A Standish Group (1994) study showed that only 16% of all information technology projects come in on time and within budget. The situation is not better concerning health information systems. Many health information system implementations are less than completely successful (Berg, 2001; Giuse & Kuhn, 2003; Lorenzi & Riley, 2003). In this article, the health information system means “a system, whether automated or manual, that comprises people, machines and /or methods organized to collect, process, transmit, and disseminate” data that represent user information in healthcare (Kuhn & Giuse, 2001, pp. 275). What is successful implementation and whose success is measured? Successes can be measured in many ways. Delone and McLean have been finding out the success factors of management information system which are also applicable to health information system. The success factors are: system qualities, e.g., the ease of use or time savings, information quality, e.g., completeness or data accuracy, usage, e.g., the frequency of use or the number of entries, user satisfaction, e.g., user-friendliness or overall satisfaction, individual impact, e.g., changed work practices or direct benefits and organizational impact, e.g., communication and collaboration or impact on patient care. Furthermore, user involvement during system development, implementation and organizational culture have been identified as possible factors measuring the success. However, the need for further research to determine which attributes are the most useful ones in measuring success has also been revealed. (van der Meijden, Tange, Troost & Hashman, 2003).
The different phases in implementation process are, in general, user needs and requirements analysis (specification), system design, initial system implementation and testing (Ahmad, Teater, Bentley, Kuehn, Kumar, Thomas & Mekhjian, 2002; Schuster, Hall, Couse, Swayngim & Kohatsu, 2003; Souther, 2001). The system requirements analysis includes workflow analysis, and the initial system implementation includes the technical installation of the information system, integration of the information system to other information systems and users’ training.
Project management is an important factor in every phase of the implementation project.
The purpose of this article is to highlight the health information system implementation process from end-user perspective. Which factors are crucial in the implementation process from the point of view of the end-users? How does project management contribute to the implementation process, what is the role of the end-user in system designing and how does training effect the information system implementation?
The lack of financial support was the most significant barrier to successfully implementing information technology in healthcare from both clients’ and vendors’ perspective. The vendors’ inability to deliver products, and difficulties in achieving end-user acceptance or use were the other barriers from the point of view of the clients. (HIMSS, 2002.) Costs are often underestimated because the cost of the software is only the beginning of other expenditures, e.g., person-hours for training and support have been forgotten (Ash, Stavri & Kuperman, 2003).
The social and organizational issues, not only the technical ones, are the critical issues in the implementation of information systems. The health information systems do not effectively support the health processes, and terminology for the healthcare environment is needed. (Ahmad et al., 2002; Berg & Toussaint, 2003; Berg, 2001; Giuse & Kuhn, 2003; Kuhn & Giuse, 2001; Littlejohns, Wyatt & Garvican, 2003).
Human-computer interaction is also perceived as unsatisfactory. The human-computer interaction indicates the means by which humans interact with computers, e.g., users enter and retrieve data. To optimize the design of the human-computer interaction, concepts are needed (Berg, 2001; Kuhn & Giuse, 2001). Technical issues, e.g., integration with other information systems and the need for open systems are also issues which must be solved (Giuse & Kuhn, 2003; Kuhn & Giuse, 2001).
The reasons for failures were that the complexity of healthcare tasks and social and professional cultures of healthcare organizations was not taken into account and, furthermore, the education of the users was insufficient and the timing of the education was wrong (Littlejohns, Wyatt & Garvican, 2003). Lorenzi and Riley (2003) report that the failures of the implementation of the health information system can be classified into four categories: technical shortcomings, project management shortcomings, organizational issues and information explosion. The technical failures contain, e.g., the old system maintenance and staff training. Project management issues are, e.g., project management skills. Organizational issues are concerned with constant changes. Information explosion means that knowledge has increased exponentially and new technical tools have been developed to cope with the information. Berg (2001) notes that it is important to notice that the implementation is not only a technical installation, and also that the project is not only a technical project but also an organizational development project.
