Introduction:
Hospital Information Systems (HIS) refers to a system that processes the healthcare data, provides information to the stakeholders and contributes knowledge in the healthcare environments. The information system not only assists the healthcare professionals and providers in quality decision making at the point of care but also helps them in understanding their work performance. These tasks require the integration of Electronic Medical Records (EMR) with HIS, as it creates foundational support in capturing patients' complete clinical data and provides real-time access to the healthcare professionals (1).
The timely accessible and available information about patient care and the hospital is vital and considered to be a valuable key in improving the healthcare services and formulating the healthcare policy to extend the healthcare services to the community. HIS integrated EMR enhances the quality of care, reduces the clinical errors, shrinks costs, increases legibility and many more (2).
It is necessary that the HIS integrated EMR system should be connected to the right patient at the right time on a real-time basis, as the data captured will alert the healthcare professionals in case of any health risk to the patient. The strategic planning, successful implementation and effective and efficient utilization of the system would also require a critical task of creating awareness about the system among the healthcare professionals, providers, patient and their family to achieve community health management goals (3).
HIS integrated EMR consists of different modules integrated to each other in such a way that it can collect administrative, clinical and financial data together from different sources and at the same time, it can be viewed and manipulated for providing care to the patient and perform day to day operation of the hospital. The healthcare organization should be careful in selecting a HIS integrated EMR. They should always take the end users and their requirement into consideration to identify the actual need of the system (4).
Since last two decades, healthcare organizations have felt the need of HIS integrated EMR and started contributing their time and money for its design, development, and implementation. As the investment is high, they also adopted the evaluation methods to understand the outcome of their investment. The methods mainly evaluate the results against the expected outcomes or compare the results before and after implementation of the system (5). According to DeLone and McLean, the most commonly used measure of information system evaluation is end-user satisfaction. According to them, end-user satisfaction is an important aspect in understanding the usability of the system. Once the system implemented, the end-users usability can be assessed to understand their level and degree of satisfaction towards the system. This result of the assessment can be used to address the issues related to the usability of the system. This strategy will not only enhance their acceptability but also improve the sustainability of the system in the hospital (6-8)
This study is intended to understand the attitude, challenges, limitations, and satisfaction of end user towards HIS integrated EMR to help the hospital to understand the usability of the system and to enhance the feature of HIS integrated EMR for better acceptance and sustainability.
Methods:
A descriptive cross-sectional study was carried out in a super specialty hospital in Southern India. A total of 412 hospital staff including 278 Nurses, 84 Paramedical, 25 Front Office, 19 Billing and 6 Medical Records Department Staff were included in the study. The study was carried out in three phases. The first phase observational of the HIS integrated EMR of the hospital. During the second phase, a structured and validated questionnaire was used to assess the attitude and satisfaction level of the end-user towards HIS integrated EMR. The questionnaire consisted of 3 sections, namely, demographic characteristics of the respondent, attitude towards HIS integrated EMR (Strongly Agree to Strongly Disagree on a scale from 5-1) and satisfaction level of present HIS integrated EMR (Extremely Satisfied to Not at All Satisfied on a scale from 5-1). The questions of the second and third section categorized into six domains - User Interface, Hardware and Software, Connectivity, Process, Data Security and Data. In the third phase, a survey was conducted among the 412 staffs who had reported their attitude and satisfaction level in the second phase. A structured and validated checklist was used to ask the respondents about the challenges and limitations associated with the present system. The checklist included the parameter to assess both technical and human challenges faced by the staff and also the limitations of present HIS integrated EMR. The data collected during the second and third phases were analyzed using SPSS 20.0 and presented as frequency, percentage, mean score, and standard deviation. ANOVA test was conducted to analyze the group differences in attitude and satisfaction level.
