G, Bonde. E-Readiness of Ingutsheni Central Hospital in Implementing An Emr System PDF

NATIONAL UNIVERSITY OF SCIENCE AND TECHNOLOGY
FACULTY OF COMMUNICATION AND INFORMATION SCIENCE
DEPARTMENT OF LIBRARY AND INFORMATION SCIENCE
E-READINESS OF INGUTSHENI CENTRAL HOSPITAL IN IMPLEMENTING AN

ELECTRONIC MEDICAL RECORDS SYSTEM
BY
Gamuchirai Bonde
(N0175287W)
A RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILMENT OF THE

REQUIREMENTS OF THE MASTER OF SCIENCE DEGREE
IN
LIBRARY AND INFORMATION SCIENCE
Academic Supervisor Mrs. E. Maisiri
BULAWAYO, ZIMBABWE
YEAR: 2019
COPYRIGHT DECLARATION
NAME OF AUTHOR: Bonde Gamuchirai
TITLE OF PROJECT: E-Readiness of Ingutsheni Central Hospital in

Implementing an Electronic Medical Records
System
PROGRAMME: Master of Science Degree in Library and

Information Science
YEAR THIS DEGREE GRANTED: 2019
Permission is hereby granted to the National University of Science and Technology Library
to reproduce copies of this project and to lend or sell such copies for private, scholarly or
scientific research purposes only.
The author reserves other publication rights and neither the project nor extensive extracts
from it may be reprinted or otherwise reproduced without the author’s written permission.
SIGNED ……….………………………...
PERMANENT ADDRESS: No. 12 Cawston Road, Northend
Bulawayo
DATE ……………………………………
ii
DECLARATION ON PLAGIARISM
I am aware of and understand the University’s policy on plagiarism. I hereby declare that this
research project is the result of my own independent scholarly work, and that in all cases
material from the work of others is properly acknowledged. Quotations and paraphrases are
properly referenced. Referencing in this project was done according to the Department of
Library and Information Science citation guidelines.
I have not sought or used the services of professional agencies to produce tis project. This
written work has not previously been used as examination material at this university or any
other university and the work has not yet been published. In addition, I understand that any
false claim in respect of this work will result in disciplinary action in accordance with
university regulations.
NAME: ………………………………………………………….
SIGNATURE: ………………………………………………….
DATE: ………………………………………………………….
iii
RELEASE FORM
I certify that I have read and recommended to the National University of Science and
Technology for acceptance a research project entitled, “eReadiness of Ingutsheni Central
Hospital in implementing an Electronic Medical Records System”, submitted by Gamuchirai
Bonde, in partial fulfillment of the requirements of the Master of Science Degree in Library
and Information Science.
I further certify that she attended all meetings that were scheduled with me and that all
requirements were fulfilled. It is my professional judgment that the project is of a satisfactory
standard as to be submitted with my name attached to it as the supervisor.
I therefore release the student to submit her dissertation for marking.
Mrs. E. Maisiri
Supervisor
………………………………………..
Signed
………………………………………..
Date
iv
DEDICATION
To my family, for never giving up on me.
v
ABSTRACT
Despite the importance of e-health, most healthcare institutions in Africa are noted to have
failed to conduct an initial assessment of the institutions’ readiness before the implementation
of ICT applications, which contributes to high failure rates. To this end, the study explored
the eReadiness of Ingutsheni Central Hospital in implementing an EMR system. The study
was guided by Beebeejaun and Chittoos (2017) Framework whose constructs include: core
readiness, engagement readiness, technological readiness, societal readiness and policy
readiness. The study adopted a mixed methods research design and the survey within a case
study design. Data was collected from the 124 healthcare workers who were selected using
stratified random sampling. Semi structured interviews were conducted with 7 hospital
administrators who were selected using purposive sampling. SPSS was used in quantitative
data analysis and qualitative data was coded and integrated with quantitative data. The
research established that Ingutsheni was not fully ready to implement an EMR system. The
hospital was only prepared in terms of core readiness and engagement as the healthcare
workers expressed much dissatisfaction with paper-based health information management.
However, the hospital was not ready in terms of technological, policy and societal readiness.
It was thus recommended that the Zimbabwe Ministry of Health and Child Care introduce
ICT programmes into the nursing curriculum, increase subsidies for the healthcare facilities;
especially the non-income generating hospitals like Ingutsheni Central Hospital and develop
enabling policies for EMR implementation. Ingutsheni Hospital was recommended to prepare
an EMR implementation position paper and present it to the relevant authorities so that when
the hospital requests for funding from the Zimbabwe Ministry of Health and Child Care every
stakeholder will be in a clear position.
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ACKNOWLEDGEMENTS
I am heartily thankful to my supervisor, Mrs. E. Maisiri, for her encouragement, guidance

