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DEVELOPMENT OF IMPLEMENTATION MODELS FOR
HOSPITAL INFORMATION SYSTEM (HIS) IN MALAYSIAN
PUBLIC HOSPITALS
NURUL IZZATTY BINTI ISMAIL
UNIVERSITI TUN HUSSEIN ONN MALAYSIA
iv
DEVELOPMENT OF IMPLEMENTATION MODELS FOR HOSPITAL
INFORMATION SYSTEM (HIS) IN MALAYSIAN PUBLIC HOSPITALS
NURUL IZZATTY BINTI ISMAIL
A thesis submitted in
fulfilment of the requirement for the award of the
Doctor of Philosophy in Technology Management by Research
Faculty of Technology Management and Business
Universiti Tun Hussein Onn Malaysia
SEPTEMBER 2016
vi
DEDICATION
I dedicated my work to my beloved husband, Wazli..
My beloved mother, Norrisah..
My beloved grandmother, Hajah Fatimah..
My brother, Faizul, and all my families,
Without them, I would not go this far.
Thanks for your love, caring, understanding and huge support.
I love you all till ‘Jannah’.
vii
ACKNOWLEDGEMENT
All praises is only for ALLAH the Most Merciful and the Highest, thank you, ALLAH.
I am grateful to my supervisor who guides me sincerely through this entire doctoral
journey, Ass. Prof. Dr. Nor Hazana Abdullah for her endless support, guidance and
motivation. I also would like to express my grateful to my co-superviser who guides me
to this journey, Ass. Prof. Dr. Alina Shamsuddin. I would like to appreciate Dr. Nor
Aziaty and Dr. Roshartini for their helps in my research. Thank you for all of you.
I would like to thank you to organizations and persons participated thoughout
this research, Hospital Sultan Ismail, Hospital Keningau, Hospital Tuanku Ja’afar,
Hospital Tuanku Zahirah, Hospital Lahad Datu and Hospital Kepala Batas. Thank you
for the cooperation. I also shows my grateful to Ministry of Health Malaysia who
approved my research to be done in public hospitals.
I would also like to thankful to my colleagues, Bari’ah, Nor Fazira , Noor
Juliana, Emrozio, Farhana and Farhaini who have shared their knowledge throughout
this journey. Not to be forgotten, to those who have helped me directly and indirectly in
this journey, especially my whole families; grandmother, uncles and aunties for their
support to go this far. I know, without them, I might lost my way and helpless.
viii
ABSTRACT
Studies have shown that Hospital Information System (HIS) implementation improve
hospital’s management and activities in terms of cost and time reductions. However,
there are only 15.2% out of 138 Malaysian Public Hospitals implemented HIS.
Literatures have further highlighted various issues and challenges with regards to its
implementation. Therefore, this study aimed to explore the implementation of THIS,
IHIS and BHIS’s hospitals as well as factors affecting them. This study employed a
mixed methods approach to answer the research objectives. In the first phase of this
study, semi-structured interviews were conducted with nine participants consisted of the
hospital directors, Information Technology officers and HIS users. It is found that
THIS’s hospital implementation phases differed from IHIS and BHIS’s hospitals, while
IHIS and BHIS’s hospitals have similar phases based on Business Interaction Phases of
Business Action Theory. Human context was discovered to play important roles in the
HIS implementation. A survey was conducted in the second phase of this study among
HIS users at different categories of HIS’s hospitals. Two hundred and twenty-nine
questionnaires were returned to yield a response rate of 45.8%. Based on ANOVA
findings, factors affecting THIS implementation were significantly different from those
in IHIS and BHIS’s hospitals. There was no significance different between IHIS and
BHIS’s hospitals. There are three major contributions of this study: 1) Distinctive
implementation phases for THIS hospital and IHIS-BHIS hospital were discovered for
HIS implementation. 2) New models of HIS implementation which highlight the Human
context were proposed, and 3) Different factors were found to affect HIS
implementation at different types of HIS’s hospitals.
ix
ABSTRAK
Kajian menunjukkan bahawa pelaksanaan Hospital Information System (HIS) telah
meningkatkan mutu pengurusan dan aktiviti hospital khususnya di dalam perbelanjaan
dan pengurangan masa. Walau bagaimanapun, hanya 15.2% daripada 138 buah Hospital
Awam di Malaysia melaksanakan HIS. Kajian literatur menekankan pelbagai isu dan
cabaran berhubung pelaksanaannya. Oleh itu, kajian ini bertujuan untuk meneroka
pelaksanaan hospital THIS, IHIS dan BHIS serta faktor-faktor yang mempengaruhinya.
Kajian ini menggunakan mixed method untuk menjawab objektif kajian. Dalam fasa
pertama kajian ini, temuramah separa berstruktur telah dijalankan dengan sembilan
orang peserta kajian dari kalangan pengarah hospital, pegawai Teknologi Maklumat dan
pengguna HIS. Kajian mendapati fasa pelaksanaan hospital THIS berbeza dari hospital
IHIS dan BHIS, manakala hospital IHIS dan BHIS mempunyai fasa yang sama.
Konteks Kemanusiaan merupakan peranan yang penting dalam pelaksanaan HIS.
Tinjauan dari borang kaji selidik telah dijalankan dalam fasa kedua kajian ini melibatkan
pengguna HIS di kalangan kategori hospital HIS yang berbeza. Dua ratus dan dua puluh
sembilan soal selidik bersamaan dengan 45.8% telah dikembalikan. Berdasarkan
dapatan ANOVA, faktor mempengaruhi pelaksanaan THIS perbezaan signifikan dengan
hospital IHIS dan BHIS. Tiada perbezaan signifikan di antara hospital IHIS dan BHIS.
Terdapat tiga penemuan utama kajian ini: 1) Fasa-fasa pelaksanaan HIS yang berbeza di
hospital THIS dan hospital IHIS-BHIS telah ditemui, 2) Model-model baru pelaksanaan
HIS yang menekankan konteks Kemanusiaan telah dikemukakan, dan 3) Faktor-faktor
yang berbeza menjejaskan pelaksanaan HIS di kategori-kategori hospital HIS yang
berbeza.
