Hospital Information Systems in Nigeria: A Review of Literature

Nigerian
Hospital Information Systems/Benson 1

ISSN 2159-6743 (Online)

Hospital Information Systems

in Nigeria: A Review of
Literature
Ayodele Cole Benson, MB BCH, PhD, DHA *

Abstract

This literature review was developed to examine empirically the factors hindering
adoption of hospital information systems in Nigeria. The study was focused on the
perceived paucity of health information technology policy in Nigeria and the
causes of poor implementation of hospital information systems in the country. The
findings of the literature review highlighted hindrances to the adoption of hospital
information systems to include; the high cost of full implementation of a hospital
information system, inadequate human capital, corruption, and problems
associated with poor infrastructure in Nigeria. The recommendations were that the
Nigerian government needs to provide stable electricity, basic communication
infrastructures, and Internet access to boost private initiatives in the adoption of
health information technology across the country.

Keywords: Global health, health information systems, hospital information systems,
review of literature, Nigeria

*Principal, Echo-Scan Services, Ltd.
Correspondence: Ayodele Cole Benson, MB BCH, PhD, DHA, Email: benson_ayodele at yahoo.com

www.jghcs.info [ISSN 2159-6743 (Online)]
JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011
Nigerian Hospital Information Systems/Benson 2
Hospital Information Systems

in Nigeria: Review of
Literature
The application of information technology in health care is unceasingly evolving as the quality of patient
care in contemporary times seems to depend on the timely acquisition and processing of clinical
information related to the patient (Brailer, 2005). Cholewka (2006) asserted that a significant paradigm
shift has occurred in health care service delivery from an era of physician centeredness to emphasis on
quality of patient care, from isolationist practices by caregivers to networking in a global world, and from
competition to collaboration among practitioners. In tandem with this trend, improvement in technology
and advancement in information systems has been adopted in the health care industry as a business
strategy to improve the quality of care (Wilcke, 2008).
A clear understanding of the usefulness of hospital information systems is lacking among health care
policy makers in Nigeria. The Year 2000 World Health report ranked Nigeria 187 out of 191 countries in
health care infrastructure and health services provision. A gap in knowledge exists regarding the exact
number of hospital information systems functionally available in Nigeria, but subjective data project less
than 5% implementation of any form of hospital information technology in a country of more than 150
million people (Idowu, Adagunodo, & Adedoyin, 2006). This review was designed to explore the reasons
for lack of robust availability of hospital information systems in Nigeria.
Background
Nigeria for a long time has suffered political instability, thus creating the opportunity for corruption to
thrive and enhancing poor macroeconomic management (Okafor-Dike, 2008). Following years of military
dictatorship and lack of government accountability, infrastructural decay did not attract the desired
attention (Okogbule, 2007). The petroleum-supported economy faced years of blatant economic
mismanagement and the squandering of resources through institutionalized corruption (Pierce, 2006).
After a few attempts at democracy in the 20th century, Nigeria reestablished a democratically elected
government in 1999, but one still recycling much of the political elements of the military era. A change in
the body polity of the nation has been painfully slow and in some cases retrogressive (Okafor-Dike, 2008).
A major task facing the current civilian regime is to rebuild the social institutions and health care sector
by introduction of new national policies. As a result of decades of neglect, there is a serious shortage of
modern health care facilities. The government has taken steps to promote the development of a basic
national primary care program in the villages, but concerns abound about serious lack of specialized
health care facilities (Ouma & Herselman, 2008).
The most recent population census held in Nigeria in 2006 estimated a population of 140 million
inhabitants, whereas current projections puts the population at more than 150 million people making
Nigeria the most populous country in Africa (World health report, 2008). According to the National
Population Commission (2007), the population is young with 42% in the age group 0-14, 55% in the age
group 15-64, and only 3% age 65 and above. The National Population Commission (NPC) published a
wide range of information including the fact that the population is growing rapidly by 2.4% every year.
The birth rate is 40 per 1000 and the death rate is 17 per 1000. The fertility rate is 5.5 children per woman.
The population, which is ethnically very diverse, representing more than 250 different tribes and


population groups, is also diverse in religious beliefs. About 50% are Muslims, 40% Christians, and 10%
of different indigenous beliefs (National Population Commission, 2007).
Nigeria practices both orthodox medical care and traditional healing. Traditional medical
practitioners are native doctors who practice in rural areas but occasionally find patronage in urban cities.
The health care services by native doctors do not follow formal protocols or depend on scientific tests to
arrive at diagnosis. Sometimes their treatments endanger the lives of their patients from overdose of
herbal extracts. These traditional healers do not have orthodox training, but depend on generational
beliefs handed down by ancestors (Okeke, 2008). Even though the practice of Western medicine is rapidly
expanding in Nigeria, the non-availability of modern medical technologies in the health care arena
remains a threat to the success of orthodox medicine (Pierce, 2008).
Health care service delivery in Nigeria falls short of international standards resulting from poor state
of health care infrastructure, shortage of medical professionals, threat of re-emerging infectious diseases,
and poor sanitation. Over the last five decades post-independence, growth, and development in health
care has been dismal. HIV/AIDS has been a very serious health challenge. About 3.6 million of the
population are HIV positive or have developed AIDS (equivalent to a prevalence of 5.4% of the adult
population). More than 300.000 individuals die from AIDS every year (Arikpo, Etor, & Usang, 2007).
Another major problem is that of infant mortality. The World Health Organization Report (2008)
indicated an infant mortality of 110 per 1000 live births. As a comparison, the infant mortality in Sweden
is 2.7 per 1000 live births. Poverty has compounded these problems to give low life-expectancy of 52
years for women and 49 years for men .
Recognizable demographic diversity exists in Nigeria with consequent disparity in availability of
health care facilities across the country (Okeke, 2008; Ouma & Herselman, 2008). Electronic medical
record systems help to improve access to health care in remote suburban areas and ensure improved
maintenance of long-term care (Keenan, Nguyen, & Srinivasan, 2006). Onwujekwe (2005) and Ofovwe
and Ofili (2005), in separate studies conducted to assess patient and community satisfaction, found
discontent with community members who decried the poorly staffed and inadequately equipped Primary
Health Centers (PHCs) in their rural settlements compared to hospitals in urban centers. Such
demographic disparity in health care accessibility benefits from hospital information technologies and
telemedicine to foster collaboration between clinicians in urban areas and those in rural settlements
(Ouma & Herselman, 2008).
Hospital information systems include strategic decision support systems and clinical documentation
systems. Some of the clinical support systems include Laboratory Information Systems (LIS), Radiology
Information Systems (RIS), and Computerized Order Entry (COE). Others are pharmacy information
systems and personal data analysis systems with important added feature for messaging between
providers and staff, and the ability to share data with other medical facilities (Keenan et al., 2006).
Telemedicine is a unique application of hospital information technologies. In its simplest form,
telemedicine uses audiovisual information and communications apparatus to deliver health care services
in a bid to modify socio-economic circumstances of the beneficiaries and improve accessibility to medical
care (Yun & Chun, 2008).
A paucity of government policy regarding the implementation of hospital information systems exists
in Nigeria. The lack of strategic government programs has culminated in the poor adoption of hospital
information technologies in health care facilities across the country. Okeke (2008) asserted that the lack of
access to modern medical health care facilities has compelled many Nigerian patients to seek treatment
with traditional healers and patent medicine dealers. The more affluent echelon of the society resorts to
medical tourism overseas to obtain health care services, resulting in a loss of foreign exchange to Nigeria.
According to Okafor-Dike (2008), poor leadership in Nigeria has led to years of economic downturn
affecting every aspect of social life. Rather than develop medical services in Nigeria, government officials
and wealthy individuals frequently seek medical treatment abroad even for the most basic health care
needs. Former Vice President Atiku goes to Germany for treatment of his arthritis. Political analysts in
both national and foreign media have often questioned the rationale behind former President Yaraduas
frequent trips for medical treatment in Saudi Arabia even for renal dialysis rather than developing
medical facilities in the country. In an apparent endorsement of the existing malady in the Nigerian
health care system, Judge Abutu of an Abuja High court, in a case brought before him in 2010, ruled that


Yaradua violated no laws by remaining on hospital admission in Saudi Arabia for more than two months
(Nigeria Judge Rules, 2010). The judgment appears illogical; the decision from a respected legal authority
seems to legitimize the quest for overseas medical treatment by top government officials in Nigeria as a
result of the poor health care infrastructure in the country.
Analysts acknowledge that the dearth of a modern medical infrastructure in Nigeria has promoted
medical tourism among the rich subset of the Nigerian population. Amaghionyeodiwe (2009), in a study
that examined the impact of government health care funding in Nigeria, observed that the poor health
care infrastructure continues to widen the differences between the rich and the poor in Nigeria. The major
reason for the widening of differences, according to Amaghionyeodiwe, is that the poor are more
strongly affected by public spending on health care relative to the non-poor. Whereas the rich can afford
oversea treatments, the poor continue to suffer from lack of good quality treatment, increased morbidity,
and poor medical outcomes, thereby worsening their originally compromised health status emanating
from poverty.
Available literature provides common standpoint among various authors that disparities exist in the
implementation of hospital information system in developing and developed countries (Grimm & Shaw,
2007; Williams & Boren, 2008). Speculated reasons include (a) Poor technological and funding support in
developing nations, (b) Poor management capacity at all levels that hinders seamless workflow, and (c)
complex milieu of health care service delivery. Other posited factors include (d) continual evolution of
technology, (e) Confidentiality problems with the use of hospital information systems, and (f) poor
technological background of the Nigerian society (Grimm & Shaw, 2007; Krishna, Kelleher, & Stahlberg,
2007). The consequences of non-adoption of hospital information technologies include possible mix-up
with laboratory results, misdiagnosis, medication order errors, and mismanagement of patients (Keenan
et al., 2006; Okeke, 2008).
Prior to the introduction of the health care insurance scheme in Nigeria, health care purchases were
made by individual out-of-pocket payments and few employer-based private health insurance with
different reimbursement mechanisms (Pierce, 2008). In June 2005, a National Health Insurance Scheme
(NHIS) commenced as a trial system. Policy makers planned a regular review of the program, but no
changes thus far have been made in the 5 years of its implementation. The Nigerian House of
Representatives and Senate endorsed the scheme, including a moratorium on deductions of
contributions. The intention was to extend the program to the organized private sector within 1 year of its
commencement in the public sector, but it remains to be seen if this system will provide enough health
care coverage, particularly to the poor. The lack of well-established information infrastructures within the
hospital systems in Nigeria presents a challenge to the health care delivery in the country.
Theoretical Framework
Currently, a gap in knowledge exists about the exact number of hospital information systems
functionally available in Nigeria, but the subjective data project less than 5% implementation of any form
of hospital information technology in a country of more than 150 million people (Idowu et al., 2006). The
available literature provides a common position among various authors that disparities exist in the
implementation of hospital information systems in developing and developed countries (Grimm & Shaw,
2007; Williams & Boren, 2008). Speculated reasons include poor technological and funding support in
developing nations, poor management capacity at all levels that ensures seamless workflow, and a
complex milieu of health care service delivery. Other possible factors for low implementation include the
continual evolution of technology, confidentiality problems with use of hospital information systems, and
the poor technological background of the Nigerian society (Herbst et al., 1999; Grimm & Shaw 2007;
Krishna et al., 2007).
Holden (2009) posited that much research related to adoption of health care information technology
has been atheoretical. In this study, a useful theoretical model is the maturity model to process
improvement originally described in software engineering and used in the novice-to-expert approach to
competency. The maturity theoretical model describes a modernization framework aimed at the
committed use of relevant information technology in a change process (Gillies & Howard, 2005).
Beneficial uses of information and associated technology as it relates to health care improvement in this


