Master ThesisFINALrec LastVers PR

TALLINN UNIVERSITY OF TECHNOLOGY
Faculty of Science
Institute of Infotechnology
Health Care Technology
USER SATISFACTION CRITERIA THAT INFLUENCE SCHOOL HEALTH

MANAGEMENT INFORMATION SYSTEM EKTIS.
Master's Thesis
Kristina Saar
Supervisor: Aleksandr Kormiltsyn, MSc,

(PhD Student)
Co-supervisor: Kädi Lepp, MSc
Foundation for School Healthcare in Tallinn
Health Care Technology
Tallinn
2018
Declaration on the title page
Hereby I declare that this Master's Thesis is my original investigation and achievement,
submitted for the Master of Science degree of Tallinn University of Technology.Current work
has not been submitted for any other academic degree.
Kristina Saar
(allkiri ja kuupäev)
Supervisor: Aleksandr Kormiltsyn

Master's Thesis defence committee president

Accepted for defence
...
/Name, signature, date
2
TALLINNA TEHNIKAÜLIKOOL
Infotehnoloogia Teaduskond
Kardiovaskulaarse Meditsiini Instituut
Tervishoiutehnoloogia õppekava
KOOLI TERVISHOIU INFOSÜSTEEMI EKTIS

KASUTAJATE RAHUOLU MÕJUTAVAD KRITEERIUMID
Magistritöö
Kristina Saar
Juhendaja: Aleksandr Kormiltsyn, MSc,

(Doktorant)
Kaasjuhendaja: Kädi Lepp, MSc
SA Koolitervishoid
Tervishoiutehnoloogia
Tallinn
2018
3
Autorideklaratsioon
Deklareerin, et käesolev lõputöö on minu iseseisva töö tulemus ning kinnitan,

et esitatud materjalide põhjal ei ole varem akadeemilist kraadi taotletud.
Kinnitan, et antud töö koostamisel olen kõikide teiste autorite seisukohtadele,
probleemipüstitustele, kogutud arvandmetele jmt viidanud.
Kristina Saar
Juhendaja: Aleksandr Kormiltsyn

Töö vastab magistritööle esitatavatele nõuetele.
Kaitsmiskomisjoni esimees:
Lubatud kaitsmisele
.......................................
(nimi, allkiri, kuupäev)
4
ABSTRACT
Nowadays the medical software management is one of the biggest challenges in eHealth domain. In
cooperation with the Tallinn City Government, E-Health Foundation and Tallinn School Health
Foundation, the AS Helmes that specialize in software developing has created the School Health
Management Information System (EKTIS) that provides school health department with access to the
necessary health information: pupils health records, immunization data, epicrises from hospital, pupils
with chronic condition in risk groups, diagnosis history, pupils health check data, clinical visit reports.
This research was approved by Flemish Scientific Committee in Leuven and presented in European
Union for School and University Health and Medicine at Session 9: ICT in Youth Health Care in
EUSUHM-Congress 2017 Leuven Belgium.1 EUSUHM is a pan-European union of several national
organization’s and institutions concerned with the health of well-being of youngsters.2 During the lack
of analysis performed during the EKTIS development phase the satisfaction of users was not
considered and currently might be on the lower level as expected. That can influence the quality of
health department’s daily work. In the current thesis we propose the hypothesis that there is a positive
statistically significant relationship between general satisfaction and system quality, system utility
features, data quality of the EKTIS Informational Management System. Hypothesis to be proved in
this thesis is improving quality of health management system increases user’s satisfaction and
improves overall system performance. The aim is to find the criterias that influence the general
satisfaction and therefore the overall efficiency. In this study, target population was medical/healthcare
workers in Foundation for School health care in Tallinn. They were asked about software technical
quality and satisfaction with its services. Pairwise Correlation and Multiple Regression Analysis was
selected. Multiple regression analysis was performed to study relationship between variables System
Utility, System Importance, Data Quality, System Utility Features, and System Quality. Where 3
factors are found to be statistically significant factors which influence the general satisfaction, such as
system quality, data quality and system utility features. We obtained a Pairwise correlation between
each variable of each data set, to measure how well they are related. We have found that the data are
linearly related and the residuals are normally distributed. We have identified specific aspects which
will increase users satisfaction and therefore improves overall system performance where attention
should be focused, developed prediction models for use in identifying the general satisfaction of the
system before they fail, demonstrated the importance of choosing the appropriate cut-off point for the
prediction model, and finally demonstrated that models built from survey data can be used to
successfully predict data within a single organization. This thesis is in English language and consists
of 100 pages, 11 chapters, 6 figures and 5 tables.
1
https://www.vwvj.be/eusuhm-congres-2017-leuven
2
http://www.eusuhm.org/
5
Annotatsioon
Meditsiinilise tarkvara haldamine on tulevikus üks suurimaid väljakutseid tervishoiu valdkonnas. Koostöös
Tallinna Linnavalitsuse, E-tervise Sihtasutuse ja Sihtasutusega Tallinna Koolitervishoid on AS Helmes välja
töötatud E-Koolitervishoiu infosüsteemi EKTIS, mis pakub kooli tervishoiutöötajatele juurdepääsu vajalikele
andmetele. E-Koolitervishoiu Infosüsteemi EKTIS Mitme Muutujaga Hindamise uurimistöö oli Flaami Teadus
Komisjoni (Leuven) poolt aktsepteeritud ja esitatud Euroopa Liidu Kooli ja Ülikooli Tervishoiu ja Meditsiini
Kongressil EUSUHM-Congres 2017 Leuven (Belgia). 3 EUSUHM on Euroopa mitmete organisatsioonide ja
institutsioonide ühing mis on pühendatud noorte tervisele. 4 Käesolevas väitekirjas tõestame hüpoteesi, et
eksisteerib positiivne statistiliselt oluline korrelatsioon üldise rahuolu ja süsteemi kvaliteedivahel, süsteemi
funktsioonide ja andmete kvaliteedi vahel. On näidatud, et parandades tervise juhtimise süsteemi saab
suurendada kliendi rahuolu ja üldise süsteemi toimimise. Uuringu, sihtrühm on meditsiini/tervishoiu töötajad SA
Tallinna Koolitervishoius. Neid on küsitletud tarkvara tehnilise kvaliteedi ja süsteemi teenuste rahulolu kohta.
Uuringu metoodikaks on valitud paarikaupa korrelatsioon ja mitme muutujaga analüüs. Mitme muutujaga
analüüs oli läbi viidud selleks, et uurida seoseid järgmiste muutujate vahel: süsteemi vahendid, süsteemi tähtsus,
andmete kvaliteet, süsteemi kasulikud funktsioonid ja süsteemi kvaliteet. Teostatud uuringus leiti 3 statistiliselt
olulist tegurit, mis mõjutavad üldist rahulolu, Need on: süsteemi kvaliteet, andmete kvaliteet ja süsteemi
kasulikud funktsioonid.
Oleme läbi viinud paarikaupa korrelatsiooni iga muutuja ja iga andmekogumi vahel selleks, et mõõta, kui hästi
nad on omavahel seotud. Me oleme leidnud, et andmed on lineaarselt seotud ja jäägid on normaalselt jaotatud.
Me oleme kindlaks määranud konkreetseid aspekte, kuhu peaks rohkem tähelepanu pöörama, mis võivad
suurendada kasutajate rahulolu ning seega parandada kogu süsteemi toimivust. On välja töötatud prognoosimise
mudeleid süsteemi üldise rahulolu identifitseerimise kasutamiseks, et ennetada süsteemi läbikukkumist. Samuti
on näidatud sobiva murdepunkti määramise tähtsus mudeli õigepärase toimimise hindamisel. Kokkuvõtteks
demonstreeriti, et küsimuste andmete põhjal konstrueeritud mudeliga võib edukalt prognoosida andmeid ühe
organisatsiooni piires. See magistritöö on inglise keeles ja koosneb 100 leheküljest, 11 peatükkidest, 6 joonisest
ja 5 tabelist.
3
https://www.vwvj.be/eusuhm-congres-2017-leuven
4
http://www.eusuhm.org/
6
ABBREVIATIONS
CBIS – Computer Based Information System
EDPI- Estonian Data Protection Inspectorate
EEHF - the Estonian eHealth Foundation
EEIS- Estonian Educational Information System
EHIS- Eesti Hariduse Infosüsteem
EHR – Electronic Health Record
EKTIS – Estonian School Nursing Information Management System
HCOs – Healthcare Organizations
HIS – Health Information System
HL7 CDA - Health Level 7 Clinical Document Architecture
ICT- Information and communication technologies
IS – Information System
MIS- Management Information Systems
NASN- The National Association of School Nurses
NHS – Nursing Health Systems
PP- Patient Portal
SNIMS – School Nursing Informational Management System
TIS- Tervise Infosüsteem
UI- User Interface
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DEFINITIONS
DATABASE - a comprehensive collection of related data organized for convenient access,
generally in a computer [8].
DIGITAL IMAGE – (in Estonian language Digipilt), all digital snapshots or video material of
the patient are stored and available online through a single portal [56].
DIGITAL PRESCRIPTION – (in Estonian language Digiretsept), a single Estonian national

database for exchanging and storing prescription information between health care
professionals, pharmacies, residents and the Estonian Health Insurance Fund [56].
DIGITAL REGISTRATION – (in Estonian language Digiregistratuur), is an online tool that

can be used both by the patients and the providers. A central database will store the referral
notes and manage the appointment booking, changing and reminders [56].
EHEALTH - is an emerging field in the intersection of medical informatics, public health and
business, referring to health services and information delivered or enhanced through the
Internet and related technologies. In a broader sense, the term characterizes not only a
technical development, but also a state-of-mind, a way of thinking, an attitude, and a
commitment for networked, global thinking, to improve health care locally, regionally, and
worldwide by using information and communication technology [31].
ELECTRONIC DATA MANAGEMENT SYSTEM - is a software program that manages the

creation, storage and control of documents electronically [21].
ELECTRONIC DOCUMENTATION SYSTEM - was an early hypertext system – also known

as the Interactive Graphical Documents (IGD) hypermedia system – focused on creation of
interactive documents such as equipment repair manuals or computer-aided instruction texts
with embedded links and graphics [22].
ELECTRONIC HEALTH RECORD - is the systematized collection of patient and population

electronically-stored health information in a digital format. These records can be shared
across different health care settings. Records are shared through network-connected,
enterprise-wide information systems or other information networks and exchanges. EHRs
may include a range of data, including demographics, medical history, medication and
allergies, immunization status, laboratory test results, radiology images, vital signs, personal
statistics like age and weight, and billing information [69].
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HEALTH CARE – a comprehensive compilation of information, traditionally placed,
in the medical record but also covering aspects of thepatient's physical,mental,and social healt
h that do not necessarily relate directly to the condition under treatment [4].
HEALTH PROMOTION - is the process of enabling people to increase control over, and to
improve, their health. It moves beyond a focus on individual behavior towards a wide range of
social and environmental interventions [97].
HEALTHCARE PROVIDER - A person who provides any form of health care

eg, physician, nurse, dentist, mentalhealth worker, birth control counselor [19].
HL7 CDA- is an XML-based markup standard intended to specify the encoding, structure and
semantics of clinical documents for exchange. In November 2000, HL7 published Release
1.0. The organization published Release 2.0 with its "2005 Normative Edition [59].
INFORMATION MANAGMENT SYSTEM - is a general term for software designed to

facilitate the storage, organization and retrieval of information [97].
MEDICAL RECORDS- a record of a patient's medical information (as medical history, care
or treatments received, test results, diagnoses, and medications taken) [88].
SCHOOL NURSE - a specialized practice of public health nursing, protects and

promotes student health, facilitates normal development, and advances academic success.
School nurses, grounded in ethical and evidence-based practice, are the leaders that bridge
health care and education, provide care coordination, advocate for quality student-centered
care, and collaborate to design systems that allow individuals and communities to develop
their full potentials [5].
SCHOOL NURSING SOFTWARE - The records that school nurses keep in their daily care of
over 95% of U.S. school-aged children provide an important window into child health in our
nation. Records are being kept on students who are well (screening, immunization, and
episodic health room care); and students with chronic health conditions (emergency care
planning; daily treatment and response data for students with conditions such as asthma;
severe allergies; seizure disorders; and Type I Diabetes). School nurses also maintain health
records on students who fall outside the typical health care provider systems and whose only
source of care may be the school nurse [10].
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TELEMEDICINE - is the use of telecommunication and information technology to
provide clinical health care from a distance. It has been used to overcome distance barriers
and to improve access to medical services that would often not be consistently available in
distant rural communities. It is also used to save lives in critical care and emergency
situations. Although there were distant precursors to telemedicine, it is essentially a product of
20th century telecommunication and information technologies. These technologies permit
communications between patient and medical staff with both convenience and fidelity, as well
as the transmission of medical, imaging and health informatics data from one site to another.
Early forms of telemedicine achieved with telephone and radio have been supplemented
with video telephony, advanced diagnostic methods supported by distributed client/server
applications, and additionally with telemedical devices to support in-home care [16].
USER INTERFACE- in the industrial design field of human–computer interaction is the space
where interactions between humans and machines occur. The goal of this interaction is to
allow effective operation and control of the machine from the human end, whilst the machine
simultaneously feeds back information that aids the operators' decision-making process.
Examples of this broad concept of user interfaces include the interactive aspects of
computer operating systems, hand tools, heavy machinery operator controls,
and process controls. The design considerations applicable when creating user interfaces are
related to or involve such disciplines as ergonomics and psychology [89].
X-ROAD PLATFORM- The X-Road interoperability platform is comprised of the core

technology (Unified eXchange Platform), integration interfaces (portals, adapters etc), trust
services, and the surrounding regulatory framework [83].
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Table of Contents
DEFINITIONS ........................................................................................................................................ 8
1 Introduction ................................................................................................................................... 16
2 Research Methodology .................................................................................................................. 23
3 Aspects related to school nursing information systems ................................................................. 26
3.1 School nursing overview ............................................................................................................. 26
3.2 Technical and legal factors affecting EKTIS .............................................................................. 27
3.3 Patient Portal in the EHIS ........................................................................................................... 29
3.4 Information System Requirements .............................................................................................. 30
3.5 Patient identifiers, privacy and access right ................................................................................ 32
3.5.1. Use of unique patient identifiers.......................................................................................... 32
3.5.2. Privacy issues related to health IT systems ......................................................................... 32
3.5.3. Access rights........................................................................................................................ 33
4 CRITERIA CATEGORIZATION IN USER SATISFACTION MEASUREMENT ................... 35
4.1. Information Quality .................................................................................................................... 35
4.2. System Usefulness ...................................................................................................................... 36
4.3. System Quality and System Usage Characteristics .................................................................... 36
4.4. Overall satisfaction ..................................................................................................................... 38
4.5. Perceived Usefulness .................................................................................................................. 38
4.6. Importance of the system............................................................................................................ 39
5 EKTIS Informational Management System .................................................................................. 41
5.1 Description of the EKTIS Information System ........................................................................... 41
5.1.1 EKTIS Requirements............................................................................................................ 43
5.1.2 EKTIS architecture and interaction with HIS....................................................................... 45
5.1.3. User Interface ...................................................................................................................... 46
5.1.4 Functionality of the system .................................................................................................. 48
6 EKTIS USERS FEEDBACK COLLECTION .............................................................................. 50
6.2 Data collection ......................................................................................................................... 50
6.3 Survey questioners development ............................................................................................. 50
6.4 Ethical consideration ............................................................................................................... 54
7 EKTIS USER FEEDBACK DATA ANALYSIS .......................................................................... 55
7.1 Participant Demographics. .......................................................................................................... 55
7.2 Model Validity, Reliability and Hypotheses testing .................................................................... 56
7.3 Models identification ................................................................................................................... 57
7.3.1 Interpretation of Multiple Regression and Pairwise correlation indicators .......................... 58
11
7.3.2 Parameters ............................................................................................................................ 58
7.3.3 Output Coefficients .............................................................................................................. 59
8 Results ........................................................................................................................................... 63
9 Discussion ..................................................................................................................................... 66
10 Suggestions for future research ................................................................................................. 71
11 Conclusion ................................................................................................................................. 73
References
Appendix
Acknowledgements
12
LIST OF FIGURES
Figure 1 DS research methodology (Peffers, et al., 2007, p.54) ........................................................... 25

Figure 2 Estonian Information System. Data flow process. .................................................................. 29
Figure 3. EKTIS architecture. ............................................................................................................... 42
Figure 4. EKTIS and information exchange with systems..................................................................... 46
Figure 5. User interface flow diagram for EKTIS web based information management system .......... 48
Figure 6. Model of relationship among software quality and healthcare indicators [4]...................... 72
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LIST OF TABLES
Table 1. IS quality criteria [4]. ............................................................................................................. 40
Table 1. Questionnaire 1 constructs and measurements. ...................................................................... 53
Table 2. Questionnaire 2 constructs and measurements. ...................................................................... 53
Table 3. AIC best model. ....................................................................................................................... 58
Table 4. Pairwise correlation analysis. .................................................................................................. 64
Table 5. Multiple Regression analysis results. ...................................................................................... 65
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LIST OF APPENDICES
Appendix 1. Evaluation of EKTIS Informational software technical quality ....................................... 84