Results:
The results of the assessment of the usability of HIS integrated EMR conducted among 412 end users in three phases are discussed hereunder:
Response Rate
Out of 412 respondents, 340(82.50%) were female and 72(17.50%) male. The result related to the duration of working with system indicated that 103(25%) respondents had less than 12 months of experience with HIS, 174(42.23%) with 12-24 months, 80(19.24%) with 25-36 months, 29(7.04%) with 37-48 months and 26(6.31%) had 49-60 months of experience with HIS. (Table 1)
| Table 1: Characteristics of respondents (N=412) |
Gender-wise distribution |
Frequency |
Percentage |
Female |
340 |
82.50% |
Male |
72 |
17.50% |
Distribution based on job category |
Nurses |
278 |
67.47% |
Billing staff |
19 |
4.61% |
Front office staff |
25 |
6.07% |
Paramedical staff |
84 |
20.39% |
MRD staff |
6 |
1.46% |
Distribution based on months of experience using HIS (interval in months) |
Less than 12 months |
103 |
25% |
12-24 months |
174 |
42.23% |
25-36 months |
80 |
19.42% |
37-48 months |
29 |
7.04% |
49-60 months |
26 |
6.31% |
| Note: N- Total number of staff according to the groups |
Assessment of end user attitude
The end-users were asked to respond to 20 questions related to their attitude based on a five-point Likert scale from Strongly Agree to Strongly Disagree on a scale from 5-1 under the following six headings:
a) User Interface
- Information presented on the screen is concise
- The arrangement of different pages in the HIS is understandable
- Use of multiple colors cause strain while working
- Frequent notifications on the screen cause distraction while working
b) Hardware & Software
- I am comfortable in using mouse and keyboard in daily work
- Momentary stoppage of work due to power failure or connectivity problems
c) Process
- Paper-based health information helps in better decision making
- Making daily reports using the system is easier than using manual records
- Learning various aspects of using a computer was comfortable
- Manual documentation of patient data is easier than the present system
- Correcting errors on the HIS is easier than in paper-based medical records
d) Connectivity
- Sharing of multiple files with multiple people
- Working with multiple people by sharing the same set of information is easier
e) Data Security
- I am confident about the security of data entered into the system
- I am comfortable with retrieving the data stored for years than a paper-based record
- I am confident about maintaining patient privacy for the information
- I am aware of data security and privacy rules of the hospital
f) Data
- I prefer paper-based record over HIS integrated EMR in collecting patient data
- HIS provides instant access to clinical data
- I prefer HIS over paper-based record while accessing patient information
| Table 2: Frequency, mean and standard deviation of the overall attitude of the staff (N=412) |
Group |
Frequency |
Mean |
SD |
Nursing Staff |
278 |
73.41 |
6.92 |
Billing Staff |
19 |
71.84 |
3.76 |
Front office staff |
25 |
69.48 |
5.28 |
Paramedical Staff |
84 |
74.33 |
6.85 |
MRD Staff |
6 |
66.16 |
6.17 |
| Note: N- Total number of staff according to the groups |
The respondent group-wise overall attitude towards the HIS integrated EMR as frequency, mean and standard deviation is shown in Table 2. When the 2SD value is less than the mean value then, ANOVA test can be done to identify whether the groups differ in any variable. From this table, it is clear that the 2SD value is less than the mean value of all the group. ANOVA test was done to identify the significant difference between the groups. The Sig. (p) value of the ANOVA test was 0.002, and it is less than an alpha of 0.05 (p < .05). This is evident of a significant difference in the attitude of staff towards HIS integrated EMR. Tukey HSD was used to find which groups differ significantly in their attitude. The Post Hoc test showed that the p-value of the overall attitude of the billing staff, paramedical staff and MRD staff when compared with nurses, was greater than alpha (0.05). The result illustrated that there was a significant difference between these groups in their attitude towards HIS integrated EMR.