model includes monitoring individual and organizational performance, facilitating information sharing
among different health care organizations through a multi-agency approach, and empowering
individuals by providing relevant information to consumers, thereby helping them to make informed
choices (Gillies & Howard, 2005).
An additional theoretical standpoint in this study is that in a heterogeneous society as Nigeria with
significant disparity in accessibility of health care facilities between urban and rural communities,
hospital information systems will help to bridge the gap in availability of patient care (Ouma &
Herselman, 2008). Sammon, OConnor, and Leo (2009) associated patient data analysis systems (PDAs)
with enhanced storage and analysis of patient data, enabling physicians to reach improved clinical
decisions on patient care. Similarly, clinical information systems capture clinical data to enhance prompt
and efficient decision making (Ward, Joana, Bahensky, Vartak, & Wakefield, 2006; William & Boren,
2008). Hospital information systems improve workflow and increase patient throughput (Ouma &
Herselman, 2008; Shekelle et al., 2006; Wallis 2007). Sisniega (2009) asserted that the applications of
information and communication technologies (ICT) facilitate ubiquitous and instantaneous
communication between organizations and their stakeholders. Information communication technology
enables people and organizations to achieve a seamless workflow and effective processes through
improved interactions.
Literature Review
The literature search brought to the fore contextual issues and brief historical overview of hospital
information systems. The discussion focused on the infrastructural requirements for implementation of
hospital information systems alongside the cost implications and the role of government in funding the
cost. A significant portion of the literature review centered on the Nigerian situation as it relates to the
poor implementation of hospital information systems. Issues highlighted about Nigeria include
demographic diversity and cultural effects on health care, lack of support infrastructure, corruption, lack
of technical support services, problems with human capital, an import-dependent economy, and the high
the cost of capital in the Nigerian capital market. The concluding aspects of the literature search contain
discussions on the limitations of hospital information systems and future trends.
Brief Historical Overview
The processes used to collect, process, and store patient information to aid clinical treatment are
probably as old as medicine. The formats for collection of patients records and the ways in which this
information is used and subsequently stored for future references has continued to evolve from regular
paper note takings to electronic taped records and present-day hospital information technologies. Wilcke
(2008) defined information literacy that affects medical practice as the ability to identify the need for
information and seek, evaluate, and use information in any presented format. Information technology
infusion that aids globalization refers to the degree to which various information technology tools
integrate into organizational activities (Idowu et al., 2006).
The growth of computer technology in the 1980s with consequent improvement in information
literacy saw the advent of the first breed of hospital information systems (Keenan et al., 2006). Earlier
researchers in hospital information systems categorized them into three types: Consumer informatics,
medical and clinical informatics, and bio informatics based on areas of application (Detmer, 2001).
Consumer informatics focuses on communications between patients and the public. According to
Svensson (2002), consumer informatics helps to create virtual communities for sharing of health care
information.
Medical and clinical informatics applications relate directly to health care organizational processes,
structure, and clinical outcomes. Electronic medical records system is a major medical and clinical
information system aimed at the lowering cost of health care therapies (Svensson, 2002), In its earliest
applications, hospital information systems were mostly used for patients electronic record keeping, but
has advanced into almost all areas of medical discipline. Common applications of hospital information
technologies include Computerized Physician Order Entry, Pharmacy Information Systems, Laboratory


Information Systems, Radiology Information System and Picture Archival and Communication Systems,
telemedicine, and many others as these technologies are constantly evolving.
William and Boren (2008) acknowledged that most European countries and the United States are
increasingly adopting electronic medical record (EMR) technology to enhance health care outcome and
quality. William and Boren posited that Nigeria lacks robust health care infrastructures and policies for
implementation of information and communications technology (ICT). Complicated by challenges of
epidemics and civil wars, African countries lack ICT in their health care systems. The authors asserted
that historically, lack of human expertise and inadequate financial resources is a bane to robust to
adoption of ICT in Sub-Saharan Africa.
Benefits of Hospital Information Systems
Hospital Information Systems improve workflow and increase patients access to health care (Ouma
& Herselman, 2008; Shekelle et al., 2006; Wallis 2007). Sisniega (2009) asserted that the applications of
information and communication technologies facilitate ubiquitous and instantaneous communication
between organizations and their stakeholders. ICT enable people and organizations to achieve seamless
workflow and effective processes through improved interactions. Electronic health technologies enable
effective networking by physicians, allow online review of patients treatment, and provide for accurate
prescription of drugs. Radiology information systems enable the transmission of radiological images for
evaluation in remote sites (Weimar, 2009).
Electronic data interchange is part of the applications of a robust and integrated electronic health
record system. The type of integrated system envisioned by President Bushs administration is aimed at
warehousing the health care information of all Americans in a national database by 2014 (Thielst, 2007).
Electronic data interchange primarily is aimed at achieving seamless continuity of care, irrespective of
patient migration from one clinician to another or from one city to another.
A study on electronic medical records by Keenan et al. (2006) found improvement in daily work and
enhanced patient care: (a) medication turn-around times fell from 5:28 hours to 1:51 hours; (b) radiology
procedure completion times fell from 7:37 hours to 4:21 hours; and (c) lab results reporting times fell from
31:3 minutes to 23:4 minutes. In the same study, transcribing errors for orders declined, and length of
hospital stay decreased. Other benefits of electronic medical records systems are possibility for online
monitoring of vital signs, capability for multi-site review of patients records, and improved physicians
collaboration in patient care. EMR facilitates easy access to medication administration records, sharing of
consultation reports, and decreased transmit time of test results by reducing the time taken to deliver
paper versions (Keenan et al., 2006).
In a heterogeneous society like Nigeria with significant disparity in accessibility of health care
facilities between urban and rural communities, hospital information systems may help to bridge the gap
in availability of patient care (Ouma & Herselman, 2008). Sammon, et al. (2009) associated patient data
analysis systems (PDAs) with enhanced storage and analysis of patient data enabling physicians to reach
improved clinical decisions on patient care. Similarly, clinical information systems capture clinical data to
enhance prompt and efficient decision making (Ward et al., 2006; William & Boren 2008). Health care
policy makers seeking ways of improving quality of patient care at a reduced cost are leveraging hospital
information systems to achieve these objectives (Sammon et al., 2009; Simon et al., 2008).
A major challenge that exists for health care systems is the integration of software systems that can
service the various needs of the organization. Stone, Patrick, and Brown (2005) opined that effective
organization creates specific and strategic objectives, including objectives related to the clinical and
operational strategies (p. 33). Failing to address the interrelationships that exist between the strategies can
result in unforeseen negative consequences (p. 34). In the implementation of an electronic medical record,
an organization that fails to identify the need for the EMR system to communicate or integrate with the
billing software may likely encounter increase process failures requiring additional resources for
correction. Successful organizations develop strategies capable of identifying organizational needs. Such
organizations anticipate challenges and launch remediation efforts by installation of computer networks
and systems (Stone et al., 2005)


A positive correlation is found between adoption of health care information technology and positive
organizational financial performance in general, and operationally (Weimar, 2009). This observation is
thought to emanate from superior organizational performance by health care providers using novel
information systems (Menachemi, Burkhardt, Shewchuk, Burke, & Brooks, 2006). In the general industry,
electronic commerce transactions have enabled banking and the retail industry to lower cost of services
and improved ease of access to products for their customers by using the Internet (Sisniega, 2009).
Attributes of superior organizational performance in health care include improved quality of care and
patient safety.
Morath and Turnbull (2005) recommended creating a culture of safety in health care organizations by
recognizing and accommodating the multiple complexities of those organizations. A laudable approach
would be to take advantage of the ability of large-scale data systems to amass information as means of
identifying significant trends, and enable creation of blame-free sanctuaries in which care errors and
observations of incompetence receive prompt solutions. Data production and collection requires
knowledge to facilitate this undertaking. Various forms of knowledge are essential business asset used
for development of new products and services, thereby useful in developing a competitive advantage in
the marketplace (Rennolls & AL-Shawabkeh, 2008).
Cohan (2005) expressed a contrary view that investment in information technology does not
necessarily transcend to improvement in productivity. Cohan stressed that shortfall in productivity
expectations have made industrial leaders more cautious in adopting information technology in their
organizational processes. Presenting a balanced view, Farquharson (2009) asserted that adoption of
information technology increases productivity but falls short of expectation in improvement of
productivity considering the high capital investment required for implementation. Farquharson surmised
that industry productivity paradox exists to some extent with implementation of ICT. Furukawa, Raghu,
Spaulding, and Vinze (2006) argue that hospital information systems enhance quality of health care
delivery and safety.
Medical errors in diagnosis and drug administration decline with applications of electronic health
systems. Electronic physician order entry and medication reconciliation helps patients to understand
better, the beneficial effect of drugs and deleterious effects of drug misuse (Kramer et al., 2007). Fuji and
Galt (2008) opined that more than 1.5 million United States residents suffer injuries from prescription
errors and other medical errors annually. Citing the 2008 Institute of Medicine report, To Err is Human,
the authors suggested that the above figure might represent only a fraction of patients exposed to adverse
medical errors when patients own mix-up is taken into account. Fuji and Galt surmised that some
elements of hospital information systems increase patient participation in care process, thereby reducing
unwanted outcome of treatment.
Laboratory information systems (LIS) have evolved within the last decade (Harrison & McDowell,
2008). Harrison and McDowell (2008) linked the evolution of the LIS technology to advancements in
information technology solutions, stressing that LIS has led to an increased awareness in the
development of technological solutions designed to minimize medical errors. Following the publication
of the Institute of Medicines reports in the early 2000s and the Institute for Healthcare Improvements
Saving 100K Lives Campaign, industry awareness has increased on the need for solutions to minimize
medical errors (Harrison & McDowell, 2008).
The LIS industry has accepted the challenge and developed innovative software solutions that
include patient result verification, the recognition of critical values in addition to the immediate transfer
of critical values to physicians for evaluation, and enhanced turnaround time (Harrison & McDowell,
2008). Interfacing software is available to merge the laboratory information operating systems with
electronic health record (EHR) systems, enhancing the continuum of communication among providers.
Stone, et al. (2005) and Harrison and McDowell anticipated the future of LIS and EHR will provide for
increased patient safety, enhanced quality of care, and a leaner operating system resulting in efficient and
productive processes.
Woodside (2007) concur that health care organizations use electronic data interchange to share
patient histories, treatment plans, lab results, and insurance information. Sharing the patient's history in
an exchange facilitates initiation of care and decreases the chances of errors. Data interchanges that
involve physician's orders and pharmacies can protect the patient by detecting prescriptions of


