Hospital Information Systems Implementation : An Evaluation of Critical Success Factors in Northeast of Iran

Introduction: Implementation of hospital information systems (HIS) is considered as a difficult and sensitive task in terms of its scope and its mission to collect identity-related, demographic, clinical and managerial data of patients in an integrative manner as well as due to the changes it makes in users’ working practices. The purpose of the present study was to investigate users’ views and attitudes towards the key elements of successful implementation of HIS. Methodology: This applied study was conducted in a descriptive cross-sectional form. To this end, 248 users of HIS at teaching hospitals in the city of Mashhad (Northeast of Iran) were selected through stratified random sampling, and then a questionnaire was distributed to collect the required data. After collecting the questionnaires, data was entered into the SPSS software and the findings were examined by using descriptive statistics (frequency) and then illustrated in tables and diagrams. Results: Functional factors, meeting users’ needs and ease of use had the highest prominence in successful implementation of a HIS. This mean that HIS considering demands of users is the first critical success factors in HIS implementation. Conclusion: The analysis of the research findings demonstrated that three groups including system users, technical operators (professionals) and managers have important role in implementation of HIS. Furthermore, successful implementation of HIS was required to be performed through a formulated program with specified time, costs, and manpower in which the employment and participation of various users of the system had been precisely defined. In this respect, financial supports and presence of hospital management team in meetings and decisions was also of utmost importance.

It should be noted that successful implementation of a system at hospitals requires a series of issues and measures in a formulated and relatively long-term program.Provided that such programs is not implemented through full awareness of the needs of various users as well as wrong principles and methods, there is a high probability of program failure and consequently loss of time and costs (Sheikhtaheri, Kimiafar, & Sarbaz, 2014).In this regard, use of experts (Borycki et al., 2011;Hayajneh et al., 2006), allocation of adequate financial and human resources (Fritz, Tilahun, & Dugas, 2015), clarity of goals (Horowitz & Zhang, 2012), provision of training programs (Igira et al., 2007;McAlearney, Hefner, Sieck, Rizer, & Huerta, 2015;Mobasheri, Mirzaeian, Shervani, Ziaee Nejad, & Habibi, 2014), users' participation in implementation process (Ash & Bates, 2005), upgraded technical knowledge of users (Ash & Bates, 2005), senior management support (Ahmadi et al., 2014), and effective communications between managers and employees (Nguyen, Bellucci, & Nguyen, 2014) are of the main requirements for a successful implementation.
Another important point in HIS implementation is the power and ability of management teams in medical centers to motivate the users to perform their tasks on due time.The management is required to assure timely implementation of such changes in the working system of manpower and agree to take their consequences.Making such changes in the activities of medical teams (especially physicians) is not straightforward and needs establishment of a working culture in the form of a systematic implementation of a development plan.In other words, information systems should be implemented in centers where in medical teams have sufficient knowledge of such systems and consider them important to problem-solving and show their dedication in implementation of the system.Moreover, implementation of an information system in both medical and non-medical centers is accompanied by introducing a new culture.If a computer system is unable to meet users' expectations, users will leave it aside.Given the significance of successful HIS, this study was to examine the critical success factors of HIS implementation in an organized manner through users' views and contribute to promotion and implementation of HIS.

Methodology
This applied study in the form of a descriptive-analytic cross-sectional research was conducted at Imam Reza Hospital and Ghaem Hospital in the city of Mashhad in 2014.The reason behind the selection of these two centers was related to the frequency of the study population in the given centers.Both centers were also as the medical hubs in Northeast of Iran with a full coverage of all specialties.The statistical population of this study included physicians, nurses, and radiology personnel's, laboratory, pharmacy, operation room, information management, and accounting sections.Stratified random sampling method was used to select the study sample and 248 individuals personnel were selected through Cochran's sample size formula.A researcher-designed questionnaire comprised of two parts was also employed as the data collection instrument in this study.The first part of the questionnaire was associated with users' demographic information, and the second part included five categories of project management factors (including use of experts in project implementation process, adequate budget and resource allocation, transparency in implementation steps, positive thinking of project operators, clarity of project goals, assessment of project costs, development of vision document, and continuing control of project implementation); human factors (including users' involvement in implementation process, familiarity with systems, supports for users in legal cases and proceedings, clinical problem-solving, knowledge and experiences of HIS users, management problem-solving and positive thinking of users towards the system); functional factors (including ease of use, flexibility, user-friendliness, alarm system, system architecture, user interface; standards for information input, retrieval, exchange and decision support); management factors (including knowledge of project managers, management stability, granting rewards or penalties to users, senior management supports for project, strong leadership, communications between managers and employees, and management styles); and technical factors (including integrated communication networks, information processing speed, powerful hardware terminals, use of modern hardware and software, enough terminals, suitable network infrastructure, and robust software).At first, the questionnaire purpose and the objectives of the study were introduced to the users.In the first part (demographic information), 7 items were raised about users' specialty, age, gender, working experience, education, and working hours with HIS.Then, in the second part of the questionnaire, factors affecting successful implementation of HIS were set in five points including strongly agree (scale 5), agree, neutral, disagree, strongly disagree (scale 1) and each user was scored based on responses to the items.Afterwards, the reliability and validity of the questionnaire were approved.The validity of the questionnaire was determined through its submission to professors and experts and the required revisions were made.To determine the reliability of the questionnaire, it was distributed among 25 users and it was confirmed by a Cronbach's alpha coefficient equal to 0.857.After determining the validity and reliability of the questionnaire, it was administered to the users and they were given enough time to fill it out; then the completed questionnaires were collected by the researcher.The SPSS software and descriptive statistics were used to examine and present the findings from the questionnaire in the form of frequency distribution tables and parameters of mean and percentage.