and support throughout the study. I offer my kindest regards to all who supported me in any
way during the completion of this dissertation. I owe special thanks to my colleagues,
Brilliant Ndlovu and Nyaradzo Machimbidza for their emotional support. I would also want
to thank the authorities at Ingutsheni Central Hospital for allowing me to conduct this study.
Lastly, this project could not have been completed without the kind cooperation of Ingutsheni
Central Hospital staff. I thank you.
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TABLE OF CONTENTS
COPYRIGHT DECLARATION……………………………………………………………...ii
DECLARATION ON PLAGIARISM ..................................................................................... iii
RELEASE FORM ..................................................................................................................... iv
DEDICATION ........................................................................................................................... v
ABSTRACT .............................................................................................................................. vi
ACKNOWLEDGEMENTS .....................................................................................................vii
TABLE OF CONTENTS ....................................................................................................... viii
LIST OF TABLES ................................................................................................................. xiii
LIST OF FIGURES ................................................................................................................ xiv
LIST OF APPENDICES .......................................................................................................... xv
LIST OF ACRONYMS .......................................................................................................... xvi
CHAPTER 1: INTRODUCTION ........................................................................................... 1

1.1 Background to the study................................................................................................... 1
1.2 Statement of the problem ................................................................................................. 5
1.3 Purpose of the study ......................................................................................................... 6
1.4 Research Questions .......................................................................................................... 6
1.5 Significance of the Study ................................................................................................. 7
1.6 Assumptions of the Study ................................................................................................ 7
1.8 Definition of terms ........................................................................................................... 7
1.8 Scope (Delimitation of the Study) .................................................................................... 8
1.9 Limitations of the Study .............................................................................................. 8
1.10 Summary ........................................................................................................................ 9
CHAPTER 2: LITERATURE REVIEW ............................................................................ 10

2.1 Introduction .................................................................................................................... 10
2.2 Information Management ............................................................................................... 10
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2.3 Medical Records ............................................................................................................. 10
2.4 The concept of E-Health ................................................................................................ 11
2.4.1 Electronic Medical Records System ........................................................................ 12
2.5 E-Health Implementation in Developing Countries ....................................................... 15
2.5 E-health readiness assessment ........................................................................................ 16
2.6 eReadiness Theoretical Frameworks .............................................................................. 18
2.6.1 Technology Readiness Index (TRI) ......................................................................... 18
2.6.2 Campbell et al. (2001) Readiness Framework......................................................... 18
2.6.3 Demiris et al. (2004) Readiness Framework ........................................................... 19
2.6.4 Jennett et al. (2005) Readiness Framework ............................................................. 19
2.7 Beebeejaun and Chittoos Theoretical Framework ......................................................... 20
2.7.1 Core Readiness Construct ........................................................................................ 20
2.7.2 Technological Readiness Construct......................................................................... 21
2.7.3 Societal readiness construct ..................................................................................... 23
2.7.4 Acceptance and Use Readiness ............................................................................... 25
2.7.5 Engagement Readiness Construct ........................................................................... 27
2.7.6 Policy Readiness Construct ..................................................................................... 29
2.8 Summary ........................................................................................................................ 30
CHAPTER 3: RESEARCH METHODOLOGY ................................................................ 31

3.1 Introduction .................................................................................................................... 31
3.2 Research Philosophy ...................................................................................................... 31
3.3 Research Approach ........................................................................................................ 32
3.4 Research Strategy ........................................................................................................... 33
3.5 Population....................................................................................................................... 35
3.6 Sampling and Sampling Frame ...................................................................................... 35
3.6.1 Stratified Random Sampling ................................................................................... 35