Appendix 2. IS User Satisfaction Questionnaire ................................................................................... 88
Appendix 3. Results of the evaluation of EKTIS Informational software’s technical quality .............. 90
Appendix 4. Results of IS User Satisfaction Questionnaire .................................................................. 97
Appendix 5. Q1, Q2 Survey Datasets .................................................................................................. 100
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1 Introduction
Over the last few years we have seen major changes in the way health care is delivered. There
is a need for nursing informatics to evolve to meet the changing requirements of our health
care system to serve our patient’s needs [91]. Computer technology is a reality of our modern
world. It gives us tools that can be used to help us to cope with the complexity and efficiency
that are often required in many areas of work. It is an erroneous assumption that it robs people
of their human qualities [89]. In many ways, the use of the computer frees the person from
the routine and gives more time and efforts for the more personal skills to find expression.
Recording assessment data using a computer keyboard allows just as much caring
communication between nurse and clients as writing it down on a form. The critical factor is
not the method of recording but the interpersonal skills and motivation of the nurse [89]. The
nursing profession is finally beginning to appreciate the role the new technology can play in
improving the service provided for patients. Only by introduction of computers in clinical
practice, nurses can maintain control over their own professional contribution to the large
complex systems at present being implemented in many health care settings. Knowledge
based systems are set to become a major component in the nurse’s ability to take on this role
[5].
Information and communication technology (ICT) opportunities in Estonia healthcare sector

have been investigated and implemented since 1973, when the Ministry of Health has created
the Healthcare Computing Centre. In the last 10-15 years across the world, including Estonia,
the healthcare sector has largely abandoned paper-based data management, and computers
became an everyday tool for the healthcare professionals. In healthcare domain data is
collected for a variety of purposes and data quality, system quality and general satisfaction of
the system is important and very critical. Especially for the children and adolescents who are
our future, their health and well-being impacts on difficult combination of biological, cultural,
social, economic and environmental factors. Children’s chronic diseases such as mental health
disorders have become more frequent for a number of reasons. Problems are caused by health-
related behavior in a negative direction. The school nurses in Tallinn and Tartu have the
ability to transmit data in the electronic school health management information system
(EKTIS), that is controlled by AS Helmes5, which provides software development solutions
5
https://www.bloomberg.com/research/stocks/private/snapshot.asp?privcapid=24653359
16
for customers in Estonia and all over the world. The company was founded in 1991 and is
based in Tallinn, Estonia.
There are various types of software that are used in healthcare organizations to manage
information and care processes. The quality of software, healthcare data and general
satisfaction of the system has been an important concern for both health authorities and
designers of the Health Information Technology. Thus, assessing the effect of software
quality and health data on the performance quality of healthcare institutions is essential,
however, the new school nursing information system can benefit nurses, but it will change the
nurses’ way of work [4]. Thesis research was approved by Flemish Scientific Committee in
Leuven and presented as the first part of the next research in European Union for School and
University Health and Medicine at Session 9: ICT in Youth Health Care in EUSUHM-
Congress 2017 Leuven Belgium.
Literature review shows [89, 110], that deriving requirements that satisfy the needs and
desires of users is crucial in software engineering. However, to specify these requirements,
potential users must be identified and prioritized first [52, 83, 110]. In organizational and
commercial settings, users have often well-defined roles and responsibilities tied to specific
work-flows that are exploited in requirements of engineering methodologies. However, in
more social settings, such as platforms for enhancing social interaction, there is a range of
non-specific users with ill-defined roles [86].
Changes and innovation are not only on hardware but on software as well. So definition of
this word is changing over time. EKTIS software, as an efficient system, provides an
important service for the school nurses. School nurses, as the most influential group of the
society, have the responsibility to care and educate the children. Nursing process is one of the
most essential factors in improving the quality of nursing cares. It is also one of the most
important components of the nursing profession and all nursing cares require applying this
procedure and integration of them [7]. Nurses, designers and health authorities need to pay
extra attention to the new system, so they are interested in tools that enable them to work
effectively and efficiently, otherwise it may affect systems in the achievement of the targets.
The main research question of this thesis is how to find criteria that influence the general
satisfaction and therefore the overall efficiency of the healthcare process in the information
system.
17
The aim is to find the criteria which influence the general satisfaction and therefore the
overall efficiency.
Following the main research sub questions were set up to complete the study:
 What are the important healthcare environment aspects of healthcare information

systems?
 What are the main technical functions of EKTIS Information System that influence the
performance in healthcare process?
 What are the important and effective criteria of user satisfaction in the EKTIS
Information system, that will improve overall system performance?

 to define important aspects of the Healthcare IS that allows knowing and
characterization the study’s object
 to define technical functionalities of EKTIS
 to define user satisfaction measurement criteria of EKTIS IS
 to analyze the survey of user satisfaction feedback data for finding the criteria that
influence user general satisfaction
 to suggest and propose solutions for the EKTIS system improvement
The answer to the first sub question helps to study the environment which contributes to IS
and collects knowledge base about important aspects of the healthcare information system.
Information has a great impact on making decision, and hence its value is closely tied to the
decisions that result from its use. The most important aspects were examined and presented in
the first and second chapter of this master thesis. This section Overview of issues related to IS
and EKTIS Information System goes through the cases one by one and explains their subject
of artifacts, theoretical foundation (legal issues, standards and access rights, privacy issues,
information system requirements, architecture and functionality of the system). This
knowledge provides data that can lead to information that allows knowing and
characterization of the study’s object. This perspective allows investigating knowledge base
of different parts of the project, without losing track of where the project as a whole is going.
The literature review [54, 86] suggests, that theoretical knowledge of information systems
18
allows researchers to go deeper into learning the system and make more effective evaluation
of the IS.
The answer to the second sub question will allow investigating the technical functions of the
system. Therefore knowledge about technical functions, functionality and requirements of the
EKTIS information systems allows finding and categorizing criteria for assessing health
information system satisfaction and will give answer to the third sub question. In order to
determine criteria for user satisfaction it was considered to review most cited models for user
satisfaction. One of the most cited models for measuring information systems success is the
DeLone and McLean Information Systems Success Model [25, 26]. The model is a basic
model consisting of six categories of IS success: System quality, Information quality, Use,
User satisfaction, Individual impact, Organizational impact [26]. The literature on
organizational IS success suggests, that the system quality positively influences user
satisfaction, and that user satisfaction with an IS is associated with increased individual
effectiveness [25]. System Quality is used in relation to the correct functioning and overall
system behavior. Quality means that a system is ‘fits for purpose’, thereby meeting the
explicit and implicit requirements that are set for its operational deployment. The literature
also suggests that success of any software depends on the quality which contributes as main
pillars that should be taken in consideration, where the quality is an important issue for the
whole kind of software. It is considered to cover quality in more detail. Scientific literature
provides a model for measuring satisfaction with software quality [48]. Where the Jensen et
al. (2012) divides them into six categories: Functionality, Reliability, Usability, Efficiency,
Maintainability, and Evaluation of interface of program. This distribution of criteria will lead
us to more significant results [48]. User experience is all about supporting the design of a
product or service to fit their needs. User experience plays an important part in this research,
it will help to understand EKTIS users well, assess how well their needs are served, and
improve opportunities to create something even better. EKTIS user experience will help to
improve quality of health management system. Therefore multiple regression and pairwise
correlation analysis will help to analyze the gathered data from the users, develop a model of
general satisfaction and identify specific aspects which will increase user’s satisfaction and
therefore improves overall system performance.
19
Because the lack of analysis performed during the EKTIS development phase the satisfaction
of users was not considered and currently might be on the lower level as had been expected.
That can influence the quality of health department’s daily work.
Hypothesis states that there is a positive statistically significant relationship between general
satisfaction and system quality, system utility features, data quality of the EKTIS
Informational Management System. Hypothesis to be proved in this thesis is improving
quality of health management system increases user’s satisfaction and improves overall
system performance.
The aim is to find the criteria which influence the general satisfaction and therefore the
overall efficiency.
The sub aims include:
 to define important aspects of the Healthcare IS that allows knowing and

characterization the study’s object
 to define technical functionalities of EKTIS
 to define user satisfaction measurement criteria of EKTIS IS
 to analyze the survey of user’s satisfaction feedback data for finding the criteria that
influence user general satisfaction
 to suggest and propose solutions for EKTIS system improvement
The analysis of system’s capabilities has been left subdued while AS Helmes focused only on
the system development. Unfortunately, not all schools are able to join the EKTIS database to
transfer data, because of joining fee, which depends on the number of the school students, but
the government does not finance a program for the acquisition of schools [72]. It’s still
remaining for a large amount of data - school children health entries that are collected by
school nurses on paper. In 2018 paper documents will be removed and replaced by computer
files.
In order to achieve the main objective, following tasks are to be completed:
 Collect feedback from system users, nurses,

 Collect information from service provider
 Find the criteria which influence the general satisfaction
 Suggest solution for improving the system
20
Current thesis has 10 main chapters and conclusion. The first chapter covers the introduction,
focusing on the changes in information communication technologies in the health care sector.
In this chapter the main research question, sub questions, hypothesis, the aim, sub aims,
objectives and tasks of the research are presented.
The second chapter describes the used methodology. This chapter describes the Design
Science method that is widely used in information systems. It explains the methodology that
was used in this research.
The third chapter describes aspects related to school nursing information systems, background
of school nursing, technical and legal factors affecting EKTIS, overview of information
system, data collection, legal issues, standards in Information System (IS) and technology,
system requirements, patient identifiers, privacy and access rights.
The fourth chapter focuses on the criteria categorization in user satisfaction measurement.
This chapter gives the overview about IS criteria, describing IS criteria as information quality,
system usefulness, system quality, system usage characteristics, overall satisfaction, perceived
usefulness and importance of the system.
The fifth chapter tells about EKTIS Information System; architecture of the system, which
refers to the high level structures of a software system, the discipline of creating such
structures, and the documentation of these structures. Each structure comprises software
elements, relations among them, and properties of both elements and relations; system
functionality - combination of special data for different hardware components and software
modules, only one component of web based application is used by school nurses; this chapter
also presents data and methods used in this research.
The sixth chapter tells how the survey questioners were developed; it also covers the data
collection and ethical consideration. The seventh chapter describes EKTIS user feedback data
analysis. It contains explanations of multiple regression and correlation analysis with graphs
and tables. The seven chapter explains step by step, how the final analysis model was built,
and how fit criteria for the final model were built. This chapter states The Akaike information
criterion (AIC) and present the Breach–Pagan test that is used in analysis.
The eights chapter is a result of the research; it highlights findings of the research, where
responses are presented and analyzed. Therefore the ninth chapter presents discussion,
meanings of the results; also it describes the future research. These are discussing factors that
21
can affect the school nurses, what factors influence the general satisfaction of the system, how
this findings can help the organization to get benefits from the system.
The tenth chapter contains suggestions for future research, the recommendations for using the
specific aspects which will increase users’ satisfaction and therefore improves overall system
performance within a single organization.
The eleventh chapter is a conclusion that completes the work by presenting an overall
evaluation of the outcomes of the study and suggesting future work. This chapter presents
summary of paragraphs, main findings reminding the original contribution and significance of
the research field.
22
Research Methodology
In this thesis we use the Design Science method because it spans many disciplines, it is
widely used in information systems, in the methodology development and in the engineering.
The Design Science has proven successful in Information Systems and other disciplines in
aligning both business needs and research objectives. This research itself is a Design Science
research. We describe our Design Science Research process and the resulting artifact.
The Design Science is a research method for producing innovative constructions, intended to
solve problems faced in the real world and, by that means, to make a contribution to the
theory of the discipline in which it is applied [105]. The Design Science approach was used to
develop research instruments in information system research. Design science research focuses
on the development and performance of (designed) artifacts with the explicit intention of
improving the functional performance of the artifact. Design science research is typically
applied to categories of artifacts including algorithms, human/computer interfaces, design
methodologies (including process models) and languages. Design science is the
epistemological basis for the study of what is artificial. It is a method that establishes and
operationalizes research when the desired goal is an artifact or recommendation.
In addition, the research based on the design science can be performed in an academic
environment and in an organizational context. Its application is most notable in the
Engineering and Computer Science disciplines, though is not restricted to these and can be
found in many disciplines and fields. In design science research, as opposed to explanatory
science research, academic research objectives are of a more pragmatic nature [105]. The
Design Science research methodology consists of six main phases: problem identification and
motivation, definition the objectives for a solution, design and development, demonstration,
evaluation and communications as it is shown in figure 1.
A key feature of design science research is a method that is oriented at solving of the specific
problems to obtain a satisfactory solution for the situation even if the solution is not optimal.
However, the solutions generated by design science research should be liable to generalization
for a specific class of problems. This generalization for a class of problems can enable other
researchers and practitioners in various situations to use generated knowledge.
23
Therefore Hevner et al. (2007, 2010) lists Design Science research contributions for
organizations as:
• problem identification and a clear description of an organizational problem;

• demonstrating that no clear solution exists;
• design, development and presentation of an artefact – construct, model, method or
instantiation;
• rigorous evaluation and assessment of the utility of the artefact;
• expressing the practical and theoretical added value of the artefact;
• explaining implications of implementation of an artefact to both technical and managerial
members of an organization. [45, 46].
The philosophical assumption of a Design Science research paradigm implies a problem-

