Investigating Technology Utilization: Ethnographic Experiences of KFMMC in Deploying Health Informatics

Abstract: The goal of this research is to investigate the current situation of technology utilization at King Fahd Military Medical Complex (KFMMC). The findings were based on ethnographic experiences of KFMMCs Computer Services Department in deploying telemedicine and Hospital Information Systems (HIS) to deliver healthcare services as part of an ongoing research being undertaken by the department on e-health and egovernment. The investigation shows that the loss of interest among major stakeholders remains to be the most influential factor in the failure to adopt telemedicine programs despite the hospitals infrastructure capability to deploy of such. Moreover, the low adoption of telemedicine among patients and doctors is due to traditionalism and the lack of sufficient information campaigns, training and literacy programs that could help them gain awareness on its benefits. Consequently, this eventually results to underutilized health informatics programs such as telemedicine. The research suggests that the government should take extensive efforts to deploy training and literacy programs on e-health and e-government initiatives to improve the information society. Moreover, incentives to persuade stakeholders to use technology are highly encouraged to boost the adoption rate. Hence, stakeholders readiness should be one of the main thrusts of the government to prepare the society in embracing technological innovations by 2010 as a requisite to the fulfillment of the Yesser vision.

Keywords: e-readiness, information society, information literacy, Yesser vision, egovernment

Introduction The advent of health informatics in Saudi Arabia has created unprecedented healthcare options that promise to bring better care to its citizens. Health informatics or medical informatics is defined by Al-Shorbaji (2001) as an emerging discipline that refers to the study, invention, and implementation of structures and algorithms to improve communication, understanding and management of medical information (p. 4). The main objective of this is the coalescing of data, knowledge, and the tools necessary to apply that data and knowledge in the decision-making process, at the time and place that a decision needs to be made (p.4). The potential benefits of this undertaking are to maximize the information technology (IT) in reducing cost for doing business and operations, improve performance and efficiency, and allow strategic management of health information (p.5). The deployment of electronic health (e-health) systems is expected to generate around 10 to 15 percent savings for the Saudi Ministry of Health. In the United States, the use of the Internet for e-health through the Healtheon/WebMD initiative has generated a cost savings of around USD 250 billion from its annual budget of USD 1.3 trillion spent on healthcare (Egger, 2000). In order to capture these economic benefits, the Ministry of Finance has allocated around SR 4 Billion (1.1 billion USD) for the deployment of ehealth within four years (SAHI, 2007). The creation of this initiative

This paper relates the experiences of KFMMC in deploying health informatics programs such as telemedicine and Hospital Information Systems (HIS) to various stakeholders. The intention is to provide insights to government policy-makers on the reality of deploying technology to deliver electronic services in the healthcare sector. This can be used as a benchmark to develop contingency plans for possible technology failures and prepare the government on setting realistic goals governing the electronic government (egovernment) under its Yesser program. Moreover, the findings could also be used to simulate the adoption of health informatics programs by various stakeholders such as patients and doctors with potential applications to large-scale programs to deliver ehealth and other e-government initiatives across various sites in the Kingdom. Background Health informatics has a range of applications in management, epidemiological surveillance, computer-based medical record systems, and access to literature and information services. It may also be used for knowledge-based services, geographic information systems and telemedicine applications (Al-Shorbaji, 2001). The key motivating factors in the development of health informatics is its role in automating processes and information management. Also, it enables information sharing across the organizations and enhances services to patients as well as ensures the security and privacy of patient information (Altuwaijri, 2008). These benefits have been very evident in the management of hospital information at KFMMC. KFMMC is a 320-bed capacity hospital located in Dhahran, KSA. It is considered to be the most modern medical institution among the Armed Forces Medical Service hospitals. It provides comprehensive medical services to an average of 33,000 outpatients and 1,000