x
CONTENT
DEDICATION vi
ACKNOWLEDGEMENT vii
ABSTRACT viii
ABSTRAK ix
CONTENT x
LIST OF TABLES xvii
LIST OF FIGURES xxi
LIST OF SYMBOLS AND ABBREVIATION xxiii
LIST OF APPENDICES xxiv
CHAPTER1 INTRODUCTION 1
1.0 Introduction 1
1.1 Healthcare Background in Malaysia 2
1.2 Problem Statement 2
1.3 Research Questions 4
1.4 Research Objectives 4
1.5 Significance of the Study 5
1.6 Scope of the Study 5
1.7 Operational Definition 6
1.8 Structure of the Thesis 7
CHAPTER 2 LITERATURE REVIEW 9
2.0 Introduction 10
2.1 Healthcare in Malaysia 10
2.1.1 Malaysian Public Hospitals 12
2.2 Healthcare Services and Transformation in Malaysia 15
2.3 Hospital Information System (HIS) 18
xi
2.3.1 Components of Hospital Information System (HIS) 19
2.4 Development of Hospital Information System (HIS) 21
2.5 Hospital Information System (HIS) Implementation
Phases 23
2.5.1 Hospital Information System (HIS) Implementation
in Malaysia 26
2.6 Benefits of Hospital Information System (HIS)
Implementation 28
2.7 Issues and Challenges of Hospital Information System
(HIS) Implementation 29
2.8 Models/Theories 33
2.8.1 Theories Related to Implementation Phases 33
2.8.1.1 Business Action Theory (BAT): A Phase Model
33
2.8.1.2 Systems Development Life Cycle (SDLC) 36
2.8.2 Technology Acceptance or Adoption Theories 37
2.8.2.1 Theory of Reasoned Action (TRA) 37
2.8.2.2 Theory of Planned Behaviour (TPB) 40
2.8.2.3 Technology Acceptance Model (TAM) 42
2.8.2.4Technology, Organisational and
Environmental (TOE) Framework 45
2.8.2.5 DeLone and McLean IS Success Model 46
2.8.2.6 Unified Theory of Acceptance and
Use of Technology (UTAUT) 48
2.8.2.7 HOT-Fit Model 50
2.8.2.8 Innovation of Diffusion Theory 53
2.8.3 Theory Adopted for HIS Implementation Phases 55
2.8.4 Theories Adopted in HIS Acceptance 56
2.9 Previous Studies in Hospital Information System (HIS) in
Malaysia 58
2.10 Theoretical Framework 66
2.11 Chapter Summary 67
xii
CHAPTER 3 METHODOLOGY 69
3.0 Introduction 69
3.1 Research Methodology 69
3.1.1 The Nested Table Approach 70
3.1.2 The Research Onion 71
3.1.2.1 Research Philosophies 72
3.1.2.2 Research Approach 75
3.1.2.3 Research Strategy 75
3.1.2.4 Research Choices 76
3.1.2.5 Time Horizons 77
3.1.2.6 Technique and Procedure 77
3.2 Mixed Methods Approach 79
3.3 MOH Procedures for Research 80
3.4 First Phase: Qualitative Research 81
3.4.1 Research Strategy in Qualitative Study 82
3.4.2 Case Study Protocol 83
3.4.3 Data Collection in Qualitative Study 84
3.4.4 Population and Target Population in Qualitative
Study 85
3.4.5 Research Site in Qualitative Study 86
3.4.6 Type of Research Sampling in Qualitative Study 86
3.4.7 Background of Participants 86
3.4.8 Research Sampling in Qualitative Study 87
3.4.9 Qualitative Research Instrument 87
3.4.10 Qualitative Ethics 88
3.4.11 Interview Preparation Stages 88
3.4.12 Interview Phases 90
3.4.13 Data Validity in Qualitative Study 90
3.4.14 Reliability in Qualitative Study 91
3.5 Qualitative Data Analysis 92
3.5.1 Content Analysis 92
3.5.2 Within-Case Analysis 95
3.5.3 Cross-Case Analysis 95
3.6 Phase 2: Quantitative Research 95
xiii
3.6.1 Research Strategy in Quantitative Study 96
3.6.2 Data Collection in Quantitative Study 96
3.6.3 Research Instrument in Quantitative Study 96
3.6.4 Research Population in Quantitative Study 99
3.6.5 Research Site in Quantitative Study 99
3.6.6 Type of Research Sampling in Quantitative Study 99
3.6.7 Pre-Test 100
3.6.8 Data Validity in Quantitative Study 100
3.6.9 Reliability in Quantitative Study 101
3.6.10 Survey Preparation Stages 102
3.7 Quantitative Data Analysis 103
3.7.1 Data Cleaning 103
3.7.2 Data Transformation 104
3.7.3 Testing Assumptions 104
3.7.3.1 Normality Test 104
3.7.3.2 Levene’s Test ofn Homogeneity Variance 105
3.7.3.3 Data Analysis Strategy 106
3.7.3.4 Parametric Test 107
3.8 Conclusion 107
CHAPTER 4 QUALITATIVE FINDINGS 109
4.0 Introduction 109
4.1 Criteria For Participants in Interview 109
4.2 Case Study 1: Hospital A (THIS) 110
4.2.1 Case Study 1: Hospital A (THIS) 110
4.2.1 Case Study 1: Hospital A (THIS) Background 110
4.2.2 Case Study 1: Participants Involved in Hospital
A 111
4.3 Within Case Analysis: Hospital A (THIS) 112
4.3.1 Explore of HIS Implementation Phases at THIS’s
Hospital (Hospital A) 113
4.3.2 Explore Factors Affecting HIS Implementation at
THIS’s Hospitals (Hospital A) 125
4.4 Case Study 2: Hospital B (IHIS) 143
xiv
4.4.1 Case Study 2: Hospital B (IHIS) Background 143
4.4.2 Case Study 2: Participants Involved in Hospital
B 143
4.5 Within Case Analysis: Hospital B (IHIS) 144
4.5.1 Explore of HIS Implementation at IHIS’s
Hospital (Hospital B) 145
4.5.2 Explore Factors Affecting HIS Implementation
at IHIS’s Hospital (Hospital B) 158
4.6 Case Study 3: Hospital C (BHIS) 172
4.6.1 Case Study 3: Hospital C (BHIS) Background 172
4.7 Within Case Analysis: Hospital C (BHIS) 173
4.7.1 Explore of HIS Implementation at BHIS’s
Hospital (Hospital C) 174
4.7.2 Explore Factors Affecting HIS Implementation at
BHIS’s Hospital (Hospital C) 184
4.8 Cross-Case Analysis 195
4.8.1 To explore HIS implementation among THIS,
IHIS and BHIS’s hospitals. 195
4.8.1.1 HIS Prerequisites Phase 197
4.8.1.2 Exposure and Contact Search Phase 198
4.8.1.3 Contact Establishment and Proposal Phase 198
4.8.1.4 Fulfilment Phase 198
4.8.1.5 Completion Phase 202
4.8.2 To explore factors affecting HIS implementation
of THIS, IHIS and BHIS’s hospitals 206
4.8.2.1 Factors Affecting THIS, IHIS and BHIS’s
Hospital in Technological Context 208
4.8.2.2 Factors Affecting THIS, IHIS and BHIS’s
Hospital in Organisational Context 208
4.8.2.3 Factors Affecting THIS, IHIS and BHIS’s
Hospital in Environmental Context 209
4.8.2.4 Factors Affecting THIS, IHIS and BHIS’s
Hospital in Human Context 210
xv
4.9 Discussions in Qualitative Findings 212
4.10 Chapter Summary 213
CHAPTER 5 QUANTITATIVE FINDINGS 215
5.0 Introduction 215
5.1 Demographic Data of Respondents 216
5.1.1 Gender 216
5.1.2 Age 217
5.1.3 Ethnicity 217
5.1.4 Highest Education Level 218
5.1.5 Position 219
5.1.6 Work Experience 221
5.1.7 Department Involved 223
5.1.8 Computer Training 224
5.2 ANOVA 225
5.2.1 Post-Hoc Test 226
5.2.1.1 Technological Contexts 228
5.2.1.2 Organisational Contexts 230
5.2.1.3 Environmental Contexts 231
5.2.1.4 Human Contexts 232
5.2.3 Hypothesis 234
5.2.4 Size Effect 234
5.5 Discussions 235
5.6 Chapter Summary 236
CHAPTER 6 DISCUSSIONS 237
6.0 Introduction 237
6.1 Objective 1: To Explore the HIS Implementation at
THIS, IHIS and BHIS’s Hospitals 237
6.1.1 HIS Implementation Phases at THIS, IHIS and
BHIS’s Hospitals 238
6.1.2 Activities in HIS Implementation Phase at THIS,
IHIS and BHIS’s Hospitals 239
6.1.3 Important Bodies Involved in HIS Implementation
xvi
at THIS, IHIS and BHIS’s Hospitals 241
6.2 Objective 2: To Explore Factors Affecting HIS
Implementation at THIS, IHIS and BHIS Hospitals 242
6.2.1 Importance of Human Context in HIS
Implementation at THIS, IHIS and BHIS’s
Hospitals 246
6.2.2 THIS Implementation Model 248
6.2.3 IHIS/BHIS Implementation Model 252
6.3 Objective 3: To Test the HIS Implementation Models at
Different Categories of HIS’s Hospitals 255
6.4 Chapter Summary 256
CHAPTER 7 CONCLUSION AND RECOMMENATIONS 258
7.0 Introduction 258
7.1 Research Contributions 258
7.2 Research Implications 259
7.2.1 Implication to Researchers 259
7.2.2 Implication to Ministry of Health (MOH) 260
7.2.3 Implication to Malaysian Public Hospitals 261
7.3 Limitation of the Study 261
7.4 Conclusion 262
7.5 Recommendations 263
REFERENCE 264
APPENDICES 297
VITA 351
xvii
LIST OF TABLE
Table 2.1 Total Number of Patient Admissions (Adapted from Health
Informatics Centre, MoH, 2013) 10
