Hospital Information System Evaluation

Transcription

1 Hospital Information System Evaluation Prodromos D. Chatzoglou, Leonidas L. Fragidis, Triantafyllia Doumpa, and Vassilios P. Aggelidis Democritus University of Thrace, Department of Production and Management Engineering, Xanthi, Greece {pchatzog, lfrangid, Abstract. Information technology has rapidly penetrated into the healthcare sector and it has been proved that it can lead to better decision support, organizational support and even influence the quality of the services offered to patients. The evaluation of any HIS is, therefore, a very critical issue. After an extended and systematic review of the existing literature, user satisfaction was chosen as the measurement of IS success. The proposed research model of IS success is based on widely validated user satisfaction models. System quality, information quality, service quality and user background were selected to measure user satisfaction. A structured questionnaire has been used to collect data from four Greek state hospitals, in order to empirically test the validity of the proposed model. Structural Equation Modeling is the main statistical technique used to test the fit of the structural model. The main conclusion is that user background, information quality and service quality directly and positively affect user satisfaction confirming three out of four initial hypotheses (H1, H3, and H4). System quality has been found to influence user satisfaction only indirectly, through information quality, but not directly, as it was initially stated. Keywords: user satisfaction, hospital information systems, evaluation 1 Introduction Hospital information systems (HIS) have changed spectacularly since the introduction of computers in health care organizations. These changes were inevitable not only because of the changes in the information technology (IT), but mainly because of the realization of the benefits a computerized hospital offers. Initially, hospital information systems incorporated financial and partial patient care systems [1]. Later, many hospitals stated adopting specialized systems in other areas, such as laboratory, pharmacy and medical records, with more emphasis to patient interest. As a result, the number of the organizational personnel who directly interact daily with computers has also recorded an explosive growth [2]. 240

2 Due to the complex environment that hospitals function in, the use of HIS is of great importance. When choosing an information system (IS), hospitals must avoid mistakes and must consider very carefully their actual needs [1], [3]. Therefore, the evaluation of HISs is an extremely important issue, which helps to test the effectiveness of these systems. According to DeLone and McLean (1992), the most widely known measure of information system evaluation is user satisfaction. The literature suggests that user satisfaction can play a vital role and can affect users' behavior toward computer use, which, in turn, can also affect the actual usage of the system [3]. The aim of this study is to evaluate Greek hospital information systems, focusing on the development of an instrument (conceptual model) considering the most important issues involved. The participants in the present survey were the actual users of four Greek hospitals; General Hospital of Heraklion Crete Venizeleio-Pananeio, General Hospital of Thessaloniki Georgios Papanikolaou, General Hospital of Thessaloniki Papageorgiou, and General University Hospital of Alexandroupoli. 2 IT and Healthcare There is no doubt that paper-based records and written documentation can no longer follow the needs of the modern health care and their use reaches its limits as different technological achievements, such as hospital information systems (HIS), take control [4]. Traditional systems are replaced with information systems that provide patient safety and improve the quality and efficiency of health care systems. Different innovations, such as electronic patient records and especially hospital information systems, have significantly changed the workflow in healthcare [5]. Αn HIS is an information system used within a healthcare organization to facilitate communication, perform record-keeping, or otherwise support the functions of the organization [6]. Further, according to Ammenwerth et al [7], HIS can be defined as the complete information processing and information storing subsystem of a hospital, including both computer-based and paper-based information processing tools. The value of HISs could be an assessed by recording the multiple benefits that are generated from their use and comparing them with the old and historical paper based records. A good clarification of the benefits that are generated by the use of information and communication technologies (ITC) in the health care sector is given by Lampsas et al [8]. HIS incorporates Electronic Health Records (EHR), which provide to clinicians real-time decision support providing them with a full patient profile [9]. Generally, the use of an integrated information system allows the creation of a well organized historical patient profile, which leads to a better patient care [10] and affects (positively) personnel s productivity and diagnostic quality. Finally, some researchers, have proved that the use of HIS increase revenues, Clayton, et al.; as found in [11] and savings, Souther, 2001; as found [11]. 241