patient admissions per month. To cater to this large volume of patients, the Computer Services Department provides health informatics technologies to automate data management and hospital business operations. As such, the department became one of the well-equipped and modernized departments in the KFMMC hospital. It consists of several sections such as the Network, Hardware, Software Development, Help Desk, and Management Information System. Through this, Information Technology (IT) related services and support are rendered to various stakeholders. Methodology This is a case study of KFMMCs experiences on health informatics that intends to generate insights on the status and realities of deploying ICT projects in the healthcare sector. In particular, it adopts the experiences of the Computer Services Department at KFMMC in deploying projects such as telemedicine and HIS. This is part of the ongoing efforts of the department to evaluate the adoption of health informatics among hospitals in the Kingdom. Moreover, personal communication with various stakeholders are also incorporated based on occasional conversations being undertaken by the department with doctors, patients, staff and participants during in-house training programs of KFMMC on e-health. This research therefore used an ethnographic approach in generating insights, generalization, conclusions and recommendations based on KFMMCs experiences (Myers, 1999). Results and Discussions The ethnographic experiences of KFMMC on deploying health informatics has provided several realizations, insights and ideas on the best practices and risk management of using technological innovations in the healthcare sector.

KFMMCs Experiences on Telemedicine The telemedicine solution of KFMMC is supported by Medunet and MedReach. Medunet is the leading provider of e-health services in the Kingdom. In 2005, KFMMC started to offer telemedicine and undertaken the training of doctors in Riyadh in preparation for its deployment. Figure 1 shows a glimpse of the telemedicine infrastructure of KFMMC. These hardware capabilities are being supported by a software counterpart provided by MedReach through an IP-based system. These capabilities are also similar to the e-health centers at King Faisal Specialist Hospital and Research Center (KFSH&RC). Hence, these infrastructures are available to deploy e-health options such as telemedicine. In 2005, KFMMC began to deliver telemedicine programs; but unfortunately, this was not consistently adopted. In a few months from its initial deployment, many doctors and patients lost their interest in using this technological option. The result is an underutilized technology due to the loss of interest among these major stakeholders as shown in Figure 1. At present, KFMMC stopped the deployment of telemedicine services. Consequently, the telemedicine tools have become outdated. Hence, KFMMCs experience can be viewed as an example of a technology with inconsistent adoption. This is also especially true among other healthcare institutions. In fact, despite the presence of support and provision of e-health options such as telemedicine service in the Kingdom, its adoption rate remains relatively low (Altuwaijri, 2008).

Figure 1. The underutilized telemedicine infrastructure of KFMMC

The lack of interest among doctors to use telemedicine has been the major limiting factor that accounts for this failure of KFMMC. Personal communications with doctors revealed that there is a lack of incentives that would motivate them to deploy these technologies consistently. Also, the low adoption rate among patients is also a factor that discourages doctors to use the technology. Indeed, even if doctors would encourage patients to use it, many of them remain traditional in availing of healthcare services. In particular, concerns relevant to privacy of information and the presence of human interpersonal sincerity are the major reasons on the low adoption of telemedicine among stakeholders. Hence, the traditional person to person contact between patients and doctors remain dominant in most of the hospital encounters. The investigation of KFMMC proposes three major recommendations to improve the adoption rate of telemedicine. First, it is advocated that incentives for both patients and

doctors be given to encourage the use of technology. Second, training programs that would be impressive and highly persuasive should be undertaken to prepare stakeholders in adopting this innovation. Third is the use of user-friendly telemedicine portals that can be marketed to a large number of Saudi nationals using various media such as television, newspapers and other websites. The first recommendation is also based on the study conducted by Abanumy et al (2008) who provided an insight that incentives should be given to those who accommodate the access to e-government sites. These incentives could be considered as a motivating factor to enhance the adoption of technology. In this way, stakeholders would take considerable efforts to learn the technology due to a reward system. The second recommendation is based on investigations conducted by Qurban and Austria (2008) as well as Edirippulige (2007). This is relevant to the necessity to deploy literacy campaigns on computer fundamentals to equip citizens with the awareness and skills in adopting technological innovations. This implies that information literacy is a major factor that could influence the realistic adoption of technology in an information society. In addition, Hoymany (2006) reiterated that the digital divide could addressed by enhancing digital Arabic content and distributing to the public free training materials on CDs, which cover basic PC and internet skills. The third recommendation is also based on the studies conducted by Abanumy et al. (2005) who discussed the website accessibility of e-government sites in Saudi Arabia. They recommended that the government should set a policy for web accessibility together with an enforcement of procedure e.g. make the accessibility of governmnet websites a compulsory requirement (p. 104). In this way, stakeholders will have an