Table 2.2: Bed Occupancy Rate (BOR) and Total Patient Days (TOD)
(Adapted from Health Informatics Centre, MoH, 2013) 11
Table 2.3: Categories and Lists of Malaysian Public Hospitals (Adapted
from Health Informatics Centre, MoH, 2012) 13
Table 2.4: Strategic Reform Initiatives (SRIs) and National Key Economic
Areas (NKEAs) 16
Table 2.5: Key Research Areas (KRAs) for Health Sector 18
Table 2.6: Differences of HIS Components 20
Table 2.7: The components of HIS in Malaysia 21
Table 2.8: Categories of HIS in Malaysia 27
Table 2.9: HIS Benefits and Issues of HIS Implementation 32
Table 2.10: Business Process (1996) and Business Interaction (1998)
(Adapted by Goldkuhl, 1998) 34
Table 2.11: TRA Variables 38
Table 2.12: Variables of Theory of Planned Behaviour (TPB) 41
Table 2.13: Variables of Technology Acceptance Model (TAM) 44
Table 2.14: Variables of TOE Framework 46
Table 2.15: Variables of DeLone and McLean IS Success Model 47
Table 2.16 Variable in UTAUT 49
Table 2.17: Examples of Evaluation Measures of the Proposed HOT-Fit
Framework 52
Table 2.18: Variables of Innovation of Diffusion Theory 55
xviii
Table 2.19: Variables Affecting HIS Implementation Based on Acceptance
Theories and Literatures 56
Table 2.20: Previous Studies on HIS 59
Table 2.21: Previous Studies of Factors Affecting HIS Implementation 62
Table 2.22: The Previous Studies Based on the Contexts of Technological,
Environmental and Human Contexts 66
Table 3.1: Procedures and Elements of the Research Onion 72
Table 3.2: Research Philosophies (adapted from Saunders et al., 2008) 73
Table 3.3: Differences of Deduction and Induction (adapted from
Saunders et al., 2009) 75
Table 3.4: Result of Preliminary Interviews 89
Table 3.5: Qualitative Codings (adapted from Neuman, 2012) 92
Table 3.6: Descriptions of Measurements for Quantitative Study 97
Table 3.7: Measurements of Questionnaires 98
Table 3.8: Returned Questionnaires in Each Categories of HIS’s Hospitals 100
Table 3.9: Cronbach’s Alpha Coefficient for Pilot Test Study
(adapted by George and Mallery, 2003) 102
Table 3.10: Pilot Test: Cronbach’s Alpha Result 102
Table 3.11: Test of Normality 105
Table 3.12: Test of Homogeneity of Variance 106
Table 4.1: Participants at Hospital A 112
Table 4.2: THIS Components and Descriptions 119
Table 4.3: Participants at Hospital B 145
Table 4.4: IHIS Components and Descriptions 153
Table 4.5: Participants at Hospital C 173
Table 4.6: BHIS Components and Descriptions 180
Table 4.7: Participants Responded on HIS Implementation Phases 196
Table 4.8: Vendor for Human Resource, Billing and Imaging in THIS’s
Hospital 197
Table 4.9: The HIS Components and Their Percentages of THIS,
IHIS and BHIS’s Hospitals 200
Table 4.10: HIS Implementation Phases at THIS, IHIS and BHIS’s hospitals 203
Table 4.11: The Activities in HIS Implementation Phases at THIS Hospital 204
xix
Table 4.12: The Activities in HIS Implementation Phases at IHIS and BHIS
Hospitals 205
Table 4.13: The Factors Affecting of HIS Implementation among THIS,
IHIS and BHIS’s Hospitals 207
Table 5.1: Gender of Respondents Among THIS, IHIS, and
BHIS’s Hospitals 216
Table 5.2: Age of Respondents in THIS, IHIS, and BHIS’s Hospitals 217
Table 5.3: Ethnicity of Respondents in THIS, IHIS, and BHIS’s
Hospitals 218
Table 5.4: Highest Academic Qualification of Respondents in THIS,
IHIS and BHIS’s Hospitals 219
Table 5.5: Working Position of Participants in THIS, IHIS and BHIS’s
Hospitals 220
Table 5.6: Working Experience of Respondents in THIS, IHIS and
BHIS’s Hospitals 221
Table 5.7: Working Department of Respondents in THIS, IHIS
and BHIS’s Hospitals 223
Table 5.8: Computer Training Attended Yearly in THIS, IHIS and
BHIS’s Hospitals 224
Table 5.9: Differences of Technological, Organisational, Environmental
and Human Contexts 226
Table 5.10: Differences of THIS, IHIS and BHIS’s Hospitals By
Technological, Organisational, Environmental and Human
Contexts 227
Table 5.11: Factors Affecting HIS Implementation under Technological
Context at Different Categories of HIS’s Hospitals 229
Table 5.12: Factors Affecting HIS Implementation under Organisational
Context at Different Categories of HIS’s Hospitals 231
Table 5.13: Factors Affecting HIS Implementation under Environmental
Context at Different Categories of HIS’s Hospitals 232
Table 5.14: Factors Affecting HIS Implementation under Human Context at
Different Categories of HIS’s Hospitals 233
Table 5.15: User Fulfilment under Human Context at Different Categories
of HIS’s Hospitals 233
xx
Table 5.16: Eta-Squared of Technological, Human and Organisational
Contexts 235
Table 6.1: The Activities in HIS Implementation Phases 240
Table 6.2: The Descriptions of THIS Implementation Model 252
Table 6.3: The Description of THIS and IHIS Implementation Model 255
xxi
LIST OF FIGURE
Figure 2.1: Four Pillars of National Transformation (Adapted from National
Economic Advisory Council, 2010) 15
Figure 2.2: Strategies to a Quality Healthcare & Active Healthy
Lifestyle 17
Figure 2.3: Components in Hospital Information System (HIS) (adapted from
Biomedical Informatics Ltd., 2006) 19
Figure 2.4: Business Action Theory: A Phase Model (adapted by
Goldkuhl, 1998) 35
Figure 2.5: Theory of Reasoned Action (Fishbein & Ajzen, 1975) 38
Figure 2.6. Theory of Planned Behaviour (TPB) adapted from
Ajzen (1985) 41
Figure 2.7: Technology Acceptance Model (TAM) adapted from
Davis (1986) 43
Figure 2.8 Technological-Organizational-Environmental Framework (TOE)
adapted from Tornatzky and Fleischer (1990) 45
Figure 2.9: DeLone and McLean IS Success Model (DeLone &
McLean, 1992) 47
Figure 2.10: Unified Theory of Acceptance and Use of Technology
Model (UTAUT) adapted from Venkatesh et al. (2003) 49
Figure 2.11: HOT-fit Model (Adapted from Yusuf et al., 2008) 51
Figure 2.12: Rogers’ Innovation Diffusion Theory Curve (adapted from
Rogers, 1995) 53
Figure 2.13: Diffusion of Innovation Model (adapted from Rogers, 1995) 54
Figure 2.14: Theoretical Framework of HIS in Malaysian public
hospitals 65
Figure 3.1: The Nested Approach (adapted by Kagioglou et al., 2000) 70
xxii
Figure 3.2: The Research Onion (adapted by Saunders et al., 2008) 71
Figure 3.3: Exploratory Sequential Design (Adapted from Creswell, 2012) 79
Figure 3.4: The Interview Sources Uploaded into the NVivo 93
Figure 3.5: Nodes created in NVivo 93
Figure 3.6: Data coded inNvivo 94
Figure 4.1: Percentage of HIS Components of THIS, IHIS and BHIS’s
Hospitals 201
Figure 4.2: The Types of HIS and Affected Factors to HIS Implementation 211
Figure 6.1: Diagram of THIS and IHIS/BHIS Implementation Phases 238
Figure 6.2: THIS Implementation Model 251
Figure 6.3: IHIS Implementation Model 254
xxiii
LIST OF SYMBOL AND ABBREVIATION
η2
-Eta-Squared
BCS -Business Continuity System
HIS -Hospital Information System
BHIS -Basic Hospital Information System
IHIS -Intermediate Hospital Information System
IS -Information System
MOH -Ministry of Health
NMRR -National Medical Research Register
THIS -Total Hospital Information System
UTHM -Universiti Tun Hussein Onn Malaysia
xxiv
LIST OF APPENDICES
APPENDIX TITLE PAGE
A Interview Guide 297
B Consent Letter 298
C Approval Letter 318
D Interview Data 321
E SPSS Result-Factor Analysis 332
F SPSS Result-Normality Data (Graphical) 331
G Survey Form 343
CHAPTER 1
INTRODUCTION
1.0 Introduction
This chapter begins with a general overview on healthcare sector in Malaysia. It
includes a problem statement, research questions, research objectives, significance of
study, scope of study and operational definitions. The structure of the thesis is also
presented at the end of this chapter.