The front office staff (p=0.041) showed the difference in their attitude towards HIS when compared with nurses. The comparison between front office staff and the remaining groups of staff showed that only front office and paramedical staff (p=0.014) differ in their attitude towards HIS integrated EMR. Comparison of the attitude of paramedical staff against MRD staff (p=0.034) showed that the groups differ significantly in their attitude towards HIS integrated EMR. The attitude of remaining groups towards HIS integrated EMR was similar. (Table 3)
| Table 3: Post Hoc Test (N=412) |
Overall Attitude |
(I) Group |
(J) Group |
Mean Difference |
Sig. |
95% Confidence Interval |
Lower Bound |
Upper Bound |
Nursing staff [N=278] |
Billing staff |
1.56 |
0.861 |
-2.78 |
5.923o |
Front office staff |
3.93 |
0.041 |
0.09 |
7.76 |
Paramedical staff |
-0.92 |
0.803 |
-3.2 |
1.36 |
MRD staff |
7.24 |
0.069 |
-0.33 |
14.82 |
Billing staff [N=19] |
Nursing staff |
-1.56 |
0.861 |
-5.92 |
2.78 |
Front office staff |
2.36 |
0.775 |
-3.227 |
7.9519 |
Paramedical staff |
-2.49 |
0.587 |
-7.15 |
2.17 |
MRD staff |
5.67 |
0.37 |
-2.92 |
14.27 |
Front office staff [N=25] |
Nursing staff |
-3.93 |
0.041 |
-7.7649 |
-0.0953 |
Billing staff |
-2.36 |
0.775 |
-7.9519 |
3.2277 |
Paramedical staff |
-4.85 |
0.014 |
-9.0376 |
-0.6691 |
MRD staff |
3.31 |
0.813 |
-5.036 |
11.6626 |
Paramedical staff [N=84] |
Nursing staff |
0.92 |
0.803 |
-1.3634 |
3.2099 |
Billing staff |
2.49 |
0.587 |
-2.1745 |
7.1569 |
Front office staff |
4.85 |
0.014 |
0.6691 |
9.0376 |
MRD staff |
8.16 |
0.034 |
0.4056 |
15.9277 |
MRD staff [N=6] |
Nursing staff |
-7.24 |
0.069 |
-14.8218 |
0.335 |
Billing staff |
-5.67 |
0.37 |
-14.2761 |
2.9252 |
Front office staff |
-3.31 |
0.813 |
-11.6626 |
5.036 |
Paramedical staff |
-8.16 |
0.034 |
-15.9277 |
-0.4056 |
| Note: N- Total number of staff according to the groups |
Assessment of end-user satisfaction level
The end-users' satisfaction was measured using 21 questions based on a five-point Likert scale from Extremely satisfied to Not at all satisfied on a scale from 5-1 under the following six heading:
a) User Interface
- Clear and concise interface
- Easily usable and navigable interface
- Interoperability
- Screen layout
- Screen color
b) Hardware & Software
- Data Storage
- Data Retrieval (obtaining data when required)
- Technical support and training from the IT department
- The frequency of System failure
c) Process
- Notification system to avoid mistakes
- Enhanced Patient Safety by on time availability of the information
- The speed of retrieving data
- Reduction in per patient documentation time
- Support in better decision making during patient care
- Simple functions to correct errors
- Ability to generate daily reports
- Ease in learning the system
d) Connectivity
- Efficient communication to share relevant information to relevant people
e) Data Security
- Reliability of the system
- Access control
- Preventive measures to block the misuse of information
f) Data
- Accuracy in maintaining patient data
g) Overall satisfaction
The result of the assessment indicated that the 173(62.23%) nurses, 17(89.47%) billing staff, 14(56%) front office staff, 46(54.76%) paramedical staff and 3(50%) MRD staff were moderately satisfied with the present HIS and it comes up to 61.40% of the total staff included for the study. (Table 4)
| Table 4: Frequency and percentage of overall satisfaction of the staff (N=412)Post Hoc Test (N=412) |
Group |
ES |
VS |
MS |
SS |
NS |
f |
% |
f |
% |
f |
% |
f |
% |
f |
% |
Nursing staff [N=278] |
2 |
0.72 |
93 |
33.45 |
173 |
62.23 |
10 |
3.59 |
0 |
0 |
Billing staff [N=19] |
0 |
0 |
2 |
10.53 |
17 |
89.47 |
0 |
0 |
0 |
0 |
Front office staff [N=25] |
0 |
0 |
7 |
28 |
14 |
56 |
4 |
16 |
0 |
0 |
Paramedical staff [N=84] |
1 |
1.19 |
33 |
39.29 |
46 |
54.76 |
3 |
3.57 |
1 |
1.19 |
MRD staff [N=6] |
0 |
0 |
0 |
0 |
3 |
50 |
2 |
33.33 |
1 |
16.67 |
| Note: ES- Extremely Satisfied, VS- Very Satisfied, MS- Moderately Satisfied, SS- Slightly Satisfied, NS- Not at all Satisfied, f- Frequency, N- Total number of staff according to the groups |
About 93 nurses (33.45%), 7(28%) front office staff and 33(39.29%) paramedical staff reported that they were very satisfied with the HIS integrated EMR. Only one each of paramedical and MRD staff reported that they were not at all satisfied with the system. As they were new to the system, they were finding it difficult to utilize the system in their practice. They wanted little more time to learn and adopt the system in their practice. (Table 5)
Table.5 depicts the mean of overall satisfaction of the end-users which is greater than the double value of the standard deviation (2SD). The Sig. (p) value of ANOVA test was 0.000 which is less than alpha (.05), and it showed that there is a significant difference in the overall satisfaction of present HIS among the staff.
