterion is a strategy of selecting informants who can give rich information based on some interest. The sample targeted for this research is among medical and IS staffs; champion, IS officer, doctors and group of nurses. Data analysis was conducted manually based on several techniques suggested by Bailey (2007) such as visual representative, coding and memoing. This research attempts to use manual type of analysis due to its suitability for first stage of research that does

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not require large volume of information while computerization is suitable for large data analysis and proper for the further stages research. Before the in-depth interviews were conducted, a pilot study was done as a guide for the main interviews. A pilot study was conducted during the first phase of the system implementation. Based on the interview with one of the users revealed even though training for the system and manual was provided, yet some of the senior nurses still preferred to use manual process rather than using the system. This respond was different from the view of one of the administrative officer who believed the system could help to simplify work, save more time, and it is integrated. This argument has led to a study to be carried out to confirm the factors that cause to the discrepancy of the opinions. Therefore, more in-depth interview is relevant as the method of this study. FINDINGS Main system users acceptance The following discussion is related to the research findings. Each subtopic represents the findings gathered from the factors asked during the interview. Previous study showed that level of acceptance of the system was low. However, in XYZ hospital, the acceptance is quite high but there are still a few number of users refused to use the it. Good acceptance level is reflected by positive users feedbacks, which being discussed below. Next, the major factor that causes the resistance is discussed later in other subtopic. System objectives Leaders involvement and support are important to ensure system objectives are clearly delivered. When it came about system objectives, all informants could understand it because the objectives were effectively communicated by the top management, through continuous meeting, training and workshop. Matron said: Yes, we do understand the system objectives. We know it through the documentation, instructions, workshops and from our supervisors. Besides, we were given one to one training to understand more on the system. Moreover, internal and external trainings are provided from the top management of hospitals and also from the vendor itself. This is evident in Bahri (2009) research that found system training is crucially needed especially hands-on training in aspects related to handling the systems function. Professional autonomy Introduction of HIS is found to give different impact to the staffs and patients. For the staff, the system provides the ability to store and produce data needed. Despite the fact that the system is very helpful to them, IS officer claimed there were some users refused to follow the manual provided as he said: The system is good but some of the staff is not quite familiar in using it. They are not following the manual. It thus creates problems and increase patients waiting time.

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On the other hand, the impact for patients is slightly different. This had been explained by the Champion that the system has stored and provided historical data of patients thus less communication is needed with them. That means everything that the medical staffs need to know is in the system. Even though the system is very supportive, the social relationship between healthcare providers and patients has become less important. This shows that in early stage of the system implementation, change process has taken place. Nevertheless, the users were trying to get used to the new system. Previous study by Anderson (1997) found that doctors were not likely to change their traditional practice because of their familiarity in using the manual system. Work and Career The system helps to build and expand the information thus enable knowledge sharing among the staffs. HIS is also very useful in assisting and facilitating research. This statement is supported by IS officer in this hospital. IS officer responds: I always use the system to facilitate my research. I am able to understand the medical terms from the system. Overall, HIS helps the users in their career development. Law Cases HIS also helps the users in accomplishing the law cases through data retrieval. All the data are important for the references in legal cases. However, to ensure the integrity and confidentiality of information, only authorized persons are allowed to access the system. Professional hierarchy Changes occurred when hospital introducing HIS. The person that is most directly affected by these changes according to the sequence are; junior doctors, senior doctors, senior nurses and the managers because they need the accurate and complete data to assess their patients health stages and to ensure the proper treatment for them. Thus, top managements are responsible to showcase the awareness of HIS usage for the main users. To prove that the roles of the users in using HIS, below is the example of specific person in charge for specific information as shown in Table 1 below: TABLE 1: TYPE OF INFORMATION AND PERSON IN CHARGE Person in charge Administration assistant Doctor and nurse Type of information General information on patients background Consultation and medication-detail on patients medical treatment

The distribution of tasks will help different users to get involved with the system. This is found in Malik and Khan (2009) believe that the practical usage and early user involvement are the key factors that make HIS implementation successfully accepted. As a conclusion for this part, the

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overall factors had shown that the users able to accept the system implementation, although some responses had shown resistance towards the implementation. Main system users awareness In terms of awareness, the overall response from the informants proved that they are aware of the benefits of HIS. When they were asked about their experience of using the system, the informants (Champion and IS officer) could share their knowledge about it and understood the benefits of the system. But to be in this position, the users usually have two years experience in their professional field. Hence, it will lead to high acceptance and positive attitude towards the system. Bahri (2009) said that resistance can be countered by earning trust from the users. This can be done by sharing benefits (awareness) of the system through how the system has assisted their work. It is supported by Malik and Khan (2009) that believe users should use the system, later they will experience the benefits from it. As the consequence, the users will be able to accept the system. It can be summarized that the above discussion has shown that informants have the awareness and acceptance on the system usage because of the benefits and experience that can be utilized in their workplace. In addition, the great support and involvement from the top management are vital. Overall system design Although the awareness and acceptance exist, resistance still occurred in the early stage of this system implementation. However, in this study, the level of resistance is not that high as shown in the previous study of other researchers. It is found that the factors that caused this resistance were not from what other researchers had proposed (managerial implication, law cases, professional autonomy, professional hierarchy, work and career). Based on the interview with informants, the weaknesses were caused by the system itself which then affected the users attitude and usage. It is shown in Figure - 1. FIGURE - 1: SYSTEM WEAKNESSES AND IMPACT ON ATTITUDES
System design

System weaknesses Impact on attitude System has problem, hang and jammed. Slow typing because unfamiliar with the new system. Difficult to save data, cannot save with Modules are not followed accordingly. or without click confirmation. Too many applications that are Attitudes confusing.