incompatible drug combinations, and highlighting potential allergens to patients. Another vital function
of the electronic interchange is the verification of insurance benefits. Many providers do not run tests,
ship supplies, or provide care without assurance that the patient has insurance coverage and that the
insurance company has authorized the expenditures. Electronic interchange between entities helps avoid
delays in the approval process and decrease the possibility of poor outcome because of a delay in
treatment.
Information technology in general enables intra organizational networking that facilitates effective
information flow within the various units of a firm. In the world of an organizations complex network,
workforce diversity, and departmentalization, information can become lost in a milieu of activities; hence,
decision-making, schedule of responsibilities, and an information flow chart are necessary for effective
organizational operations (Hargie & Dickson, 2007). In addition to prompt delivery of investigation
reports to patients and clinicians, some aspects of information technology enable decisions made on
organizational processes to be timely and effectively disseminated to the workforce.
Analytical software systems provide means for both dissemination of information and relevant
quantitative data to support management decisions. Analytical information systems help organizations to
maintain a competitive edge in the marketplace by increasing operational speed and maintaining fluidity
of information flow (Azevado, Ferraira, & Leitao, 2008). Crane and Crane (2006) reported that numerous
solutions for the medication error problem in hospital settings might be averted with the use of an
integrated systems approach. However, execution of an organizations integrated electronic medical
record without use of communication billing software may escalate process breakdowns. Phillips (2009)
stated that the use of an integrated system offers considerable conceptual flexibility and data integration
capabilities instead of using one module for electronic records. An integrated records system promotes a
user-interface with e-records repository to facilitate storage and eventual retrieval of records.
Other benefits of electronic health systems include optimization of clinical time because of effective
communication and increased compliance with regulatory guidelines (Georgiu, Westbrook, Braithwaite,
& Iedema, 2005). Keenan et al. (2006) opined that electronic medical records system provide an effective
educational tool for training of resident doctors and medical students. Health care information
technology and e-health offer strong potential in research and development of clinical protocols. Future
studies in this area may provide broader implications of health care information technologies
applications (Keenan et al., 2006).
Barriers to Adoption of HIS in the United States
Policy implementations in the general industry and health care over a decade ago focused on
constant improvement in quality of goods and services by using innovative technology. Containment of
rising health care cost added to the drive for adoption of information technology in health care (Sobol,
Averson, & Lei, 1999; Weimar, 2009). Simon, et al. (2008) asserted that Australia and England are near
universal adoption of electronic health systems but significant barriers exist causing a slow pace of
implementation of hospital information systems across hospitals and health care organizations in the
United States.
According to Ford, Menachemi, and Phillips (2006), in 1991 the Institute of Medicine (IOM) issued a
report calling for paperless health records system within 10 years. This visionary call fell short of media
attention. Scholarly and governmental support was also deficient compared to other reports by the IOM.
The consequence is that integrating electronic health record systems into the workplace health care,
critical care, and the ambulatory setting does not equate other areas of medical care. Davis (2006), reports
that America is ranked 66th among 100 countries with top class health care infrastructure and systems.
Recent studies indicated that whereas 4% to 6% of the United States hospitals and health care
organizations have achieved full implementation of hospital information systems, 14-16% have partial
adoption of some forms of hospital information systems (Moore, 2009; Simon et al., 2008; Ward et al.,
2006;).
The high cost of implementation of electronic health systems commonly receives the blame for their
poor adoption. Ward, et al. (2006), in a study of Iowa hospitals, found an 80% adoption rate for urban
hospitals and 3040% adoption rate for rural hospitals, citing the robust financial capabilities of urban
hospitals as the reason for the disparity. Furukawa, et al. (2006), in their analysis of disparity in adoption


rate of electronic health record systems, asserted that big hospitals with more than 200 beds, teaching
hospitals, not-for-profit hospitals, and multi-hospital systems have higher rates of implementation than
independent non-teaching hospitals. Private not-for-profit health care organizations have twice the
adoption rate than for-profit organizations because of reinvestment of organizational profit into health
care technologies and hospital information systems as a means of retaining not-for-profit status
(Feldstein, 2007; Furukawa et al., 2006).
Hikmet, et al. (2008) concurred that organizational characteristics influence the implementation of ehealth information systems, but argue that geographical location does not significantly affect rate of
adoption. In an attempt to provide more insight about HIS adoption pattern, Kazley and Ozcan (2007)
found that hospital characteristics affect the rate of adoption of hospital information technology. These
authors reported that poor implementation occur among smaller hospitals, more rural hospitals, nonsystem-affiliated health care organizations, and hospitals in areas of high environmental uncertainty. The
lower rate of implementation among rural hospitals correlates more to their small size and limited
resources rather than geographic location.
Other barriers have constrained adoption of electronic health systems in the last decade. These
include inadequate knowledge of available technology; poor service delivery by some product vendors;
fear of workflow disruption causing clinicians resistance; uncertainties about return on investment;
difficult approval processes for high-capital spending, especially in for-profit organizations; database
incompatibility causing poor interoperability of various systems; training difficulties to cover large
staffing requirements; regulatory and legal considerations; and differences in information technology
preferences between clinicians and administrators (Alquraini, Alhashem, Shah, & Chowdhury, 2007;
Ouma & Herselmen, 2008; Poon, Biumantiial, Jaggi, Honour et al., 2004; Simon et al., 2008; Sobol et al.,
1999; Ward et al., 2006; Weimar, 2009).
In the 2005 health data management meeting, a survey of Chief Information Officers in attendance
found 74% of participants showing willingness to introduce clinical information systems in their
respective hospital practices as a top priority. The surveyed executives worried about the challenges in
implementing effective change management and difficulties in overcoming end-user resistance
(Anderson, 2005). Atkinson (2005) asserted that employees are more averse to changes that directly affect
their status quo. Countering the tendency of end user-resistance requires organizational leaders to adopt
strategies that encourage employees, and yet be persuasive for the workforce to accept and implement
desired change (Atkinson, 2005).
Greene (2005) recommends that organizations wishing to adopt hospital information technologies
must plan strategically to avoid unintended consequences of information technology implementation.
The information gap between management and staff leads to resistance in the implementation of EMRs.
Too often managers, who do not perform the daily tasks of documentation, make decisions on the system
components without staff input only to find that adjustments must be made.
In a pilot study in Cyprus on the implementation of electronic medical record systems, Samoutis, et
al. (2007) found that the physician's perceptions of the system's effect on their workflow, legal concerns,
transition issues, and lack of familiarity with electronic equipment were among the implementation
impediments. On a positive note, Samoutis, et al. found that the computerized system increased
efficiency and improved the quality of care to the patients served. With reimbursement becoming
increasingly associated with quality of care outcomes, implementing the right system with the
appropriate components becomes imperative.
Based on the research by Samoutis, et al. (2007), an important step in the implementation process of
hospital information systems is for the medical director to seek the input of associate physicians and
advanced practice nurses within the organization during the appraisal phase, as recommendations from
the major players in the care delivery process are vital to success. A challenge that exists for the
installation of computer networks is the culture of the organization and the makeup of each division that
would use the system. Nurses and physicians may be averse to computer systems because of the
perception that personalization of care would be affected (Thede, 2008). Technology advances frequently,
and the projected costs of the system upgrades may deter managers' decisions to go forward with the
installations. The lack of knowledge, poor understanding, and the negative experiences of managers with
information technology all represent challenges that could be deterrents to adoption.

Barriers to Implementation of E-Health in Africa

The Bulletin of the World Health Organization (2008) stated that Nigeria has been searching for the right
policy formulation in health care more than 30 years since the Alma Ata declaration of health for all in
1978. Successive Nigerian governments have not enacted any policy on the implementation of hospital
information systems in the health care delivery apparatus of the nation. This lack of policy partly explains
the continued poor national health outcomes as revealed by the Nigerian Ministry of Health survey in
2003. The report put infant mortality at 110 per 1000 births and maternal mortality of 1100 per 100,000 live
births. The United Nations report ranked Nigeria as the second highest in maternal mortality in the world
(Akinyemi, 2008).
In Africa, the loss of health triggers the near-poor into poverty with consequent dehumanizing effects
of extreme poverty (Pick, Rispel, & Doo, 2008). The Millennium Declaration pledged freedom for men,
women, and children from adverse consequences of poverty, but in Sub-Saharan Africa, concerns abound
on the projected outcome of the current millennium development initiatives that do not include any
elements of electronic health system implementation (Pick et al., 2008). Ouma and Herselman (2008)
indicated that whereas the developed Western nations are at the forefront of implementation of electronic
health, African countries are still at the rudimentary stages of adoption processes. Some of the reasons
attributed to this disparity include poverty, poor economic diversification, and lack of supportive
infrastructure and inadequate use of natural resources. Stressing that lack of leadership responsibility in
setting the right health care priorities may well have been the bane on accelerated development of the
Nigerian health care.
The peculiar Nigerian situation. The Nigerian health care system has continued to suffer from years
of neglect by successive governments, hence the poor infrastructural base of both public and private
health establishments (Okogbule, 2007). The trend is the same in almost every subset of the national life.
At the 2009 UNESCO conference organized to review and evaluate development efforts by member states
after a decade, the Nigerian score card showed failure in all ramifications. Other West African countries
like Senegal and Ghana were proud of their achievements within the last 10 years (Ogunlana, 2009).
According to Gyoh (2008), the revised health policy document indicated that government expenditure on
health was below $8 per capita, against the $34 recommended internationally. Compounding poor
government funding of health care in Nigeria is the high rate of corruption in the national polity
(Christoff, 2005). Overvalued contracts and failed projects abound in an economic system leading to nonactualization of technological breakthroughs and infrastructural decay.
Poverty seems to be a common excuse for poor investment in infrastructure in Nigeria. Sofowora (in
press) opined that despite the abundant natural resources in Nigeria, the country ranks ninth poorest in
the world because of its failure to harness its natural wealth. World Bank (2007) statistics indicated that
the poverty rate rose from 27% in 1980 to 70% in 1990, and even at present does not show any economic
index of improvement. The consequence is the dearth of basic social infrastructure (Sofowora, in press).
Electric power supply is at its lowest ebb with less than 50% of the country connected with electricity. In
places with electric power connectivity, the supply is fewer than 12 hours daily. Lack of consistent power
has caused poor industrialization of the country at large. In a related subject examining the poor adoption
of innovative information technology in the Nigerian banking industry, Ayo, Ayodele, Tolulope, and
Ekong (2008) reported that poor electric power supply is a major hindrance. The erratic power supply is a
challenge to infrastructural development in every facet of the Nigerian economy.
Inadequate Internet bandwidth is also a notable challenge in Africa. Internet connectivity problems
abound in Nigeria with the few Internet service providers in the market offering very poor services
because of bandwidth constraints (Ayo et al., 2008). Other barriers hindering adoption of hospital
information technology in Nigeria, and some African countries include the high cost of implementation,
poor infrastructural development, and inadequate trained manpower. Ouma and Herselman (2008)
conducted multiple case studies of technological assessments in the province of Nyanza in Kenya to
ascertain how rural hospitals are adapting to technology shift in health care. The issues examined were