Results
Reliability coefficient of the questionnaire was examined by using the SPSS software.The coefficient was reported very high in terms of reliability (Cronbach's alpha was equal to 0.915) which showed an acceptable level of confidence.It should be noted that 35% of respondents were men (87 people) and 65% were women (161 individuals).
Tables 1 and 2 presented the analysis of factors affecting successful implementation of information systems from the views of users.Since the users at the hospitals reviewed were among the first centers in Iran using HIS, the duration to use the system was high and users in these two centers had greater experience compared with users in other regions of the country.The results of this analysis would be employed in implementing HIS in other regions and it could help developers and those involved in this respect.The factors affecting successful implementation of HIS also require special attention.Table 1 showed the mean of the factors affecting implementation of HIS in order of priority.Functional (4.65), project management (4.44),human (4.41), technical (4.35), and management (4.11)factors had the highest importance considering HIS implementation.The most important success factor for HIS in terms of functional factors was meeting the needs of users (4.85) and use of experts was considered as a success factor among project management factors (4.77).Moreover; provision of continuing training for users (4.77), suitable network infrastructure (4.55), and strong leadership (4.76) were among the important success factors among human factors, technical factors, and management factors; respectively.The sub-categories of each group of factors were illustrated in Table 2 in terms of priority.

Discussion
Frequency distribution of participants' age showed that 7% of individuals were under 25 years old, 49% were 26 to 35, 38% were 36 to 50, and 5% of individuals were included in the over-50-years-oldage group.The results also indicated that people aged over 50 years (5%) were less likely to respond to the questionnaire which could be due to their reluctance to use information systems (Khalifa, 2014).Furthermore, frequency distribution of work group of participants revealed that most participants were nurses due to the higher population of users in this work group.
The level of participation among physicians were relatively low which originated from lack of time (Ludwick & Doucette, 2009), unwillingness to use information systems due to technical issues (Fritz et al., 2015), lack of experience (Yucel et al., 2012) and excessive workload (Ismail et al., 2010).
Also the results of this study suggest that critical factors for HIS success rely on the functionality of the implemented system and the availability of technical infrastructure and managerial leadership.Amazingly, in this study financial issues has not been found to be the first major criteria, although this may seem to be an essential factor in HIS implementation.Misplace of these issues might be due to the fact that many of these programs were funded by the vendors or executive management, and users of HIS have no responsibility relating to initial and on-going costs of implementation.Lewis, Synowiec, Lagomarsino, & Schweitzer (2012) in their studies confirmed that about half of the health IT programs in developing countries are based on donor funding.Regardless, financial issues need to be taken into account.Also studies show that there is a return on investment in low-resource settings after 3 to 5 years.The initial funding is therefore crucial to bridge the gap until the HIS generates a value to the health care institution.Otherwise, the argument could be made to use the budget for direct medical care (Fritz et al., 2015).Therefore the success factors include: functionality, project management, human application andtechnical and managerial leadershipthatare discussed below.

Functionality
According to results of this study functionality is the most important critical success factor for HIS implementation.The results of other studies showed that the system will not accomplished if there are lack of clarity in functionality and poor user-interface design (Heeks, 2006;Lucas, 2008).
Another important success factors in this set of factors is data security.Ensuring the data security and confidentiality of HIS is very crucial.Many of data stored in the system are valuable.Unsecured data can be abused and violated and can leading to unpleasant events for both patient and caregiver (Clifford, Blaya, Hall-Clifford, & Fraser, 2008).Audit trails and log-in identification are two main and simple methods to obtaining data security.In audit trails management can supervise the data usage and access.Also username and password protect system from anonymous access.Also to achievement of these goals establishing security and privacy policies in the organizations is necessary (Ismail et al., 2010).