| Table 5: Frequency, mean, standard deviation and Sig. value of overall satisfaction of staff (N=412) |
Group |
Frequency |
Mean |
SD |
Sig. |
Nursing staff |
278 |
74.1187 |
9.66797 |
.000 |
Billing staff |
19 |
70.6316 |
7.53666 |
Front office staff |
25 |
67.84 |
10.40304 |
Paramedical staff |
84 |
74.5833 |
9.67323 |
MRD staff |
6 |
57.8333 |
19.11457 |
| Note: N- Total number of staff according to the groups, f=frequency |
The comparison of overall satisfaction of the staff towards present HIS is evident in significant differences in their overall satisfaction level between nursing and front office staff (p=0.019), nursing and MRD staff (p=0.001 and also front office and paramedical staff (p=0.022). (Table 6)
| Table 6: Post Hoc Test (N=412) |
Overall Satisfaction |
(I )Group |
(J) Group |
Mean Difference |
Sig. |
95% Confidence Interval |
Lower Bound |
Upper Bound |
Nursing staff [N=278] |
Billing staff |
3.48713 |
0.563 |
-2.8816 |
9.8558 |
Front office staff |
6.27871* |
0.019 |
0.6708 |
11.8866 |
Paramedical staff |
-0.46463 |
0.996 |
-3.8086 |
2.8794 |
MRD staff |
16.28537* |
0.001 |
5.203 |
27.3678 |
Billing staff [N=19] |
Nursing staff |
-3.48713 |
0.563 |
-9.8558 |
2.8816 |
Front office staff |
2.79158 |
0.883 |
-5.3827 |
10.9659 |
Paramedical staff |
-3.95175 |
0.507 |
-10.7747 |
2.8712 |
MRD staff |
12.79825* |
0.044 |
0.2209 |
25.3756 |
Front Office Staff [N=25] |
Nursing staff |
-6.27871* |
0.019 |
-11.8866 |
-0.6708 |
Billing staff |
-2.79158 |
0.883 |
-10.9659 |
5.3827 |
Paramedical staff |
-6.74333* |
0.022 |
-12.8623 |
-0.6244 |
MRD staff |
10.00667 |
0.165 |
-2.2031 |
22.2164 |
Paramedical staff [N=84] |
Nursing staff |
0.46463 |
0.996 |
-2.8794 |
3.8086 |
Billing staff |
3.95175 |
0.507 |
-2.8712 |
10.7747 |
Front office staff |
6.74333* |
0.022 |
0.6244 |
12.8623 |
MRD staff |
16.75000* |
0.001 |
5.4005 |
28.0995 |
MRD staff [N=6] |
Nursing staff |
-16.28537* |
0.001 |
-27.3678 |
-5.203 |
Billing staff |
-12.79825* |
0.044 |
-25.3756 |
-0.2209 |
Front office staff |
-10.00667 |
0.165 |
-22.2164 |
2.2031 |
Paramedical staff |
-16.75000* |
0.001 |
-28.0995 |
-5.4005 |
| Note: N- Total number of staff according to the groups, f=frequency |
Analysis of technical challenges
The acceptability and sustainability of the information system in an organization is only possible when the organization has well-placed strategies to provide technical support and maintenance. The strategy not only resolves the day to day challenges faced by the end-user but also improve the usability of the information system. The end-users were asked to list their day to day technical challenges associated with the HIS Integrated EMR using a checklist. There