solving- and engineering research methodology. Peffers et al. (2007) emphasize the problem-
solving and engineering basis of DSR. According to Peffers et al. (2007), DSR methodology
comprises three elements: conceptual principles defining the research methodology, practice
rules and a research process [77]. Design Science was chosen for this research because it
involves the development of a solution that has practical and theoretical relevance. The
purpose of the DS research methodology is not only to develop an artefact but also to
answer research questions.
This research is concerned with the design of a model for use in an organizational
environment and therefore detecting the criteria which influence the general satisfaction and
therefore the overall efficiency. In agreement with the ideas of Simon (1996) in his
description of the sciences of the artificial, Hevner et al. (2007) describes design science
research as a strategy used in IS [46]. Hevner (2007) explains that IS research identifies
needs in an organizational environment that concern people using systems and technology
[46].
24
Figure 1 DS research methodology (Peffers, et al., 2007, p.54)6
6
http://umfundi.barbourians.org/article/peffers2008design
25
2 Aspects related to school nursing information
systems
In this chapter we consider general aspects of school nursing information systems such as use
of school health records, the standards and requirements for nursing practice are also
described. There is an overview about health documentation and what legal requirements it
provides and includes. Therefore this section includes information about unique patient
identifiers which improve efficiency, and provide better privacy protection for patients; it tells
about privacy issues, policies existing in healthcare organizations and access rights.
3.1 School nursing overview
Traditionally the nursing professions have often perceived themselves as data gatherers rather
than data users. The traditional training of nurses did not prepare the profession well for data
analysis and using quantitative methods to present the case for change. Much of nursing
making decisions are characterized by professional judgment based on observation with the
reporting systems based on the traditional nursing hierarchy [68]. The lack of supporting of
quantifiable data often means that the nursing view is not supported in the competition for
scarce resources. This leads to frustration, as the nursing view often reflects the complex
realities of health care. School health records provide the mechanism for a school nurse to
convey information to students, families, the school multidisciplinary team, emergency
personnel, other healthcare providers, and school nurse substitutes [68]. Data from school
health records can show evidence of student health problems that should be addressed. Data is
also used for evaluation of school health system, quality assurance, disease surveillance and
evaluation of system outcomes [20].
The large caseloads and volumes of longitudinal student information collected by school
nurses result in a quantity of data that is not readily managed by paper processes. Electronic
documentation systems allow for efficient data management processes including the
documentation, reporting, and analysis of student health data [40]. Electronic data
management systems also allow for the aggregation of data from multiple sources if the data
elements are standardized across systems. The ability to build a database requires the EHRs to
be able to speak the same language. Data in systems that use standardized languages and are
interoperable across a variety of settings will allow the expansion of evidence to determine
nursing interventions that support student academic success [68].
26
Using aggregate data from standardized school nurse documentation would support the
development of a national school health database that could be used to describe the student
healthcare needs, the best outcome based interventions, and academic success [53]. The
Office of the National Coordinator for Health Information Technology (ONC) predicted that
the knowledge of EHRs will strengthen the communication of information, improve care
coordination, and enhance the quality of care [40]. Aggregate data and EHRs also will assist
school nurses to function within their broader role as public health nurses by providing the
opportunity to improve links between other healthcare providers and public health
departments [17].
3.2 Technical and legal factors affecting EKTIS
Documentation for school nurses must meet the standard of practice for all nurses and is the
legal requirement for nursing care in any practice environment, documentation must be
accurate, comprehensive, and flexible enough to retrieve clinical data, maintain continuity of
care, track patient outcomes, and reflect current standards of nursing practice [70].
Documentation is a requisite to verify that the nurse and the school district provided the legal
standard of care and protects both from liability as well as the nurse’s license [10]. Johnson,
K. H., Bergren, M. D., and Westbrook, L. O. [53], identified the primary objectives of
documentation in school nursing practice as promoting high quality school nursing services,
advancement of efficient and effective school health systems, and creation of a legal record of
nursing services provided to students. Johnson, K.H., and Guthrie, S., [54], recognized other
important objectives for health documentation, such as providing a historical record of care,
facilitating care team communication, developing aggregated reports of student needs,
supporting care planning and delegation, and describing emergency care planning. Student
health documentation methods must be commercial school nursing software [49].
On 20 December, 2007, the Estonian Parliament (in Estonian: the Riigikogu) ratified the
amendment act that establishes the legal basis for implementing the eHealth projects. The
Draft of the Health Services Organization Act and Associated Acts Amendment Act provides
the legal basis for future development of various eHealth initiatives such as the Electronic
Health Record, Digital Image, Digital Registration and Digital Prescription7. The goal of these
accepted changes is to unify all information systems created for a specific health care
organization into one central health information system [30].
7
http://www.e-tervis.ee/index.php/en/
27
The concept of eHealth is to create a basis to enable the electronic processing of different
medical documents. Paper documents will be gradually replaced by digital documents. The
diagnostic systems and medical equipment will be interfaced with the information systems
that allow us to quickly process information and utilize the modern methods of telemedicine.
The amendment act was enforced on 1 September, 2008. [30].
Estonia has already established and maintains a nationwide technical infrastructure called the
X-road platform8. X-road is a platform of independent standard interface for secure data
processing, connection of all Estonian public sector databases and information exchange.
Other IT-solutions such as digital signatures and ID-card authentication are recent
innovations, and their use is comprehensively regulated by national law. These developments
are the basis of implementing sectoral policies such as creating a countrywide electronic
health record [73].
The idea of eHealth and electronic health record has already emerged in 2002. The purpose
was to develop a nationwide framework (database) to facilitate the exchange of digital
medical documents and diffuse available health information so far only in local databases and
information systems that were not able to communicate with each other. In 2005, as the
recipient of the structural aid, the Estonian Ministry of Social Affairs launched a new e-health
concept by phasing in four projects: Electronic Health Record, Digital images, Digital
Registration and Digital Prescription (eHealth projects). The result of implementing eHealth
projects is the Electronic Health Record that was launched on 17 December, 2008 [73].
The rules for data usage state that only the health care employee currently associated with
patient's treatment has the right to make enquiries about patient's data, i.e. the patient's
attending physician or a medical assistant. Making enquiries about patient's health data
outside of treatment process is not allowed. Health data will be issued to health care
employees registered with Health Care Board and who are marked as the attending physician.
[73].
8
https://e-estonia.com/solutions/interoperability-services/x-road/
28
Figure 2 Estonian Information System. Data flow process.
Retrieved from: http://www.ebn.lt/news-and-events/news/estonia-as-an-example-for-lithuanian-e-government/
3.3 Patient Portal in the EHIS
Patients can use the Patient's Portal to manage access to their health data. In this case the
patient will be informed by information system at the time of setting the restriction that it is
dangerous to his/her life and health to provide health care services based on insufficient
information. There will be no access allowed to initial documents even in the emergency
situation and the patient will take full responsibility regarding possible consequences that may
arise from banning access to data [72]. Patient data is guarded by Guardtime's technology KSI
blockchain9, which stores basically every state of the data. If the data is amended or even
already has been viewed this will be automatically reflected in blockchain. A blockchain is a
distributed public ledger – a database with a set of pre-defined rules for how the ledger is
appended by the distributed consensus of the participants in the system. Due to its widely
witnessed property, blockchain technology makes it also impossible to change the data
already on the blockchain [18].
Gathering of the data began on 17 December, 2008 and by March 2010 the EHR contains
over a million medical documents. For the moment the agreed amount of data is sent to the
9 https://geenius.ee/uudis/guardtime-hakkab-eesti-patsientide-andmete-terviklikkust-valvama/
29
system, containing discharge letters (inpatients and outpatients), referrals and links to digital
images [73]. To effect their legally binding obligation to send medical documents to the
information system over a thousand health care providers out of the total 1021 licensed in
Estonian Health Care Board10 have signed the contract with Estonian eHealth Foundation who
is the authorized processor of the EHR. 309 of them are by now participating in the actual
data exchange [73].
3.4 Information System Requirements
The term requirement could be described as a user need or a necessary feature, function or
attribute of a system that can be sensed from an external position to that system or as a
statement of a system service or constraint [32]. There are different types of requirements,
such as: system requirements, user requirements and software requirements. System
requirements describe the behavior of the system as seen from outside with respect to the
user. So they are the high–level requirements that represent the system as a whole, which
contains both hardware and software. User requirements (also called stakeholder
requirements) describe the tasks the user must be able to accomplish with the product.
Software requirement is a function or constraint of the system from the software developer’s
point of view. This consists of all the requirements of the software which must be applied to
the system to meet the user requirements [47].
Building new information system is a complex process consisting of many steps which have
to be done before the final product is prepared for the customer. It is very important to meet
customer needs and expectations so as to keep him for future projects [58]. There are different
approaches and techniques in software design. TOGAF Architecture Development Method
(ADM) forms the core of TOGAF [79]. It is a reliable, proven method for developing an IT
architecture that meets the business needs of an organization, utilizing the other elements of
TOGAF described in this document, and other architectural assets available to the
organization11. Another approach is Agent Oriented Modelling, the purpose of goal models is
to serve as communication media between technical- and non-technical stakeholders for
generating understandable domain knowledge. Goal models are used in the context of
requirements-engineering processes [55]. Segmentation is a commonly-used approach in
10
https://www.terviseamet.ee/en/information.html
11 http://www.opengroup.org/public/arch/p2/p2_intro.htm
30
marketing. Firms wish to take advantage of available opportunities in different markets, and
wish to know more about their customers and apply that information to increase their income
and customer base [86].
Health documentation supports legal requirements, provides a historical record of care,

facilitates care team communication, develops aggregated reports of student needs, supports
care planning and delegation, and describes emergency care planning [55]. EKTIS12 can help
a school nurse manage and use data in a quick, efficient manner. Reports generated from
electronic documentation systems allow the nurse to:
 Efficiently describe health room activity
 Develop evidence for practice
 Describe nursing sensitive student outcomes
 Analyze population health
 Evaluate the effectiveness of care delivery
 Manage appropriate resource allocation
 Describe student health needs
 Link health interventions and educational outcomes [54].
School nurses are key members of the education team and leaders of school health who
collect valuable data through their documentation; and who use data to keep students healthy,
safe, and ready to learn [49].
User needs included access, quality data, and security of records, flexibility, connectivity, and
efficiency. Records need to be easily accessible when and where a provider wants or needs to
refer to them [26]. In terms of quality, needs included legibility, accuracy, completeness, and
clarity of the meaning. There are two security requirements: student privacy must be
protected, and software systems cannot be tampered with. Flexibility is a requirement because
user needs are too many and too varied for only one combination of input. Users will request
the same data in different ways, and records must be responsive and accessible in each ones.
The records should have the potential to link with the district administrative system. Finally,
12
https://ektis.helmes.ee/
31
the records should require a minimum of expense and effort to use, so they should not be
complicated or wasteful [71].
3.5 Patient identifiers, privacy and access right
In this chapter important aspects of medical data security are described such as patient
identifiers, existing policies in healthcare organizations and management of EHR and patient
rights. This chapter is structured as follows: it describes about use of unique patient identifiers
with an example of other countries, it tells about privacy issues related to health IT systems,
that speaks about privacy protection and confidentiality, and it describes access rights to the
EHR system and highlighted the most important rules that ensure the proper use of access
rights.
3.5.1. Use of unique patient identifiers

Unique patient identifiers help facilitate data sharing between different health care
organizations and benefits of their use include reduced risk of medical errors, improved
efficiency, and better privacy protection for patients. The use of unique patient identifiers is
common in many of the global leaders in health IT, including Denmark, Finland and Sweden
[80]. An identity and authentication solution based on smart card technology currently
provides the best foundation for improving EHRs in secure, private and sensitive way. Using
their digital signature, as example citizens of Denmark can log on their personal web space in
order to book appointments, order medications and renew prescriptions, review their own
medication and health care data and communicate with healthcare authorities [94].
3.5.2. Privacy issues related to health IT systems

Although there are policies existing in healthcare organizations (HCOs), they are not suitable
for protecting privacy in electronic healthcare. ''Having necessary privacy a policy on an
enterprise does not directly ensure privacy protection if there is no effective means of
consistent policy enforcement across multiple applications and across enterprise boundaries.’’
[67]. Enforcement of the privacy policy is essential to ensure that personal information is
accessed, used and disclosed in accordance with ethical norms, so privacy policies should be
represented electronically and be managed through software tools capable of detecting the
underlying hidden errors. This approach will enable HCOs to enforce a policy while sharing
information with other HCOs [67]. The key issue when creating databases for collecting and
managing the entire population data is building the trust in society and among its members.
Trust is a two-way relationship that requires constant effort for creating and maintaining it. In
32
addition, trust is extremely relevant to many different levels and relationships existing in
healthcare system, i.e. doctor-patient, doctor- doctor, doctor-healthcare system, patient-
healthcare system [67].
According to Health Information System Statute (HISS) all access rights and data use are
regulated by law. Access is available for licensed medical professionals, citizens and
authorized persons. However patients’ data can be analysed by other health care professionals
registered with the Health Care Board (HCB) under the Ministry of Social Affairs (MoSA).
Residents have access into their all personal information related to medical data through
Patient’s Portal (PP)13 and rights to close access to documents, summary reports or any other
personal information. Also it is possible to follow the incidence of access into personal
information by the third parties and inform the Estonian eHealth Foundation (EEHF) and/ or
Estonian Data Protection Inspectorate (EDPI)14 [93].
3.5.3. Access rights

The EHR systems are becoming more and more sophisticated and include nowadays
numerous applications, which are not only accessed by medical professionals, but also by
accounting and administrative personnel. This could represent a problem concerning basic
rights such as privacy and confidentiality. Individual is responsible for managing personal
data access rights and not the HCO processing this data. Implementing such a policy is
moving towards patient empowerment which society should encourage and governments
should promote [93]. Most of the eHealth experts agree that access to the EHR is a
fundamental patient right and that the implementation of personally accessible electronic
health records should not be delayed. The question is how much information should be
provided and weather access should be given only to the “relevant” content in the EHR.
Ideally, this clinical information should be coupled with tailored educational materials to help
people meet their information needs. The second approach is to provide full access to all
information contained within the EHR and allow the patients to decide what information they
consider to be relevant. In this approach, educational information could also be linked to fully
accessible personal electronic health records [93]. In modern, electronic-based HCOs,
individuals from diverse professional backgrounds work collaboratively in decision-making
processes concerning patients’ health, and patients have the right to influence these processes.
13
https://www.digilugu.ee/login;jsessionid=7D3183784244403D23A4C011C47D1086
14
http://www.aki.ee/en/inspectorate
33
Winkler states that an organization-wide policy that covers all individuals in an HCO and
deals with both standard and morally controversial medical practices ensures autonomy,
quality, fairness and efficiency of decision-making processes. The privacy policies of many
developing countries, which mainly assume a traditional physician–patient decision-making
approach, fall short of fulfilling such goals [67].
Since all of the e-health projects15 involve a significant amount of sensitive personal data,
ensuring the safety of this information is an extremely important issue. Therefore, great effort
has been put into designing the most appropriate and comprehensive security solutions to
prevent any adverse events. To correctly identify a specific EHR user, it is necessary to apply
complex authentication methods. A good example of this is the ID card and its coding system,
which enables Estonian citizens to provide electronic signatures and to identify themselves.
The most important rules that ensure the proper use of access rights are described in [93].
15
http://www.e-tervis.ee/index.php/en/
34
3 CRITERIA CATEGORIZATION IN USER SATISFACTION
MEASUREMENT
There are several models for evaluating information systems, and a plentitude of models for
evaluating specific details within an IS. Literature defines many criteria for what characterizes
a good information system [52, 26, 86, 96]. Several instruments have been developed and
validated to evaluate information system success. This chapter gives the overview about IS
criteria that influence user satisfaction.
4.1. Information Quality
Information quality criteria describe content issues and characteristics of the information
systems output. Criteria have been measured by examining the output of an information
system in terms of timeliness, accuracy, reliability, and trustworthiness [73]. These criteria
provide information quality in terms of the correctness, usefulness and timeliness of the
information generated by the information system in use. Seddon and Kiew [84], used 10 items
for the measure of Information Quality. The literature on information quality reflects the
existence of a number of views on what constitutes the attributes of information. A large
number of empirical studies have been conducted to develop a framework for measuring the
quality of information [50, 73], from the many characteristics identified by Bailey and
Pearson [9], such as accuracy, precision, currency, timeliness, completeness, conciseness,
format and relevance. Confirming the previous frame, Watson and Shneider [100] identified
five characteristics of information quality as: accuracy, timeliness, conciseness, convenience
and relevance. In this sense, Huang and Wang [50] have conducted a series of studies on
information quality and have used the accuracy, relevance and accessibility. Miller [66] used
usefulness, accuracy, timeliness and relevancy to measure the information quality, while Alka
[12] used the clarity, relevance, accuracy and timeliness of research users. Similarly, Bovee
(2004) used the relevance, interpretability, accuracy and accessibility [12]. Seddon and Kiew
used seven items to measure a construct called As a measure of System Quality. Seddon and
Kiew used 10 items for the measure of Information Quality. We reduced the number of items
to five on the basis of factor loadings shown in their paper [84, 85]. The response format used
for System Usage Characteristics was also used here.
35
4.2. System Usefulness
System usefulness can explain the majority of the variance in user satisfaction. Seven of the
16 studies [36, 39, 51, 48, 96, 102, and 106] tested the association between “system use” and
“individual impacts” and the association was found to be significant in each of the studies.
System use was typically voluntary and was measured as frequency of use, time of use,
number of accesses, usage pattern, and dependency. Individual impacts were measured in
terms of job performance and decision-making performance. The criteria System Usefulness,
is related to gains in terms of efficiency and effectiveness resulting from IS usage: For
example, increases in productivity and job performance resulting from usage of the IS. The
items used to tap this factor are almost identical to those used by Seddon and Kiew [85] in
their System Usefulness Scale. It consists of six questions on Perceived Usefulness from
Davis (1989). A common feature of the scale is that it can be used transversally in any type of
task or system considered in the area of study. These scales consider mostly items that have
been broadly used in the literature. Seddon and Kiew's concept of usefulness is equivalent to
the idea of perceived usefulness in Technology Acceptance Model by Davis [24, 25]. They
argued that, for voluntary systems, use is an appropriate measure; however, if system use is
mandatory, usefulness is a better measure of IS success than use. According to Seddon and
Kiew's concept [85], System Usefulness criterion was used in research in terms of efficiency
and effectiveness resulting from EKTIS usage.
4.3. System Quality and System Usage Characteristics
In addition to information quality, the overall quality of a system is also one of the most
common dimensions which allow to evaluate information systems. System quality indirectly
impacts the extent to which the system is able to deliver benefits by means of mediational
relationships through the usage intentions and user satisfaction constructs. System quality
measures the desirable characteristics of an information system. Several IS studies have
measured this, using such characteristics as perceived ease of use, system features, response
time, and flexibility [6, 24, 27]. However, this study assesses system quality by examining the
ease of use, associated with EKTIS information systems as well as functionality and
flexibility. The measurement of the quality of information systems is a multidimensional
process focusing on different aspects, because a system has many aspects such as system
aspects, quality aspects and other aspects related to technical issues. System Quality in
36
services is increasingly becoming important in healthcare world and many criteria have so far
been defined to achieve and assess it. Different characteristics have been defined for software
quality in different studies. Many of them overlap with similar definitions; this is perhaps the
most important challenge of classification of the software quality [3, 4].
ISO 9126 standard16 model was used as a standard way of defining of software quality
characteristics. In general, the measure of system quality concentrates on the specifications of
a target system. All five studies [6, 36, 85, 86, 104] that tested the direct association between
“system quality” and “individual impacts” found those associations to be statistically
significant. System quality was measured in terms of ease-of-use, functionality, reliability,
flexibility, data quality, portability, integration, and importance. Individual impacts were
measured as quality of work, environment and job performance. Portability, reflecting the
users’ needs, depends on system quality. However, from a practical point of view, a high level
of system quality can provide users convenience, more privacy and quicker responses. For
example, Lederer et al. [61] has shown that the capacity of the system have had a positive
impact of perceived ease of use and perceived usefulness of the system. Indeed, many
researchers [42, 43, 106, and 109] have generally focused on the performance characteristics
of a system to measure the system quality. These features were mostly drawn from the list of
Hamilton and Chervany [42, 43] concerning measures of the quality system. The list is
probably the best known in the literature in terms of the measure of the system quality [42, 43
106, and 110]. The list includes response time or so-called the turnaround time, reliability,
flexibility and ease of use. The researchers found that the list covers all relevant elements of
the quality system. Seddon and Kiew [85] measure the system quality by reliability, user
interface, consistency, ease of use and quality, which is consistent with the list of Hamilton
and Chervany [42, 43]. The System Usage Characteristics criteria, that were used in this
research describes the ease of system use, depth of learning required, and the adaptability of
the system to organization-specific requirements. Again, the criterion has a counterpart in the
work of Seddon and Kiew who employed a seven-item scale labeled System Quality.
According to Seddon and Kiew [86], Jensen et al. [53] and ISO 9126 standard model was
used six criteria and a set of sub characteristics (See. Table 1), which will allow evaluating
viewpoints of EKTIS users more effectively. According to Jensen et al. [53] it was used the
option of disagreement or it does not apply in various aspects of the technical quality
16 http://www.sqa.net/iso9126.html
37
evaluation, explaining that they either did not know the standards and laws which were
applied (item FUNCTIONALITY: conformity), given the absence of failures while using the
software (items RELIABILITY: tolerance of failures and MANTAINABILITY:
analyzability), for not having access to the source code (item MANTAINABILITY: stability)
or for it.
4.4. Overall satisfaction
Overall satisfaction or User satisfaction: This is considered one of the most important
measures of system’s success, often measured by overall user satisfaction [6, 9]. User
satisfaction is an important dimension for evaluating information system success through
correlation to user behaviors and affective reaction to information technology [110, 26, and
44]. Thus, user satisfaction is appropriate for use as an index to evaluate the system
performance according to users’ needs and to indicate users’ perceptions of the information
system, which may effectively reflect users’ intentions to adopt the information system [76,
1]. The outcome of user satisfaction can contribute useful information to improving the
information system design and to examining the extent of impacts on organizational decision
making, operational efficiency, and benefits [64, 65, and 103]. It was assessed in the study by
capturing overall user satisfaction with the EKTIS information system. The overall user
satisfaction was recorded through questionnaire (See Appendix 1). Before using IS, some
judgments and feelings about system are occurred by a user and “user satisfaction” depends
upon how much user’s expectation has been met by the IS that he used. When “user
satisfaction” is wanted to be measured, the decision about which measures will be taken must
be investigated carefully [85, 86, 26, 27, 96]. There are some important measures which are
respectively; satisfaction of software and hardware, graphical interface and information and
user complaints about system [85, 86].
4.5. Perceived Usefulness
The perceived ease of use refers to the extent to which users believe that using a particular
system would be easy to manage, manipulate and regroup [24, 25, and 50]. The perceived
ease of use shows the degree to which a system is considered as not being too difficult to
understand, learn and use. The perceived ease of use was found to influence the behavior of
users, either directly or indirectly, by the use of the system. On the other hand, Perceived
usefulness refers to whether the system provides accurate, timely, relevant, reliable and valid
38
information for users or not [67]. Therefore, using the system will enhance job performance,
Seddon and Kiew used six items to assess this construct. Inspection of factor of loadings
suggested a high degree of overlap among these items, so we implemented the first three
retained ones and then added two new items which assessed whether the system saved time
and money. The response format was the same as that used for Information Quality.
Productivity, efficiency and quality of work. As noted by Bhattacherjee [12], the willingness
of a person to interact with a particular system is already considered useful. Thus, it is
expected that users will adopt a system if they believe that it will help them to achieve the
desired results of performance [6]. In the literature, the perceived ease of use and perceived
usefulness are interdependent and used together in most aspects of research that affect each
other in individual aspects [24, 25]. Perceived usefulness is regarded as a term for the
individual impacts such as improving individual productivity and performance [85, 86]. In
addition, Wixom and Watson [103, 104] found that the quality of information, system quality
and perceived usefulness are related to each other, expressing that the higher is the level of
quality of information and quality system, the more efficiently the system works. There are
also many scholarly works in the field of Information Systems that investigate the
consequences of user satisfaction for organizations and users such as perceived usefulness and
continued use [12, 23, 57, 70,103, and 104]. According to Seddon and Kiew we have used
five items to assess this construct. Moreover, Pai and Huang [75] pointed out that perceived
usefulness positively influence user’s intention for healthcare information systems. Therefore
Dillon, Lendin, Crews, and Blankenship [28] also asserted that construct of PU is critical as
evaluation measure in the early stages of clinical and administrative IS implementation.
According to Dixon concept [29], Perceived Usefulness criterion was used in research in
terms of cost effectiveness, work performance, patient care quality, and productivity resulting
from EKTIS usage.
4.6. Importance of the system
Importance of the System was one of the new scales introduced by Seddon and Kiew to assess
the perceived importance of the evaluating of function. The DeLone and McLean [26, 27]
added a new construct called “importance of the system”. They found that it can explain the
majority of the variance in user satisfaction. Their rationale for applying this scale was that
perceptions of other components of the system may be overshadowed by the perceived
importance of those components. One can then control for its influence when examining
relations among other variables by measuring perceived importance.
39
Most organizations (ATOS17, VieCuri18, Heliomare19) in Europe rely on prepackaged
software. This reliance implies the need for inclusion of a construct to enable evaluation of
usage or importance of individual components of the IS to enable researchers to control for
different application types during data analysis.
The IS quality criteria Definition
1. FUNCTIONALITY (Adequacy,Accuracy, The sum or any aspect of what a product, such
Interoperability) (Conformity, Secure
as a software application or computing device,
access)
can do for a user [4].
2. RELIABILITY (Maturity, Tolerance to How reliable (repeatable, stable) is the
failures, Recoverability)
information within the IS [4].
3. USABILITY (Intelligibility, Learnability, How to make systems easier to use, and
Operability)
matching them more closely to user needs and
requirements. It is the extent to which a
product can be used by specified users to
achieve specified goals with effectiveness,
efficiency and satisfaction in a specified
context of use. [4].
4. EFFICIENCY (Time, Resources) How much energy does a user need to put into
the system to produce a desired result [4].
5. MAINTAINABILITY (Analyzability, Ability of a computer program to be retained in