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3.6.2 Judgemental Sampling ............................................................................................. 36
3.7 Data Collection Instruments ........................................................................................... 37
3.7.1 Questionnaires ......................................................................................................... 37
3.7.2 Interviews ................................................................................................................ 39
3.8 Reliability and Validity .................................................................................................. 40
3.9 Data Collection Procedures ............................................................................................ 42
3.10 Data Presentation and Analysis Procedures ................................................................. 42
3.11 Ethical Considerations.................................................................................................. 43
3.12 Summary ...................................................................................................................... 44
CHAPTER 4: DATA PRESENTATION AND ANALYSIS .............................................. 46

4.1 Introduction .................................................................................................................... 46
4.2 Demographic Data.......................................................................................................... 46
4.3 Acceptance and Use ....................................................................................................... 47
4.3.1 Age and Knowledge in Computer Use .................................................................... 47
4.3.2 Age and Commitment .............................................................................................. 49
4.3.3 Gender and Awareness in EMR systems ................................................................. 49
4.3.4 Experience and Commitment to Dedicate to the Training and Use of EMR systems
.......................................................................................................................................... 49
4.4 Core readiness ................................................................................................................ 49
4.4.1 Awareness of EMR systems .................................................................................... 49
4.4.2 Previous use of EMR systems ................................................................................. 51
4.4.3 Satisfaction with the current medical records management services ...................... 51
4.4.4 Challenges faced ...................................................................................................... 51
4.5 Technological Readiness ................................................................................................ 53
4.5.1 Availability of ICT infrastructure ............................................................................ 53
4.5.2 Training on the use of EMRs ................................................................................... 54
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4.5.3 ICT Skills ................................................................................................................. 54
4.5.3 Adequacy of ICT support ........................................................................................ 55
4.6 Engagement Readiness................................................................................................... 56
4.6.1 Importance of EMR ................................................................................................. 56
4.6.2 Perceived benefits of EMR implementation ............................................................ 56
4.6.3 Fear about potential negative impacts ..................................................................... 58
4.6.4 Willingness to dedicate to training .......................................................................... 59
4.7 Societal Readiness .......................................................................................................... 59
4.8 Policy Readiness ............................................................................................................ 61
4.9 Data Interpretation and Discussion ................................................................................ 61
4.9.1 Acceptance and Use................................................................................................. 61
4.9.2 Core Readiness ........................................................................................................ 62
4.9.3 Technological Readiness ......................................................................................... 64
4.9.4 Engagement Readiness ............................................................................................ 65
4.9.5 Societal Readiness ................................................................................................... 67
4.9.6 Policy Readiness ...................................................................................................... 68
5. Summary .......................................................................................................................... 69
CHAPTER 5: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS .............. 70

5.1 Summary ........................................................................................................................ 70
5.2 Conclusions .................................................................................................................... 71
5.2.1 Core Readiness ........................................................................................................ 71
5.2.2 Technological Readiness ......................................................................................... 71
5.2.3 Engagement Readiness ............................................................................................ 71
5.2.4 Societal Readiness ................................................................................................... 72
5.2.5 Policy Readiness ...................................................................................................... 72
5.3 Recommendations .......................................................................................................... 72

xi
References ............................................................................................................................... 74
APPENDIX A .......................................................................................................................... 89
APPENDIX B .......................................................................................................................... 95
APPENDIX C .......................................................................................................................... 97
APPENDIX D .......................................................................................................................... 98
APPENDIX E: LETTER OF AUTHORISATION TO CONDUCT RESEARCH ................. 99
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LIST OF TABLES
TABLE DESCRIPTION PAGE
Table 3.1 Sample size calculations for each ward 36