In this study, Hospital Information System (HIS) is seen as an important national
agenda in the Malaysian healthcare system. Thus, an implementable model of HIS
needs to be developed to ensure that the HIS can be successfully executed in the near
future. Accordingly, this study focuses on the development of an implementation model
for HIS in Malaysian public hospitals.
1.1 Healthcare Background in Malaysia
Healthcare sector remains a significant indicator of quality of life of a nation. Therefore,
each country continuously striving to improve their healthcare sector by enhancing the
healthcare management, services and treatments.
2
In Malaysia, the healthcare sector is divided into three (3) categories which are
public healthcare, Non-Governmental Organisation (NGO) healthcare and private
healthcare (Ministry of Health, 2011; Rasiah, 2011). Under each category, there are
hospitals and clinics. Public hospitals and clinics are administered by Malaysian
Ministry of Health (MOH) to serve the public, while the NGO hospitals such as
Hospital Universiti Kebangsaan Malaysia and Hospital Universiti Sains Malaysia are
administered by universities to serve the university students and staff. The private
hospitals and clinics, however, are administered by private bodies such as Pantai
Holdings Berhad. Evidently, the public healthcare is the most important healthcare
category in Malaysia because it has the largest number of hospitals and patients.
Improving national healthcare has been always a priority agenda since 6th
Malaysian Plan (MP) but only in the 10th
MP, the Malaysian Government launced
several initiatives under Ministry of Health (MOH) to enhance Information Technology
(IT) applications in public hospitals. Such initiatives are to ensure that public hospital
services become faster, manageable and efficient, for example by implementing Hospital
Information System (HIS) in Malaysian public hospitals. Therefore, this study focused
on issues related to HIS implementation among public HIS‘s hospitals.
1.2 Problem Statement
Even though the Malaysian Government has played an important role to support the
Public Healthcare especially the public hospitals, there are several pressing issues. Most
of these issues are about the services provided by the hospitals.
According to Saari (2007) and Wee & Jomo (2007), the government hospital
services are slow and inefficient where the patients need to wait for a long time to get
their medical treatments. Pillay et al. (2011) claimed that the average waiting time from
registration to getting the prescription slip is more than two hours in his study at
Malaysian public hospitals.
Moreover, according to Ministry of Health (2012), the average negligence cases
reported by the medical staffs are between five to eight cases a month and the number of
negligence cases which reportedly in public hospitals in year 2000 to 2008 has increased
3
to 144 cases with 61.9% from the total cases are bought to court (Ministry of Health,
2012). In addition, public hospitals faced with increasing cost of healthcare expense
every year in Malaysia (Ahmadi et al., 2015). For example, RM 6,348,632.28 was spent
on compensation cost for medical negligence cases from year 2000 to May 2009
(Bernama, 2009). Root cause of these cases often arised from large numbers of patients
to be nursed at once and administrative tasks. The implementation of HIS is aimed to
reduce these common management problems in public hospitals. Therefore, Malaysian
Government has enhanced the healthcare quality and reduce the cost (Lee & Ramayah,
2012).
However, HIS implementation is not encouraging in where level of adoption of
HIS is only 60% to 78% worldwide (Hsiao & Hing, 2012, Artmann et al., 2010). This
might caused by different phases of HIS implementation in different categories of
Hospital (Houser, 1984; Rossi et al., 2009). According to Malaysian Ministry of Health
(2012), only 21 out of 138 or 15.2% of Malaysian Public Hospitals has implemented
HIS. From 21 public hospitals that had implemented HIS, 7.8% is categorized as THIS,
1.4% as IHIS and 7.2% as BHIS.
Conversely, several factors have been claimed to influence HIS implementation
for example high initial cost (Boonstra & Broekhuis, 2010; Smelcer et al., 2009), high
initial physician time (Smelcer et al., 2009; Ganesh & Al-Mujaini, 2009), technology
and technical matters (Boonstra & Broekhuis, 2010), lack of skills (Boonstra &
Broekhuis, 2010) and ethical issues (Boonstra & Broekhuis, 2010; McKenzie & Kelly,
2002).
Similarly, Ahmadi et al. (2015) and Sulaiman & Wickramasighe (2014) found
various factors affecting HIS implementation which could be delineated under the
contexts of Technology, Organisation and Environment as proposed by TOE Framework
(Tornatzky & Fleischer, 1990). Majority of these studies focused on THIS hospitals
alone whereby existence of other factors unique to different categories of HIS could not
be unearted. In addition, most of these studies are quantitative in nature.
Moreover, there are limited empirical studies on HIS in Malaysia. Most of these
empirical studies only focused on implementation of THIS alone (Abdul Hamid, 2010;
Ibrahim, 2007; Ismail et al., 2010; Abdullah, 2012; Mohd. Yusof et al., 2008; Hassan,
4
2012; Fadhil et al., 2012; Ismail & Ali, 2013; Mohd Amin et al., 2011; Mohamad Yunus
et al., 2013), while others focused on Electronic Medical Records (EMR) since it was
synonym with the HIS (Mohd & Syed Mohamad, 2005; Syed Mohamad et al., 2008;
Nik Ariffin et al., 2010). None has studied the implementation of HIS in different
categories of HIS in public hospitals. Lack of such study would limit our understanding
on how to encourage HIS implementation in Malaysian Public Hospitals. This is
because, most studies discuss HIS for one specific HIS category without integration and
combination other categories of HIS.
1.3 Research Questions
The above of problem statements have led to three research questions as follows:
(i) RQ1: How is HIS being implemented at THIS, IHIS and BHIS‘s hospitals?
(ii) RQ2: What are factors affecting the HIS implementation at THIS, IHIS and
BHIS‘s hospitals?
(iii) RQ3: Is HIS implementation model similar across different categories of HIS‘s
hospitals?
1.4 Research Objectives
Based on the research questions above, three research objectives have been formulated
as follows:
(i) RO1: To explore HIS implementation at THIS, IHIS and BHIS‘s hospitals.
(ii) RO2: To explore factors affecting HIS implementation at THIS, IHIS and
BHIS‘s hospitals.
(iii) RO3: To test HIS implementation model across different categories of HIS‘s
hospitals.
5
1.5 Significance of Study
This study contribute to the body of knowledge and fill in the existing literatures gap on
HIS implementation of HIS at different categories of HIS‘s hospitals using mixed
methods approach based on limited qualitative studies of HIS and limited empirical
studies in IHIS and BHIS‘s hospitals in Malaysia.
The HIS implementation model incorporating its implementation phases and
factors affecting it might be used as a guide to refine, improve and enhance the HIS
implementation at different categories of HIS‘s hospitals in future.
Consequently, this study provides empirical data of HIS implementation to give
an in-depth understanding to Ministry of Health (MOH), healthcare sectors, HIS users
and HIS vendors on implementation of different categories of HIS in Malaysian Public
Hospitals. In addition, this study is signicant to the hospitals to overcome their services
especially the longer waiting time and negligence cases towards the patients.
1.6 Scope of the Study
This study focuses on the implementation of Hospital Information System (HIS) in
Malaysian Public Hospitals at Total Hospital Information System (THIS), Intermediate
Hospital Information System (IHIS) and Basic Hospital Information System (BHIS).
This is because, Abdul Hamid (2010), Ismail et al. (2010), Mohd. & Syed Mohamad
(2005) and Syed Mohamad (2008) have categorised HIS into three categories: THIS,
IHIS and BHIS. Thus, this study included hospitals in each category to provide deeper
insight.