3 In Greece, the initiation of adopting ICT in Health sector began ion the mid 80 s. By the end of 90 s, the incorporation of ICT in Health sector was still in the designing phase. Public hospitals actually started implementing information systems between , when an initiative was undertaken to introduce integrated information systems into public Greek hospitals [5]. However, although the penetration of information technology in health care sector is now satisfactory, HIS use is still surprisingly very low. Furthermore, despite the high penetration of IT in the administrative departments of hospitals, the medical and the nursing part face a relatively low level of computerization. 3 Information Systems Evaluation Nowadays, it is generally accepted that the use of information technology has become a necessity for the health care sector. The most important advantage of the IT use in health sector is the reduction of errors which are caused by humans, well informed patient records, and the improved quality of the health care system [9], [12]. On the other hand, there are some disadvantages that can also derive from the use of IT. First of all, integrated information systems are very expensive to implement [13]. Additionally, the loss of productivity and efficiency by the staff is another disadvantage that derives from the fact that at the beginning the system is timeconsuming, which can also lead to patient neglect [14]. The evaluation of Hospital Information Systems can take place at different phases and by different people at each phase [6]. Different approaches have been developed concerning information systems evaluation and each of them have both positive characteristics and flaws as well. According to Ammenwerth, et al [15], there is no standard method of how to evaluate an integrated information system. [16] stated that the evaluation of a system in terms of its success is an inherently complex phenomenon. It is of vital importance that during the evaluation process both the technology that is used and the role of the users that participate and their relation to the technology must be taken into account [15]. 3.1 Approaches to IS success measurement A large number of possible measurements of IS success exists mainly because an information system can be viewed from many different angles. Specifically, there are two perspectives: the organizational viewpoint and the socio-technical viewpoint [17]. From the organizational point of view, emphasis is given to the information that is provided from the IS and the way this interact with users. This perspective has been criticized because it ignores the human element. On the other hand, the sociotechnical viewpoint focuses on individual needs. Furthermore, six dimensions of IS success have been identified by DeLoan and McLean [18]: system quality, information quality, information use, individual impact, and organizational impact. All 242

4 these six dimensions characterize an IS both from the organizational viewpoint and the socio-technical viewpoint. [19] later added one more dimension, service quality. Later the discussion has primarily focused around three different measures of success: Cost-benefit analysis, System usage, User satisfaction. In a cost-benefit analysis, the actual value of the IS, as far as the organization is concerned, can be described as the difference between the benefits in terms of the organizational effectiveness. This analysis has been criticized because it is difficult to prove that the benefits are connected to IS and the costs and benefits are difficult to be measured in terms of monetary value [17]. System usage, on the other hand, shows whether users trust the effectiveness of the system. There are different ways of measuring the IS success, and these are [17]: a) The actual time that the users are linked with the system, b) The amount of patient or client records that have been registered, c) The amount of computer functions that have been used. Criticism is also applied to this method because it is relevant only when it is voluntary. The measure of IS success that is considered to be the most widely known among the researchers is user satisfaction. According to Au et al [17], user satisfaction is defined as the IS end-user s overall affective and cognitive evaluation of the pleasurable level of consumption-related fulfillment experienced with the IS. IS end-users refer to non-technical personnel who use or interact with the system directly. IS users evaluate the quality of the system in their daily life. If they are not satisfied with the quality and the functions provided by the system, the quality of the information generated and, generally, by the services of the system, they will not use it, or they will not use it correctly [20]. More specific, for a hospital information system to be successful, it must not be very complicated in use, it must be adapted based on user s needs, it must be friendly in use and meet user expectations [20]. According to the literature, the most important user satisfaction measurement models, which are used for the evaluation of HIS, are [21-26], [5]. Cost-benefit analysis was the first method that was rejected because it is difficult to prove that a specific benefit is a result of an information system itself. More precisely, this method is too hard to get implemented into Greek hospitals, because of the lack of appropriate data (before and after the implementation and the usage of the IS). On the other hand, the method of system usage has also been rejected as an option, because of the fact that system usage is not always voluntarily, but most of the times personnel is forced to use the IS. So, system usage is not able to generate valuable results for the IS effectiveness and success. According to Ives et al [11], an information system is not considered as a success when its users are dissatisfied with its functionality. It is for sure that when users are not satisfied with the quality of the system, the quality of the information and the services provided, the system will be 243