the availability of information and communication technology infrastructure, electronic health
technologies in place, knowledge of caregivers on the benefits of ICT use in health care, and challenges
constituting barriers to adoption of ICT in the hospitals investigated. The results revealed inadequate ICT
infrastructure for electronic health implementation, a limited number of health care staff with basic
knowledge of ICT operations, and a high cost of adoption of electronic health systems. The authors also
identified end-user resistance in the few hospitals that had some applications of hospital information
technology.
Several authors were in agreement about the high-capital requirement for implementation of hospital
information technologies as a major barrier to adoption (Jha et al., 2009; Menachemi et al., 2006; Simon et
al., 2008; Ward et al., 2006). According to Getzen (2007) and Morris, Devlin, and Parkin (2007), adoption
of health care technology comes at significant cost implications that consequently impact the cost of
health care delivery. Nigeria undoubtedly is more than 95% a consumer society with no recognizable
production of medical hardware taking place in the country; cost of importation and delivery further
influences the eventual cost of adopting niche health care technology (Okeke, 2008).
Multiple forces impacting policy and health care. Nigeria for a long-time suffered political
instability that created an opportunity for corruption to thrive and enhanced poor macroeconomic
management (Apter, 2007; Okeke, 2008; Pierce, 2006). Following years of military dictatorship and lack of
government accountability, infrastructural decay did not attract desired attention (Okogbule, 2007). The
petroleum supported economy faced years of blatant economic mismanagement, and squandering of
resources through institutionalized corruption (Arikpo et al., 2007; Transparency International, 2006).
Nigeria has a democratically elected government, but one still propagating much of the political elements
and ideologies of the military era. Change in the body polity of the nation has been painfully slow, and in
some cases, retrogressive (Nullis-Kapp, 2005; Okafor-Dike, 2008). Consequent upon decades of neglect,
Nigeria is experiencing a serious shortage of modern health care facilities. The government has taken
some steps to promote the development of a basic national primary care program in the rural areas, but
with undesirable outcomes because of a lack of basic drugs, inadequate manpower, and serious lack of
specialized health care facilities (Okeke, 2008; Ouma & Herselman, 2008).
The major challenge for the current Nigerian government is to provide a policy roadmap and
adequate funding to support health care delivery in the nation. Lister and Jabukowski (2008) stated that
governance is the exercise of political, economic and administrative authority in the management of a
countrys affairs at all levels (p. 156). One of the cardinal functions of leadership is to promote change,
and providing the roadmap for change is a fundamental leadership requirement (Hamm, 2006). Wren
(2005) asserted that leadership entails an individual or a team inducing collective action to pursue an
objective, setting the pace for others to follow. Analysts have studied the responsibilities of Nigerian
leaders as they affect national development in terms of the success or failure of government reform
programs in the coming one to two decades. These analysts opine that the leaders successes will enable
the country to transform itself from present state of poverty and corruption to join progressive, large
economies in technological advancement and prosperity (Apter, 2007; Arikpo et al., 2007).
The high cost of startup investment for implementation of hospital information systems demands
some level of government leadership by ensuring strategic involvement in funding. According to Hikmet,
et al. (2008), a report presented to Congress by the Medicare Payment Advisory Commission during the
Bush administration indicated that adoption of hospital information technology was a major requirement
for improvement of quality, safety, and good clinical outcome in United States hospitals. The commission
sought for more government funding to improve the rate of implementation of hospital information
technologies across the country (Thielst, 2007).
Within 90 days of enactment of President Bushs policy to implement universal electronic health
record systems (EHRs), Larkin (2005) reported that implementation could be achieved in fewer than the
targeted 10 years. Larkins comments were based on the work of Brailer, who had designed a framework
for implementation. Larkin expressed concerns that such elaborate adoption of interoperable electronic
health records would cost more than the Apollo mission to the moon spearheaded by President Kennedy.
The Obama administration in its 2010 health care reform bill sought expansion of implementation of
hospital information systems (Jha et al., 2009). Because the decision to facilitate implementation of the


policy on EHRs commenced by Bushs administration within the new health care policy was attracting
debate, the Obama administration released $19 billion in ARRA to move the process forward (Jha et al.,
2008).
The need for a robust government policy on health care technologies exists in Nigeria and other
African countries to facilitate the implementation of e-health initiatives (Bulletin of World Health
Organization, 2008). Furukawa, et al. (2006) opined that variation in health information systems and
demographic differences between rural and urban areas presents a challenge to policy formulation aimed
at universal adoption of health care information technologies. This concern is even more prevalent in
Sub-Saharan Africa in which about 80% of the population domicile in rural communities deprived of
basic social infrastructure and amenities (Okeke, 2008).
Effect of Policy Gap and Poor Implementation of HIS
The absence of robust implementation of hospital information systems has compromised some
critical aspects of patients safety and quality of care both in Nigeria and in the United States. Fuji and
Galt (2008) suggested that more than 1.5 million United States residents suffer injuries from prescription
errors and other medical errors annually. The Institute of Medicine report titled To Err is Human indicated
that the number of patients exposed to adverse medical errors might be more than the above-cited figure
when patients own mix-ups with the use of prescription drugs are taken into account.
The practice of Western medicine is rapidly expanding in Nigeria, but non-availability of modern
medical technologies in the health care arena remains a threat to the success of orthodox medicine (Linz
& Fallon, 2008). The consequences of non-adoption of hospital information technologies in Nigerian
hospitals include (a) Mix-up with laboratory results, (b) misdiagnosis, (c) medication order errors, and (d)
mismanagement of patients (Linz & Fallon, 2008; Okeke, 2008). Worsened by a shortage of medical
professionals, the threat of re-emerging infectious diseases, poor sanitation, and the prevalence of water
borne diseases; the growth and development in health care has been dismal in Nigeria (Pond & McPake,
2006).
Infrastructural Requirement for Adoption of HIS
The ease of adoption of electronic health information systems is dependent on existing infrastructure
in a hospital or health care organization (Ward et al., 2006). In a study of Iowa hospitals in the United
States, Ward, et al. (2006) found a higher adoption rate among hospitals already using computer systems
for scheduling of outpatients, scanning of medical records, patient indexing, transfer, discharge of
patients, and waiting list administration. Effective application of hospital information systems requires
broadband Internet connectivity with high-speed capability for data retrieval and transfer (Ouma &
Herselman, 2008).
Ayo, et al. (2008), in a study of the framework for implementation of e-commerce in Nigeria, decried
the abysmally low Internet-access in the country. Internet connectivity enables effective data
management systems, picture archival, and communication systems, and is specifically important for
running of radiological information systems and teleradiology. Other requirements include well-trained
health care workers and information system administrators (Alquraini et al., 2007; Ouma & Herselmen,
2008; Simon et al., 2008; Ward et al., 2006; Weimar, 2009).
Resulting from diverse organizational backgrounds, hospital information system vendors tailor
installation of their technologies to the needs of each health care organization (Moore, 2009). An
uninterrupted power supply is a prerequisite for adoption of hospital information systems and ensures
avoidance of unintended shutdowns that could lead to loss of data or permanent system damage. The
power supply is erratic or nonexistent in many regions of the Sub-Saharan Africa. Duke, et al. (2005)
asserted that improvement in quality of health care for children in commonwealth of independent states
must address infrastructural development and focus on provision of mechanisms for prompt and
effective dissemination of health care information to facilitate compliance with clinical guidelines.
Cost Implications
The high investment cost and uncertain return on investment is a notable challenge to
implementation of electronic health strategies (Menachemi et al., 2006). More worrisome is the


observation by researchers that technology spending does not necessarily transcend to expected
improvements in productivity and profitability (Roztocki & Weistroffer, 2006). Weimar (2009) estimated
the cost expectation of full implementation of hospital information systems in a 100-bedded hospital is
about $35 million in five years. Ward, et al. (2006) asserted that with problems of uncertain
reimbursement and a focus on technology at the detriment of healthy business consideration, a
disconnection exists between the drive for adoption of e-health and the continued survival of healthcare
organizations.
The changes to health care reimbursement and reduction in funding pose financial threat to
organizations. Compounded by the need to install computer networks as a requirement for
implementation of hospital information systems, health care organizations find the cost benefit analysis
increasingly challenging. Moore (2009) argued that return on investment is achievable by creating
efficient paperless and filmless systems that leads to staff reduction and decrease or eliminate need for
report transcription. Moore reported a one million dollar cost saving at their cardiac hospital by
eliminating services of medical transcriptionists for a year. The hospital equally achieved staff reduction
in the front and back offices during the same period.
Menachemi, et al. (2006) asserted that regardless of analysis approach or method of electronic health
system employed, information technology adoption consistently correlates with increased financial
outcome operationally and in general organizational processes with consequent improvement in
organizational performance. Brailer (2005) projected a 7.5% cost saving from reduction of drug
prescription error and in general 30% improvement in financial performance by adoption of
comprehensive electronic health record system and widespread organizational restructuring. The
electronic health record systems improve the efficiency and reduce cost of data storage and retrieval (Linz
& Fallon, 2008). Simon, et al. (2008), in a study conducted to ascertain the estimated use of electronic
health records (EHRs) in ambulatory care practices in the United States, found practice size influenced
the adoption of EHRs with solo and small practices lagging behind larger practices. Most participants
agreed that electronic health records systems have the potential to improve the quality and safety of
health care, and may reduce health care costs.
The opportunity costs that an organization may face if it does not invest in these tools include a lack
of process performance improvements and a decline in profit margins. Aggregation of data into a data
warehouse facilitates analysis and supports frequent process improvement. This involvement assists
organizational efforts with assessment of patient outcomes, patient safety, and organizational skills. Profit
margins are constantly dwindling in health care delivery organizations with decreased payment for
rendered services. Data warehousing, data mining, and analytics may promote maximal intensity,
efficiencies, and effectiveness. A suggestion for the use of hospital information technology is to improve
business, clinical processes, health care outcomes, and profit margins (Glandon, Smaltz, & Slovensky,
2008, p. 236).
Health care organizations have an opportunity to maximize outcomes when they select to invest in
profitable systems. Wickramasinghe, Bali, Gibbons, and Schaffer (2008) asserted that the health care
industry has the history of using leading edge technologies and embracing new scientific discoveries to
facilitate better cures for diseases. The limitation is that adoption of health care technology often increases
the cost of health care delivery (Getzen, 2007). In a poor country like Nigeria, further increase in health
care cost may alienate a sizeable subset of the population from accessing care from orthodox medical
practitioners (Okeke, 2008).
Human Resources Problems
Human resources requirements in the health care industry include a wide range of personnel who
deliver clinical care, supportive services in laboratory, radiology, physiotherapy, and ancillary services.
The trend to use digital medical equipment with the possibility for networking demands that medical
staff possess a good knowledge of information technology applications and uses. In Nigeria, there has
been an ongoing depletion of the highly skilled workforce resulting from migration to foreign nations.
The health care workforce shortage in the rural areas originally caused by rural-urban migration within
the country is made worse by large numbers of Nigerian doctors, nurses, radiographers, and laboratory