This study used two models which are Business Interaction of BAT (Goldkulh,
1998) to provide framework for understanding HIS implementation phases, and the TOE
framework (Tornatzky & Fleischer, 1990) to understand factors affecting the HIS
implementation at different categories of HIS‘s hospitals. The participants for
qualitative phase were chosen among the hospital directors, Physicians, Information
Technology (IT) officers and HIS users. While, quantitative phase was conducted
6
among HIS users to determine factors affecting the HIS implementation at different
categories of HIS‘s hospitals.
1.7 Operational Definition
Operational definition remains important in giving clear definitions of major
terminologies, especially to avoid an uncertainty in understanding the information
contains along the study, as follows:
Development – The process of starting to experience of creating something over a period
of time.
Implementation - Implementation is efforts, including the phases and stages which are
applied to be develop a new innovation to accomplish an objective in an Organisation.
Model - A structure of of ideas or facts that provide support as an example to follow or
imitate.
Information Technology - Technologies, techniques and equipments of computers and
electronic devices used by people to acquire, store, retrieve, evaluate, distribute and
exchange the data and information in Organisations.
Information System - Information System (IS) is a system designed to work with
electronic devices like computers to collect, record, process, store, retrieve and display
information and to attain an objective by an Organisation
Hospital Information System (HIS) - HIS refered to an integrated electronic systems
that collect, store, retrieve and display overall patients‘ data and information such as
history of patients‘ information, results of laboratory test, diagnoses, billing and others
related hospital‘s procedures which are used in several departments within the hospitals
7
Public Hospitals - Public Hospitals refered to the hospitals administered by Malaysian
Government under Malaysian Ministry of Health.
Total Hospital Information System - Total Hospital Information System is an integrated
systems under the HIS which is brings a complete Information System to be linked or
connected in every departments within the hospitals to achieve paperless hospitals.
Intermediate Hospital Information System - Intermediate Hospital Information System
is an integrated system under the HIS which is brings half or intermediate set of
integrated systems of what the THIS have to be linked or connected in several
departments within the hospitals.
Basic Hospital Information System - Basic Hospital Information System is an
integrated system under the HIS which is brings a basic or least set of integrated systems
of what the IHIS have to be linked or connected in several departments within the
hospitals.
1.8 Structure of the Thesis
This study has seven chapters. Each chapter has its own contents which relates to the
implementation of HIS in Malaysian Public Hospitals. Thus, the contents had been
identified as follows: Introduction, Literature Review, Research Methodology, Data
Analysis, Qualitative Findings, Quantitative Findings and Conclusion.
Chapter 1 introduces the overall study. It includes the general introduction, background
of problem, problem statement, research questions, research objectives, significance of
study, limitation of study, operational definitions and structure of the thesis
Chapter 2 discusses the literature review. It provides background of healthcare in
Malaysia, HIS in Malaysia, acceptance theories of IS and previous HIS study in
Malaysia. It provides an understanding of the HIS implementation based on previous
8
conceptual and empirical HIS studies. In addition, a theoretical framework was
developed as interview guide for data collection process.
Chapter 3 explaines the research methodology. This chapter had been divided into two
phases which are qualitative and quantitative research, as this study employed mixed
methods. Both phases are includes the research method and data collection techniques
used in this study.
Chapter 4 describes the qualitative findings. These findings are divided into three case
study as follows: Case Study 1: Total Hospital Information system (THIS), Case study
2: Intermediate Hospital Information system (IHIS) and Case Study 3: Basic Hospital
Information System (BHIS). These findings have meets the research objectives number
1, 2 and 3 based on interview data.
Chapter 5 describes the quantitative findings. These findings were analysed to test and
confirm the qualitative findings. These findings have meets the research objectives
number 4 based on survey data.
Chapter 6 describes discussions. It provides the discussions of both qualitative and
quantitative findings, as well as research contribution based on this study.
Chapter 7 describes conclusion and recommendation. It provides the conclusion on
HIS implementation in Malaysian public hospitals, as well as recommendations or
suggestions.
9
CHAPTER 2
LITERATURE REVIEW: IMPLEMENTATION OF HOSPITAL
INFORMATION SYSTEM (HIS) IN MALAYSIAN PUBLIC HOSPITALS
2.0 Introduction
Literature review is an important part in conducting a research. Its main purposes are to
develop a deeper understanding of a research topic and to widen a researcher‘s
knowledge base of the study. This chapter presents a literature review of the
implementation of Hospital Information System (HIS). This review is important to
compare and critique the available information, which will provide guidance and support
for the current research; the sources of these relevant data are related articles, research
papers, conference papers, seminar papers, seminar handouts, journals and books from
all over the world.
Discussions of this chapter centre around three important areas essential to this
section. The first area introduces healthcare in Malaysia, and healthcare transformation
which encompasses history, implementation as well as associated issues and challenges
in Malaysia and abroad. The second area explains the nature and characteristics of HIS
and its components, development and implementation phases. The third area discusses
related theories and previous studies.
10
2.1 Healthcare in Malaysia
All sectors of the healthcare system are pivotal and beneficial to the welfare of the
Malaysian citizens. The overall healthcare system provides them with medical
treatments for a better quality of life. According to the Department of Statistics,
Malaysia (2015), there are 30.73 million of Malaysian population, in year of 2015. The
population growth is 81.40 percent compared to last year.
This statistics clearly indicated that more than 30 millions of Malaysian citizens
might be using healthcare services. Healthcare services are offered by both public
hospitals, private hospitals and NGO‘s hospitals (Ministry of Health, 2014). Table 2.1
shows the numbers of patients admission in different categories of hospitals. The total
number of admissions in the public hospitals is 2,110,628 patients compared with
1,020,397 patients in private hospitals. These statistics show huge numbers of patient
admissions in Malaysian public hospitals. Clearly, public hospitals have the largest
numbers of patients admission. Table 2.1 proves that the public healthcare sector is the
citizens‘ priority to seek medical treatments.
Table 2.1 Total Number of Patient Admissions (Adapted from Ministry of Health
Malaysia, 2015)
State
Public Sector
Private Sector
Total
Admission Hospital Special
Medical
Institution
Non-MOH
Perlis 33,618 - - - 33,618
Kedah 194,799 - - 49,076 243,875
Pulau Pinang 129,432 - - 165,407 294,839
Perak 229,990 2,405 3,633 90,643 326,671
Selangor 355,803 78 - 315,673 671,554
W.P. Kuala
Lumpur
128,595 3,628 100,501 168,400 401,124
W.P. Putrajaya n.a 2,929 - - 2,929
W.P. Labuan 7,432 - - - 7,432
Negeri Sembilan 112,215 - 337 50,973 163,525
Melaka 83,885 - 3,354 60,112 147,351
Johor 318,154 1,315 - 91,584 410,910
Pahang 152,039 0 - 18,117 170,156
Terengganu 132,894 0 - 2,859 135,753
Kelantan 137,664 0 40,420 17,968 196,052
Sabah 196,502 47,412 205 13,748 257,766
Sarawak 194,100 573 - 38,641 233,258
Malaysia 2,407,122 58,040 148,450 1,083,201 3,696,813
11
According to the Ministry of Health Malaysia (2015), there were 35,318 beds in
the 138 public hospitals in Malaysia. The number was higher compared to the 13,038
beds in 184 private hospitals in Malaysia. The Bed Occupancy Rate (BOR) and Total
Patient Days (TOD) has increased from 2011 to 2012 in all types of public hospitals
except the medical institutions.