option to consider online consultations such as telemedicine as part of a routine during patient-doctor encounters. AFMSDs Hospital Information System The Armed Forces Medical Services Division (AFMSD) has recently deployed the creation of a Unified Hospital Information Systems among military hospitals (KFMCC is included) in the Kingdom through Kerfi Arabia and Nexus Ag. This program has been initiated to resolve problems on inconsistent medical records among military personnel in various healthcare facilities especially during relocations. The system hopes that upon its implementation, all medical records can be retrieved regardless of location. KFMMC has participated in the initial phase of its development. Currently, Kerfi Arabia is coordinating the customization of some important special features specific for KFMMC that can be integrated to the unified system. This requirements engineering stage has given KFMMC the opportunity to compare its in-house created HIS (which the hospital has been using for some time now) with the proposed one. The new system is soon to be deployed by 2010. As the department orients stakeholders on this future initiative, many perceive this new system as more complicated than the one currently used. This perception is expected since people normally try to resist change. This resistance is not necessarily due to the lack of interest but can be regarded as mainly attributed to the lack of comfort in using the new technology. Further, Wargin and Dobiey (1999) considered this resistance to be due to the lack of skills to use the technology, poor understanding of the applications or the redefinition of the organizational structures.

Researches Undertaken by KFMMC In support of the research-based approaches on improving management practices and policies, KFMMC has generated several researches on health informatics and egovernment. The vision is to make KFMMC as the center of excellence in the knowledge management of ICT practices among various hospitals in the Eastern Province. This is to create a model of an effective e-health system in the Kingdom. Moreover, these research initiatives have collective applications for KFMMC, the Saudi Arabian government, other Middle Eastern governments and the World Health Organization. In February 2008, KFMMC participated during the 3rd E-Services Symposium held at the Meridian Hotel in Al Khobar. The discussion focused on the best practices to manage the cost, market potential and business opportunities in deploying e-health and other egovernment initiatives. It highlighted that the Saudi Arabian government should utilize the benefits of a click and mortar business strategy in the e-commerce of ICT products and services (Qurban and Austria, 2008a). This means that various businesses should coordinate very well with the government to foster public-private partnerships (PPP) to capture the market potential of an increasing trend in ICT investments in Saudi Arabia, Jordan, UAE and Oman until 2012. This is especially feasible in Saudi Arabia since the Yesser vision targets 2010 as the focal point of e-government deployment by investing heavily on infrastructure, architecture and technology processes (Qurban and Austria, 2008). The KFMMCs participation to the Saudi e-Health Conference 2008 has provided several insights to various stakeholders involved in the deployment of e-health and other egovernment initiatives in countries such as the UAE, Oman, Jordan and KSA (Qurban

and Austria, 2008b). This highlighted that these countries have their unique practices and performance in e-health readiness. The analysis of strengths, weaknesses, opportunities and threats (SWOT) showed that there is a growing disparity in the implementation, pace and prioritization among various Middle Eastern governments on their e-health projects. This suggests that regional cooperation should be initiated to unify and foster international linkages among various institutions in developing e-health goals to be at par with the North American performance. The results of KFMMCs participation on the European and Mediterranean Conference on Information Systems 2008 (EMCIS 2008) in Dubai, UAE showed that the Saudi government should take steps to develop literacy campaigns, training programs to introduce to the public the benefits, requirements and applications of e-health programs (Qurban and Austria, 2008c) . The overwhelming acceptance among various stakeholders whether medical practitioners or patients signify that e-health and other e-government initiatives remain feasible but would eventually face problems on rate of adoption. This indicates that despite acceptance of e-services, many people would still fail to avail of these e-government services due to the apparent digital divide that limits the governments potential to fully deploy e-services on a large-scale platform. Other on-going researches of KFMMC on e-government and health informatics are underway to monitor the Kingdoms performance in implementing the Yesser vision. Hence, KFMMC targets to deliver high-end research-based recommendations to the government in achieving e-government success by mitigating risks involved in the deployment of technology especially in the healthcare sector.