(Modifiability, Stability, Testability)
its original form, and to be restored to that form
in case of a failure [4].
6. PORTABILITY (Adaptability, (Capacity How easy it is to transfer archived information
to be installed, Conformity, Capacity to
to another system [4].
replace)
Table 1. IS quality criteria [4].
17 https://atos.net/en/
18 https://www.viecuri.nl/
19 https://www.heliomare.nl/
40
4 EKTIS Informational Management System
This chapter reports the EKTIS Information System description, giving an overview of the
system and its features, describing software architecture, functionality, user interface. This
section gives a short overview of Estonian Health Informational System, and explains EKTIS
interaction with other systems.
5.1 Description of the EKTIS Information System
Nowadays most of school nurses make decisions (basically) on getting health data from the
parents, because of the limited access to state-centered health information system. In
cooperation with the Tallinn City Government, E-Health Foundation and Tallinn School
Health Foundation, the AS Helmes20 has developed the School Health Information System-
EKTIS that provides school health staff with access to the necessary information. School
health information system is interacting with National Health Information System, which
contains important information of the patient's state of health. On 05 July 2010, Helmes AS
with registry code 10364097 and Foundation for School Health Care Services with registry
code 900084488 have made cooperation agreement NR 1-4/116/10 and thus from 01.09.2009
Foundation of School Health Care Services can use the software21.
EKTIS realized authorization, authentication and logging system, and has set up a web-based
application for on-line database, which is used by the end users, administrators and others
participants, depending of their importance [30].
EKTIS Information System provides a number of new opportunities for all involved groups:
1) School nurses: The student's visit registration, which entered data is also available through
the National Health Information System (HIS) to other doctors; health care provider can also
look the student outpatient epicrisis from HIS. Referral letters sending to HIS and
immunization data exchange with HIS. During the performing vaccination health care
provider can find information about contraindications, previous vaccinations and vaccination
refusals; ability to request a time-critical data: chronic diseases, allergies, the operations
performed; as well as restrictions on physical education and special needs; health records,
where data has already been collected from HIS; medical records of health checks which were
carried out of the student's and a medical history. Information about students / schools /
20
https://www.helmes.com/
21
http://www.kth.ee/
41
classes comes directly from Estonian Education Information System (EHIS). Health care
provider is possible to carry out the work by classes: parasite control, first aid and health
lectures, risk group consultations, etc.). Fast, reliable statistics, reports for Health Insurance
Fund and to The Health Protection Agency. The family doctor and other doctors have access
in relation to the student's health information through the HIS [30].
Figure 3. EKTIS architecture.
EKTIS features are:

 Students/schools/classes data – goes to Estonian Education information system (EHIS)
and is available in real time in EKTIS when the pupil comes to school or changes the
class. Registry existence gives the opportunity to the medical officer to carry out the work
by the class.
 Students health card – registration appeals, referral. The opportunity to receive from other
medical institutions health records of the outpatient epicrisis and time critical data
(chronic diseases, allergies, conduct of operations).
 Vaccinations – enter bids and a succession will be sent from HIS.
42
 Medical record –the earlier medical examinations which are carried out and collected by
family doctors and appear in EKTIS.
 Health promotion– parasites control, first aid and health lectures, consultations for the risk
groups, etc.
 Reporting vaccinations, pupil appeals, health promotion and health surveillance on the
basis of the classes.
 Schools with special needs
 Treatment processes (reversal, screening, vaccinations) automatic price publishing in
accordance with the health insurance Fund price list codes.
 Main medical bill submission to the Health Insurance Fund.
5.1.1 EKTIS Requirements
EKTIS allows a huge volume of data to be entered rapidly, analyzed comprehensively from
multiple perspectives, and efficiently reported to key stakeholders. Data and non-functional
requirements will help to effectively characterize the object of study and to define
requirements that specify criteria that can be used to judge the system. The EKTIS
Information System requirements are: computer and Windows operating system; MS Internet
Explorer browser; Internet; ID-card reader and ID-card software; Information system hosted
and maintained by AS Helmes.
5.1.1.1 Data requirements.
Data requirement is a set of procedures for identifying the data needs of system. During
requirement elicitation phase users were asked about what data must contain the system?
What data should be shown by the system? How will they use the system? By using
interview, observation, and document review technique, system inputs and outputs were
identified [103].
In the current system information includes demographic, nursing records, assessment,

diagnosis, care plan for the children in risk groups, implementation, evaluation, following up,
vital sign, immunizations, and health promotion. After successful data entry, these inputs will
be processed to get information like number of pupils who have been vaccinated, number of
pupils in risk groups, epicrisis data from the hospital, pupil’s health information, diagnosis
history and help menu.
43
5.1.1.2. Non-functional requirements.
Non-functional requirement means quality of the new system that is not directly related to the
functionality of the new system. The following are the main non-functional requirements of
the system [32]. Availability: Foundation for School Healthcare in Tallinn22 gives service for
8-10 hours, the system should be available 24 hours /7 day a week and there should be 24
hours / day electricity and backup source available such as generator. Scalability: it is
considered that the system is increasing interoperability between nurses in different schools;
the system should be scalable to accommodate these changes. Therefore the web based
information system uses the web as a platform which makes it easy to accommodate any
changes [86].
User interface and Human factor: School nurses communicate with the system through the
application interface which is easy to use. This will minimize the time needed for nurses to
adapt to use the system. There will be interfaces and menus for each function provided by the
system to easily navigate/direct from one point to the other [89].
Performance: Currently, there is high need for reliable, accessible and timely quality patient
information within the health care for information based action. Since the system is web based
it takes these needs of nurses into consideration [34].
Reliability: The system shall show appropriate messages to user’s terminal when system is
continuing to work or down. The system generates error messages when the user attempts to
enter invalid data [86].
Security: The system is going to handle personal information which is confidential, it should
protect patient data from unauthorized access and use, the system provides restriction in using
the functionality and information’s right to use by user [80], no one can log into the system
without ID card and password. The system will use encryption techniques to avoid the tapping
of the data in transfer.
22
http://www.kth.ee/
44
5.1.2 EKTIS architecture and interaction with HIS
The architecture of a system describes its major components, their relationships (structures),
and how they interact with each other. Software architecture and design is a process that
includes several contributory factors such as Business strategy, quality attributes, human
dynamics, design, and IT environment [63]. Since most of the systems came from different
vendors, they are often heterogeneous and isolated. In order to fulfill the digital workflow
among these systems, a kind of framework or model is necessary to specify how to exchange
messages among these systems to achieve the workflow integration [105]. EKTIS
Informational Management System interacts with different organizations, such as Estonian
Health Information System, from which school nurses can obtain time critical data, health
records, immunization reports, epicrises summary and also sent back to HIS pupil’s important
examination records.
Estonian Education Information System (EHIS) is a state database that brings together all the
information related to education in Estonia. The database stores details about education
institutions, students, teachers and lecturers, graduation documents, study materials and
curricula. EHIS is connected with EKTIS Informational Management System, which allows
transferring pupils’ demographic data, which can be viewed in EKTIS according to each
class. The Figure 4. was developed on the information retrieved from Helmes organization, it
presents the data flow between EKTIS and different organizations.
45
Figure 4. EKTIS and information exchange with systems.
5.1.3. User Interface

Regardless of how the requirements were gathered, the team members have communicated
with each other to understand user interface design proposals and inputs from the stakeholders
in the process. The medium and language are used to communicate these requirements can be
problematic. Development and verification test engineers wanted to see detailed requirements.
Developers wanted the details so they wouldn’t need to fill in requirements as part of the
design and implementation process, while guessing what the various stakeholders want.
Verification testers want the details that will help them design test protocols without guessing
about how the features of the user interface will be implemented. The question of how much
detail to put in requirements is a source of much debate [56]. However, the following items,
as a minimum, should be considered for specifying a user interface:
 Size, placement, and color scheme of the display or sub display area.
 Font, font size, and font color.
46
 Exact text to be displayed and any formatting that is critical.
 Navigation to and from the display element.
 Details of any user inputs that are activated or deactivated in that display mode [56].
User Interface (UI) plays a significant role in web design, as the usability and success of a
website will completely depend on how the UI is designed. Web user interface is basically a
graphical user interface that accepts inputs from users and provides output (web pages)
requested by the users [63]. UI design will make the users interaction effective, sophisticated,
and smooth. User interface is the front-end application view to which user interacts in order to
use the software. User can manipulate and control the software as well as hardware by means
of user interface. User interface is part of software and is designed in such a way that it is
expected to provide the user insight of the software [65, 107].
EKTIS provides a fundamental platform for human-device interaction, it presents graphical

and text-based environment. Requirements for EKTIS were designed as effective user
interface that suits the school nurses, the user interface must be attractive, simple to use,
responsive in short time, clear to understand, consistent on all interfacing screens. The
following diagram provides an architectural view of how each user in the system is allowed to
use and access different functionalities and data entry usage based on their own administrator
assigned privilege.
47
Figure 5. User interface flow diagram for EKTIS web based information management
system
The flow diagram shows that to start working with the system first of all school nurse has to
login into the system using ID card and ID card password; in which the log-in validates the
user. If the user is valid, school nurse is allowed to access the system. Once the system is
opened the school nurse can get the main form of pupil records which contains detailed
pupils’ information.
The help menu provides different information about the services. The menu hyperlinks that
are found at the top, lead to different locations and provide different functions. Most
importantly, in order to get the required services from the system, the user must login into the
system thus the user have to click on the Sign In button.
5.1.4 Functionality of the system

Functionality is the ability of the system to do the work for which it was intended. Among all
of the requirements, functionality has the strangest relationship to architecture [35]. In this
study an attempt is made to find criteria which influence the general satisfaction, and the
functionality is one of the factors that were analyzed in the present research. Accordingly, the
system has the following functionalities:
 The system is designed to create, update and remove user account.