5 rejected or not used correctly [20]. This is valid especially into hospitals where the personnel may be suspicious towards new technologies and easily neglect them [27]. 3.2 Hospital Information System Evaluation: The research It is of great importance to determine the users of IS. Users are all the stakeholders of an HIS that are involved in its operation and functionality. According to Ribiere et al.[20], HIS users can be categorized into internal and external. As internal users can be characterized the nursing staff, doctors, the administrative staff, and generally all those directly related to the use of an HIS. External users are the patients, suppliers, insurance providers, and everyone that is indirectly related to an HIS. The present research focuses on internal users only. Theoretical model and hypothesis. The evaluation of Greek hospitals IS will be conducted measuring user satisfaction. According to[19] model there are three dimensions that are related to user satisfaction: a) system quality, b) information quality and c) service quality, while according to Mahmood et al. [25] another important dimension that is related to user satisfaction is d) user background (user experience, user skills, and user training). In addition, internal support and external support were selected as the variables that compose the service quality factor. The measure of information quality is comprised by content, accuracy, format, and timeliness that were adopted from Doll and Torkzadeh s [23] model, and by data security that was chosen from Ives et al [22] model. Finally, ease of use, system speed, screen interface, and error recovery were also selected to compose the typical measures of system quality [23], [24], [20], [22]. The model is presented in Figure

6 Fig. 1. Research model of measuring user satisfaction User background. User background can be measured with experience, training, and user s skills [25], [28] and it is associated to IS success by leading to greater satisfaction. Computer experience is related to computer anxiety decrease and, thus, to the enhancement of user s confidence and satisfaction [29]. Many researchers have shown that user experience can positively affect user satisfaction even though it is hard to measure [30-31], while some other researchers suggest otherwise (significant correlation) [32], [25]. Furthermore, training has also been identified as a factor that affects IS effectiveness and user satisfaction, and thus to system usage [28], [33]. Finally, user s skills with computers and, generally with IT have also been identified as a factor that is directly associated with user satisfaction and performance [34]. Their findings have shown that user s computing skills can help users to accept new computer applications and, increase their involvement with information systems and, thus, user satisfaction. H1. User background will positively affect the hospital personnel satisfaction. System Quality. System quality is one of the most important factors that influence user satisfaction and can be measured with ease of use, system speed, screen interface, and error recov- 245