What to expect? The Yesser vision stands for the unified target of providing equitable access to government services using the promise of technology. To achieve this, the government has allocated billions of Riyals to improve the infrastructure and technological capabilities of various government agencies. The relative success of several egovernment initiatives such as the SADAD e-payment gateway holds for the potential of other projects in view of the Yesser targets (Sahraoui et al., 2006). However, risks involved in the deployment of technology remain formidable. Also, considerable efforts to improve government practices apparently restrict the achievement of full success in implementing e-government development goals. There is also scarcity in the number of ICT infrastructure despite the governments plan to provide fiscal allocation on e-health and e-government. In fact, Qurban and Austria (2008a) confirmed that despite that there are almost five million users of Internet across the Kingdom (largest in the Middle East), the population penetration remains relatively low at 19.5% compared to UAEs 42.9% penetration rate. This indicates that there are more Saudi nationals who are not using the Internet than those otherwise while considering its total population of nearly 25 million. In addition to this reality, the Madar Research (2005) as cited in Sahraoui et al (2006) estimated that the Saudi government requires around 5 Billion USD to deploy e-government projects to its large population base. However, the government only allocated 800 million USD for e-government infrastructure and programs for the next five years (Sahraoui et al., 2006). There is also an additional budget of 1.1 billion USD for e-health deployment within the four-year

development plan (SAHI, 2008). Hence, considering these challenges, the e-government plans of Saudi Arabia faces problems on both infrastructure and human capital issues. In a review provided by Altuwaijri (2008), it has become clear that despite these investments and best intentions, people are still reluctant to use technology probably due to the lack of interest to use it or in many cases that they have not begun to adopt it at all. Hence, adoption of technology should be treated as a priority area in the deployment of various e-government initiatives. Conclusions The deployment of health informatics projects in KFMMC has created several insights on the realities faced by people working in the healthcare IT sector. These concerns are related to the lost of interest among major stakeholders to adopt e-health and other egovernment initiatives. Consequently, resistance to change remains predominant in the society and this limits the capacity of the public to embrace technological innovations towards the achievement of an efficient information society. To resolve these issues, this paper recommends that incentives should be given to stakeholders who would adopt the technology. In this way, they can be motivated to use new technologies and improve technical skills to avail these services. It is also necessary to provide additional funding on the deployment of e-government initiatives since Saudi Arabia faces a problem on population expansion. This would eventually require the government to consider several economic diversification efforts to increase government funds and allocate these resources to human capital development. This is particularly advocated by this research where the focus should now be directed to the literacy campaigns on keeping citizens

aware of these innovations. It also includes the continued enhancement of IT skills among citizens to adopt these technologies. KFMMCs telemedicine experience could enlighten the ICT sector on the reality of digital divide, resistance to change and traditionalism persistent in Saudi Arabia. The failure to support and sustain telemedicine on a continuous and full scale performance would eventually lead to under- to un-utilized infrastructure similar to the case of KFMMCs telemedicine experience. Indeed, despite efforts to provide sufficient infrastructure, human factors should be equally treated as essential. Moreover, these ethnographic experiences give us insights on the difficulty in persuading people to adopt technology as this would require the development of additional and updated skills. Along the course of KFMMCs research efforts on regional ICT development, these ethnographic experiences provide the forefront of realistic expectations governing egovernment adoption as 2010 approaches. These researches have been very consistent and conclusive in supporting advocacies calling for strong literacy programs to prepare citizens to embrace these technological innovations. The government is therefore highly urged to provide sufficient budget and support processes on the extensive development of technology awareness, literacy programs and training projects on technology fundamentals that would reduce the threats of a growing digital divide. Finally, KFMMCs telemedicine experiences are hard evidences that technology adoption requires more programs other than infrastructure development goals as literacy should be equally prioritized and addressed seriously

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