48
 The system enables the authentication of different users and their role.
 The system registers, organizes and displays essential demographic patient information,
school children nursing history, school nursing assessment, diagnosis, care plan,
immunization, implementation, evaluation and following up.
 The system provides severity index and nursing diagnosis guideline.
 The system enables school nurses to search student information from the data base by
name, surname, by class or by ID number.
 The system enable users to generate different reports based on the selected report’s
parameter to support quality improvement (daily, weekly, monthly, quarterly and yearly).
49
5 EKTIS USERS FEEDBACK COLLECTION
In this section, we present a method for pairwise correlation and multiple regression analysis.
In this method, we first develope the best model which will allow us to identify specific
aspects which will increase users satisfaction and therefore improve overall system
performance. Finally, we will find the criteria which influence the general satisfaction and
therefore the overall efficiency.
6.2 Data collection

A survey design was adopted in Survey Monkey23 online tool. The samples are 73 school
nurses working in the schools in Tallinn, Estonia. In total, 2 different questionnaires: User
Satisfaction Questionnaire - Q1 and Evaluation of EKTIS Informational software’s technical
quality- Q2 hyperlinks were sent by the work email to all school nurses, where the research
period was mentioned from 29.05.2017 to 17.06.2017 which was held by the researcher.
Questionnaires were examined by the researcher, where the open ended question is being
dropped due to incomplete responses. Thus, from 73 school nurses who have participated,
Q1- 53 and Q2 - 34 completed the questionnaires; usable questionnaires were used for
statistical analysis, representing a response rate of Q1- 81.0 % and Q2- 34%.
6.3 Survey questioners development

Survey questionnaires contain previously validated and published questionnaires which were
used to examine user satisfaction of software [6, 53]. The questionnaire included a subset of
the items used by Seddon and Kiew [84,85], who has developed a model for measuring
information systems’ success, inspection of item content and statistical data reported in their
paper suggested a certain amount of item redundancy. According to Armstrong, B. [6] from a
psychometric point of view, there is nothing wrong with item redundancy but if items can be
deleted without reducing the reliability or validity of the scale, efficiencies can be achieved.
The items were recast in general terms according to Armstrong, B. [6], rather than targeting a
particular software package, like the case in their study. Both of these changes were aimed at
achieving a more generic instrument. Other changes are discussed below for each section of
the questionnaire. The survey questionnaire Q1 contains three parts: general demographical
questions:
23
https://www.surveymonkey.com/
50
Demographics
The questionnaire began with a series of items relating to demographic characteristics of the
participants (gender, age, profession, general work experience and education). These
questions, with summary statistics, are shown in Appendix 3 and Appendix 4.
System Quality and System Usage Characteristics
Seddon and Kiew used seven items to measure a construct named as measures of System
Quality. According to Armstrong, B. [6] we selected the four of the items with the highest
loadings’ factor that was selected from the Seddon and Kiew study, plus three additional
items and added three new items from Armstrong, B. [6] intended to broaden this scale to
include aspects of costs and benefits. According to Armstrong, B. [6], the construct uses the
more neutral term System Usage Characteristics. The items employed a seven-point Likert
response format with Strongly Disagree and Strongly Agree anchoring the opposite ends of
the response scale. The three additional items were:
•The costs are higher than the benefits using the system.
•The system is complex.
•It is expensive to operate and use the system.
All items for this scale and the remaining scales employed a seven-point Likert response
format.
Information Quality
Seddon and Kiew [84] used 10 items for the measure of Information Quality. According to
Armstrong, B. [6] we reduced the number of items to five on the basis of loadings’ factor
shown in their paper. The response format used for System Usage Characteristics was also
used here.
Perceived Usefulness
Seddon and Kiew [85] used six items to assess this construct. Inspection of loadings’ factor
suggested a high degree of overlap among these items, so we implemented and retained the
first three and then added two new items which assessed whether the system saved time and
money. The response format was the same as that was used for Information Quality.
51
Importance of the System
Importance of the System was one of the new scales introduced by Seddon and Kiew [84, 85]
to assess the perceived importance of the evaluating function. Most organizations (ATOS,
VieCuri, Heliomare) in Europe rely on prepackaged software. This reliance implies the need
for inclusion of a construct to enable evaluation of usage or importance of individual
components of the EKTIS to enable researchers to control for different application types
during data analysis. Seddon and Kiew [84, 85] in fact recommended that future research
needs to control for task importance associated with CBIS function. The main reason for this
control requirement is that users could be expected to have different opinions of the
importance or criticality of different components of their CBISs. As most prior studies that
have looked at CBIS as a generic entity, it is difficult to compare results as CBIS comprises
many different applications to meet the full range of business functions. Their rationale for
including this scale was that perceptions of other components of the system may be
overshadowed by the perceived importance of those components. By measuring perceived
importance, one can then control for its influence while examining relations among other
variables. Given the broader scope of our own instrument, according to Armstrong, B. [6], we
extended this section to include all functions of the EKTIS software. The items employed a
seven-point Likert response format with Not Important and Essential anchoring the opposite
ends of the response scale.
The survey questionnaire Q1 contains three parts: general demographical questions. One
open-ended question and perceptual scales of each construct. Table 1 provides a summary of
the 7 constructs and 28 prompts. Except for open-ended question, the other six constructs are
on a seven-point Likert scale24 ranging from strongly disagree (= 1) to strongly agree (= 7).
As for the open-ended question, the respondent was free to write down any ideas about
EKTIS. See Appendix 1.
The second questionnaire included model for evaluating the functionality of the system
developed by Jensen, R. et al. (2012) [53]. Seddon and Kiew [64], Jensen et al. [53] and ISO
9126 standard model was used six criteria and a set of sub-characteristics (See. Table 1),
which will allow evaluating viewpoints of EKTIS users more effectively. According to
24
https://www.cdc.gov/dhdsp/pubs/docs/cb_february_14_2012.pdf
52
Jensen, R. et al. [53]. There were selected the option disagreement or it does not apply in
various aspects of the technical quality evaluation explaining they either did not know the
standards and laws that are applied (item FUNCTIONALITY: conformity), given the absence
of failures while using the software (items RELIABILITY: tolerance of failures and
MANTAINABILITY: analyzability), for not having access to the source code (item
MANTAINABILITY: stability) or for its impossibility to evaluate the item (item
PORTABILITY: ability to replace). The Q2 contains three parts: a general demographical
question, Table 1 provides a summary of 10 constructs and 112 prompts. Numerical data was
recorded and results were grouped together using Likert scale from 0 to 1 point, were
agreement (A), partially agree (P), correct (Y) =1, Disagreement (D) and Does not apply
(NA), not correct (N) =0. See Appendix 2.
Questionnaire № Construct Number of Items Source

Q1 Information Quality 5 Armstrong, B. (2005)
System Usefulness 3 Armstrong, B. (2005)
System Usage Characteristics 3 Armstrong, B. (2005)
System Quality 7 Armstrong, B. (2005)
Overall satisfaction 3 Armstrong, B. (2005)
Perceived Usefulness 5 Armstrong, B. (2005)
Importance of the system 1 Armstrong, B. (2005)
Table 2. Questionnaire 1 constructs and measurements.
Questionnaire № Construct Number of Items Source

Q2 Functionality 85 Jensen, R. et al.(2012)
Reliability 4 Jensen, R. et al.(2012)
Usability 7 Jensen, R. et al.(2012)
Efficiency 3 Jensen, R. et al.(2012)
Maintainability 4 Jensen, R. et al.(2012)
Evaluation of interface 9 Jensen, R. et al.(2012)
and adequacy of program
Table 3. Questionnaire 2 constructs and measurements.
53
6.4 Ethical consideration
For this study, prior to their agreement on participating in the research, the participants were
informed about the purpose of the research and data gathering. Participants were also told that
their confidentiality would be protected, and that they have the right to withdraw from the
study. The questionnaire link was sent via organizational email.
54
6 EKTIS USER FEEDBACK DATA ANALYSIS
The data from questionnaires was collected and then extracted from the place of location
(SURVEY MONKEY 25online tool) to the Microsoft Excel26, where questions were grouped
together according to the meanings which are related to: Data Quality, System Utility,
System Utility Features, System Quality, Perception Utility, System Importance, Age and
General Satisfaction according to the Linkert Scale. The R Statistical Computing Software
3.4.2.,27 R is a language and environment for statistical computing and graphics. R provides a
wide variety of statistical (linear and nonlinear modelling, classical statistical tests, time-
series analysis, classification, clustering, etc.) and graphical techniques, and is highly
extensible. The S language is often the instrument of choice for research in statistical
methodology, and R provides an Open Source route to participation in that activity and was
also used to analyze the data of participant’s answers. The multiple regression analysis was
used to test the hypotheses. In addition, model validity and reliability were tested with
pairwise correlation analysis using AIC model criteria in the RCS 3.4.2. Table 3 illustrates
participants’ answers that are grouped together according to Linkert Scale. Data sets used in
analysis can be viewed in Appendix 4.
7.1 Participant Demographics.
Participant demographics is the first part of analysis. Among the 53 respondents, all were
women, and more than half of them (n =26, 50, 94%) were younger than 50 years old. The
majority of them (n = 51, 98, 0 %) had completed an associate or baccalaureate degree, and
most of them (n =45, 84.91 %) had worked in school nursing for at least 6 and more than 25
years. Approximately all nurses had 6 to 10 years of computer experience. In terms of
organizational level the majority of nurses were responsible for over 700 students (but less
than 1,000). Participants’ demographics can be viewed in Appendix 3 and Appendix 4.
25
https://www.surveymonkey.ru/
26
https://drive.google.com/open?id=1rX6kGVx0eKiAzrs7KbKjLG_xzsNFdymX
27
https://www.r-project.org/about.html
55
7.2 Model Validity, Reliability and Hypotheses testing
The Pairwise correlation was first performed to examine the model validity. First of all it’s
important to find the correlations using the formula:
𝑟 ∗ √(𝑛 − 2)
𝑡=
√(1 − 𝑟𝑥 2 )
1 − 𝑟𝑥 2
𝑠𝑒 = √( )
𝑛−2
Pairwise correlation between sets of data is a measure of how well they are related. The most
common measure of correlation in stats is the Pearson Correlation. The full name is the
Pearson Product Moment Correlation or PPMC. It shows the linear relationship between two
sets of data. Pearson correlation is the most common form of correlation. It is a parametric
test, and assumes that the data is linearly related and that the residuals are normally
distributed. The correlation equation can be expressed as bellow, whereas mx and my are the
means of x and y variables:
∑(𝒙 − 𝒎𝒙 )(𝒚 − 𝒎𝒚 )
𝒓=
√∑(𝒙 − 𝒎𝒙 )𝟐 ∑(𝒚 − 𝒎𝒚 )𝟐
The p-value of the correlation can be determined by using the correlation coefficient table for
the the𝐷𝐹: 𝑑𝑓 = 𝑛 − 2 , where n is the number of observation in x and y variables or by
calculating the t value as follow:
𝒓
𝒕= √𝒏 − 𝟐
√𝟏 − 𝒓𝟐
The t and Standard Errors are determined by using the fisher z transform of the correlation:
𝟏
𝒔𝒆 = √( )
𝒏−𝟑
Multiple regression is an extension of simple linear regression. As a predictive analysis, the

multiple linear regression is used to explain the relationship between one continuous
dependent variable and two or more independent variables. The independent variables can be
continuous or categorical. Multiple regression also allows determining the overall
56
correspondance of the model and the relative contribution of each predictors to the total
explained variance [32]. So it is possible to elaborate multiple linear regression models of
the general form:
𝒚 = 𝜶 + 𝜷𝟏 𝒙𝟏 + 𝜷𝒏 𝒙𝒏……. + 𝝐
The best model based on AIC-based backward and forward selection more specifically:
𝒀𝑮𝒆𝒏𝑺𝒂𝒕𝒊𝒔𝒇 = 𝜷_𝟏 𝑺𝒚𝒔𝑼𝒕𝒊𝒍𝒊𝒕𝒚 + 𝜷_𝟐 𝑺𝒚𝒔𝑰𝒎𝒑 + 𝜷_𝟑 𝑫𝒂𝒕𝒂𝑸𝒖𝒂𝒍𝒊𝒕𝒚

+ 𝜷_𝟒 𝑺𝒚𝒔𝑼𝒕𝒊𝒍𝒊𝒕𝒚𝑭𝒆𝒂𝒕𝒖𝒓𝒆𝒔 + 𝜷_𝟓 𝑺𝒚𝒔𝑸𝒖𝒂𝒍
7.3 Models identification
The seven models were tested using multiple regression and pairwise correlation analysis,
which were based on AIC criteria. The General Satisfaction, Age, System Importance,
Perception Utility, System Quality, System Utility Features, Data Quality. However the
Perception Utility, Age and System importance were not significantly related to general
satisfaction. The results will be discussed in more detail in the next section.
Akaike’s information criterion (AIC) compares the quality of a set of statistical models to
each other. The AIC will take each model and rank them from best to worst. The “best”
model will be the model that neither under-fits nor over-fits. Therefore, once the best model
is selected, it is considered to use a hypothesis test to figure out the relationship between the
variables in the model and the outcome of interest. Akaike’s Information Criterion is usually
calculated with software [14].
The basic formula is defined as: 𝐴𝐼𝐶 = −2(𝑙𝑜𝑔 − 𝑙𝑖𝑘𝑒𝑙𝑖ℎ𝑜𝑜𝑑) + 2𝐾
Where:
 K is the number of model parameters (the number of variables in the model plus the
intercept).
 Log-likelihood is a measure of model fit. The higher the number is, the better the fit is.
This is usually obtained from statistical output [14].
model.1 => YGenSatisf ~ Age
model.2 => YGenSatisf ~ Age + SysImp
57
model.3 => YGenSatisf ~ Age + SysImp + PerceptUtil
model.4 => YGenSatisf ~ Age + SysImp + PerceptUtil + SysQual
model.5 => YGenSatisf ~ Age + SysImp + PerceptUtil + SysQual+ SysUtilityFeatures
model.6 => YGenSatisf ~ Age + SysImp + PerceptUtil + SysQual+ SysUtilityFeatures +

SysUtility
model.7 => YGenSatisf ~ Age + SysImp + PerceptUtil + SysQual+ SysUtilityFeatures +

SysUtility + DataQuality
model.final = YGenSatisf ~ SysUtility + SysImp + DataQuality+SysUtilityFeatures+SysQual
Based on AIC criteria the best model is selected:
Result = AIC (model.final, model.1, model.2, model.3, model.4, model.5, model.6, model.7)
Table 4. AIC best model.

7.3.1 Interpretation of Multiple Regression and Pairwise correlation indicators
We obtained Pairwise correlation between each variable and developed the best model for the
general satisfaction, and established multiple regression analysis that indicates the criteria
which influence general satisfaction. In this section we explain multiple regression parameters
and their interactions, therefore this section will give explanations of ANOVA table, and
output coefficents.
7.3.2 Parameters
The inferences and interpretations made in multiple linear regression are similar to those that
were made in simple linear regression (in fact, the assumptions required for multiple linear
regression are the same as those that are for simple linear regression except here they must
58
hold for all predictors and not just the one used in simple linear regression) with four major
differences [38].
The t−tests for the slope coefficients are conditional tests. That is, the tests are analyzing the
significant predictive value that a variable adds to the model when the other variables are
already included in the model [38].
The values of the slopes are interpreted as to how much of a unit change in Y will occur for a
unit increase in a particular X predictor variable, given that the other variables are held
constant [20].
The coefficient of determination, 𝑅 2 , still measures the amount of variation in the response
variable Y that is explained by all of the predictor variables in the model. However, where
before the square root of 𝑅 2 could be interpreted as the correlation between X and Y, this
result no longer holds true in multiple linear regression. Since we now have more than one X,
this square root is no longer representative of a linear relationship between two variables
which is what correlation measures [20].
The F−test is a test that all of the slopes in the model are equal to zero (this is the null
hypothesis, Ho, versus the alternative hypothesis, Ho that the slopes are not all equal to zero;
i.e. at least one slope does not equal zero. This test is called the F−test for Overall
Significance. The hypotheses statements appear as follows:
𝐻0 : 𝛽1 =… = 𝛽𝑘 = 0
𝐻1 : 𝐴𝑡 𝑙𝑒𝑎𝑠𝑡 𝑜𝑛𝑒 𝑜𝑓 𝛽𝑖′ 𝑠 𝑖𝑠 𝑛𝑜𝑛 𝑧𝑒𝑟𝑜
F statistic [MSR is Mean Square Regression and MSE is Mean Square Error]:
𝑀𝑆𝑅
𝐹=
𝑀𝑆𝐸
7.3.3 Output Coefficients
The Analysis of Variance table is also known as the ANOVA table (for ANalysis Of
VAriance). There is variability in the response variable. It is the uncertainty that would be
present if one had to predict individual responses without any other information. The best
thing one could do is to predict each observation to be equal to the sample mean. The amount
59
of uncertainty or variability can be measured by the Total Sum of Squares, which is the
numerator of the sample variance. The ANOVA table partitions this variability into two parts.
One portion is fitted by (many incorrectly say "explained by") the model. It's the reduction in
uncertainty that occurs when the regression model is used to predict the responses. The
remaining portion is the uncertainty that remains even after the model is used. The model is
considered to be statistically significant if it can account for a large amount of variability in
the response [38].
The column labeled Source has three rows, one for total variability and one for each of the
two pieces that the total is divided into Model, which is sometimes called Regression,
and Error, sometimes called Residual. The C in C Total stands for corrected. Some
programs ignore the C and label this Total. The C Total Sum of Squares and Degrees of
Freedom will be the sum of Model and Error. [38].
Sums of Squares: The total amount of variability in the response can be written as (y-
ybar) ², where ybar is the sample mean. (The "Corrected" in "C Total" refers to subtracting the
sample mean before squaring.) If we were asked to make a prediction without any other
information, the best we can do, in a certain sense, is the sample mean. The amount of
variation in the data that can't be accounted for by this simple method of prediction is given
by the Total Sum of Squares [38].
When the regression model is used for prediction, the amount of uncertainty that remains is
the variability about the regression line, (𝑦 − 𝑦ℎ𝑎𝑡)². This is the Error sum of squares. The
difference between the Total sum of squares and the Error sum of squares is the Model Sum
of Squares, which happens to be equal to (𝑦ℎ𝑎𝑡 − 𝑦𝑏𝑎𝑟)² [38].
Each sum of squares has corresponding degrees of freedom (DF) associated with it. Total df
is one less than the number of observations, n-1. The Model df is the number of independent
variables in the model, p. The Error df is the difference between the Total 𝑑𝑓 (𝑛 − 1) and the
Model 𝑑𝑓 (𝑝), that is, 𝑛 − 𝑝 − 1. [38].
The Mean Squares are the Sums of Squares divided by the corresponding degrees of
freedom.
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The F Value or F ratio is the test statistic used to decide whether the model as a whole has
statistically significant predictive capability, that is, whether the regression SS is big enough,
considering the number of variables needed to achieve it. F is the ratio of the Model Mean
Square to the Error Mean Square. Under the null hypothesis that the model has no predictive
capability--that is, that all population regression coefficients are 0 simultaneously--the F
statistic follows an F distribution with p numerator degrees of freedom and n-p-1 denominator
degrees of freedom. The null hypothesis is rejected if the F ratio is large. Some analysts
recommend ignoring the P values for the individual regression coefficients if the overall F
ratio is not statistically significant, because of the problems caused by multiple testing. I tend
to agree with this recommendation with one important exception. If the purpose of the
analysis is to examine a particular regression coefficient after adjusting for the effects of other
variables, I would ignore everything but the regression coefficient is under study. If the focus
of a study is a particular regression coefficient, it gets most of the attention and everything
else is secondary.) [38].
The Root Mean Square Error (also known as the standard error of the estimate) is the
square root of the Residual Mean Square. It is the standard deviation of the data about the
regression line, rather than about the sample mean [38].
R² is the squared multiple correlation coefficient. It is also called the Coefficient of