7 er[19-24]. When a system is easy to use, and complex procedures do not exist, it is more likely to be accepted by users [35]. According to Igbaria et al. [36], a system must be developed based on user s abilities and needs, in order to achieve ease of use and, then, user satisfaction. Furthermore, another variable that leads to high levels of user satisfaction is system speed. The rapid development of technology and the constantly increased demands of the organizations to their staff make system speed as one of the most important variables influencing IS success [24]. Screen interface and error recovery are also stated among the most significant variables that affect user satisfaction [20]. H2. System Quality will positively affect the hospital personnel satisfaction. Information Quality. Information quality mostly refers to measures of information systems output [37]. Typical measures of information quality contain content, accuracy, format, timeliness, and data security [38],[23-24]. The content of the information provided by the system will satisfy users if it fits to their needs [23-24]. At the same way, researchers have shown that, measures that refers to information, such as the accuracy of the output information, as well as the format and the availability, positively influence user satisfaction[21], [23-24]. Finally, the confirmation and the confidence that data are secured from unauthorized alteration or loss leads to greater user satisfaction [21], [38]. H3. Information Quality will positively affect the hospital personnel satisfaction. Service quality. Service quality is another major factor that, according to DeLone and McLean [19], affects user satisfaction and IS effectiveness. Typical measures of service quality mainly include internal and external support [3], [38]. It is for certain that, when the IS department (internal support), and the external vendor (external support) provide assistance and solutions to different problems that derive from computer usage, users feel more confident towards overcoming obstacles, which, in turn, leads to greater satisfaction and system usage [3],[38]. H4. Service Quality will positively affect the hospital personnel satisfaction. 4 Methodology Research 4.1 Instrument Development Many researchers have spent a lot of time to find a valid instrument for user satisfaction. Among these researchers [21], were the first to develop an instrument that was composed of 39 items that measure user satisfaction. Later on, Ives et al.[22] created a short form version of 13 items from the initial Bailey and Pearson s[21] instrument. Furthermore, Doll and Torkzadeh [23] revised the Ives [22] instrument and created a 12 item new one, which measured end-user computing satisfaction based on five factors: content, accuracy, format, ease of use, and timeliness. Their instrument is one of the most common used in the field of user satisfaction and the one that has been validated by many researchers. To continue with, Doll and Torkzadeh s [23] instrument was later enhanced and revised by Chin and Lee [24]. They added one more factor; system speed, and enriched each factor with more items in the instrument. The present research uses as a basis the Chin and Lee[24] model, because it is an instrument that 246

8 is well validated and widely used, and it has been developed especially for end-user computing applications [24]. Table 1 presents the operationalization of the factors included in the proposed research model. Table 1. Definitions and Supported Literature 4.2 Research Sample The population sample was restricted to healthcare personnel, such as medical staff, nursing staff, and administrative staff from every department of the hospitals. Addi- 247

9 tionally, the research was limited to hospitals in Greece, which were randomly selected to participate in the research. The five hospitals were General Hospital of Xanthi, General Hospital of Heraklion Crete Venizeleio-Pananeio, General Hospital of Thessaloniki Georgios Papanikolaou, General Hospital of Thessaloniki Papageorgiou, General Panarkadiko Hospital of Tripolis, and General University Hospital of Alexandroupoli. Initially a pilot study was conducted including the chief of the IS department of each hospital. After that, the initial questionnaire was partly adjusted and it was sent to the research sample. From the 140 questionnaires that were initially distributed, a total of 100 were finally gathered from four hospitals (71.40% response rate). The demographic profile of the respondents shows that the research sample is composed of 39% nursing staff, 8% doctors and 53% administrative staff. Furthermore, the sample consists mainly of female, between the ages of 31-50, well educated, reaching a 10 year experience with using an information system. Data analysis. At the beginning, confirmatory factor analysis was conducted in order to estimate the adequacy of the measurement model [39] and, after that, Structural Equation Modelling (SEM) was also performed to test the structural model s fit [40] with the use of the AMOS software. 4.3 Construct validity and construct reliability In the present survey, a factor analysis was performed by using the Kaiser-Meyer- Olkin (KMO) measure of sampling adequacy and the Bartlett s Test of Sphericity, which are recommended for measuring construct validity [41]. Additionally, the Cronbach s (a) reliability test was used in order to estimate the internal consistency of measurements [42]. Finally, the Total Variance Explained (TVE) score was also used to measure the cumulative percentage of the variance that is explained by all factors. The results of the factor and reliability analysis, and the results of the descriptive statistics are summarised at Table (2). Starting with the factor analysis, it can be stated that KMO is above the 0,500 threshold for all factors [41]. More precisely, KMO varies between 0,500 and 0,870. The Cronbach s (a) reliability test revealed values greater than the 0,600 threshold [43], while TVE score is above 0,500 for all factors [44]. Further, factor loadings are at acceptable levels for all items. At this point, it must be pointed out that 3 out of 52 items were dropped out of the analysis. The results suggest that users have a very satisfactory background with acceptable experience in programs for personal computing and information systems as well. As far as the training factor is concerned, it is obvious that, it is a result of personal effort and self study rather than a privilege that should be provided to them by the IS de- 248