Project Management
Project management is the principle determining success factor of an HIS.Also high quality project management and detailed planning will ensure good implementation, institutionalization and user acceptance (Ismail et al., 2010).Organization's readiness is another success factor for implementation.Although an organization's readiness must create by top managers and technical developers, its angles such as the clear goals of the project, positive thinking of developers and allocation of sufficient resources must be explored fully before starting an implementation process (Peute, Aarts, Bakker, & Jaspers, 2010).

Human
Our results showed that human training is one of the most important factors to avoid failure of the HIS.In this regard continuous training is critical for success of implementation.However, the available time to train is usually limited because of limitations in patient care, staff, and other facility problems.Also users underestimate the essential time of training and expect to have less training than is needed to become expert in working with the new HIS (Joukes et al., 2015).
In various studies, raising users understanding of the system requisites and benefits are mandatory for all users, diminish technical problems, and ensure HIS success.Also the important role of baseline computer knowledge was evident in other some studies (Ball, 2003;Joukes et al., 2015).
Nevertheless, considering similar and same amount of training to everyone is not likely proper.Unfortunately age and computer experiences are negatively correlated and younger employees feel more comfortable than older users in working with HIS (Terry et al., 2008).Expectation is that the older users need more training.It would be advisable for developer to adjust the times of training for personnel based on the users characteristics.
Participation of user in implementation process is another factor that can effect on HIS implementation.Involvement of users in decision making, and having knowledge about the effects of HIS is necessary for successful implementation.People tend to judge an activity more enthusiastically if the results was successful than when those are less successful, especially when they were involved in implementation progress (Hirt, Zillmann, Erickson, & Kennedy, 1992).Moreover in order to prosperity of HIS implementation, physicians must have significant involvement in the IT initiatives and developers must take personnel feedback into account before, between and during system builds and designs.Surely without physicians participation, failure of implementation process was not unexpected (McAlearney et al., 2015).

Technical
Users of HIS must be satisfied with the available technical features.Providing appropriate technical, and communicational infrastructure is very critical for success implementation of HIS (Mohammadzadeh & Safdari, 2014).Note to availability of software and hardware equipment, proper networking, adoption of new technologies, strong hardware terminals, high speed Information processing, combination of hardware interfaces that available through modern technologies like smart phones are necessary.Generation of false alarms can effect on patient safety and effectiveness of care.So in design and provide technical factors must be considered (Choi & Kim, 2012;Fritz et al., 2015;Ismail et al., 2010).

Managerial Leadership
Successful implementations needs to provide personalized and full-time managerial support.One managerial support must have sufficient knowledge for organizations leadership.Managerial leadership like physician leaders, chief information officer and clinical manager had to work together to move the HIT initiatives forward (Robinson, 2007).As well as the importance of IT champions has been noted in most studies and in our study, this concept was more stressed (Terry et al., 2008).Also in-house development of HIS can have many benefits.Reducing of cost, development in accordance with user's needs, upgrading of hardware and software on needed, flexible development accommodate with technology changes and advancements.At the end of discussion it is necessary to remind that the HIS implementation's success depends on the satisfaction of the initially set goals and the elimination of any negative side effects.

Conclusion
The success or failure of HIS implementation in hospital's organization are very elaborated.For this complexity HIS implementationis not similar to other sophisticated technology.Also successful implementation of HIS is affected by numerous factors.Among the most important ones were functional factors, project management factors; and human, technical, and management factors.Moreover, three groups should be considered in the successful implementation of a HIS.The first group was system users who needed training, financial and spiritual incentives, appeal to participate in implementation process, meeting operational needs, process and feedback control to be considered in the implementation process.The effectiveness and efficiency of the system should be also approved for users to encourage them that the system is not an obstacle for their activities and it reduced their workloads and improved their activities.The second group was technical operators who had expertise and adequate resources to conduct implementation process effectively and with high accuracy.The third group included managers who supported implementation process from the beginning to the end and even after its completion through financial and spiritual supports and effective communications.In addition to the factors listed; some factors such as cultural, ethical and behavioral factors could be effective in some regions and special centers.

Table 1 .
The mean critical success factors of a HIS implementation from the views of users (range 1-5)

Table 2 .
The mean of subcategory critical success factors of a HIS implementation from the views of users (range 1-5)