The three major reasons that a project will succeed are user involvement, executive management support and the clear statement of requirements (Standish Group, 1994). Doolan, Bates and James (2003) reported that the factors associated with successful implementation are unusually strong leadership, a clearly defined long-term commitment, clear focus on improving clinical processes and gaining clinical involvement and support improving productivity. Lorenzi and Riley (2003) included technical skills, project management skills and people and organizational skills to the success factors. The skills mean knowledge, experience and abilities in each area. Ahmad et al. (2002) stated that success factors are a continuous executive support, engagement of physicians, an effective implementation team, a consistent user-friendly interface and on-going user support.
User involvement during system development, implementation process and organizational culture may explain the failure of the information system. The attributes assigned to system development were the extent of user involvement, redesigning work practices and the reconstruction of content and technical limitations. Communication, training and technical support were attributes addresses to implementation process. Organizational aspects attributes were organizational culture, e.g., control and decision-making, management support, professional values as well as support and maintenance. (van der Meijden, Tange, Troost & Hashman, 2003.)
THE ROLE OF THE PROJECT MANAGEMENT
A project approach is the most common way to implement health information systems. Project management is the process of planning for organizing and controlling projects. From the end-users’ point of view, the objectives of health information system projects must make explicit, i.e., improve patient care or efficiency. It is recommendable to set a stage for improvements, e.g., reduce the number of phone calls or move manual files to on-line files. The objectives of the project must also improve workflows and work practice, in other words the hospital managements and also clinicians involved in the project must also upgrade their work performance. The implementation of information system must add value for the end-user. Clear objectives motivate the end-users for implementation. (Ash, Stavri & Kuperman, 2003; Berg, 2001; Berg & Toussaint, 2003; Doolan, Bates & James, 2003, FitzHenry & Snyder, 1996; Giuse & Kuhn, 2003; Littlejohns, Wyatt & Garvican, 2003; Lorenzi, Riley, Blyth, Southon & Dixon, 1997; Nikula, Elberg & Svedberg, 2000; Lechleitner, Pfeiffer, Wilhelmy & Ball, 2003)
The information system implementation process must be seen as an organizational change process (Anderson & Stafford, 2002; Berg, 2001; Lorenzi, Riley, Blyth, Southon & Dixon, 1997). Change management, which means “the process of assisting individuals and organizations in passing from an old way of doing things to a new way of doing things” (Lorenzi & Riley, 2003 pp.200), should be taken into account from the start of the implementation process. Organizational resistance always occurs during the implementation of new information systems. The change management is one reason why the leader has an important role in projects. (Lorenzi & Riley, 2003; Lorenzi, Riley, Blyth, Southon & Dixon, 1997; FitzHenry & Snyder, 1996) Furthermore, the implementation process itself requires effective leadership (Ash, Stavri & Kuperman, 2003;Lorenzi & Riley, 2003; Souther, 2001). Leadership is needed at multiple levels in organizations; high-level leadership was considered the single most important factor. It was demonstrated by the long-term commitment of resources. (Ahmad et al. 2002; Doolan, Bates & James, 2003; Littlejohns, Wyatt & Garvican, 2003). At the executive level, leadership is needed to promote a shared vision the purpose of health information system, which is e.g. to improve patient care. At the project management level, the leadership is needed to make practical, effective and useful decisions (Ash, Stavri & Kuperman, 2003). The need for bottom-up participative and top-down authoritarian approaches are also useful when changing organizational behavior. (FitzHenry & Snyder, 1996; Souther, 2001). External consults can also be used as change agents. (FitzHenry & Snyder, 1996; Lechleitner, Pfeiffer, Wilhelmy & Ball, 2003; Souther, 2001)
There is a need for different people, and many types of skills, both technical and medical, in implementation process. The persons who are assigned to the projects must be influential and knowledgeable and they must represent significant organizational groups and professionals. The challenge is to find the right persons. The multidisciplinary team approach has proven advantageous in health information system implementation.(FitzHenry & Snyder, 1996; Lechleitner, Pfeiffer, Wilhelmy & Ball, 2003; Littlejohns, Wyatt & Garvican, 2003; Souther, 2001) There must be different levels of teams: an executive steering team, a project steering team and a project work team. The end-users are representatives in different levels of teams. It is important that physicians and nurses belong to the project steering team, which makes major policy decisions based on user needs and requirements, organization infrastructure and general implementation strategies. The end-users also belong to the project work team, whose focus is training, user-interface, testing, security policy and pilot implementation. (FitzHenry & Snyder, 1996; Souther, 2001) The end-users’ participation to the project enhanced their involvement.