Table 2.2: Bed Occupancy Rate (BOR) and Total Patient Days (TOD) (Adapted
from Ministry of Health Malaysia, 2012) Type of
Hospital by
Functional
Classification
Bed Occupancy
Rate (BOR) %
Average Length
of Stay (ALOS)
Days
Turn Over
Internal (TOI)
Total Patient Days
(TOD)
2011 2012 2011 2012 2011 2012 2011 2012
Hospital
Kuala
Lumpur and
State Hospital
79.71 81.28 4.40 4.3 1.21 0.99 3,574,879 3,876,589
Major
Specialiast
Hospital
75.61 76.16 2.41 3.79 1.39 1.19 2,679,046 2,996,244
Minor
Specialist
Hospital
53.00 57.71 3.10 3.13 3.77 2.3 733,481 727,288
Non-
Specialist
Hospital
47.30 46.98 2.77 2.73 3.84 3.09 943,377 930,006
Specialist
Medical
Institution
66.08 78.62 204.1 23.9 78.7 6.5 1,124,519 1,244,779
All these statistics show that the numbers of patients increases every year,
especially in public hospitals. This increasing demand for medical services has exerted
pressure on the public hospitals. Consequently, there are several issues faced by the
Malaysian public hospitals related to their care and services. These includes inequity in
access to health services, inappropriate interventions and treatments as demanded by
patients or induced by providers, varying quality and standards of care and costs
insufficient number of experienced specialists, limited or imbalanced medical facilities
and workload complexity due to the increasing number of patients (Ministry of Health,
2012).
The above statistics and information indicate that the public healthcare sector
plays a more prominent role compared to the private healthcare. The public healthcare
12
sector appears to become more complex since be serves patients twenty four hours a
day.
2.1.1 Malaysian Public Hospitals
The increasing numbers of patients seeking treatments from public hospitals caused
more public hospitals to be built from year to year. For example, there are 135
Malaysian public hospitals in 2010 (Ministry of Health Malaysia, 2012). However, as to
June 2015, there are 138 public hospitals in Malaysia (Ministry of Health, 2015). The
hospitals are located in every state and city within the country as shown in Table 2.3.
These public hospitals are divided into two categories: (1) Specialist Hospital and
Institutions and (2) Non-specialist Hospitals.
13
Table 2.3: Categories and Lists of Malaysian Public Hospitals (Adapted from
Ministry of Health Malaysia, 2015)
Specialist Hospitals and Institution
State Hospitals Major Specialist
Hospitals
Minor Specialist
Hospitals
Special Medical
Institutions
1. Hospital Kuala
Lumpur
2. Hospital Tuanku
Fauziah, Kangar
3. Hospital Sultanah
Bahiyah, Alor
Setar
4. Hospital Pulau
Pinang
5. Hospital Raja
Permaisuri Bainun,
Ipoh
6. Hospital Tengku
Ampuan Rahimah,
Klang
7. Hospital Tuanku
Jaafar, Seremban
8. Hospital Melaka
9. Hospital Sultanah
Aminah, Johor
Bahru
10. Hospital Tengku
Ampuan Afzan,
Kuantan
11. Hospital Sultanah
Nur Zahirah, Kuala
Terengganu
12. Hospital Raja
Perempuan Zainab
II, Kota Bharu
13. Hospital Umum
Sarawak, Kuching
14. Hospital Queen
Elizabeth, Kota
Kinabalu
1. Hospital Putrajaya
2. Hospital Sultan
Abdul Halim,
Sungai Petani
3. Hospital Kulim
4. Hospital Seberang
Jaya
5. Hospital Taiping
6. Hospital Teluk Intan
7. Hospital Sungai
Buloh
8. Hospital Ampang
9. Hospital Selayang
10. Hospital Serdang
11. Hospital Kajang
12. Hospital Tuanku
Ampuan Najihah,
Kuala Pilah
13. Hospital Pakar
Sultanah Fatimah,
Muar
14. Hospital Sultan
Ismail, Pandan
15. Hospital Sultanah
Nora Ismail, Batu
Pahat
16. Hospital Segamat
17. Hospital Sultan Haji
Ahmad Shah,
Temerloh
18. Hospital Kemaman
19. Hospital Kuala Krai
20. Hospital Sibu
21. Hospital Miri
22. Hospital Bintulu
23. Hospital Duchess of
Kent, Sandakan
24. Hospital Tawau
25. Hospital Queen
Elizabeth II, Kota
Kinabalu
26. Hospital Tanah
Merah
1. Hospital Labuan
2. Hospital Langkawi
3. Hospital Kepala
Batas
4. Hospital Bukit
Mertajam
5. Hospital Sri
Manjung
6. Hospital Slim
River
7. Hospital Grik
8. Hospital Kuala
Kangsar
9. Hospital Banting
10. Hospital Port
Dickson
11. Hospital Kluang
12. Hospital Kota
Tinggi
13. Hospital Kuala
Lipis
14. Hospital Bentong
15. Hospital Pekan
16. Hospital Kapit
17. Hospital Limbang
18. Hospital Sarikei
19. Hospital Sri Aman
20. Hospital Datin Seri
Endon Lahad Datu
21. Hospital Keningau
22. Hospital Beaufort
23. Hospital Kota
Marudu
24. Hospital Wanita
dan Kanak-Kanak,
Likas
25. Hospital Dungun
26. Hospital Tampin
27. Hospital Mukah
1. Institut
Perubatan
Respiratori,
Kuala Lumpur
2. Pusat Darah
Negara, Kuala
Lumpur
3. Pusat Kawalan
Kusta Negara,
Sungai Buloh
4. Hospital
Bahagia, Ulu
Kinta
5. Hospital Permai,
Johor Bahru
6. Hospital Mesra,
Kota Kinabalu
7. Hospital
Sentosa,
Kuching
8. Hospital Wanita
& Kanak-Kanak
Likas
9. Hospital
Rehabilitasi
Cheras
14
The Specialist Hospitals and Institutions are further categorised as follows: State
Hospitals, Major Specialist Hospitals, Minor Specialist Hospitals, and Special Medical
Institutions. In total, there are 71 specialist hospitals and institutions in the Malaysian
public healthcare system (Ministry of Health, 2015).
Non-Specialist Hospitals
1. Kedah
a. Hospital Baling
b. Hospital Jitra
c. Hospital Kuala
Nerang
d. Hospital Sik
e. Hospital Yan
f. Pulau Pinang
g. Hospital Balik
Pulau
h. Hospital Sungai
Bakap
i. Perak
j. Hospital Batu
Gajah
k. Hospital
Changkat
Melintang
l. Hospital Kampar
m. Hospital Parit
Buntar
n. Hospital Selama
o. Hospital Sungai
Siput
p. Hospital Tapah
q. Selangor
r. Hospital Kuala
Kubu Baru
s. Hospital Tanjung
Karang
t. Hospital Tengku
Ampuan Jemaah,
Sabak Bernam
2. Negeri Sembilan
a. Hospital Jelebu
b. Hospital Jempol
c. Hospital Tampin
3. Melaka
a. Hospital Alor
Gajah
b. Hospital Jasin
4. Johor
a. Hospital Mersing
b. Hospital Pontian
c. Hospital Tangkak
d. Hospital
Temenggong Sri
Maharaja Tun
Ibrahim, Kulai
5. Pahang
a. Hospital Jengka
b. Hospital Jerantut
c. Hospital Muadzam
Shah
d. Hospital Raub
e. Hospital Sultanah
Hajjah Kalsom,
Cameron
Highlands
6. Terengganu
a. Hospital Besut
b. Hospital Dungun
c. Hospital Hulu
Terengganu
d. Hospital Setiu
7. Sarawak
a. Hospital Bau
b. Hospital Betong
c. Hospital Daro
d. Hospital Dalat
e. Hospital Kanowit
f. Hospital Lawas
g. Hospital Lundu
h. Hospital Marudi
i. Hospital Rajah
Charles Brooke
Memorial,
Kuching
j. Hospital Saratok
k. Hospital Serian
l. Hospital
Simunjan
8. Kelantan
a. Hospital Gua
Musang
b. Hospital Jeli
c. Hospital
Machang
d. Hospital Pasir
Mas
e. Hospital Tengku
Anis, Pasir Puteh
f. Hospital Tumpat
9. Sabah
a. Hospital
Beluran
b. Hospital
Kinabatangan
c. Hospital Kota
Belud
d. Hospital Kuala
Penyu
e. Hospital Kudat
f. Hospital Kunak
g. Hospital Papar
h. Hospital Pitas
i. Hospital Ranau
j. Hospital
Semporna
k. Hospital
Sipitang
l. Hospital
Tambunan
m. Hospital Tenom
n. Hospital Tuaran
15
2.2 Healthcare Services and Transformation in Malaysia
Vision 2020 is to gear Malaysia to become a developed country not only in terms of
economic but also political, social, spiritual, psychological and cultural (Ministry of
Health Malaysia, 2012). It is expected to form a national unity and social cohesion in
terms of economy, social justice, political stability, system of government, quality of
life, social and spiritual values, national pride and confidence (Ministry of Health
Malaysia, 2012). Four pillars of National Transformation have been developed to guide
the nation to achieve its Vision 2020 (National Economic Advisory Council, 2010).