Apart from its successful implementation, reluctance still exists among users towards the system implementation in this hospital. When being asked, shockingly the informants revealed that the poor user interface was the main cause of resistance. This factor has been highlighted by Davis (1993) that believe the poor user interface design may lead to system implementation failures.

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Moreover, poor user interface contributed to poor users attitudes towards using the system. This is related with some new staffs who were not familiar using the system. Therefore, they did not follow the given modules thus bring problems to the system controller and especially to the patients. It is expressed by IS officer: More work to do and patients waiting time is increasing. The poor interface and less user friendly made the users tend to dislike using the system despite its benefits and importance. Davis (1993) in his research concluded that people accepted the system not only because of its benefits, but they enjoyed the process of using them, which referred to the friendliness of the system interface. This was supported by Champions answers during the interview. Champion said: Sometimes it can be complicated, hopefully can be improved so that it can be more user friendly. It is believed that good system features do not promise tasks could be completed (Davis 1993). The system needs to have good system designs, and the most important part is functioning well for completing the tasks. Thus, vendor commitment is crucial to improve system design for users. The effective support and assistance will enable the users to solve technical problems. It was supported by Bahri (2009) the vendors and IS officer or champion should have direct communication to communicate problems regarding the system. CONCLUSION A good level of acceptance and awareness towards the system do not guarantee success or failure of HIS implementation. As being discussed in this study, the level of acceptance and awareness is high in this XYZ hospital when considering the same factors taken from previous researchers (Darr et al. 2003; Anderson 1997); Spathis and Ananiadis 2005). Although XYZ hospital is successful in implementing the system in the early stage, at the same time, it is very crucial to have a consideration to the resistance that is still occurred during early phase. The factor of system design of user interface should not be overlooked as it is one of the factors that leads to successful of the system implementation. In system design, early user involvement has to be included so that they are not left behind. Let them be involved and this may be a good opportunity for high user acceptance (Malik and Khan 2009). SUGGESTIONS Future research may take these factors and test them in different hospitals that have implemented HIS. The testing will enable researchers to identify the discrepancy results among the hospitals. These would be helpful and provide guidance to the hospital management for implementing a successful HIS. Moreover, next research should concern more on the factor of system design as the finding shows that this factor can affect the acceptance of system implementation. Supported by Malik and Khan (2009) and Davis (1993) this factor can contribute to the successfulness of HIS implementation. REFERENCES Aggelidis, V. P. & Chatzoglou, P. D. (2008), Methods for evaluating hospital information systems: a literature review, EuroMed Journal of Business, 3 (1), 99-118.
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Ammenwerth, E., Kaiser, F., Wilhelmy, I, & Hofer, S. (2003), Evaluation of user acceptance of information systems in health care: the value of questionnaires, Studies in Health Technology and Informatics Europe, 95, 643-648. Anderson, J., G. (1997), Clearing the way for physicians use of clinical information systems, Communications of the ACM, 40 (8), 83-90. Ashcroft, M. (1998), The impact of information use on decision making by physiotherapists, Library Management, 19 (3), 174-195. Bahri, S. (2009), Managing the implementation of an innovative technology in a hospital: a case study, Journal of Systems and Information Technology, 11 (3), 269-285. Bailey, C. A. (2007), A guide to qualitative field research, London: Pine Forge Press. Burke, R. J., Eddy, N. S. W., Fiksenbaum, L. (2009), Virtues, work satisfactions and psychological wellbeing among nurses, International Journal of Workplace Health Management, 2 (3), 203-219. Caccia-Bava, MDC., Guimaraes, VCK, & Guimaraes, T. (2009), Testing some major determinants for hospital innovation success, International Journal of Health Care Quality Assurance, 22 (5), 454-470. Caldeira, M., & Dhillon, G. (2010), Are we really competent? Assessing organizational ability in delivering IT benefits, Business process Management Journal, 16 (1), 5-28. Darr, et al. (2003), Physicians and nurses reactions to electronic medical records, Journal of Health Organization and Management, 17 (5), 349-359. Davis, F., D. (1993), User acceptance of information technology: system characteristics, user perceptions and behavioral impacts, International Journal Machine Studies, (38), 475-487. Hammad, S. A., Jusoh, R., & Oon, E. Y. N. (2010), Management accounting system for hospitals: a research framework, Industrial Management & Data, 110 (5), 762-784. Hegji, C., E. et al. (2007), The link between hospital quality and services profitability, International Journal of Pharmaceutical and Healthcare Marketing, 1 (4), 290-303. Loranger, L., & Fuentes, M. (2005), Widespread Adoption of Health Information Technology could save $162 Billion a year, says RAND Study, But The Federal Government Needs to Help, Retrieved September 12, 2011, from http://www.rand.org/health.html Lowe, A. (2000), The construction of a network at health Waikato: the towards clinic budgeting project, Accounting Auditing and Accountability Journal, 13 (1), 84-144.

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Lee, OF., & Meuter, ML. (2010), The adoption of technology orientation in healthcare delivery: Case study of a large-scale hospital and healthcare systems electronic health record, International Journal of Pharmaceutical and Healthcare Marketing, 4 (4), 355-374. Procter, S. & Brown, AD. (1997), Computer-integrated operations: the introduction of a hospital information support system, International Journal of Operations & Production Management, 17 (8), 746-756.

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