The organizational readiness for information system innovation could also be assessed in advance. The information about the organizational readiness could be used in planning implementation strategy (Nikula, 1999; Snyder-Halpern, 2001; Yetton, Sharma & Southon, 1999), e.g., in what order to engage different parts of the organization or in which phase of implementation process managerial influence must be at its highest. The healthcare organizational readiness for information system innovation could be assessed by the validated eight sub-dimensions of knowledge, end-users, technology, administrative support, management structures, processes, resources, values and goals. The end-user readiness themes include, e.g., skills to use computers or involvement in the change process. The information about the end-user readiness could be used in planning their training. (Snyder-Halpern,2001)
THE END-USERS’ ROLE IN DESIGNING INFORMATION SYSTEM
For the design of information systems, the conventional approach has been to model a system completely before implementing it (Berg, 2001; Kuhn & Giuse, 2001; Lorenzi,Riley, Blyth, Southon & Dixon, 1997). Prototyping has proven a successful project (Ahmad et al., 2002; Doolan, Bates & James, 2003; Lechleitner, Pfeiffer, Wilhelmy & Ball, 2003; Lorenzi, Riley, Blyth, Southon & Dixon, 1997; Schuster, Hall, Couse, Swayngim & Kohatsu, 2003). Prototyping requires an iterative approach, in which information system analysis, design, implementation and evaluation merge. It is evident that the information system changes work practices and vice versa. Therefore, the first step is to model the environment of the system. A socio-technical approach is suitable for system design. It means that the work practices in which information systems will be used are the starting points for design and implementation of the information systems. This means defining the core actors, their core tasks, the flow of work and the flow of data. The present workflows are analyzed, the future workflows described and documented. (Berg & Toussaint, 2003; Berg, 1999; FitzHenry & Snyder, 1996; Schuster, Hall, Couse, Swayngim & Kohatsu, 2003; Souther, 2001) The interactive model increases end-user involvement. The need for optimally adapting information systems to the work practice in the healthcare organizations and the users’ terminology are important, as well as reducing workload and simplifying the workflow (Anderson & Stafford, 2002; Berg & Toussaint, 2003; Doolan, Bates & James, 2003; Giuse & Kuhn, 2003, Kuhn & Giuse, 2001; Lechleitner, Pfeiffer, Wilhelmy & Ball, 2003; Lorenzi, Riley, Blyth, Southon & Dixon, 1997). Health professionals must develop the information system together with the vendors. The interaction between the vendor, the teams installing the information system and the users is a crucial point. Representatives must include all different health professionals and administrative personnel (Anderson & Stafford, 2002; Berg & Toussaint, 2003; Doolan, Bates & James, 2003; Kuhn & Giuse, 2001; Lechleitner, Pfeiffer, Wilhelmy & Ball, 2003; Lorenzi, Riley, Blyth, Southon & Dixon, 1997 Nikula, Elberg, Svedberg, 2000; Schuster,Hall, Couse, Swayngim & Kohatsu, 2003; Sleutel & Guinn,1999)
TRAINING AND SUPPORT
The proper training and support are an essential part of the health information system implementation process (Ahmad et al., 2002; Anderson & Stafford, 2002; Ash, Stavri & Kuperman, 2003; Doolan, Bates & James, 2003; Littlejohns, Wyatt & Garvican, 2003; Lorenzi, Riley, Blyth, Southon & Dixon, 1997; Schuster, Hall, Couse, Swayngim & Kohatsu, 2003; Souther, 2001). An implementation of the health information system requires extensive support and training in order to achieve user acceptance. The training plan must be completed before the initial implementation and it should also include intensive support at the time of the implementation. In the most successful implementation the end-users have more support after initial implementation than before it (Ash, Stavri & Kuperman, 2003).