were multiple options/challenges listed in the checklist, and the end-users were allowed to choose more than one option. More than 70% of the end-users reported slow network as a major technical challenge. About 20% agreed upon some of the common but crucial challenges such as poor system integrity, difficulty in accessing data, unavailability of user guidance, and the complex design of the HIS. Lack of maintenance and technical support was reported by 15% end-users whereas 13.35% of staff mentioned the issue of difficulty in data retrieval. (Table 7)
| Table 7: Frequency and percentage of responses related to the technical challenges (N=412) |
Technical Challenge |
Nursing Staff [N=278] |
Billing Staff [N=19] |
Front Office Staff [N=25] |
Paramedical Staff [N=84] |
MRD Staff [N=6] |
Total [N=412] |
f |
% |
f |
% |
f |
% |
F |
% |
f |
% |
f |
% |
Poor integrity |
19 |
6.83 |
2 |
10.5 |
0 |
0 |
29 |
34.5 |
5 |
83.3 |
55 |
20.5 |
Lack of information security |
22 |
7.91 |
2 |
10.5 |
1 |
4 |
1 |
1.2 |
1 |
16.7 |
27 |
6.6 |
Slow network |
216 |
77.7 |
16 |
84.2 |
17 |
68 |
41 |
48.8 |
3 |
50 |
293 |
71.1 |
Complex design |
35 |
12.6 |
2 |
10.5 |
0 |
0 |
27 |
32.1 |
3 |
50 |
67 |
16.3 |
Difficulty in accessing data |
51 |
18.4 |
1 |
5.3 |
21 |
84 |
5 |
6 |
2 |
33.3 |
80 |
19.4 |
User interface language is difficult |
17 |
6.12 |
1 |
5.3 |
1 |
4 |
13 |
15.5 |
5 |
83.3 |
37 |
8.98 |
Old/ lack of computer terminals |
16 |
5.76 |
6 |
31.6 |
4 |
16 |
13 |
15.5 |
1 |
16.7 |
40 |
9.7 |
No guidelines for using HIS |
66 |
23.7 |
2 |
10.5 |
1 |
4 |
10 |
11.9 |
0 |
0 |
79 |
19.2 |
Difficulty in entering data |
15 |
5.4 |
1 |
5.3 |
15 |
60 |
7 |
8.3 |
1 |
16.7 |
39 |
9.5 |
Difficulty in retrieving data |
47 |
16.9 |
2 |
10.5 |
2 |
8 |
3 |
3.6 |
1 |
16.7 |
55 |
13.4 |
Modules are not fully integrated |
45 |
16.2 |
2 |
10.5 |
1 |
4 |
21 |
25 |
4 |
66.7 |
73 |
17.7 |
System interface is not user friendly |
48 |
17.3 |
1 |
5.3 |
0 |
0 |
24 |
28.6 |
2 |
33.3 |
75 |
18.2 |
Lack of maintenance and technical support |
51 |
18.4 |
2 |
10.5 |
0 |
0 |
8 |
9.5 |
3 |
50 |
64 |
15.5 |
| Note: N- Total number of staff according to the groups, f=frequency |
Analysis of human challenges faced by the end user
The end-users look upon an information system as a modality to ease their day to day work and a medium to interact with the outside world. But to do so, they are required to spend more time with the information system which not only allows them to learn the features but also makes them adopt the system into their practice. In many instances, lack of time in learning the system has led to dissatisfaction among the end-users and sometimes also to complete ignorance of the system.