10 partment of the organization or the vendor of the IS. Furthermore, users believe that they have a satisfactory level of the ability to easily interact with and execute software applications (skills). To continue with, users are highly satisfied with a) their interaction with the system which is understandable, friendly in use and easy to handle; b) the speed that the system operates; and c) the screen interface of the system, such as the screen layout and colors which are considered as pleasant. It is very interesting to see that most of the users are very satisfied as far as the information provided to them by the system is concerned. They believe that the information delivered to them covers their needs regarding the content, the accuracy, and the way that the information is presented to them. As far as the factor timeliness is concerned, it can be claimed that overall users are satisfied with the time a system takes to generate useful information. Data security is the factor most users are neutral with, revealing that they are not very sure or convinced that the system is protected against unauthorized alteration or physical damage. Furthermore, as far as the internal and external support are concerned, the support provided to the users comes mainly from the IS department of the organization and then from the vendor of the system. Finally, the results for the overall satisfaction reveal that most of the users hold a neutral position (moderately satisfied). This may mean that the systems used need improvements so that users to become more satisfied with their operation. 249

11 Table 2. Factor and reliability analysis 250

12 4.4 Structural Model Fit The hypothetical model was tested using the Structural Equation Modeling approach (AMOS). Five fit measures were used to evaluate the overall model fit: chisquare/degree of freedom (x 2 /df), goodness-of-fit index (GFI), comparative fit index (CFI), normed fit index (NFI), and root mean square residual (RMR). The results of the second order factor analysis are demonstrated in Figures (2), (3), (4) and (5), while the results concerning the empirical test of the proposed research model and the hypotheses testing are presented in Figure (6) and Table (3). The results presented in Figures (2-5) show that all main factors (user background, system quality, information quality and service quality) are appropriately and accurately measured. Fig. 2. User Background Fig. 3. System Quality 251

13 Fig. 4. Information Quality Fig. 5. Service Quality 252

14 Fig. 6. User Satisfaction Table 3. Statistics concerning structural equation models The results (Table 3) indicate that the CMIN/DF scores are within the acceptable levels, below 5 [2] except from the system quality (8,956), which, though, is still acceptable. GFI scores are above the 0,90 threshold [45], CFI scores are also close to 253

15 the 0,90 threshold [46], while NFI is close to 0,90. Last, RMR scores are below the 0,1 threshold [47-48] except from users satisfaction value which is very close (0,119). Figure (6) presents the overall model, the extracted path coeffients within the model and the adjusted R2 score (53%). This indicates that the suggested model can explain 53% of the variance in user satisfaction. More specifically, it is noticed that there is a rather weak (0,23) positive relationship between user background and user satisfaction. This relation suggests that experienced users, with adequate skills and training provided (either by the organization itself or by the vendor), may be more satisfied with the system in use. As far as the relationship between information quality and user satisfaction is concerned, it is observed that there is a highly positive relation (0,54), which allow us to assume that if the information provided to users, such as accuracy of the information and appropriate content, cover/satisfies their daily needs, on time, then their satisfaction with the use of the system will be increased. Moreover, the model reveals that there is a highly positive impact (0,43) between service quality and user satisfaction. This relation suggests that high quality services provided to users, whenever is needed, internally or externally, increase the level of users confidence and satisfaction. Finally, it can be observed that there is a very high relationship between system quality and information quality (0,88), but no direct impact of system quality on user satisfaction. Summarizing, from the initial four hypotheses Figure (1) three have been accepted: Hypothesis 1 (H1) showing that user background positively affect user satisfaction; hypothesis 3 (H3) showing that information quality positively affect user satisfaction, and hypothesis 4 (H4) showing that service quality positively affect user satisfaction. Hypothesis 2 (H2), which referred to the direct positive relationship between system quality and user satisfaction, has been rejected. It must be stressed though that it has been found that system quality indirectly affect user satisfaction through information quality. This indirect impact is too strong (0,48) that forces us to accept H2 as well. 5 Conclusions and research limitations This survey has examined the relationship between user satisfaction and user background, system quality, information quality and, finally, service quality. Users (100) from four Greek Hospitals participated in the empirical validation of the proposed theoretical model. Firstly, factor analysis was conducted in order to estimate the adequacy of the measurement model, and the construct validity and reliability of the instrument. Secondly, Structural Equation Modeling was performed in order to test the structural model fit and examine the paths of the model, with the use of the AMOS software package. The statistical analysis has indicated that user background positively (directly) affect user satisfaction (H1), confirming this way the research of [25], where the first hypothesis was based on. The modification concerns the [19] three factors that have been proved to affect user satisfaction. Information quality (H3) and service quality (H4) have been tested and their positive (direct) impact on user satisfaction has also been confirmed. As far as the relationship between system quality and users satisfaction is concerned, the results are inconclusive. Although no direct statis- 254