scientists departing to developed western countries in search of better pay, better living conditions, and
career improvement (Glasser, Peters, & MacDowell, 2006).
A shortage of a skilled health care workforce known to affect mostly rural communities all over the
world has currently taken a new dimension in Nigeria with acute shortage of various categories of
medical staff in urban hospitals leading to a systematic decline in the quality of health care services in
Nigeria (Glasser et al., 2006; Okeke, 2008). Meetings held by senior government officials on December 2
and 3, 2004, decried the growing shortage of health care professionals in the country. The participants
stressed the need for urgent actions to curtail the trend as it could jeopardize the governments efforts to
reduce poverty and disease. Another major concern was that the depletion of a skilled workforce is
capable of hindering developmental goals (Nullis-Kapp, 2005). Okeke (2008) opined that underfunding of
health care services by the government because of neglect and claims of over-stretched budgets have left
many hospitals in Nigeria in a poor physical state, under-staffed, and lacking in modern medical
equipment. Consequently, the limited health care professionals inundated by excessive workload seem
often stressed to the limits (Perry, 2005).
In these circumstances, adoption of hospital information system may be relevant to improve
workflow and bridge the gap created by personnel shortages (Ouma & Herselman, 2008; Shekelle et al.,
2006; Wallis, 2007). The challenge remains that time spent training depleted s health care workforce in
Nigeria will amount to increased waiting time for patients to access care. Uploading patient information
from paper-based records into hospital information systems results in an increased workload and
constitutes a significant reason for end-user resistance. With an already over-stretched health care staff,
the increased workload on information technology training will constitute a barrier to adoption of HIS.
A study conducted by Kaliyadan, Venkitakrishnan, Manoj, and Dharmaratnam (2009) showed an
increase in time taken to complete patient records for new cases using EMR compared with paper
records. The study results indicate that average time taken for the completion of the EMR-based
consultation for new cases was 19.15 minutes (range, 10-30 minutes; standard deviation, 6.47). The paperbased consultation had an average time of 15.70 minutes (range, 5-25 minutes, standard deviation, 6.78).
Following the t-test, the p-value was 0.002, which was significant. Chambliss, Rasco, Clark, and Gardner
(2001) attributed these timing problems to disruptions in clinical routines and poor typing speed by some
clinicians. Samoutis, et al. (2007) in their study of EMR adoption in Cyprus reported that physicians
perceptions of the impact of EMR systems on their workflow and lack of familiarity with electronic
equipment were among the barriers to implementation. These challenges may be rifer in Nigeria because
of already compromised health care workforce population.
Corruption in Nigeria
Corruption in Nigeria is a major challenge that has shaped the socio-economic life of the nation and
negatively impacted the health-care development and service delivery. The ugly face of the present-day
Nigeria is endemic multidimensional corruption (Okogbule, 2007). According to Amnesty International,
Nigeria ranked between the most corrupt and the second most corrupt nation in the world from1996 to
2006. Nigeria's Corruption Perception Index (CPI) score has ranged from 0.69 to 2.2 (out of a maximum of
10) reaching above the 2 score line for the first time in 2006 (Transparency International, 2006). A nation
once extolled as the giant of Africa because of its massive land area, large population size, and
assertiveness of its political elite compared to other African nations once again is making another round
of popularity, but in a derogatory manner.
According to Apter (2007), in the committee of nations, Nigeria often denotes fraud and corruption.
The extent of involvement of fraud perpetuators in Nigeria and those operating outside the shores of the
country is unquantifiable. Apter stated that fraudulent practices range from online identity theft,
marketing of nonexistent goods, prosperity churches, false non-governmental organizations soliciting
funds from foreign donors, to outright imposition by persons as government officials awarding bogus
contracts. The activities of corrupt elements in society have tarnished the social and corporate image of
the nation, causing a drought of foreign investment in the country (Arikpo et al., 2007). Corruption exists
in every facet of life in Nigeria, and has negatively affected the willingness of international investors to
do business in Nigeria. The engagement of the larger society in corruption occurs by ambivalent
complicity (Apter, 2007). Sustained aiding and abetting of corruption in the Nigerian society makes it


impossible for the nation to rise above mediocrity in almost every area of socioeconomic endeavor
including health care (Apter, 2007; Arikpo et al., 2007).
Nigeria as an Importing Economy
Sustainable economic growth has been far from attainment in Nigeria because the nation is over 95%
a consuming economy (Okeke, 2008). Technological advancement produces positive change in social
structure and innovations, and acts as vehicle for modernization (Arikpo et al., 2007). Nigeria is lacking in
technological depth; hence, it depends on foreign technology to drive the countrys developmental
efforts. The consequence has been slow economic growth and over dependence on importation for most
consumer products. Nigeria seems to have become a dumping ground for substandard products from
Asia and other parts of the world (Arikpo et al., 2007).
Nigeria is the fifth largest exporter of crude oil in the world, yet lacks the capacity to produce
finished petroleum products. Locally consumed petroleum products are imported from foreign nations.
The three Nigerian refineries have since broken down, and because of obsolete technology, have
remained unserviceable over the years. Institutionalized corruption is the bane of infrastructural
development in Nigeria (Ayo et al., 2008). Most government officials use their offices to facilitate money
laundering through inflated contracts. The arrest of two Nigerian governors in London in 2004 and 2005
under different circumstances of money laundering charges are clear manifestations of the scale of
corruption in Nigeria and how it has robbed the nation of much needed resources for technological
advancement (Okogule, 2007).
High Lending Interest Rates in Nigeria
Financial stability of the capital market affects every aspect of national economy (Ayo et al., 2008).
The Nigerian financial market has been unstable for many years. High capital-flight as a result of high
rates of money laundering, bad loans, and massive importations often depleted the capital base of the
banks (Ayo et al., 2008; Okogbule 2007; Sanusi, 2009). These shortcomings and corrupt practices by bank
executives have forced many Nigerian banks and other financial institutions out of business over the
years. The most recent effort to improve the capital base of Nigerian banks took place in 2006. The aim
was to boost the economy, encourage lending and decrease interest rates to single digits as obtainable in
other developed economies (Soludo, 2007). This effort did not yield the desired effects as lending interest
rates remained between 22-25% in all the Nigerian banks, depending on type, and tenure of credit (Ayo et
al., 2008). The high interest rates have not encouraged investment in health care because of longgestational periods required for return on investment in health care and the economic uncertainties that
surround technological investment in health (Ward et al., 2006).
Frequent market failures have not encouraged Nigerian medical practitioners to invest significantly
into health technology. Aside from the high cost of innovative medical technologies, the credit market in
the country is averse to long-tenure loans compelling most practitioners to invest into other areas of the
economy that have better prospect for quick return on investment, like housing, stocks, oil, and gas (Ayo
et al., 2008). Because the recent global economic meltdown and consequent collapse of most lending
institutions around the world, further lag in medical investment in Nigeria may be inevitable. A major
shakeup of the Nigerian banks in July 2009 by the Central Bank governor exposed massive fraudulent
acts perpetuated by highly placed bank officials in five Nigerian banks. Records revealed that grants of
unsecured personal loans depleted the capital base of the affected banks (Sanusi, 2009), making it
impossible for them to engage in meaningful banking that could facilitate investments into health care
infrastructure.
Cultural Influence on Adoption of HIS in Nigeria
Culture by common understanding refers to a peoples way of life. Nigeria has a large demographic
setting represented by more than 250 ethnic groups and presents diversity of cultural practices and
norms in minute detail (Okeke, 2008). Certain peculiarities are becoming a way of life in Nigeria; notable
within the emergent common culture are materialism and individualism. Whereas the political
grandfathers of the nation of Nigeria fought for independence based on the common good of all, the new


political elite have introduced a culture of materialism and individualism to the detriment of a common
goal. Eckersley (2005) asserted that the impact of societal cultures on health is often underestimated,
explaining that culture could influence the levels of inequalities. For instance, materialism and
individualism accentuate the rich-poor divide, thereby breeding social vices because of the perceived
dictum of survival of the fittest.
Materialism leading to social inequality has become a hindrance to development in Nigeria. A recent
minister of health and officials of the ministry embezzled 300 Million Naira, an equivalent of about two
million United States dollars meant for the pilot study of telemedicine in the country. Although, the
government official was fired from office but as of 2010, telemedicine practices are nonexistent in any
form in Nigeria. The culture of corruption in Nigeria and mismanagement of economic resources by
government office-holders borne out of the need to satisfy materialistic and individualistic aspirations
has led to the impoverishment of the nation. The prevalence of poverty rose sharply from 28.1% in the
1980s to 65.6% in 1996 (Onwujekwe, 2005). The yearning for quick wealth among Nigerians has led to
massive corruption in the national frontier and fraudulent practices internationally.
The new face of Nigeria has become an impediment to the free flow of goods and services in Nigeria.
Foreign companies trade cautiously with Nigerian business entities and this will no doubt impact any
major initiative to implement hospital information technology in Nigeria on a large scale. The culture of
institutional corruption by government officials does not encourage the delivery of the best products into
the country because of the kick-backs (bribes) they receive from product vendors who, in turn, supply
substandard products in a bid to achieve desired profit margins. In the view of Aripko, et al. (2007)
because Nigerians allow these practices to continue unabated, the citizenry are in ambivalent complicity.
Analysts surmise that this culture is here to stay, except the nation seeks the only way out which may
require a total re-orientation of value systems (Okogbule, 2007).
The need exists to replace individualism and materialism with aspirations that promote the common
good of all. Ghana, a close West African neighbor of Nigeria, has transformed successfully in the past two
decades from similar circumstances of corruption and poverty to becoming a rallying point in the region.
Therefore, there is hope for Nigeria if the leadership will simply provide the new orientation. Wren
(2005), described leadership as the process by which an individual or a team induces followership to
pursue objectives set by the leader not necessarily by persuasion but through examples set by the conduct
of the leader. The change in Ghana implies that a new culture of accountability, honesty, pursuit of a
common goal, and nation building is possible for Nigeria through cultural reformation spearheaded by
the right type of leadership. As a benefit of socio-cultural reformation, Ghanas industries currently
attract capital once targeted for Nigeria in areas of education, health care, tourism, and several other
investments because of Ghanas stable socio-political climate, stable electrical power supply, and low
corruption-rate (Somiah, 2006).
Limitations of HIS
Management of electronic health record systems is constantly evolving with about 17 different
systems currently available to service various clinical applications, facilitate strategic decision making,
and improve administrative workflow (Hikmet et al., 2007). Although aimed at constant quality
improvement, the rapid evolution of these information technologies is a major limitation. The short shelflife compels users to upgrade frequently or lose the ability to interface with newer innovations (Brailer,
2005). The upgrade and running cost burden is remarkable and outside the reach of small hospitals and
health care trusts. Physsician health care administrators and boards understand the benefits of hospital
information technologies, but they do not find easy justification for the cost (Thielst, 2007).
Compounding the cost issues, the lack of interoperability of information systems marketed by
different vendors is a significant concern (Brailer, 2005). Problems with Interoperability do not allow
seamless retrieval of patient information across different operating systems. Patient clinical data may be
accessed only in hospitals with compatible information systems, thereby hampering the key benefit of
easy and universal access to patient data that the technology is meant to support (Arrow et al., 2009).
Other key concerns constituting major limitations of hospital information technologies include wrong
identifications, wrong or incomplete information documented in hospital systems, the possibility of