This study also indicated lack of time given for training as a major challenge, as reported by 160(38.83%) end-users because the organization had kept very less time gap between the implementation and utilization. Those who had early experience with the system found it easy to adopt compared to others. The study result also showed that 20% of the end-users reported lack of experience in using HIS, 14.32% claimed lack of support from the healthcare providers, 13.35% were scared to use HIS, and 8.49% stated lack of motivation from hospital management for learning and training. (Table 8)
| Table 8: Frequency and percentage of human challenges (N=412) |
Human challenges |
Nursing staff [N=278] |
Billing staff [N=19] |
Front Office Staff [N=25] |
Paramedical staff [N=84] |
MRD staff [N=6] |
Total [N=412] |
f |
% |
f |
% |
F |
% |
f |
% |
f |
% |
f |
% |
Lack of experience in using HIS |
65 |
23.4 |
5 |
26.3 |
0 |
0 |
8 |
9.5 |
4 |
66.7 |
82 |
19.9 |
Lack of time allowed for training and learning HIS |
101 |
36. 3 |
8 |
42.1 |
15 |
60 |
35 |
41.7 |
1 |
16.7 |
160 |
38.8 |
Scared to use HIS |
26 |
9.4 |
1 |
5.3 |
2 |
8 |
21 |
25 |
5 |
83.3 |
55 |
13.4 |
Lack motivation in training and learning |
18 |
6.9 |
5 |
26.3 |
2 |
8 |
10 |
11.9 |
0 |
0 |
35 |
8.5 |
Lack of health care professionals’ support |
36 |
13 |
6 |
31.6 |
3 |
12 |
12 |
14.3 |
2 |
33.3 |
59 |
14.3 |
| Note: N- number of staff according to the groups, f=frequency |
Analysis of limitations of the present HIS integrated EMR
Any information system works with an aim to make the information available to the end-user in a complete, accurate, adequate and timely manner. These features contribute immensely in usability and acceptance of the system. This study reported information availability as one of the major limitations with the present HIS Integrated EMR, as reported by 137(33.25%) end-users. About 111(26.94%) end-users reported the issues related to daily report preparation and efficiency of the HIS and 13.35% of the total staff reported the limitations related to information security and confidentiality. (Table 9)
| Table 9: Frequency and percentage of limitations faced by the staff (N=412) |
| Limitation |
Nursing staff [N=278] |
Billing staff [N=19] |
Front Office Staff [N=25] |
Paramedical staff [N=84] |
MRD staff [N=6] |
f |
% |
f |
% |
f |
% |
f |
% |
f |
% |
Information security and confidentiality |
35 |
12.6 |
5 |
26.3 |
1 |
4 |
10 |
11.9 |
4 |
66.7 |
Hardware |
51 |
18.4 |
3 |
15.8 |
9 |
36 |
7 |
8.3 |
2 |
33.3 |
Software |
78 |
28.1 |
7 |
36.8 |
2 |
8 |
22 |
26.2 |
2 |
33.3 |
Communication System |
57 |
20.5 |
1 |
5.3 |
6 |
24 |
28 |
33.3 |
2 |
33.3 |
Information Availability |
80 |
28.8 |
10 |
52.6 |
13 |
52 |
31 |
36.9 |
3 |
50 |
| Note: N- Total number of staff according to the groups, f=frequency |
Discussion:
Usability assessment is one of the important tasks that an organization can carry out to understand the outcome of the implemented information system and the factors that influence the human-computer interaction. In many instances, implementation of a new information system fails to reach to the expectations of the end-user. At this point, it is not possible and feasible to change the complete system according to the need of the end-user. Usability assessment is the only possible way to know whether the implementation of the information system is a success or failure.
There are many factors that directly and indirectly influence the attitude and the satisfaction level of the end-user of the information system. The study conducted by Triantafyllia Doumpa reported higher satisfaction level among those who had worked with the system for longer compared to other users.6 This study also reflected similar finding, where the end users with more than 12 months of working with the system reported moderate satisfaction whereas age group from 25-36, 37-48 and 49-60 were found to be more satisfied the HIS. The finding is true to the fact that longer the experience of working with the information system better the acceptability and satisfaction.
Information quality is another important factor that influences the satisfaction level of the information system end-users. Information quality consists of data security, information availability, the structure of information and timeliness. This study also reflected similar findings where about 137(33.25%) end-users reported information availability and 55(13.35%) end-users reported data security as the major limitations with the HIS integrated EMR.
The quality of services offered by the IT support team and the vendors for the maintenance of information system play a greater role in enhancing the usability and lead to greater satisfaction among the end-users. These services are not only technical but also more human in nature, where the IT team make the end-users aware of the system and provide hands-on training. The study conducted by Khalifa & Osama and Sima Ajami & Zohreh Mohammadi-Bertiani showed that the quality human resource, good support system, user-friendly system and adequate training of the end-user determine the success of implementation of the HIS (9,10). Similar findings were observed in this study, where 150(36.33%) staff reported lack of training as a major human challenge in working with the system.