Determination. R² is the ratio of the Regression sum of squares to the Total sum of squares,
𝑅𝑒𝑔𝑆𝑆/𝑇𝑜𝑡𝑆𝑆. It is the proportion of the variability in the response that is fitted by the model.
Since the Total SS is the sum of the Regression and Residual Sums of squares, R² can be
rewritten as (𝑇𝑜𝑡𝑆𝑆 − 𝑅𝑒𝑠𝑆𝑆)/𝑇𝑜𝑡𝑆𝑆 = 1 − 𝑅𝑒𝑠𝑆𝑆/𝑇𝑜𝑡𝑆𝑆. Some call R² the proportion of
the variance explained by the model. I don't like the use of the word explained because it
implies causality. However, the phrase is firmly entrenched in the literature. If a model has
perfect predictability, 𝑅² = 1. If a model has no predictive capability, 𝑅² = 0. (In practice, R²
is never observed to be exactly 0 the same way the difference between the means of two
samples drawn from the same population is never exactly 0.) R, the multiple correlation
coefficient and square root of R², is the correlation between the observed values (𝑦), and the
predicted values (𝑦ℎ𝑎𝑡) [38].
As additional variables are added to a regression equation, R² increases even when the new
variables have no real predictive capability. The adjusted-R² is an R²-like measure that
avoids this difficulty. When variables are added to the equation, adj-R² doesn't increase unless
61
the new variables have additional predictive capability. Where R² is 1 − 𝑅𝑒𝑠𝑆𝑆/
𝑇𝑜𝑡𝑆𝑆 , 𝑤𝑒 ℎ𝑎𝑣𝑒 𝑎𝑑𝑗 𝑅² = 1 − (𝑅𝑒𝑠𝑆𝑆/𝑅𝑒𝑠𝐷𝐹)/(𝑇𝑜𝑡𝑆𝑆/(𝑛 − 1)), that is, it is 1 minus
the ratio of (the square of the standard error of the estimate) to (the sample variance of the
response). Additional variables with no explanatory capability will increase the Regression SS
(and reduce the Residual SS) slightly, except in the unlikely event that the sample partial
correlation is exactly 0. However, they won't tend to decrease the standard error of the
estimate because the reduction in Residual SS will be accompanied by a decrease in Residual
DF. If the additional variable has no predictive capability, these two reductions will cancel
each other out [38].
However it is important to keep in mind, that one of the important assumptions of linear
regression is that, there should be no heteroscedasticity of residuals [34]. Therefore residual
analysis will be conducted as well through statistical tests. For this purpose, there are a couple
of tests that come handy to establish the presence or absence of heteroscedasticity The
Breush-Pagan test:
BP = 2.9541, df = 5, p- value = 0.7071
With a p-value of 0.91 is failed to reject the null hypothesis and therefore infer that their
residuals are homoscedastic. The model has only one predictor, where base on F-criteria there
is possible to check the absence between dependable and undependable variables. F-criteria is
10.14, what is more than 1 having p-value at 1.369e-06. An AIC criterion is 142.4164.
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7 Results
This section describes the results of the study, following the steps described in the
methodology section above. Comparisons in terms of parameter estimates, AIC criteria can be
viewed in Table 4. Breush Pagan test in particular is carried out, discussed and presented. A
total of 140 prompts are included in the study with age parameters. The R Statistical Software
Code (R CODE) can be viewed in Google drive28.
Based on the pairwise correlation analysis final model was developed:

𝑌𝐺𝑒𝑛𝑆𝑎𝑡𝑖𝑠𝑓 ~ 𝑆𝑦𝑠𝑈𝑡𝑖𝑙𝑖𝑡𝑦 + 𝑆𝑦𝑠𝐼𝑚𝑝 + 𝐷𝑎𝑡𝑎𝑄𝑢𝑎𝑙𝑖𝑡𝑦 + 𝑆𝑦𝑠𝑈𝑡𝑖𝑙𝑖𝑡𝑦𝐹𝑒𝑎𝑡𝑢𝑟𝑒𝑠 +
𝑆𝑦𝑠𝑄𝑢𝑎𝑙, which are presented in Table 4. The pairwise correlation indicated a significant
relationship between System Utility, System Importance, Data Quality, System Utility
Features and System Quality. User General Satisfaction and the following criteria: Data
Quality (r=0,61***), System Utility (r=0.57***), System Utility Features (r=0,48***),
System Quality (r=0,58***). However the pairwise correlation showed that Perception Utility,
Age and System importance were not significantly related to general satisfaction and were
excluded from the model.
The results, visualized in the Table 4, show that user general satisfaction fluctuated in direct
relation to System Utility, System Importance, Data Quality, System Utility Features and
System Quality which support user satisfaction. We obtained a Pairwise correlation between
each variable of each data set, to measure how well they are related. We have found that the
data are linearly related and the residuals are normally distributed.
Multiple regression analysis was performed to study relationship between variables: System
Utility, System Importance, Data Quality, System Utility Features, and System Quality. The
variables that represent attributes of user satisfaction and are calculated by the user satisfaction
score, which is the average rating of user’s responses, are presented in Table 5. Where 3 criteria
are found to be statistically significant factors which influence the general satisfaction, such
as system quality, data quality and system utility features.
28
https://drive.google.com/open?id=1NYg-nkyBvzqQspAoMhQc7CRdx1T2IAZi
63
Table 5. Pairwise correlation analysis.
The model has only one predictor, while base on F-criteria there is possible to check the
absence between dependable and undependable variables. F-criteria is 10.14, what is more
than 1 having p-value at 1.369e-06. An AIC criterion is 142.4164. But, main goal is to find
the criteria which influence the general satisfaction and therefore the overall efficiency.
From the regression of standardized model, this study shows that 3 of five factors that are
presented in Table 5 have positive relationship on the customer satisfaction with EKTIS IS.
The probability of System Quality was 0.00222, which evaluated the most important factor of
general satisfaction of the system. Therefore the System Utility Features with probability
0.03786, and Data Quality with probability 0.05546. These significant factors have different
signs of influence. System Utility, System Importance had lower significant factor, but there
are other important factors related to general satisfaction, in this analysis the age factor had no
statistically significance. T-value is applied to test the different level of user satisfaction
between the criteria. Table 5. shows the result of t-value of different level of user satisfaction
with EKTIS IS.
The Breush-Pagan test indicators are BP = 2.9541, df = 5, and p- value = 0.7071 and with a p-
value of 0.91 is failed to reject the null hypothesis and therefore infer that their residuals are
homoscedastic.
64
Residuals :
Min 1Q Median 3Q Max
-4.5289 -0.2693 0.1142 0.4373 1.1938
Coefficients :
Estimate Std. Error t value Pr ( >|t|)
( Intercept ) 0.03453 0.65232 0.053 0.95802
SysUtility 0.21998 0.16209 1.357 0.18135
SysImp 0.15992 0.10047 1.592 0.11828
DataQuality 0.29409 0.14966 1.965 0.05546 .
SysUtilityFeatures -0.35945 0.16812 -2.138 0.03786*
SysQual 0.62520 0.19297 3.240 0.00222**
Table 6. Multiple Regression analysis results.
Based on the survey analysis it also indicated that the majority of school nurses at the
Foundation of School Healthcare in Tallinn agreed that EKTIS Information System which
they used fulfilled their needs to perform documentation and were satisfied with the data that
they get from the system. They were also satisfied with System Utility Features and with the
system quality of the EKTIS software that they are using in the organization. The survey and
interview data clearly shows that the school nurses move towards moderately high levels of
competency.
In some instances, the increase in skill and ability levels was improved dramatically over the
implementation period. In addition, the interview data revealed that the EKTIS had a positive
impact on changing nurses’ attitudes to their professional responsibilities related to electronic
data processing and information management. EKTIS features provide extensive insight into
the health of the school district. With immediate access to pupil’s data, practicing preventive
care becomes more attainable. In the field of communications EKTIS facilitates high-level
communication with HIS and EEIS to produce more effective results.
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8 Discussion
Literature review [71, 76, 83] shows that using School Nursing Informational Management
System can improve healthcare quality, increase security of patient information, reduce the
cost and time spent for documentation and maintaining legible and accurate records in
comparison with paper records. However, according to some of the other studies such as
research conducted by Sue Bowman [13], attitudes towards digital documentation; some of
the limiting factors of using these systems include: duplication of records, frequent computer
failures, lack of motivation of users, delay in the electronic record process, lack of experience
in working with computer systems and uncommon deletions of information.
It is worth noting, that factors, affecting the staff commitment, include workload, total
manpower, complexity of personnel rules and services, flexibility of the software, the quality
and quantity of input data, advanced level of hardware tool, availability of computer in each
school [27]. With the participation of the staff members of organization, system designers can
stimulate the involvement of the active users and identify their responsibility for new system
functions; it is useful in assessing the needs, involving the employees in expectations,
providing a sense of ownership and commitment to system [34].
According to Sherkat, M., Miller, T., & Mendoza, A. [86], the organization members and staff
will not benefit properly and efficiently from the system, if they are not satisfied with its
quality, system utility features as well as quality of service integration. Besides the limitations
mentioned above, informational management system EKTIS tries to provide procedure in
which nurses can easily enter the pupils’ health assessment information in the computer
(which is consistent with the nursing process), among them are: the easy usage of the software
on computer, working in the web environment, withstanding of long typing, using charts for
better evaluation of pupils, using standard patterns in records and avoiding the waste of time
and nursing care activities, and the formal inclusion of the health assessment parameters in the
software [87].
Pairwise correlation analysis was performed for general satisfaction model identification. The
most common measure of correlation in stats is the Pearson Correlation. The full name is the
Pearson Product Moment Correlation or PPMC. Pearson’s correlation coefficient is the test
statistics that measures the statistical relationship, or association, between two continuous
66
variables. It is known as the best method of measuring the association between variables of
interest because it is based on the method of covariance. It gives information about the
magnitude of the association, or correlation, as well as the direction of the relationship.
In this research for determining the criteria which influence the general satisfaction multiple
regression analysis was used that is used the most widely as statistical methods for analyzing
customer satisfaction data. With multiple independent variables researchers often correlate the
independent variables with dependent variables to determine which independent variables are
most highly correlated with the dependent variable. Regression analysis is used as standard in
most customer experience and consumer strategy projects. It can help predict future trends or
identify key drivers of customer behavior. The main aim of using regression analysis in
customer experience work is to estimate which factors affect general satisfaction. Although
it’s interesting, that regression on a single factor is of limited use in a real world situation in
which multiple factors influence behavior. The true power of regression becomes apparent
when the influence of more than one factor is assessed, e.g. satisfaction with product, service,
customer services etc. Using multiple regression techniques, it is possible to model how a
large number of factors affect overall satisfaction and their relative influences. It is also
possible to identify those factors that do not have a statistically significant effect and remove
them.
Results reveal that Data Quality, System Utility Features and System Quality significantly
influence general satisfaction. System Utility Features and System Quality are two factors that
frequently effect on the success of any software which contributes as main pillars that should
be taken in consideration, where the system quality and system utility features are an
important issues for the development of the whole kinds of software [106], specifically in
school nursing where the software is used as a mean for nursing practice. In the current study,
it is evident that the respondents expect their efforts to adopt EKTIS to lead to improved
school nursing practice.
Moreover, the respondents’ suggestions regarding the system interfaces and functions prove
that data quality, system features and system quality are particularly important. For example,
some school nurses underscored the importance of emergent issues such as data transfer from
health information system, and data uploading flexibility (see Appendix 3, 4). From these
respondents’ opinions, EKTIS still needs an improvement in regard to functions, and
operations in order to increase usefulness and ease of use.
67
Toromanovic, S., et al. [97], assert that system quality, data quality and system utility features
will increase the nurses’ understanding to the information management system. The research
also showed that school nurses are able to understand the functions, procedures, and
characteristics of the information system. Consequently, school nurses can accept the new
system with confidence while simultaneously increasing their satisfaction with the
information management system [48].
Similarly, most school nurses in this study agreed that system quality, system utility features
and data quality will influence their willingness to adopt the information system. Although
system utility and system importance factor did not demonstrate a significant statistical effect
on users’ general satisfaction.
According to Bhalla, V. et al., [11], software functionality and quality will be improved after
operating the new technology practically, even if they might doubt their ability in the
beginning. Guskey, T. [40], also suggests that an innovation might initially bring some
negative impacts to users. Once they have become accustomed to the new technology, users’
general satisfaction will be gradually improved. Therefore, although system utility does not
indicate a significant effect on user satisfaction in the current study, but it is defined as an
important factor in user satisfaction after implementation of IS [64].
With regard to System Quality, 0.00222**, System Utility Features 0.03786*, Data Quality
0.05546 of MRA which means that respondents agreed that this factors are important and
necessary for school nursing. Although analysis showed that Age factor did not indicate
significance. One possible explanation for this is that respondents have used EKTIS software
for more than 6 years despite their higher or lower educational evaluation. According to the
findings, the System Quality**, System Utility Features* and Data Quality` are the major
elements of a system and the general satisfaction has direct impact on the growth and survival
of it. The system Quality was the most important factor which influenced the general
satisfaction. In the other researches the Software Quality is presented by various criteria, for
example, ease of use, speed of process, quality of user interface, display of color and design.
Some studies showed that system quality affects user satisfaction indirectly [31]. Other
studies defined characteristics such as availability of system manual, system security,
providing interoperable communication, stability and compatibility of system, and ease of
system’s use for system quality and stated that system quality has a direct effect on its
perceived usefulness [18, 19]. On the other hand, the general satisfaction of a system is based
68
on the users’ knowledge and awareness. Members must participate in defining system
objectives, finding solutions to achieve the objectives and choose one of them. We have
evaluated the impact of general satisfaction characteristics which influence the overall
performance of the system and developed the new general satisfaction model through
pairwise correlation analysis, the model can be used for assessing effect of general
satisfaction characteristics on important software indicators. The strength of the model is that
all factors were analyzed and each variable in affecting the software indicator was
determined.
Satisfaction with the information system has been an important subject of many studies.
According to the criteria that have been studied in this thesis, school nurses vision indicates
that the system quality, system utility features and data quality are three major criteria of
general satisfaction of IS. However, most studies have included only one or two criteria in the
models. Most of the studies have been concerned with system quality and information quality,
or service quality. Finding the criteria which influence the general satisfaction has been a key
subject of this research. Nevertheless, the IT development is very fast, and information
technology use and information system is changing very quickly in recent years. Early models
of user satisfaction in Information Systems were mostly concerned with performance of the
technical system and the quality of delivered information in determining the user satisfaction
with an IS [24]. Research of general satisfaction expanded its focus on system quality, data
quality, system utility, system utility features, system importance to include service quality
provided by Foundation for School Healthcare Services in Tallinn. DeLone and McLean
(2003) documented this expanded focus in their seminal works and proposed that user
satisfaction with Information Systems is an aggregation of user perception of information
quality, system quality (performance) and service quality [25]. However, no research study
has integrated these criteria into one comprehensive model trying to predict general
satisfaction with an information system by examining the impact of general satisfaction with
IS criteria (data quality, system quality, system utility features) on overall efficiency.
Therefore, no studies have taken these steps to predict the general satisfaction with the IS
criteria. But there are studies that integrated two criteria in their research models using system
and data quality to predict general satisfaction [22, 37]. Thus, some studies have focused only
on one criterion or have failed to measure the general satisfaction or general satisfaction with
criteria [102, 103].
69
Considering the changes of the technological development and requirements of the current
software there is a need for more studies to survey the users’ point of view. We have also
identified 1 variable that was not found to be significantly related to our success variable in
these studies. This means that these variables may be excluded from any future questionnaire.
Removing irrelevant questions decreases the time required to complete it and improves
validity by substantially reducing the threat of spurious correlations. Overall, our results are
consistent with other research concerning general satisfaction and overall performance
factors.
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9 Suggestions for future research
The analysis omitted two of the key variables because they showed a relatively large number
of missing values. These variables are: System Importance, System Utility which were
allowed for each of the phases.
 How high is the quality of system utility?