making changes to patient information by unauthorized persons; an event that carries considerable safety
implications (Fuji & Galt, 2008).
Researchers recognized the cost curtailment capabilities, improved quality of care, and prompt
delivery of acute care associated with telemedicine. However, telemedicine, as a type of hospital
information technology, has some obvious barriers (Hjelm, 2005; Wootton, Jebamani, & Dow, 2005).
According to Ashley (2002), notable among the drawbacks are some legal requirements of multiple
licenses and credentials. Because practices in telemedicine sometimes require clinicians to provide
consultation across interstate boundaries, clinicians with limited licensure may have legal problems
delivering service in certain locations. Whereas credentialing stipulates minimum standards of training,
education, and qualifications needed by professionals to provide care, each state may require different
benchmarks for its practitioners according to state law. These specific statutes may affect the ability of a
clinician to offer telemedicine services.
Another drawback with telemedicine is the physical separation between the health professional and
the patient. In the 1990s, Wootton (1996) called this drawback the depersonalization of health care.
Wootton further opined that bureaucracy is another drawback of telemedicine. The use of telemedicine
may require a radical change in the way that services are provided and paid for. Concerns about how
services are billed and reimbursement obtained abound. Patient privacy is impinged upon by practices of
telemedicine. According to Ashley (2002), in a survey conducted in 1999, 20% of participants believed
that medical information was not properly used and 16.7% of participants admitted to providing
inaccurate data to conceal what they considered private information
Barjaktarevic (2008) expressed similar concerns of inadequate confidentiality for patient records
because of possibility of data mismanagement electronically. Georgiou, Westbrook, Braithwaite, and
Iedema (2005) asserted that the extent of organizational impact of adoption of hospital information
systems is often underestimated; stressing that a major incident of patient risk exposure emanating from
the system is capable of causing far-reaching organizational consequences. Callens and Cierkens (2008),
commenting on legal concerns with the use of EHRs, concur that new e-health applications, including
electronic health records, e-health platforms, health grids, and further use of genetic data, come with
fresh legal challenges and undeniable legal consequences in case of information mismanagement or
identity theft.
According to Benham-Hutchins (2009) because of challenges involved in integrating new hospital
information systems with old paper documentation and record systems, clinicians, and other health care
practitioners may become encumbered with multiple and conflicting sources of patient information.
Multiples of paper and electronic documentation may disrupt a seamless workflow and influence the
quality and efficiency of service delivery. These circumstances also have the potential to cause new types
of medical errors resulting from poor harmonization of patient information. Understanding these
concerns requires examination of human factors in the design of technology that is able to adapt to the
way health care providers do their job. The delivery of patient-friendly services demands that health care
providers continue to work toward improvement in the method of care pathways and processes.
Georgiou, et al. (2005) asserted that hospital information technologies eliminate some aspects of
human interaction among staffs, thereby hindering workplace collaboration and cohesion. Keenan, et al.
(2006) concurred that the human element is still very important in health care delivery and technology is
just a tool in the hands of trained personnel. Other economic limitations of hospital information
technologies include (a) the inability to ascertain an accurate return on investment (Menachemi et al.,
2006), (b) problems with appropriate reimbursement for technology use, and (c) focus on technological
issues at the expense of health care services and business concerns (Ward et al., 2006). In their pilot study
of the implementation of an electronic medical record, Samoutis, et al. (2007) found that the physician's
perceptions of the system's effect on their workflow, legal concerns, transition issues, and lack of
familiarity with electronic equipment were among the impediments of implementation.
Samoutis, et al. (2007) observed that computerized systems increased work efficiency and improved
the quality of care to the patients served. Recent health care debates reinforced the demands for
reimbursement that are associated with quality of care outcomes. Implementing the right systems to
incorporate the appropriate components is a necessity. Benham-Hutchins (2009) suggested adequate


input of unique and valuable nursing perspectives at all stages of the hospital information technology
(HIT) system life cycle.
Remedies Aimed at Improving e-Health Coverage
Cebul, Rebitzer, Taylor, and Votruba (2008) asserted that modern information technology promotes
the sharing and coordination of patients clinical information, but its adoption has been slow in the health
care arena. Various authors have suggested ways of improving adoption of hospital information
technologies in developed and developing countries. Although undeniable demographic differences
exists in different regions of the world, some common themes emerge that can enhance implementation
of e-health applications anywhere in the world. Suggested remedies include replacement of fee for
service payment systems with a system that rewards and encourages use of innovative information
systems, establishment of a funding agency to sponsor adoption of health care information technologies,
and identification of revenue sources accruable from the use of hospital information systems.
Other measures to encourage adoption of HIS include the provision of tax incentives for full adoption
and the development of hospital information systems that promote data exchange by interoperability and
easy access to a national database functioning as a repository of patient clinical information (Arrow et al.,
2009; Ouma & Herselman, 2008; Moore, 2009). Other recommendations for improved adoption of hospital
information systems in Africa include improving staff training on e-health applications; purchasing
cheaper options in the form of user-friendly software, especially in rural hospitals with limited economic
resources, and improving rural electrification to power information communication infrastructures in
suburban communities. To ensure long-term use of e-health facilities, contract agreements with ICT
experts are necessary for regular maintenance of information system hardware. Government should also
facilitate the adoption of hospital information systems in both urban and rural hospitals (Ouma &
Herselman, 2008).
Future Trends
The new trend among health care organizations in a changing global environment is the adoption of
sophisticated information systems to support clinical operations and strategic management. Major
attributes of current systems include an emphasis on information protection, provision of diseasemanagement software, and programs that reduce medical errors. Future trends will seek to improve
interoperability, expand the use of the Internet, and development of electronic health (e-health)
applications. More vendors are likely to focus on smart devices with wireless capabilities to improve data
entry and retrieval and support consumers through development of niche home appliances (Glandon et
al., 2008). Electronic Health Records (EHR), smart cards, and vein mapping for identification allow easy
access to medical information and prevent fraudulent use of information by others.
According to Garets and Horowitz (2008), clinicians should engage in evaluation of hospital
information technologies because information systems will become repositories of clinical data. Electronic
medical records systems and other information systems will attain commonplace applications in
hospitals and other health care centers in the coming decade. President Bush set a target of developing
electronic health records for all Americans by 2014 (Thielst, 2007). Health care policy makers and
organizational leaders should work to understand the operational intricacies of various hospital
information technology options in readiness for universal adoption in the next few years (Garets &
Horowitz, 2008).
The future trend in Nigeria is hard to predict. The demand for adoption of innovative technology
abounds, but the economic implications and other infrastructural requirement put a barrier to adoption.
The Nigerian government and governments of other African countries will have to invest heavily on
infrastructure to facilitate any attempt aimed at catching up with the developed world in the adoption of
hospital information technologies (Ouma & Herselman, 2008).


Conclusion
The analysis presented in the literature review provided insight into the enormous health care benefits of
hospital information systems, and their usefulness as educational tools in training clinicians. The
literature review brought to the fore the disparity in adoption of hospital information systems between
Nigeria, the United States, and some other countries. In Nigeria, poverty, poor government funding, lack
of appropriate government policies on adoption of health care technologies, human capital flight to
developed countries, the low technological base of the country, inadequate electricity supply, and
corruption are among common assertions that authors believed are responsible for poor adoption of
hospital information system (Apter, 2007; Arikpo et al., 2007).
Contextual issues constituting barriers to adoption of hospital information systems formed a major
part of the literature review, and there seemed to be more impediments to adoption in Sub-Saharan
Africa than in the developed western world. The high cost of implementation of all the components of
hospital information systems appears to be a global challenge. Apart from a lack of infrastructural
requirements for adoption of hospital information system in Nigeria, the neo-cultural influence of
materialism and individualism have added to an environment of corruption, thereby creating a vicious
cycle (Eckersley, 2005; Okeke, 2008). Chapter 2 also provided insight into the effects of the paucity of
health care policy on health care delivery in Nigeria with an emphasis on poor e-health applications in
the country.
The high cost of implementation of hospital information systems and other barriers are concerns to
most authors. A positive correlation has been found between the adoption of health care information
technology and positive financial performance both in general organizational and operational processes
(Furukawa et al., 2006; Weimar, 2009). Some suggestion is that the Nigerian government enacts policies
aimed at widespread implementation of HIS and provides funding support to health care organizations
across the country to facilitate adoption of HIS in their care processes.
Analysts further clamored for improvement in rural electrification to power information
communication infrastructures in suburban communities (Arrow et al., 2009; Ouma & Herselman, 2008;
Moore, 2009). Others argue that the Nigerian government needs to invest heavily on infrastructure to
facilitate any attempt at catch up with the developed world in the adoption of hospital information
technologies (Ayo et al., 2008; Ouma & Herselman, 2008).


References
Adetokunbo, O. L. (2005). Human resources for health in Africa. British Medical Journal, 331(7524), 10371038. Retrieved from http://www.bmj.com/
Akinyemi, K. (2008). Nigeria: Poor primary health care cause of maternal mortality. Retrieved from
http://allafrica.com/stories/200809150693.html
Alquraini, H., Alhashem, A. M., Shah, A., & Chowdhury, R. I. (2007). Factors influencing nurses attitudes
towards the use of computerized health information systems in Kuwaiti hospitals. Journal of
Advanced Nursing, 57(4), 375381. doi:10.1111/j.1365-2648.2007.04113.x
Amaghionyeodiwe, L. A. (2009). Government health care spending and the poor: Evidence from Nigeria.
International Journal of Social Economics, 36(3), 220- 236. doi:10.1108/03068290910932729
Anderson, H. J. (2005). Tackling the challenge of systems integration. Health Data Management, 13(4), 8.
Retrieved from http://www.healthdatamanagement. com/issues/
Angst, C. M., & Agarwal, R. (2009). Adoption of electronic health record in the presence of privacy
concerns: The elaboration likelihood model and individual persuasion. MIS Quarterly, 33(2), 339370. Retrieved from http://www.misq.org/
Apter, A. (2007). A culture of corruption: Everyday deception and popular discontent in Nigeria. African
Studies Review, 50(3), 153-155. Retrieved from http://www.africanstudies.org/p/cm/ld/fid=134
Arikpo, A., Etor, R., & Usang, E. (2007). Development imperatives for the twenty-first century in Nigeria.
Convergence, 40(1/2), 55-66. Retrieved from
http://www.uk.sagepub.com/journals/Journal201774
Arrow, K., et al. (2009). Toward a 21st-century health care system: Recommendations for health care
reform. Annals of Internal Medicine, 150(7). Retrieved from http://www.annals.org
Ash, J. S., & Bates, D. W. (2005). Factors and forces affecting EHR system adoption: Report of a 2004
ACMI discussion. Journal of the American Medical Informatics Association, 12(1), 8-12.
doi:10.1197/jamia.M1684
Ashley, R. C. (2002). Telemedicine: Legal, ethical, and liability considerations. American Dietetic
Association. Journal of the American Dietetic Association, 102(2), 267-269. doi: 10.1016/S00028223(02)90063-5
Atkinson, P. (2005). Managing resistance to change. Management Services, 49(1), 1419. Retrieved from http://www.ims-productivity.com/page.cfm /content/ManagementServices-Journal/
Austin, A., & Wetle, V. (2008). The United States health care system: Combining
business, health, and delivery. Upper Saddle River, NJ: Prentice Hall.
Ayo, C., Ayodele, A., Tolulope, F., & Ekong, U. (2008). A framework for e-commerce
implementation: Nigeria a case study. Journal of Internet Banking and
Commerce, 13(2), 1-11. Retrieved from http://www.arraydev.com/commerce/jibc/
Barjaktarevic, A. (2008). Specific implementation of electronic medical record in pediatrics practice.
Informatica Medica, 16(3), 172-175. Retrieved from http://wiki.infomedica.it/
Benham-Hutchins, M. (2009). Frustrated with HIT? Get involved! Journal of Nursing Management, 40(1), 17.
Retrieved from http://www.wiley.com/bw/journal. asp?ref=0966-0429
Brailer, D. J. (2005). Economic perspective on health information technology. Business
Economics, 40(3), 6-14. doi:10.2145/20050301
Bulletin of the World Health Organization. (2008). 86(3), 161-240. Retrieved
from http://www.who.int/bulletin/volumes/86/3/en/
Callens, S., & Cierkens, K. (2008). Legal aspects of e-health. Studies in Health Technology and Informatics,
141, 47-56. Retrieved from http://www.researchgate. net/journal/09269630_Studies_in_health_technology_and_informatics
Carter, L., & Blanger, F. (2005). The utilization of e-government services: Citizen trust,
innovation and acceptance factors. Information Systems Journal, 15(1), 5-25. doi:10.1111/j.13652575.2005.00183.x
Chambliss, M. L., Rasco, T., Clark, R. D., & Gardner, J. P. (2001). The mini electronic
medical record: A low-cost, low-risk partial solution. The Journal of Family