These pillars are:
(i) 1Malaysia
(ii) Government Transformation Programme (GTP)
(iii) Economic Transformation Programme (ETP)
(iv) Tenth Malaysia Plan
Figure 2.1: Four Pillars of National Transformation (Adapted from National
Economic Advisory Council, 2010)
16
According to Prime Minister Office (2011), Economic Transformation
Programme (ETP) Plan which is in tandem in New Economic Model (NEM) is driven
by eight Strategic Reform Initiatives (SRIs) to strengthen twelve areas of National Key
Economic Areas (NKEAs) as shown in Table 2.4.
Table 2.4: Strategic Reform Initiatives (SRIs) and National Key
Economic Areas (NKEAs) (Adapted from Prime Minister Office, 2011)
SRIs NKEA
i) Re-energising the private sector
ii) Developing quality workforce
iii) Competitive domestic economy
iv) Strengthen the public sector
v) Transparent and Market-friendly
Affirmative Action
vi) Building knowledge based information
vii) Enhance sources of growth
viii) Ensuring sustainability of growth
i) Oil, gas and energy
ii) Palm oil and rubber
iii) Financial services
iv) Tourism
v) Business services
vi) Electronics and electrical
vii) Wholesale and retail
viii) Education
ix) Healthcare
x) Communications content and
infrastructure
xi) Agriculture
xii) Greater Kuala Lumpur/Klang Valley
As shown in the Table 2.4, healthcare has been identified as one of National Key
Economic Areas (NKEAs) among the twelve sectors. All these NKEAs are to propel
Malaysia‘s future growth by executing Strategic Reform Initiatives (SRIs).
Healthcare as one of NKEAs has been prioritize in the development of
Malaysian Plans, particularly in the Tenth Malaysia Plan (MP). The Tenth MP signifies
the beginning of healthcare transformation in Malaysia in the context of integrating
healthcare information system.
According to Prime Minister Office (2010), there are four key areas under the
healthcare sector in the Tenth MP which are: (1) transforming delivery of the healthcare
system, (2) increasing quality, capacity and coverage of the healthcare infrastructure, (3)
shifting towards wellness and disease prevention rather than treatment, and (4)
increasing the quality of human resource in terms of health. In addition, six National
Strategic Directions have been formulated identified to support the Tenth Malaysian
Plan (Prime Minister Office, 2010) as follows:
17
•Establish a comprehensive healthcare system & recreational infrastructure
Strategy 1
•Encourage health awareness & healthy lifestyle activities Strategy 2
•Empower the community to plan or implement individual wellness programme (responsible for own health)
Strategy 3
•Transform the health sector to increase the efficiency and effectiveness of the delivery system to ensure universal access
Strategy 4
(i) Competitive Private Sector as the Engine of Growth
(ii) Productivity and Innovation through K-economy
(iii) Creative and Innovative Human Capital with Twenty-first Century Skills
(iv) Inclusiveness in Bridging Development Gap
(v) Quality of Life of an Advanced Nation
(vi) Government as an Effective Facilitator
Quality of Life of an Advanced Nation is further delineated into Quality
Healthcare and Active Healthy Lifestyle with their subsequent strategies as shown in
Figure 2.2.
Figure 2.2: Strategies to Quality Healthcare and Active Healthy Lifestyle
(Adapted from Ministry of Health, 2013)
According to the Ministry of Health Malaysia (2013) in Health Country Plan:
Tenth Malaysia Plan, three KRAs for the health sector have been identified from these
strategies, namely Health Sector Transformation towards a More Efficient and Effective
Health System in Ensuring Universal Access to Healthcare (KRA 1), Health Awareness
and Healthy Lifestyle (KRA 2), and Empowerment of Individual and Community to be
responsible for their health (KRA 3) as shown displayed in Table 2.5.
18
Table 2.5: Key Research Areas (KRAs) for Health Sector (Adapted from
Ministry of Health Malaysia, 2013)
Health Sector Transformation
Towards A More Efficient &
Effective Health System in
Ensuring Universal Access to
Healthcare (KRA 1)
Health Awareness & Healthy
Lifestyle (KRA 2)
Empowerment of Individual and
Community to be responsible for
their health (KRA 3)
(i) Streamline/ realign
healthcare delivery system
(ii) Unified healthcare financing
system
(iii) Common quality and
standard of care
(iv) Adequate and competent
workforce
(v) Strengthening healthcare
legislation and enforcement
(vi) Strengthening
implementation, monitoring
and evaluation system
(vii) ICT as enabler
(i) Increase access to health
knowledge
(ii) Motivate individuals, family
and community to acquire
knowledge and skill
(iii) Increase opportunities to
practice healthy lifestyle at
workplace, schools, home etc.
(iv) Formulate and enforce public
policy towards healthy
lifestyle
(i) Strategies to increase health
literacy
(ii) Provision of health information,
including cost of care and
governance policies
(iii) Providing avenues for effective
complaints or enquiries
regarding health providers
(iv) Mobilize civil society (NGOs,
support groups, community
leaders)
As shown in table 2.5, KRA 1 highlighted ICT as enabler, which are further
translated into several initiatives including introduction of HIS in Malaysian public
hospitals.
2.3 Hospital Information System (HIS)
Hyung-Joon et al. (2004) defined HIS as a system focusing on the integration of clinical
applications collectively with financial and administrative functions to increase service
efficiency. Winter & Haux (1995) and Fang et al. (2007) defines HIS as all the
information processing activities within a certain hospital, including the information
processing tools used to contribute to high-quality patient care and medical research.
Ibrahim (2007), claimed that HIS is a systematic integrated system within the hospital
that enable patient registration, medical charting and review, appointment handling
management, drug prescribing and dispensing, X-ray images storage and management,
automatic bill changing, laboratory ordering and reporting, inventory and store
management, and other routine processes and workflow. Fang et al. (2007) claim that
the system is supported with information sharing between hospitals, doctors, patients
19
Hospital Information
System (HIS) Components
Clinical Information
System (CIS) Financial
Information System (FIS)
Laboratory Information
System (LIS)
Nurse Information
System (NIS)
Pharmacy Information
System (PIS)
Picture Archiving
Communication System (PACS)
Radiology Information
System (RIS)
and administrations. All these definitions implied that HIS must be integrated within the
hospital and have several components to improve hospital efficiency. In Malaysia, HIS
is defined as an integrated system or components uses within the hospital (Suleiman,
2008).
2.3.1 Components of Hospital Information System (HIS)
Biomedical Informatics Ltd. (2006) reported that HIS consists of two or more of these
components: Clinical Information System (CIS), Financial Information System (FIS),
Laboratory Information System (LIS), Nursing Information System (NIS), Pharmacy
Information System (PIS), Picture Archiving Communication System (PACS) and
Radiology Information System (RIS) as shown in Figure 2.3.
Figure 2.3: Components in Hospital Information System (HIS) (adapted from
Biomedical Informatics Ltd., 2006).
20
These components of HIS are differentiated by their core functions, departments
that used them and type of users as shown on Table 2.6.
Table 2.6: Differences of HIS Components
HIS
component Core Functions
Differences
Departments Type of
Users
Clinical
Information
System (CIS)
A computer-based system designed for collecting, storing,
manipulating, and making clinical information accessible
to the healthcare delivery process. It is also defined as
computer-supported applications with a relatively large
and long-term database containing clinical data that are
used to assist in the management of patient care (Blum,
1986). A CIS may be limited in extent to a single area
(e.g. laboratory systems and ECG management systems)
or it may be more widespread and include virtually all
aspects of clinical information (e.g. electronic medical
records). Used by doctors and nurses in a clinical
department.