 How important is system for the school nurses?
Future data collection activities need to ensure that these variables are collected, so we can
assess the impact they have on models for predicting overall system performance outcome. In
addition, we will investigate the best approaches for dealing with missing values. For
example, are analysis methods such as Bayesian networks or case-based reasoning better able
to deal with missing values than standard logistic regression? We also need to consider
improving our questionnaire by the addition of explicit failure factors if we wish to develop
better predictive models.
Technical interoperability standards play an important role in the creation and use of
information systems. In some cases, IT standards are mandated by a national government
agency or industry association. But more often, they are selected in the marketplace, through
the adoption decisions of organizations or individuals. The economics theories make
predictions about winning and losing standards, predictions that are tested in the aggregate
across a national (or global) market; such theories have recently been used by MIS standards
researchers. Perhaps the most influential economic theory of standards adoption and
competition is that of positive network effects, also referred to as positive network
externalities. [20].
The study of EKTIS, its effects and its use to formulate and implement the new solutions are
central themes of the future research. We will aim to examine IS in the implementation of
new solutions in EKTIS, and propose to examine the relationships between software
functionality, reliability, maintainability, usability, efficiency, user satisfaction, software
workflow, health data quality, communication with HIS and software’s cost and benefit
71
incurred by the organization. This information will allow us to investigate the system
deficiency and make proposals to improve the system.
Figure 6. Model of relationship among software quality and healthcare indicators [4].
The success of the information system depends on the social structures and interactions that
prevail during and after the development process. Information systems create problems
because prevailing social arrangements inhibit creative planning and successful change. The
issue of new solution development for supporting change in software development is
improving quality of health management system, which will increase user’s satisfaction and
therefore improves overall system performance [96].
We have identified specific aspects which will increase users satisfaction and therefore
improve overall system performance where attention should be focused, developed prediction
models for use in identifying the general satisfaction of the system before they fail,
demonstrated the importance of choosing the appropriate cut-off point for the prediction
model, and finally demonstrated that models which were built from survey data can be used to
successfully predict data within a single organization.
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10 Conclusion
The Master thesis “USER SATISFACTION CRITERIA THAT INFLUENCE SCHOOL

HEALTH MANAGEMENT INFORMATION SYSTEM EKTIS” is dedicated to important
problem of computer software in health care institutions. General satisfaction with
Information system is important because it will improve overall performance of the system.
Main objective of the research was to investigate the criteria which influence the general
satisfaction and therefore the overall efficiency.
The problems with management information systems described by the nurses in this survey
are common across the European countries [47]. What these nurses want to see from the
current investment in ICT in the SNIMS is integrated electronic clinical records which enable
them to have access to full and up to date patient information at the point of care. They want
to be able to share information with their colleagues in other disciplines and in other
organizations, securely and appropriately [49]. The respondents want expert nursing
involvement in the design and implementation of the new systems, and they wish to be
assured that all nursing staff will have training appropriate for their needs, and that there will
be equity in access to information technology. They wish to see standardization of systems,
believing that this will make it easier for staff moving from one area of the country to another,
and that it will assist in bringing equity in standards of care. School nurses believe that quality
electronic information systems will improve patient care, by helping to reduce errors, increase
general satisfaction, and will give nurses more time for direct care [32]. The respondents
wished to have equity of access to knowledge based systems, to assist them in the provision of
evidence based care.
Performing this study permitted the evaluation of the general satisfaction of the EKTIS
Informational Management System. The input and output variables were set as the basis and
the resources collected from the surveys were processed through the pairwise correlation and
multiple regression analysis was conducted. According to the multiple regression analysis
results, specific factor groups are considered to identify the general satisfaction level, and
prediction can be made on which the most influential evaluation criterion is. The EKTIS
Informational Management System was evaluated according to the general satisfaction. In
conclusion, the EKTIS Informational Management System can be used by professionals who
need to perform nursing care for school units, as it permits to use informatics to help planning
and making decisions regarding the children. In this perspective, the research showed that for
73
improving the general satisfaction and overall performance with the EKTIS software, the
system quality, data quality and system utility features factors should be taken into focus and
used in the organization while developing new solutions for the software, also this expertise
can be used in other countries.
In terms of the limits of this thesis, verification has to take place after survey analysis
following the selection of different factors after the study model is designed. In order to
resolve this limit, diverse factors are to be researched for the verification of the model during
the progress of future studies. The results of this study are expected to suggest implications
during evaluating the satisfaction of local factors (software functionality, reliability,
maintainability, usability, efficiency, user satisfaction, software workflow, health data quality,
communication with HIS and software cost and benefit), which will be held in the future. If
the evaluation criteria which can cause the most influence are predicted during the analysis of
other factors and applied for marketing, it will optimize the general satisfaction level. The aim
of the research was accomplished and the hypothesis was proved.
We hold that the software achieved its initial objective to make the evaluation of diagnostic
accuracy of school nurses measurable, to “ learning concerning nursing diagnoses and allow
school nurses to more objectively assess their knowledge concerning school children health.
We expect the software to become an educational tool in teaching school nurses that
contributes to the education of nurses in making nursing diagnoses with greater accuracy.
74
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Appendix 1. Evaluation of EKTIS Informational software
technical quality
Please help us improve EKTIS Information System work by answering some questions about the system technical quality.
We are interested in your honest opinions, whether they are positive or negative. Please answer all of the questions.
Software Desktop
FUNCTIONALITY P A D NA
The software does what is appropriate (Adequacy)
The software has available all the functions required for its execution (adequacy)
The software does what was proposed correctly (Accuracy)
The software is precise in executing its functions (Accuracy)
The software is precise in its results (Accuracy)
The software interacts with the specified modules (Interoperability)
The software has capacity for multiuser processing (Interoperability)
The software has capacity to operate with networks (Interoperability)
The software complies with standards, laws, etc. (Conformity)
The software has secure access through passwords (Secure access)
The software has a internal backup routine (Secure access)
The software has an internal restore routine (Secure access)
Students/schools/classes data/ Students health card
Vaccinations
84
Medical record/ appeals
Health promotion (Health education/ first aid teaching/ Parasite control)
Reporting (vaccinations, pupil appeals, health promotion, health surveillance on the basis of the classes etc)
85
Help nursing materials
User Settings
RELIABILITY
The software has frequent failures (Maturity)
The software reacts appropriately when failures occur (Tolerance to failures)
The software informs users concerning invalid data entry (Tolerance to failures)
The software is capable of recovering data in the event of failure (Recoverability)
USABILITY
It is easy to understand the concept and application (Intelligibility)
It is easy to perform its functions (Intelligibility)
86
It is easy to learn how to use (Learnability)
The software facilitates the users’ data entry (Learnability)
The software facilitates the users’ retrieval of data (Learnability)
It is easy to operate and control (Operability)
The software provides help in a clear manner (Operability)
EFFICIENCY
The software’s response time is appropriate (Time)
The software’s execution time is appropriate (Time)
The resources used are appropriate (Resources)
MAINTAINABILITY
It is easy to find a failure, when it occurs (Analyzability)
It is easy to modify and adapt (Modifiability)
There is a great risk when changes are made (Stability)
Changes are easy to test (Testability)
Legend: Agreement (A), Disagreement (D) and Does not apply (NA)
EVALUATION OF INTERFACE AND ADEQUACY OF PROGRAM Y P N

Information provided on screen is presented in a clear and pleasant manner
The screens are self-explanatory or encourages obtaining help to learn how to use the software
The meanings on the screen are easily perceived
The meanings of the buttons and clickable regions were easily perceived
Coherent answers are obtained
Immediate answers are obtained
While using the program, You know at which point of the program you are
Based on a screen you know how to go to the remaining pages
Y N
Did you find any problem while using the program?
87
Appendix 2. IS User Satisfaction Questionnaire
Please help us improve EKTIS Information System work by answering some questions about the system services. We are
interested in your honest opinions, whether they are positive or negative. Please answer all of the questions. We also
welcome your comments and suggestions.
Information Quality Strongly Disagree ………Strongly Agree

Information I get from the system is clear 1 2 3 4 5 6 7
1 2 3 4 5 6 7
The system is accurate
1 2 3 4 5 6 7
The system provides me with sufficient information
1 2 3 4 5 6 7
The system provides me with up-to-date information
1 2 3 4 5 6 7
The system provides reports that seem to be just

about exactly what I need
Strongly Disagree ………Strongly Agree
System Usefulness
Using the system increases productivity 1 2 3 4 5 6 7
1 2 3 4 5 6 7
Using the system saves time
1 2 3 4 5 6 7
Using the system improves job performance
Strongly Disagree ………Strongly Agree

System Usage Characteristics
The system is easy to use 1 2 3 4 5 6 7
1 2 3 4 5 6 7
The system is easy to learn
1 2 3 4 5 6 7
It is easy to get the system to do what I want it to do
88
System Quality Strongly Disagree ………Strongly Agree
The system is easy to use. 1 2 3 4 5 6 7
1 2 3 4 5 6 7
The system is user friendly
1 2 3 4 5 6 7
The system is easy to learn
1 2 3 4 5 6 7
I find it easy to get the system to do what I want it to do.
1 2 3 4 5 6 7
It costs more to use the system then the benefits we get from it
The system is complex 1 2 3 4 5 6 7
It is expensive to operate and use the system
1 2 3 4 5 6 7
Overall satisfaction Never ………………………… Always
To what extent do you feel the system meets the 1 2 3 4 5 6 7

information processing needs of the work?
1 2 3 4 5 6 7
How often do you require vendor support to use the
system?
1 2 3 4 5 6 7
Overall, how often are you satisfied with the system?
Perceived Usefulness Strongly Disagree ………Strongly Agree
Using the system enables tasks to be accomplished 1 2 3 4 5 6 7

faster
1 2 3 4 5 6 7
Using the system improves job performance
1 2 3 4 5 6 7
Using the system increases productivity
1 2 3 4 5 6 7
Using the system saves time
1 2 3 4 5 6 7
Using the system saves money
Importance of the system Not Essential ………………… Essential
In relation to the work, the system is… 1 2 3 4 5 6 7
89
Appendix 3. Results of the evaluation of EKTIS Informational
software’s technical quality
EKTIS TARKVARA TEHNILISE KVALITEEDI HINDAMINE
SUGU
Response Response
Answer Options
Percent Count
Naine 100.0% 34
Mees 0.0% 0
answered question 34
skipped question 0
VANUS
Response Response
Answer Options
Percent Count
alla 35 a. 14.7% 5
36 – 50 a. 35.3% 12
üle 50 a. 50.0% 17
skipped question 0
AMET
Response Response
Answer Options
Percent Count
SA KTH Juhatus 2.9% 1
Juhtivõde 8.8% 3
Kooliõde 88.2% 30
skipped question 0
ÜLDTÖÖSTAAŽ
Response Response
Answer Options
Percent Count
0 – 5 a. 14.7% 5
6 – 15 a. 17.6% 6
16 – 25 a. 11.8% 4
üle 25 a. 55.9% 19
skipped question 0
HARIDUS
Response Response
Answer Options
Percent Count
Kesk–eri 51.5% 17
Kõrgem 48.5% 16
Teaduskraad 0.0% 0
90
skipped question 1
Tarkvara töölaud – FUNKTSIONAALSUS
Rating Response
Answer Options N EN EK O
Average Count
Tarkvara teeb, mis on asjakohane (adekvaatsus) 17 2 0 15 2.38 34
Tarkvaral on saadaval kõik need funktsioonid selle
14 3 3 14 2.50 34
täitmiseks (adekvaatsus)
Tarkvara teeb seda mida on pakutud õigesti (täpsus) 20 2 1 11 2.09 34
Tarkvara on täpne ja täidab oma ülesandeid (täpsus) 14 2 0 18 2.65 34
Tarkvara on täpne tulemites (täpsus) 16 4 1 13 2.32 34
Tarkvara suhtleb määratud moodulitega
12 3 2 16 2.67 33
(koostalitlusvõime)
Tarkvara on mitme kasutajaga töötlemiseks
18 4 2 9 2.06 33
Tarkvaral on võime tegutseda võrgustikkul
19 5 1 9 2.00 34
Tarkvara vastab standarditele, seadustele, jne
20 4 1 9 1.97 34
(vastavus)
Tarkvaral on turvalise juurdepääsu kaudu paroolid
27 2 1 4 1.47 34
(turvaline juurdepääs)
Tarkvaral on sisemine backup funktsioon (turvaline
21 3 3 7 1.88 34
juurdepääs)
Tarkvaral on sisemine taastamise funktsioon
21 2 2 9 1.97 34
skipped question 0
Õpilaste/koolide/klasside andmed / õpilaste tervisekaart - FUNKTSIONAALSUS
Rating Response
Answer Options N EN EK 0
Average Count
19 4 2 9 2.03 34
18 3 2 11 2.18 34
21 4 0 9 1.91 34
Tarkvaral on võime tegutseda võrgustikkul
20 3 0 11 2.06 34
23 3 0 8 1.79 34
(vastavus)
26 2 0 6 1.59 34
21 3 1 9 1.94 34
juurdepääs)
Tarkvara on sisemise taastamise funktsioon
21 3 2 8 1.91 34
skipped question 0
91
Vaktsineerimised – FUNKTSIONAALSUS
Rating Response
Average Count
23 1 1 8 1.82 33
täitmiseks (adekvaatsus
Tarkvara teeb õigesti, mida pakutud (täpsus) 27 1 0 5 1.48 33
Tarkvara on täpne, täidab oma ülesandeid (täpsus) 23 1 1 8 1.82 33
Tarkvara suhtleb määratud moodulite
23 1 0 9 1.85 33
22 2 1 8 1.85 33
Tarkvaral on võime tegutseda võrgustikuga
22 2 0 9 1.88 33
23 2 0 8 1.79 33
(vastavus)
28 1 0 4 1.39 33
23 3 2 5 1.67 33
juurdepääsu)
Tarkvaral on sisemine taastamise funktsioon
23 3 1 6 1.70 33
(turvaline juurdepääsu)
skipped question 1
Tervisekontrolli kaart – FUNKTSIONAALSUS
Rating Response
Average Count
25 3 1 5 1.59 34
27 2 1 4 1.47 34
24 3 0 7 1.71 34
Tarkvaral on võime tegutseda võrgustikkus
25 2 2 5 1.62 34
23 2 1 8 1.82 34
(vastavus)
27 2 0 5 1.50 34
23 4 1 6 1.71 34
juurdepääs)
Tarkvaral on sisemise taastamise funktsioon
22 4 1 7 1.79 34
skipped question 0
Tervise edendamine (terviseõpetus / esmaabi õpetamine / parasiitide kontroll) - FUNKTSIONAALSUS
92
Rating Response
Average Count
22 2 2 8 1.88 34
23 3 0 8 1.79 34
22 2 0 9 1.88 33
23 2 0 9 1.85 34
25 3 0 6 1.62 34
(vastavus)
29 2 0 3 1.32 34
26 3 1 4 1.50 34
juurdepääs)
Tarkvaral on sisemise taastamine funktsioon
21 3 2 8 1.91 34
skipped question 0
Aruandlus (vaktsineerimised, õpilane apellatsioonkaebused, tervise edendamine, tervisekontrolli põhjal
klassid jne) – FUNKTSIONAALSUS
Rating Response
Average Count
18 5 0 11 2.12 34
Tarkvara teeb õigesti seda, mida on pakutud
16 3 1 14 2.38 34
(täpsus)
20 3 1 10 2.03 34
20 3 0 11 2.06 34
20 4 0 10 2.00 34
18 3 0 12 2.18 33
(vastavus)
24 3 0 7 1.71 34
22 4 1 7 1.79 34
juurdepääs)
21 3 1 8 1.88 33
skipped question 0
Abistavad õendusabi materjalid – FUNKTSIONAALSUS
Rating Response
Average Count
93
24 1 1 8 1.79 34
25 1 0 8 1.74 34
24 1 1 8 1.79 34
22 1 3 8 1.91 34
23 1 0 10 1.91 34
(vastavus)
27 1 0 6 1.56 34
27 2 1 4 1.47 34
juurdepääs)
25 2 2 5 1.62 34
skipped question 0
Kasutaja seaded – FUNKTSIONAALSUS
Rating Response
Average Count
21 2 1 10 2.00 34
Tarkvara teeb õigesti seda, mida on
21 2 0 11 2.03 34
pakutud (täpsus)
23 2 0 9 1.85 34
23 2 1 8 1.82 34
21 2 1 10 2.00 34
22 2 2 8 1.88 34
(vastavus)
24 2 1 7 1.74 34
21 4 2 7 1.85 34
juurdepääs)
20 4 2 8 1.94 34
skipped question 0
TARKVARA USALDUSVÄÄRSUS
Rating
Response
Answer Options N EN EK O Avera
Count
ge
Tarkvaral on sagedased rikked (tähtaeg) 9 8 1 16 2.71 34
Tarkvara reageerib tekkinud vigadele asjakohaselt
15 6 0 13 2.32 34
(tolerantsuse tõrked)
Tarkvara teavitab kasutajaid kui andmed on 14 5 2 13 2.41 34
94
sisestatud valesti (tolerantsuse tõrked)
Tarkvara andmeid on võimalik taastada rikke puhul
12 8 1 13 2.44 34
(taaskasutatavus)
skipped question 0
TARKVARA KASUTATAVUS
Rating
Response
Count
ge
On kerge mõista kontseptsiooni ja rakendust
17 4 1 12 2.24 34
(arusaadavus)
Tarkvara on lihtne oma ülesannetes (arusaadavus) 20 4 0 10 2.00 34
Tarkvara on lihtne õppida kasutama (õppimisvõime) 21 2 0 11 2.03 34
Tarkvara lihtsustab kasutajate andmete sisestamist
18 2 2 12 2.24 34
(õppimisvõime)
Tarkvara lihtsustab kasutajatele andmeid otsida
17 3 1 13 2.29 34
(õppimisvõime)
Tarkvara on lihtne kasutada ja kontrollida
19 2 2 11 2.15 34
(toimivus)
Tarkvara pakub abi selgel viisil (toimivus) 17 3 2 12 2.26 34
skipped question 0
TARKVARA EFEKTIIVSUS
Rating
Response
Count
ge
Tarkvara reageerimisaeg on asjakohane (aeg) 19 4 1 10 2.06 34
Tarkvara täitmisaeg on asjakohane (aeg) 19 5 0 10 2.03 34
Kasutatud vahendid on piisavad (vahendid) 17 5 1 11 2.18 34
skipped question 0
TARKVARA HOOLDATAVUS
Res
pon
Rating
Answer Options N EN EK O se
Average
Co
unt
On lihtne leida rike kui ta on ilmunud
10 7 3 14 2.62 34
(Analüütilinevõime)
On lihtne muuta ja kohandada
10 8 2 14 2.59 34
(Modifitseerimisvõime)
On suur oht muudatuste tegemisel (stabiilsus) 6 9 2 17 2.88 34
Muutuseid on lihtne testida (Testimisvõime) 13 8 3 10 2.29 34
skipped question 0
LIIDES JA PROGRAMMI PIISAV HINDAMINE