Practice, 50(12), 1063-5. Retrieved from http://www.jfponline.com/
Cholewka, P. A. (2006). Implementation of a health care information system in Lithuania. International
Journal of Economic Development, 8(3), 716-747. Retrieved from http://www.ijesar.org/
Christoff, J. A. (2005, April 14). Developing countries: Achieving poor countries
economic growth and debt relief targets faces significant financing
challenges. GAO Reports, 1-67. Retrieved from http://www.gao.gov/
Cochran, W. G. (1977). Sampling techniques (3rd ed.). New York, NY: Wiley.
Cohan, P. S. (2005). CFOs to tech: Ill spend for the right technology. Financial
Executive, 21(3), 30-33. Retrieved from http://www.financialexecutives.
org/eweb/DynamicPage.aspx?site=_fei&webcode=mag_issue_current
Collins, G. (2003). The economic case of mergers: Old, new, borrowed, and blue.
Journal of Economic Issues, 37(4), 987-998. Retrieved from
http://www.mesharpe.com/mall/results1.asp?acr=jei
Collins, K. M. T., Onwuegbuzie, A. J., & Sutton, I. L. (2006). A model incorporating the rationale and
purpose for conducting mixed methods research in special education and beyond. Learning
Disabilities: A Contemporary Journal, 4(1), 67-100. Retrieved from
http://www.ldam.org/publications/contemporary.html
Crane, J., & Crane, F. G. (2006). Preventing medication errors in hospitals through a systems approach
and technological innovation: A prescription for 2010. Hospital Topics, 84(4), 3-8.
doi:10.3200/HTPS.84.4.3-8
Credit Valley Physicians REACH the Electronic Health Highway. (2007, October 22). The Brampton
Guardian. Retrieved from http://www.bramptonguardian.com /news/article/523664--creditvalley-physicians-reach-the-electronic-health-highway
Creswell, J. W. (2005). Educational research: Planning, conducting, and evaluating quantitative and qualitative
research (2nd ed.). Upper Saddle River, NJ: Pearson Education.
Creswell, J. W., & Plano Clark, V. L. (2007). Designing and conducting mixed methods
research. Thousand Oaks, CA: Sage
Davis, K. (2006). The best health system in the world2006 annual report. The Commonwealth Fund.
Retrieved from http://www.commonwealthfund.org
Detmer, D. (2001). Transforming health care in the Internet era. World Hospitals and
Health Services, 37(2), 7-11. Retrieved from http://www.eldis.org/assets /Orgs/7772.html
Devi, S. (2008). U.S. health care still failing ethnic minorities. The Lancet, 371(9628), 1903-4.
doi:10.1016/S0140-6736(08)60816-8
Eckersley, R. (2005). Is modern Western culture a health hazard? International Journal of Epidemiology,
35(2), 252-258. Retrieved from http://ije.oxfordjournals. org/cgi/content/full/35/2/252?etoc
Feldstein, P. J. (2007). Health policy issues: An economic perspective (4th ed.).
Washington, DC: Aupha Press.
Ford, E. W., Menachemi, N., & Phillips, M. T. (2006). Predicting the adoption of electronic health records
by physicians: When will health care be paperless? Journal of the American Medical Informatics
Association, 13(1), 106-12. doi:10.1197/jamia.M1913
Fuji, K. T., & Galt, K. A. (2008). Pharmacists and health information technology: Emerging issues in
patient safety. HEC Forum, 20(3), 259275. doi:10.1007 /s10730-008-9075-4
Furukawa, M. F., Raghu, T. S., Spaulding, T. J., & Vinze, A. (2008). Adoption of health information
technology for medication safety in U.S. hospitals. Health Affairs, 27(3), 865-875.
doi:10.1377/hlthaff.27.3.865
Georgiou, A., Westbrook, J. I., Braithwaite, J., & Iedema, R. A. (2005). Multiple perspectives on the impact
of electronic ordering on hospital organizational and communication processes. Health
Information Management Journal, 34(4), 130-135. Retrieved from http://journal.ahima.org/thejournal/
Getzen, T. (2007). Health care economics: Principles and tools for the health care industry. Hoboken, NJ: Wiley.
Gillies, A., & Howard, J. (2005). An international comparison of information in
adverse events. International Journal of Health Care Quality
Assurance, 18(4/5), 343-352. doi:10.1108/09526860510612199


Glandon, G. D., Slovensky, D. J., & Smaltz, D. H. (2008). Austin and Boxermans information systems for
health care (7th ed.). Chicago, IL: Health Administration Press.
Greene, J. (2005). Making a commitment to IT. Trustee, 58(2), 10-15. Retrieved from
http://www.trusteemag.com/trusteemag_app/index.jsp
Grimm, N., & Shaw, N. (2007). Using participatory action research to evaluate and
improve change: Pilot implementation of electronic health records in rural
Tanzania. Medinfo 2007: Proceedings of the 12th World Congress on Health (Medical) Informatics;
Building sustainable health systems. Retrieved from
http://search.informit.com.au/documentSummary;dn =790931770715577;res =E-LIBRARY
Gyoh, S. K. (2008, October 04). How to fix Nigeria: Health. Newswatch Communications. Retrieved from
http://www.newswatchngr.com/index.
php?option=com_content&task=view&id=19&Itemid=42
Hamm, J. (2006). The five messages leaders must change. Harvard Business Review,
84(5), 114-123. Retrieved from http://hbr.org/
Hargie, O., & Dickson, D. (2007). Are important corporate policies understood by employees? A tracking
study of organizational information. Journal of Communication Management, 11(1), 9-28.
doi:10.1108/13632540710725969
Harrison, J., & McDowell, G. (2008). The role of laboratory information systems in healthcare quality
improvement. International Journal of Health Care Quality. 21(7), 679-691.
doi:10.1108/09526860810910159
Hikmet, N., Bhattacherjee, A., Menachemi, N., Kayhan, V. O., et al. (2008). The role of
organizational factors in the adoption of healthcare information technology in Florida hospitals.
Healthcare Management Science, 21(1), 1-9. doi:10.1007 /s10729-007-9036-5
Hjelm, N. M. (2005). Benefits and drawbacks of telemedicine. Journal of Telemedicine and Telecare, 11(2), 6070. Retrieved from http://jtt.rsmjournals.com/cgi /content/abstract/11/2/60
Holden, R. J. (2009). A theoretical model of health information technology usage behavior with
implications for patient safety. Behavior and Information Technology 28(1), 21-38. Retrieved from
http://portal.acm.org/citation. cfm?id=1497061
Idowu, B., Adagunodo, R., & Adedoyin, R. (2006). Information technology infusion
model for health sector in developing country: Nigeria as a case. Technology
and Health Care, 14(2), 69-77. Retrieved from http://iospress.metapress.com /content
/2bg7be0dhe7c1x5d/
Jha, A. K., DesRoches, C. M., Campbell, E. G., Donelan, K., et al. (2009). Use of electronic health records in
U.S. hospitals. New England Journal of Medicine. 360(16), 1628-1638. Retrieved from
http://content.nejm.org/cgi/content/full /NEJMsa0900592
Kahn, J. S., Aulakh, V., & Bosworth, A. (2009). What it takes: Characteristics of the ideal personal health
record. Health Affairs, 28(2), 369-376. doi:10.1377 /hlthaff.28.2.369
Kaliyadan, F., Venkitakrishnan, S., Manoj, J., & Dharmaratnam, A. D. (2009). Electronic
medical records in dermatology: Practical implications. Indian Journal Of
Dermatology, Venereology and Leprology, 75(2), 157-61. doi:10.4103/0378-6323.48661
Kazley, A. S., & Ozcan, Y. A. (2007). Organizational and environmental determinants of
hospital EMR adoption: A national study. Journal of Medical Systems, 31(5), 375-384.
doi:10.1007/s10916-007-9079-7
Keeley, B. (2007). Human capital: The power of knowledge. (OECD Insights). New York, NY: Organization for
Economic Cooperation and Development.
Keenan, C. R., Nguyen, H. H., & Srinivasan, M. (2006). Electronic medical records and
their impact on residents and medical student education. Academic Psychiatry.
30(6), 522-527. doi:10.1176/appi.ap.30.6.522
Knapp, T. R. (1985). Validity, reliability and neither. Nursing Research, 34(3), 189-192.
doi:10.1097/00006199-198505000-00013
Krishna, R., Kelleher, K., & Stahlberg, E. (2007). Patient confidentiality in the
research use of clinical medical databases. American Journal of Public
Health, 97(4), 654-658. doi:10.2105/AJPH.2006.090902


Larkin, H. (2005). Uncle Sam wants your EHR. Hospitals & Health Networks, 79(2), 38-43. Retrieved from
http://www.hhnmag.com/hhnmag/html/aboutHHN.html
Lashar, J. D. (2009). Destination CRM.com. CRM Magazine, 13(2), 3-8. Retrieved from
http://www.destinationcrm.com/Issue/2594-March-2011.htm
Leech, N. L., & Onwuegbuzie, A. J. (2005, February). Increasing rigor in qualitative research: The array of tools
for qualitative analysis. Paper presented at the annual meeting of the Southwest Educational
Research Association, New Orleans, LA.
Leedy, P. D., & Ormrod, J. E. (2005). Practical research: Planning and design (8th ed.).
Upper Saddle River, NJ: Prentice Hall.
Nigeria judge rules that president violated no laws with 2-months hospitalization abroad. (2010, January
29). Washington Examiner. Retrieved from http://blog.taragana. com/law/2010/01/29/nigeriajudge-rules-that-president-violated- no-laws-with-2-month -hospitalization-abroad-19851/
Lind, D. A., Mason, R. D., & Marchai, W. G. (2000): Basic statistics for business and economics (3rd ed.).
Boston, MA: Irwin/McGraw-Hill
Linz, A. J., & Fallon, L. F., Jr. (2008). Public perception regarding the impact of
electronic medical records on health care quality and medical errors. Journal of
Controversial Medical Claims, 15(2), 10-15. Retrieved from http://journalseek.net /cgibin/journalseek/journalsearch.cgi?field=issn&query=1520-8176
Levy, S. P., & Lemeshow, S. (2008). Sampling of population (4th ed.). New York, NY: Wiley.
Lister, G., & Jabukowski, E. (2008). Public engagement in health policy: International
Lessons. Journal of Management and Marketing in Healthcare, 1(2), 154-165. Retrieved from
University of Phoenix eResource Health Policy and Regulation Course website.
Lynn, M. R. (1986). Determination and quantification of content validity. Nursing
Research, 35(6), 382-385. doi:10.1097/00006199-198611000-00017
McGraw, D., Dempsey, J. X., Harris, L., & Goldman, J. (2009). Privacy as an enabler, not an impediment:
Building trust into health information exchange. Health Affairs, 28(2), 416-427.
doi:10.1377/hlthaff.28.2.416
Menachemi, N., Burkhardt, J., Shewchuk, R., Burke, D., & Brooks, R. C. (2006). Hospital information
technology and positive financial performance: A different approach to finding an ROI. Journal of
Healthcare Management, 5(1), 40-58, 58-59. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed
/16479749
Mill, R.L. (1990). Doing research on sensitive topics. Newbury Park, CA: Sage.
Moniz, C., & Gorin, S. (2007). Health and mental health policy: A biopsychosocial perspective (2nd ed.). Upper
Saddle River, NJ: Pearson Educational.
Moore, D. (2009). 16 Keys to successful EMR implementation. In G. E. Terrell & T. Terrell, Cornerstone
health care: From paper to digital in record time (sidebar). The Physician Executive, 35(2), 16-19.
Retrieved from http://www.acpe.org
/GeneralError.aspx?aspxerrorpath=/Education/Courses/listing.aspx
Morath, J. M., & Turnbull, J. E. (2005). To do no harm: Ensuring patient safety in health
care organizations. San Francisco, CA: Jossey-Bass.
Morris, S., Devlin, N., & Parkin, D. (2007). Economic analysis in health care. Hoboken,
NJ: Wiley.
National Population Commission. (2007). Census figure for the head count conducted in 2006. Abuja,
Nigeria: Federal Government.
Nerurkar, R. (2008). Basics of statistics for postgraduates. Indian Journal of
Dermatology, Venereology and Leprology, 74(6), 691-4. doi:10.4103/0378-6323.45137
Newman, I., & Benz, C. R. (1998). Qualitative-quantitative research methodology: Exploring the interactive
continuum. Carbondale, IL: Southern Illinois University Press.
Nullis-Kapp, C. (2005). Health worker shortage could derail development goals. Bulletin
of the World Health Organization, 83(1), 5-6. doi:10.4103/0378-6323.45137
Ogunlana, O. (2009, August 07). UNESCO WCHE + 10 2009 conference: Nigerias