16 tically significant relationship was observed, examining the indirect relationship matrix it was reveled that there is a strong indirect relationship (through information quality). Anyway, system quality has been proved to be one of the major factors that has direct impact on user satisfaction by other researchers [18-19]. These findings may lead hospital organizations to realize that the use of information technology is, nowadays, very important and also that information technology is useless, if the users that daily interact with information systems are dissatisfied with their functionality and reject them. References 1. Zviran, M. (1990), Defining the Application Portfolio for an Integrated Hospital Information System: A Tutorial, Journal of Medical Systems, Vol. 14, No. 1 / 2, pp Harrison, A.W. and Rainer, R.K. (1996), A General Measure of User Computing Satisfaction, Computers in Human Behavior, Vol. 12, No. 1, pp Thompson, A.M. (1999), An evaluation of the Selection Process of Hospital Information Systems, Journal of Medical Systems, Vol. 14, No. 5, pp Uslu A.M. and Stausberg J., (2008), Value of electronic patient record: An analysis of the literature, Journals of Biomedical Informatics, Vol. 41, pp Aggelidis, V.P. and Chatzoglou, P.D. (2008), Methods for evaluating hospital information systems: a literature review, EuroMed Journal of Business, Vol. 3, No. 1, pp Nahm, E.S., Vaydia, V., Ho, D., Scharf, B. and Seagull, J. (2007), Outcomes assessment of clinical information system implementation: A practical guide, Nursing Outlook, Vol. 55, No. 6, pp Ammenwerth, E., Ehlers, F., Hirsch, B. and Gratl, G. (2007), HIS-Monitor: An approach to assess the quality of information processing in hospitals, International Journal of Medical Informatics, Vol. 76, pp Lampsas, P., Vidalis, I., Papanikolaou, C., and Vagelatos, A. (2002), Implementation and Integration of Regional Health Care Data Networks in the Hellenic National Health Service, Journal of Medical Internet Research, Vol. 4, No Jha A.K., Doolan D., Grandt D., Scott T. and Bates D.W., (2008), The use of health information technology in seven nations, International Journal of Medical Informatics, vol. 74, pp Bakker A.R., (2007), The need to know the history of the use of digital patient data, in particular the HER, International Journal of Medical Informatics, Vol. 76, pp Handel, D.A. and Hackman, J.L. (2008), Implementing electronic health records in the emergency department, The Journal of Emergency Medicine, vol. 38, pp Hayrinen, K., Saranto, K. and Nykanen, P. (2008), Definition, structure, content, use and impacts of electronic health records: A review of the research literature, International Journal of Medical Informatics, Vol. 77, pp Kluge, E.H.W., (2007), Secure e-health: Managing risks to patient health data, International Journal of Medical Informatics, Vol. 76, pp

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