Ratin
g Response
Answer Options Jah O Ei
Aver Count
age
Aknas teave esitatakse selgelt ja meeldival viisil 26 7 1 1.26 34
Ekraanid on iseenesest mõistetavad või julgustab 24 6 4 1.41 34
95
saada abi, selleks et õppida, kuidas kasutada
tarkvara
Ekraanil tähendused on kergesti märgatavad 24 5 5 1.44 34
Nupud ja klikitavad piirkondade tähendused on
25 6 3 1.35 34
kergesti märgatavad
Ühtsed vastused on saadud 23 8 3 1.41 34
Kiired vastused on saadud 22 9 3 1.44 34
Kasutades programmi, tead, kus kohas sa
27 4 3 1.29 34
programmis oled
Vastavalt ekraanile sa tead, kuidas minna ülejäänud
28 5 1 1.21 34
lehekülgedele
Kas leidsite mingi probleem kui kasutate
19 11 4 1.56 34
programmi?
skipped question 0
96
Appendix 4. Results of IS User Satisfaction Questionnaire
IS USER SATISFACTION
QUESTIONNAIRE
Sugu
Respon
Response
Answer Options se
Percent
Count
Mees 0.0% 0
Naine 100.0% 52
skipped question 0
Vanus
Respon
Response
Answer Options se
Percent
Count
alla 35 a. 11.5% 6
36 – 50 a. 40.4% 21
üle 50 a 48.1% 25
skipped question 0
Amet
Respon
Response
Answer Options se
Percent
Count
SA KTH juhatus 3.8% 2
Juhtivõde 7.7% 4
Kooliõde 88.5% 46
skipped question 0
Üldtööstaaž
Respon
Response
Answer Options se
Percent
Count
0 – 5 a. 15.4% 8
6 – 15 a. 19.2% 10
16 – 25 a. 11.5% 6
üle 25 a. 53.8% 28
skipped question 0
Haridus
Respon
Response
Answer Options se
Percent
Count
Kesk–eri 50.0% 25
Kõrgem 48.0% 24
97
Teaduskraad 2.0% 1
skipped question 2
Üdse ei nõustu......... Nõustun täielikult
Teabe kvaliteet
Respon
Rating
Answer Options 1 2 3 4 5 6 7 se
Average
Count
Teave mida ma saan süsteemist on selge 0 1 4 9 16 14 7 5.02 51
Süsteem on õige 0 2 9 9 16 10 5 4.65 51
Süsteem annab mulle piisavalt teavet 1 1 5 16 17 6 5 4.57 51
Süsteem annab mulle ajakohast teavet 1 0 6 15 12 11 6 4.73 51
Süsteem annab teavet, mis tundub, et see on umbes
1 2 8 14 15 6 5 4.43 51
täpselt, mida ma vajan
skipped question 1
Üldse ei nõustu......... Nõustun täielikult
Süsteemi kasulikkus
Rating Response
Answer Options 1 2 3 4 5 6 7
Average Count
Kasutades suurendab tootlikkust 0 2 5 8 11 17 8 5.18 51

Süsteemi kasutamine säästab aega 1 3 4 9 10 15 9 5.06 51
Kasutades süsteemi ta parandab töö tulemuslikkuse
0 1 4 10 17 10 9 5.14 51
nähtavust
skipped question 1
Üldse ei nõustu........ Nõustun täielikult
Süsteemi kasutamise omadused
Rating Response
Average Count
Süsteemi on lihtne kasutada 0 1 4 10 9 13 14 5.39 51
Süsteemi on lihtne õppida 1 0 3 10 14 11 12 5.29 51
Süsteemis on lihtne teha seda, mida ma tahan seal
1 2 7 8 17 7 9 4.86 51
teha
skipped question 1
Süsteemi kvaliteet
Üldse ei nõustu.......... Nõustun täielikult
Rating
Response
Answer Options 1 2 3 4 5 6 7 Averag
Count
e
Süsteemi on lihtne kasutada. 0 1 4 13 7 15 11 5.25 51
Süsteem on kasutajasõbralik 1 0 7 10 10 16 7 5.04 51
Süsteemi on lihtne õppida 1 0 5 10 8 15 11 5.26 50
Mul on lihtne süsteemis teha seda, mida ma tahan
2 0 6 12 11 12 7 4.88 50
seal teha.
Süsteemi kasutamine maksab rohkem, kui me
3 3 7 6 11 13 7 4.72 50
sellest kasu same
Süsteem on keeruline 11 10 7 8 7 5 3 3.33 51
See on kulukas kasutamisel ja töötamisel
6 3 7 10 13 7 3 4.10 49
süsteemiga(haldamine)
98
skipped question 1
Kunagi.....................keskmine.................. Alati
Üldine rahulolu
Rating Response
Average Count
Mil määral teie arvates süsteem vastab selle
1 1 4 14 18 6 6 4.78 50
infotöötluse vajadusele töös?
Kui sageli teil on vaja kasutada tarkvara arendaja
3 4 10 11 14 6 2 4.10 50
toetust kasutades süsteemi?
Üldiselt, kui tihti olete te rahul? 0 0 7 13 18 7 5 4.80 50
skipped question 2
Üldse ei nõustu........... Nõustun täielikult
Tajutav kasulikkus
Rating Response
Average Count
Süsteem võimaldab täidetavaid ülesandeid teha
1 0 5 10 13 13 9 5.14 51
kiiremini
Süsteemi kasutamine parandab töö tulemuslikkust
1 0 3 13 12 13 10 5.19 52
(andmete info osas)
Süsteemi kasutamine suurendab tootlikkust
1 1 3 9 13 16 8 5.20 51
(andmete info osas)
Süsteemi kasutamine säästab aega 1 2 5 9 12 10 12 5.10 51
Süsteemi kasutamine säästab raha 4 3 6 13 9 9 6 4.42 50
skipped question 0
Pole oluline ................................ Oluline
Süsteemi tähtsus
Rating Response
Average Count
Seoses tööga, süsteem on... 0 0 3 11 8 13 15 5.52 50
skipped question 2
Teie ettepanekud EKTIS süsteemi

parendamiseks:
Response
Answer Options
Count
18
skipped question 34
99
Appendix 5. Q1, Q2 Survey Datasets
DataQuality;5.00;5.60;7.00;5.00;3.60;4.80;0.00;4.20;5.40;5.80;4.00;5.00;5.80;4.00;5.00;6.00;
3.60;5.40;3.00;3.40;4.00;4.60;3.80;5.40;5.40;5.00;4.60;4.20;1.40;6.00;6.00;5.40;3.20;4.60;4.4
0;7.00;5.00;3.80;6.40;3.40;3.00;6.00;5.00;6.00;4.40;5.00;3.00;7.00;7.00;4.20;4.00;4.40
SysUtility;5.00;6.00;7.00;5.00;4.00;6.00;0.00;5.67;5.33;5.67;7.00;6.00;5.00;5.33;5.00;6.00;5.
33;5.33;3.33;3.67;4.00;6.00;4.00;6.00;6.00;5.00;2.67;5.00;1.67;5.33;6.00;4.00;3.67;5.00;3.67;
7.00;5.33;4.00;6.33;3.67;3.00;6.00;5.00;6.33;4.67;4.00;7.00;7.00;7.00;2.67;4.33;7.00
SysUtilityFeatures;5.00;5.00;7.00;6.00;3.67;6.33;0.00;3.33;7.00;6.33;6.33;5.67;5.67;6.00;5.0
0;6.33;4.00;5.67;6.00;3.67;4.00;3.33;4.00;6.00;6.00;5.33;3.33;5.00;1.33;5.33;7.00;4.00;5.67;4
.67;3.33;7.00;5.33;4.00;7.00;3.67;3.00;6.00;5.00;6.00;4.33;6.00;7.00;7.00;7.00;5.67;4.00;7.00
SysQual;5.00;4.00;5.71;5.14;3.43;5.00;0.00;4.14;4.00;4.57;4.14;5.43;5.00;4.71;5.00;5.14;4.5
7;5.29;4.86;4.00;3.71;3.14;4.14;5.00;5.14;4.43;3.14;4.71;3.71;5.29;6.43;4.57;5.43;4.29;4.29;4
.43;4.57;4.29;5.71;4.14;3.43;3.86;5.00;6.00;4.57;6.00;5.00;4.43;4.43;5.00;4.00;5.00
PerceptUtil;5.00;6.00;7.00;6.00;3.60;6.00;2.80;5.40;6.00;6.00;7.00;5.80;6.00;3.60;5.00;6.20;4
.40;5.00;3.60;3.80;5.00;4.00;4.00;5.80;5.20;5.20;2.00;3.00;1.60;5.20;5.40;4.60;3.80;3.60;3.80
;6.60;5.00;3.40;5.80;4.60;3.20;5.80;5.00;6.20;4.80;4.60;6.20;4.80;7.00;3.40;4.00;7.00
SysImp;5.00;6.00;7.00;6.00;4.00;6.00;0.00;7.00;7.00;6.00;7.00;7.00;6.00;3.00;5.00;6.00;4.00
;5.00;4.00;7.00;6.00;4.00;4.00;6.00;5.00;6.00;4.00;5.00;3.00;6.00;0.00;4.00;4.00;6.00;6.00;7.
00;6.00;4.00;7.00;4.00;3.00;7.00;5.00;7.00;5.00;5.00;7.00;7.00;7.00;5.00;4.00;7.00
Age;1.00;2.00;2.00;2.00;2.00;3.00;2.00;2.00;1.00;3.00;1.00;2.00;2.00;3.00;2.00;3.00;3.00;3.0
0;2.00;2.00;3.00;2.00;3.00;1.00;3.00;3.00;3.00;3.00;2.00;3.00;3.00;2.00;2.00;3.00;3.00;3.00;3
.00;3.00;3.00;2.00;3.00;2.00;2.00;2.00;2.00;3.00;1.00;2.00;3.00;3.00;1.00;3.00
YGenSatisf;5.00;5.33;7.00;4.33;4.00;5.33;0.00;5.33;4.67;0.00;4.00;5.00;5.67;3.00;5.00;6.00;
3.67;5.00;4.00;4.00;3.67;4.00;4.00;4.00;5.00;4.00;3.33;3.67;3.00;5.67;5.00;3.67;3.67;5.00;4.3
3;5.00;5.00;3.33;4.33;3.67;4.00;5.33;5.00;6.00;4.67;5.00;4.67;4.33;6.00;3.67;4.00;4.00
100
Acknowledgements
I would like to thank many of my friends, colleagues and family members who supported me
to complete this project and this degree. Among them, Mihhail Zujev who committed himself
to continually assuring me that I could finish, as he had "been there, done that," and was proof
that it was possible. To my work colleagues who always asked how it was going. To my
supervisor, Aleksandr Kormiltsyn, the finest role model I've known, for his gentle guidance
and steadfast belief in me. To my workout partner, Tatjana Ingi, whose faithfulness allowed
me to maintain my sanity. To my friends, special thanks to Sergei Kornilov who supported me
and helped in data analysis and Maria Ankudinova, who was gentle with critique and
generous with their praise and encouragement. A special thanks to my supervisors at my
working place, Kädi Lepp and Valentina Hazinskaja. They took me under their wings, guided
and mothered me through this process. To my parents for instilling in me the love of learning.
To my child, Elana, who sacrificed the most by allowing me the precious time I needed to
complete this project.
Thank you all.
101

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TALLINN UNIVERSITY OF TECHNOLOGY

USER SATISFACTION CRITERIA THAT INFLUENCE SCHOOL HEALTH

Supervisor: Aleksandr Kormiltsyn, MSc,

Health Care Technology

Supervisor: Aleksandr Kormiltsyn

Master's Thesis defence committee president

KOOLI TERVISHOIU INFOSÜSTEEMI EKTIS

Juhendaja: Aleksandr Kormiltsyn, MSc,

Deklareerin, et käesolev lõputöö on minu iseseisva töö tulemus ning kinnitan,

Juhendaja: Aleksandr Kormiltsyn

EDPI- Estonian Data Protection Inspectorate

EEHF - the Estonian eHealth Foundation

EEIS- Estonian Educational Information System

EHIS- Eesti Hariduse Infosüsteem

EHR – Electronic Health Record

EKTIS – Estonian School Nursing Information Management System

HCOs – Healthcare Organizations

HIS – Health Information System

HL7 CDA - Health Level 7 Clinical Document Architecture

ICT- Information and communication technologies

MIS- Management Information Systems

NASN- The National Association of School Nurses

NHS – Nursing Health Systems

PP- Patient Portal

SNIMS – School Nursing Informational Management System

TIS- Tervise Infosüsteem

UI- User Interface

DIGITAL PRESCRIPTION – (in Estonian language Digiretsept), a single Estonian national

DIGITAL REGISTRATION – (in Estonian language Digiregistratuur), is an online tool that

ELECTRONIC DATA MANAGEMENT SYSTEM - is a software program that manages the

ELECTRONIC DOCUMENTATION SYSTEM - was an early hypertext system – also known

ELECTRONIC HEALTH RECORD - is the systematized collection of patient and population

HEALTHCARE PROVIDER - A person who provides any form of health care

INFORMATION MANAGMENT SYSTEM - is a general term for software designed to

SCHOOL NURSE - a specialized practice of public health nursing, protects and

X-ROAD PLATFORM- The X-Road interoperability platform is comprised of the core

Figure 1 DS research methodology (Peffers, et al., 2007, p.54) ........................................................... 25

Appendix 1. Evaluation of EKTIS Informational software technical quality ....................................... 84

Information and communication technology (ICT) opportunities in Estonia healthcare sector

 What are the important healthcare environment aspects of healthcare information

The sub aims include:

 to define important aspects of the Healthcare IS that allows knowing and

In order to achieve the main objective, following tasks are to be completed:

 Collect feedback from system users, nurses,

• problem identification and a clear description of an organizational problem;

The philosophical assumption of a Design Science research paradigm implies a problem-

3.1 School nursing overview

3.2 Technical and legal factors affecting EKTIS

3.3 Patient Portal in the EHIS

3.4 Information System Requirements

Health documentation supports legal requirements, provides a historical record of care,

 Efficiently describe health room activity

 Develop evidence for practice

 Describe nursing sensitive student outcomes

 Analyze population health

 Evaluate the effectiveness of care delivery

 Manage appropriate resource allocation

 Describe student health needs

 Link health interventions and educational outcomes [54].

3.5 Patient identifiers, privacy and access right

3.5.1. Use of unique patient identifiers

3.5.2. Privacy issues related to health IT systems

3.5.3. Access rights

4.1. Information Quality