report card of failure and poor performance. Sahara Reporter. Retrieved from
http://www.saharareporters.com/reports/exclusive/3407-unesco-wche10-2009-conferencenigerias-report-card-of-failure-and-poor-performance.html
Okafor-Dike, L. C. (2009). The effect of leadership on economic development: A case study of Nigeria. (Doctoral
dissertation). Retrieved from ProQuest Dissertations & Theses database. (AAT 3304797)
Okeke, J. O. (2008). Shortage of health professionals: A study of recruitment and retention factors that impact
rural hospitals in Lagos state, Nigeria. (Doctoral dissertation). Retrieved from ProQuest
Dissertations & Theses database. (AAT 3350845)
Okogbule, N. S. (2007). Official corruption and the dynamics of money laundering in Nigeria. Journal of
Financial Crime, 14(1), 49-63. doi:10.1108 /13590790710721800
Onwuegbuzie, A., & Leech, N. (2006). Validity and qualitative research: An oxymoron? Quality &
Quantity, 41(2), 233-249. doi:10.1007/s11135-006-9000-3
Onwujekwe, O. (2005). Inequities in healthcare seeking in treatment of communicable
endemic diseases in Southeast Nigeria. Social Science & Medicine, 61(2), 455-463.
doi:10.1016/j.socscimed.2004.11.066
Ouma, S., & Herselman, M. E. (2008). E-health in rural areas: Case of developing
countries. International Journal of Biological and Life Sciences, 4(4), 194-200. Retrieved from
http://www.unapcict.org/ecohub /resources/e-health-in-rural-areas-case-of-developingcountries-1
Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). Thousand
Oaks, CA: Sage.
Phillips, J. T. (2009). Selecting software for managing physical & electronic records. Information
Management Journal, 43(3), 40-45. Retrieved from
http://content.arma.org/IMM/online/InformationManagement.aspx
Pick, W., Rispel, L., & Doo, S. (2008). Poverty, health and policy: A historical look
at the South African experience. Journal of Public Health Policy, 29(2), 165178.
doi:10.1057/jphp.2008.1
Pierce, S. (2006). Looking like a state: Colonialism and discourse of corruption in Northern Nigeria.
Comparative Study of Society and History, 48(4), 887-914. doi:10.1017/S0010417506000338
Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods (7th ed.). Philadelphia, PA:
Lippincott, Williams, & Wilkins.
Pond, B., & McPake, B. (2006). The health migration crisis: The role of four
Organization for Economic Cooperation and Development countries. The Lancet, 365(9520), 14481455. doi:10.1016/S0140-6736(06)68346-3
Rennolls, K., & AL-Shawabkeh, A. (2008). Formal structures for data mining, knowledge discovery and
communication in a knowledge management environment. Intelligent Data Analysis, 12(2), 147163. Retrieved from http://www.iospress.com/
Roztocki, N., & Weistroffer, H. R. (2006). Stock price reaction to investments in
information technology: The relevance of cost management systems. Electronic
Journal of Information Systems Evaluation, 9(1), 27-30. Retrieved from
http://www.ejise.com/main.html
Salkind, N. J. (2003). Exploring research (5th ed). Upper Saddle River, N.J: Prentice Hall.
Samoutis, G., Soteriades, E., Kounalakis, D. K., Zachariadou, T., Philalithis, A., & Lionis, C. (2007).
Implementation of an electronic medical record system in previously computer-naive primary
care centers: A pilot study from Cyprus. Information in Primary Care, 15(4), 207-216. Retrieved
from
Sammon, D., OConnor, K. A., & Leo, J. (2009). The patient data analysis information
system: Addressing data and information quality issues. The Electronic Journal
Information Systems Evaluation, 12(1), 95-108. Retrieved from http://www.ejise. com
Sanders, D., & Haines, A. (2006). Implementation research is needed to achieve international Health
goals. PLoS [Public Library of Science] Medicine, 3(5), e186-0722.
doi:10.1371/journal.pmed.0030186
Shekelle, P. G., Morton, S. C., & Keeler, E. B. (2006). Costs and benefits of


health information technology. Evidence Report Technology Assessment, 132, 1-71. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/17627328
Simon, M. K. (2006). Dissertation and scholarly research: Recipes for success.
Dubuque, IA: Kendall/Hunt.
Simon, S. R., McCarthy, M. L., Kaushal, R., Jenter, C. A., Volk, L. A., Poon, E. G., et al. (2008). Electronic
health records: Which practices have them, and how are clinicians using them? Journal of
Evaluation in Clinical Practice, 14(1), 43-47. doi:10.1111/j.1365-2753.2007.00787.x
Sisniega, L. C. (2009). Barriers to electronic government use as perceived by citizens at
the municipal level in Mexico. (Doctoral dissertation). Retrieved from ProQuest
Dissertations & Theses database. (AAT 3364168)
Sofowora, O. A. (in press). Impact of Satanic GSM on older adults in Southwest Nigeria. Publication in
International Journal of Library and ICT.
Somiah, T. (2006). Ethical dilemmas in Ghana: Factors that induce acceptance or rejection of bribes. (Doctoral
dissertation). Retrieved from ProQuest Dissertations & Theses database. (AAT 3232331)
Sproull, N. L. (2003). Handbook of research method (2nd ed.). Lanham, MD: Scarecrow.
Srinivasan, A. (2006). Keeping online personal records private: Security and privacy
considerations for web-based PHR systems. Journal of the American Health
Information Management Association, 77(1), 6263, 68. Retrieved from
http://journal.ahima.org/the-journal/
Stone, T., Patrick, T. B., & Brown, G. D. (2005). Strategic Management of Information Systems in Healthcare.
Chicago, IL: Health Administration Press.
Svensson, P. (2002). E-health applications in health care management. EHealth International. Retrieved
from http://www.ehealthinternational. org/content/1/1/5
Szydlowski, S., & Smith, C. (2009). Perspectives from nurse leaders and chief information officers on
health information technology implementation. Hospital Topics, 87(1), 3-9.
doi:10.3200/HTPS.87.1.3-9
Thede, L. (2008). Informatics: The electronic health record: Will nursing be on board
when the ship leaves? Online Journal of Issues in Nursing, 13(3), 6. Retrieved from
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace
/ANAPeriodicals/OJIN.aspx
Thielst, C. B. (2007). The future of healthcare technology. Journal of health management, 52(1), 7-9. Retrieved
from http://jhm.sagepub.com/
Thornton, J. (2002). Estimating a health production function for the US: Some new evidence. Applied
Economics, 34, 59-62. Retrieved from UOPX Healthcare Economics Course web site.
Transparency International. (2006). Global corruption report 2006. Retrieved from
http://www.globalcorruptionreport.org
Vujicic, M., Zurn, P., Diallo, K. Adams, O., & Dal Poz, M.R. (2004). The role of wages
in the migration of health care professionals from developing countries. Human
Resources for Health, 2(3), 1-14. Retrieved from http://www.human-resources-health.com/
Waltz, C. F., Strickland, O. A., & Lenz, E. R. (1991). Measurement in nursing research (2nd ed.).
Philadelphia, PA: F.A. Davis Co.
Ward, M. M., Jaana, M., Bahensky, J. A., Vartak, S., & Wakefield, D. S. (2006). Clinical information system
availability and use in urban and rural hospitals. Journal of Medical Systems, 30(6), 429438.
doi:10.1007/s10916-006-9014-3
Weimar, C. (2009). Electronic health care advances, physician frustration grows. Physician
Executive, 35(2), 8-15. Retrieved from http://www.acpe.org
/GeneralError.aspx?aspxerrorpath=/Education/Courses/listing.aspx
Wechsler, J. (2009). Health IT offers promise and problems. Applied Clinical Trials, 18(4), 26-28. Retrieved
from http://www.biotechmedia.com/y2001-ed-adv-act.html
Wickramasinghe, N., Bali, R. K., Gibbons, M. C., & Schaffer, J. (2008). Realising the knowledge spiral in
healthcare: The role of data mining and knowledge. Studies in Health Technology and Informatics,
137, 147-162. Retrieved from http://www.researchgate.net/journal/09269630_Studies_in_health_technology_and_informatics


Wilcke, B. (2008). Finding the knowledge in Information. Clinical laboratory Science, 21(1), 33-34. Retrieved
from http://www.ascls.org/leadership/cls/index.asp
William, F., & Boren, S. A. (2008). The role of electronic medical record in care delivery
in developing countries. International Journal of Information Management, 28(6), 503-507.
doi:10.1016/j.ijinfomgt.2008.01.016
Woodside, J. M. (2007). EDI and ERP: A real-time framework for healthcare data
exchange. Journal of Medical Systems, 31(3), 178-184. doi:10.1007/s10916-007-9053-4
Wootton, R. (1996). Telemedicine: A cautious welcome. British Medical Journal, 313, 1375-1377. Retrieved
from http://www.bmj.com/cgi/content/short/313/7069/1375
Wootton, R, Jebamani, L., & Dow, S. A. (2005). E-health and the Universitas 21 organization: 2.
Telemedicine and underserved populations. Journal of Telemedicine and Telecare, 11(5), 221-223.
doi:10.1258/1357633054471812
World Bank. (2007). Development indicators data bank. Washington, DC. Retrieved from the U.S.
Department of Labor web site: http://www.dol.gov/asp/... /report /chartbook/200701/appendix_a-population.html
World Health Organization. (2006). Taking stock: Health worker shortages and the
response to AIDS. Geneva, Switzerland: Author.
Wren, D. H. (2005). The history of management thought (5th ed.). San Francisco, CA: Wiley.


Hospital Information Systems in Nigeria: A Review of Literature

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Hospital Information Systems/Benson 1

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Barriers to Implementation of E-Health in Africa

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