Clinical Doctors,
Nurses
Financial
Information
System (FIS)
A computer system that manages the business aspects of a
hospital such as payroll, patient accounting, accounts
payable, accounts receivable, general ledger, fixed asset
management, claims management and contract
management. It used by accountants of finance
departments in hospitals.
Financial Accountants
Laboratory
Information
System (LIS)
A computer information system that manages laboratory
information for all the laboratory disciplines such as
clinical chemistry, haematology, and microbiology. It
provides modules for sending laboratory test order to the
instruments through its multiple instrument interfaces
tracks those orders and then captures the results as soon as
they become available. The results can then be analysed
and a report is generated. It used in a laboratory by
laboratory officers.
Laboratory Lab officers
Nursing
Information
System (NIS)
A computer systems that manage clinical data from a
variety of healthcare environments, which are then
available in a timely and orderly to aid nurses in
improving patient care at wards.
Ward, clinics Nurses,
Doctors
Pharmacy
Information
System (PIS)
It consists of complex computer systems that are designed
to meet the needs of a pharmacy department. Through the
use of such system, pharmacists can supervise and store
inputs on how medication is used in a hospital. It assists in
providing patient care by monitoring drug interactions,
drug allergies and other possible medication-related
complications.
It used by the pharmacists at pharmacy department.
Pharmacy Pharmacists
21
In Malaysia, the different categories of HIS have different components as shown
in Table 2.7. Hence, Suleiman (2008) explained the various IS components involved in
THIS, IHIS and BHIS shown in Table 2.7. THIS has all the features of the complete
HIS, while IHIS and BHIS have the essential components of HIS. THIS is also called
paperless hospitals in Malaysia.
Table 2.7: The components of HIS in Malaysia
2.4 Development of Hospital Information System (HIS)
In the 1960s, a physician named Lawrence L. Weed first expressed the idea of
computerised or electronic medical records when he introduced the concept of the
Problem Oriented Medical Information System (PROMIS) into medical practice at the
University of Vermont (Weed, 1964; Weed & Zimny, 1989). In 1967, the development
of an automated system started. Later, in 1970, the Problem-Oriented Medical Record
(POMR) was used in a medical ward of the Medical Centre Hospital of Vermont for the
first time, including a touch screen technology (Goldberg, 1988; Lee et al., 2009).
Picture
Archiving
Communicati
on System
(PACS)
A set of systems that facilitate the archiving, processing
and viewing of digital radiological images and their
related information. The images are acquired, archived
and retrieved over a network for diagnosis and review by
physicians. These images can be interpreted and viewed at
workstations, which can also double up as archive stations
for image storage. It used in the x-ray and imaging
department of a hospital.
Imaging Imaging
Officers
Radiology
Information
System (RIS)
A computer system that assists radiology services in the
storing, manipulation and retrieving of information. The
function of an RIS is to manage and store radiology
information. The system is used by radiologists. It used
by radiologists at radiology department.
Imaging Radiologists
Total Hospital Information
System (THIS)Basic
Intermediate Hospital
Information System (IHIS)
Hospital Information System
(BHIS)
IHIS + Radiology + PACS +
administration + Financial +
Inventory + Personnel
Information System
Integration of BHIS + Laboratory
+ Pharmacy Information System
Patient Management System +
Clinical Information System
22
Other examples of HIS for the early inpatient care systems are the Hospital-
Based Technical System, Harvard‘s Computer-Stored Ambulatory Record (COSTAR)
system for ambulatory care and Health Evaluation Through Logical Processing (HELP)
system (Zielstorff et al., 1985; Soini & Tolppanen, 1982; Lumsdon, 1993; Gardner &
Lundgaarde, 1994).
Although the concept was widely spreading in the medical practice, physicians
initially were not attracted to the technology due to integration problem (Starfield et al.,
1976). Furthermore, Subjective and Objective observation, Assessment and Plan
(SOAP) could be inappropriately complex for simple patient care problems and in some
instances, Problem-Oriented Medical Record (POMR) did little to organise the narrative
and confusing note keeping of the healthcare professionals (Switz, 1976).
Today, the HIS implementation has wide spreading around the globe. For
example, the United Kingdom employed Health Information Technology (HIT)
(Detmer, 2000), United States, Canada, United Kingdom (UK), Germany, Netherlands,
Australia, and New Zealand employed Electronic Health Record (EHR) (Jha et al.,
2008; Inokuchi et al., 2014; Protti et al., 2009), Switzerland employed DIOGENE (Borst
et al., 1999; Breant et al., 2000), Germany employed Smart-Card Technology, Taiwan
employed Taiwan‘s Bureau of National Health Insurance (TBNHI) smart card (Liu et
al., 2006), Japan employed electronic medical records (EMR), New Zealand employed
E-Health (Otieno et al., 2008), Spain employed Diraya (Protti et al., 2009) and Denmark
employed Medcom (Protti et al., 2009).
However, the rate of HIS implementation in developing countries is slower than
that of the developed countries. This is because the planning and implementation of HIS
began late in most developing countries. However, the HIS is implemented widely in
most developing countries such as Greece, Indonesia and China.
The Greek government introduced HIS in the country about 18 years ago to
change the healthcare and patient management in the hospitals (Zikos et al., 2009). The
Greek version of HIS is known as Hospital Information System Implementation
Assessment Tool (HIS.I.A.T) (Zikos et al., 2009). HIS has also been developed and
implemented in Indonesian hospitals to improve the healthcare services as the system
becomes popular in other countries. Thus, in 2005, an Indonesian version of HIS,
23
namely SIRS was implemented in RAA Soewondo Hospital (Hidayanto et al., 2012).
Hence, the Indonesian Government programmes through its Ministry of Health launched
the electronic health (e-health) in 2011 (Hayani et al., 2013). All hospitals are required
to have HIS for health care. Until 2012, there were six teaching hospitals that have
implemented HIS. China‘s hospital information systems have been progressively
developed over the last twenty years to provide the essential support for medical care
(Fang et al., 2007). This is because HIS is one of the requirements in modern hospitals
that enables information-sharing within a hospital and with users. HIS in China is
separated into two parts, the management information system to manage administrative
requirements and the clinical information system to manage clinical requirements (Rao,
2008).
In a nutshell, the HIS has been applied in both developed and developing
countries as it benefits to the hospital environment and patients in enhancing healthcare
quality and services, although it has different terms using in different countries. Thus,
any study of HIS implementation need to explore issues related to HIS implementation
phases.
2.5 Hospital Information System (HIS) Implementation Phases
The HIS implementation phases remains important to systematic procedures planning to
attain optimum efficiency of system functions. This is to ensure proper functioning of
the system when it is used by the hospital staff.
Houser et al. (1984) indicated that the HIS implementation process is divided into
three phases, namely preparatory activities for system implementation, certification and
acceptance testing, and system implementation as explained below:
(i) Preparatory Phase
In this phase, the site preparation needs to be arranged. In this area, the determination of
specifications for a computer supplier, design facility and environmental factors had
been set. In addition, a project team comprising staff, representatives of the
24
multidisciplinary user community, and the contractor‘s personnel will manage the
automated implementation of the system.
(ii) Certification and Acceptance Testing Phase
In the second phase of HIS implementation, the system should be tested. This includes
certification and acceptance testing of a hospital information system, which includes for
example, material preparation test to actual conduction test for final analysis. The test is
conducted by a small group of staff members who are familiar with the system.
(iii) System implementation
The last phase is the completion of an automated system, which requires a plan of
action. The plan includes an implementation strategy, according to departments within
the hospital. This phase also involves the installation of the system to be used within the
hospital.
However, Rossi (2009) claimed the HIS implementation process entails only two
phases, which are preparatory phase and utilisation phase. The preparatory activities
are:
(i) Involvement of stakeholders in the system programming
(a) Reviewing the existing hospital data, identifying gaps and needs at
different levels of a hospital‘s network
(b) Defining of the most appropriate reporting tools
(c) Deciding on the coding system for different types of collected
information
(d) Defining of methods for data collection and processing, and acquisition
of the requisite materials
(e) Organising educational programmes for data managers and users
The preparatory phase also cover the designing and development of a system
according the needs of a hospital. The second phase of utilisation comprises of three
activities, which include:
264
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