The study by Amin et al., showed that the characteristics of the end user, the involvement of the end user during design, development, and implementation and providing them hands-on-training for working with the system are the critical factors in the development of information system. They also expressed that the evaluation of end-user satisfaction is one of the criteria to increase the quality of information system (11).
Ajami S and Bertiani ZM reported that the training the end-user to work with the system is an important criterion for the successful implementation. Without proper training, the system will work, but the purpose of using the system will not fulfil. The result of this study suggested that the end-user participation and training should be considered as a possible method to improve the level of their satisfaction (10)
The information systems are meant to provide complete, accurate and adequate data in an instant and real-time manner to the end-users. The system should be simple to operate, easy to understand, and most importantly, it should be user-friendly. The screen design and color is not a serious concern for the information system users. The study conducted by Khalifa and Osama reported that the reason for the dissatisfaction was the difficulty in instantly accessing patient data due to the slow network and poor integrity of the system (9). This study also revealed similar finding, where 80(19.41%) end-users had difficulty in accessing patient data and they did not have the HIS user guidance. A similar number of the end-users reported that the system is not user-friendly and the design is complex and difficult to understand.
Based on the findings, the study suggests the following recommendations to overcome technical and human challenges:
Technical challenges
- Slow network issue could be eliminated by employing a higher bandwidth connection, quality-of-service software and hardware, which have fewer maintenance problems.
- Updating the operating system and upgrading communication system to enhance the performance of HIS integrated EMR
- Modification tool from the vendor will help the IT department to customize the HIS for better use.
- Inconsistency among the workflows of different departments and training issues should be eliminated to overcome the challenge of poor integrity
- To overcome data entry issues, voice recognition system, touch screen, and mobile application should be integrated with the HIS integrated EMR.
- The user interface should be simple and user-friendly. Either the hospital can design the HIS as per the end-user need or can select the best of breed from the vendor.
- The IT service provider must ensure that the end-users are supplied with adequate user manual and guidelines for using HIS integrated EMR and to solve minor technical issues.
- The system should meet the data standards to increase the accuracy, quality, and reliability of the system
- The hospital IT team should ensure the maintenance and technical support to eliminate the technical issues
Human Challenges
- Provide awareness regarding importance and benefits of using HIS to initiate a positive approach.
- Provide more hands-on training to those who are scared to use HIS that will result in reducing the number of errors in documentation
- Conduct regular feedback on HIS, as it will help the IT support team and the hospital administrator to understand the drawbacks of the HIS and will help to improve.
- To increase the level of acceptance by the healthcare professionals, they have to be involved in the stages of systems development and implementation.
- Provide direct and indirect incentives, as it will motivate the staff to learn and use HIS.
- Conduct training in a homogeneous group, and it should not be kept between the busy schedules of work.
- Recruit more health informatics specialists, as they will be a great support for the hospital in developing a user-friendly and usable HIS.
- Conduct induction and regular refresher training of HIS integrated EMR to avoid any kind of dissatisfaction and ignorance.
Conclusion:
Usability assessments are mainly carried out to highlight the factors that influence the end-users in using the information system. The assessment result also allows the IT support team to understand the level of satisfaction of end-users with the system. This study demonstrated the influence of the attitude, user-background, information quality and service quality on the satisfaction level of the end-user towards the HIS integrated EMR. The study also highlighted the challenge and the limitations of the HIS such as slow network, difficulty in accessing data, lack of maintenance and technical support, difficulty in retrieving data, lack ofintegration and non-friendly user interface. These challenges and limitations make the system a burden to the hospital and add a more repetitive task for the end-user. The healthcare organization can easily overcome these challenges and limitations, if the hospital administration involves the end-user before, during and after the implementation of the system, provide well-planned hands-on training and create a channel for the end-user to express the issues in utilizing the information system. These approaches will not only build confidence among the end-user but also create ownership about the system and will ultimately improve the acceptability and sustainability of the system.
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