Figure 1. The factors of successful implementation process- end-users perspective
There are also differences between computer literacy within healthcare professionals. (Saranto & Hovenga, 2004; Souther, 2001). Computer literacy means basic skills in computers use, e.g., read and write. Information literacy consists of computer literacy, information retrieval abilities and communication skills. (Saranto & Hovenga, 2004) Therefore, the skills of the users, as well as their needs, must be taken into account when planning the training of a new information system. The quality of user training has a key role for a good user acceptance of information system (Anderson & Stafford, 2002; Quinzio, Junger, Gottwald, Benson, Hartmann, Jost, Banzhaf & Hempelmann, 2003). Disagreement on the efficiency of the system training has occurred (Lechleitner, Pfeiffer, Wilhelmy & Ball, 2003; Quinzio et al., 2003). The well-trained users were significantly more satisfied with the information system in routine use. A three-step training strategy has been recommended. First, the employees should be informed of the planned information system. The second phase includes general on-job training, and the third phase includes the opportunity to work on the individual problems of each user. (Quinzio et al., 2003) Whitman, Hamann & Vossler (1997) have also introduced a training plan. The strengths of the training plan are the contract that identified the roles and responsibilities of staff, management, and information services and staff development. Peer trainers have proven useful. Everyone must also have their own computer during training sessions. A competency test has been suggested as improvement to training plan. Ahmad et al. (2002) report a formalized training program for all users which precedes the implementation by two or four weeks. In addition, extensive on-site training occurred during the implementation period. The traditional help-desk phone has been found inadequate for user support.
From the end-user perspective, the critical issues concerning the health information system implementation are project management, system designing, organizational issues and training and support. First of all, the project must have clear objectives. The teams must consist of different types of healthcare professionals, vendors, management and so on. It is important to find the right people to engage in the project. Project management task and responsibilities must be clear for each level of the teams and the interaction between the teams will also be efficient. The teams must work actively with the vendors. The management must also commit to the implementation process so the end-users notice that the project is important. The project management aids the change management, which is one of the critical issues of information system implementation process. The leaders can use the information about the organizational readiness in planning the implementation strategy.
It is crucial that both representatives from the future users and leaders are involved in the design process. They are the experts of their work. The iterative development process will be used and the information systems adapting to workflows is important. When the information systems’ requirements and future workflows are modeled properly it becomes evident that the work processes change, because the healthcare professionals must consider what they do and why they do it.
The training plan must be designed carefully. The information literacy of the end-users will be taken into account. A multilevel approach is good. First, the vendor can present the main functions of the information system. After that the tutors teach the users to use the information system and the users can train the system themselves. The users are also supported, they can ask questions. After that the users themselves can practice and also contact the tutors if they have any problems using the information system.
In the first stages the point of view in health information system implementation was only technical. The implementation process paid no attention to workflow patterns prior to the implementation, or to the computer experience among personnel or aspects of the organizational culture. Strategies for the successful management of health information system implementation must be planned carefully. The personnel of an organization must learn to use the information system and also change their working processes. Education is the critical point of the implementation process. Knowledge about end-user attitudes and skills prior to computerization is useful. The training will be tailored to meet the varying needs of user groups. There is a need for research in the area of evaluating health information system implementation.
Change Management: Change management is the process of assisting individuals and organizations in passing from an old way of doing things to a new way doing things.
Health Information System: Health Information System is the system, whether automated or manual, that comprises people, machines and /or methods organized to collect, process, transmit and disseminate data that represent user information in health care.
Implementation: The implementation of information system includes different phases: user needs and requirements analysis (specification), system design and initial system implementation and testing. The system requirements analysis includes workflow analysis; the initial system implementation includes technical installation of information system, integration the information system to other information systems and users’ training.
Information Literacy: Information literacy consists of computer literacy and information retrieval abilities and communication skills. Computer literacy means basic skills in computers use, e.g., being able to read and write with computers.
Project Management: Project management is the process of planning for organizing and controlling projects. The multidisciplinary team approach in project management means that there are different levels of teams: the executive steering team, the project steering team and the project work team. Different teams have their own tasks.
Prototyping: Prototyping is the development approach in which prototypes are produced. It is an iterative approach to the developing of the information system. The distinctions of the different phases of development of the information system, e.g., analysis, design, implementation and evaluation are not clear.
Socio-Technical Approach: Socio-technical approach means that the work practices in which information systems will be used are the starting points for design and implementation of the information systems.