Table 4.1 Response rate by Gender, Age and Experience 47
Table 4.2 Age*Knowledge Cross-tabulation 48
Table 4.3 Chi-square Tests on Age and Knowledge in Computer Use 48
Table 4.4 Chi-square Tests on Gender and Awareness in EMR systems 49
Table 4.5 Existence of challenges faced by healthcare workers as a result
of the way medical records are stored` 51
Table 4.6 Perceptions on the significance of EMR implementation 56
Table 4.7 Other medium of communication 59
xiii
LIST OF FIGURES
FIGURE DESCRIPTION PAGE
Figure 1.1 E-Health Readiness Assessment Framework 4
Figure 2.1 Impact of EMRs on healthcare organisations 15
Figure 2.2 Core Readiness Construct 21
Figure 2.3 Technological Readiness Construct 22
Figure 2.4 Engagement Readiness Construct 27
Figure 4.1 Awareness of an EMR system 50
Figure 4.2 Knowledge in computer use 55
Figure 4.3 Benefits of EMR implementation 57
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LIST OF APPENDICES
Appendix A - Questionnaire for HealthCare workers 89
Appendix B - Interview Guide for Matrons 95
Appendix C - Interview Guide for the Health Information Manager 97
Appendix D - Interview Guide for ICT Manager 98
Appendix E - Letter of Authorisation to conduct research 99
xv
LIST OF ACRONYMS
EMR Electronic Medical Records
ICT Information and Communication Technology
SPSS Statistical Package for the Social Sciences
TRI Technology Readiness Index
WHA World Health Assembly
WHO World Health Organisation
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xvii
CHAPTER 1
INTRODUCTION
1.1 Background to the Study

The advancements in information and communication technologies (ICTs) have led to the
implementation of different data management systems in healthcare organisations aimed to
improve healthcare services with respect to the management and communication of data in
decision making. In this regard, Yusif and Soar (2014) state that the adoption of ICTs in
healthcare delivery, which is generally referred to as e-health, has not only been credited with
improving the reliability and effectiveness of health information, but has also been applauded
for strengthening healthcare delivery systems through its various tailor made innovative
applications that include Electronic Medical Records (EMR) systems.
Electronic Medical Records systems are designed to alleviate the limitations associated with
paper-based information management and help improve the quality information. A review of
literature on the implications of using the paper-based information management approach
shows that paper-based information management has shortfalls that can weaken the
management of health records at any institution. These include inadequate physical space to
keep patients’ health cards in case of high number of patients, inconsistency in handwriting
of individuals compiling the health cards as well as vulnerability of the cars to termite attack
or other attacks. Ajala et al. (2015) add that with paper-based systems, the retrieval of patient
information takes a very long time. Also, patients may be privy to confidential information in
situations where they must take these paper-based records from unit of the hospital to
another.
Implementing EMR systems has become a priority not only in developed countries but also in
developing countries (Biruk et al., 2014). This is because EMR systems have become a
cornerstone of modern healthcare systems of the current information age to the extent that
failure to adopt an EMR system may constitute a deviation from the standard of care (Pogba-
Nzavu, 2014). Therefore, in an effort to catch up with the rest of the world as far as installing
EMR systems, the Zimbabwe Ministry of Health and Child Care has since 2014 been
working on implementation of EMR systems in public hospitals (Zimbabwe eHealth Strategy
2014-2017). However, by 2016 only a few of the public hospitals had EMR system in place
(Dube and David, 2016). One of the hospitals lagging behind was Ingutsheni Central
Hospital. This was still the case by January 2019.
Ingutsheni Central Hospital, is a national referral centre for psychiatric disorders. The
hospital offers services to outpatient, psychiatric patients on admission as well as
rehabilitative services to those with psychiatric disabilities of all nature. Since establishment
in 1910, the hospital relies on paper-based health information management for point of care
patient management and health information management. The paper-based health records are
centrally stored at the hospital’s Central Records Department, which is just a small office that
is currently running out of space to continuously cater for the continuous increase in health
records generated. As indicated in the 2017 Annual Reports and Statistics of the hospital’s
Central Records Department, the hospital had been experiencing a shortage of filling cabinets
and folders for the storage of patients’ health cards, which seriously hampered the retrieval of
patient records and the gathering of information for research. Also, the 2017 Annual Reports
and Statistics showed that it had become very difficult to accommodate new patient records
in the filing system.
Similar challenges arising out of paper-based medical recordkeeping practice across Africa
have been reported in literature. In Zimbabwe, for example, a study on health information
practices in hospitals by Chikuni (2006) found that the storage of patients’ records was
ineffective because of the use of paper-based health information practices. As a result, it was
the responsibility of patients to maintain and preserve their own patient records. According to
Chikuni (2006), this practice slowed down the provision of health services because in most
cases, patients felt that it was a burden to carry around their medical records. As a
consequence, medical staff could not effectively deliver health services since they had no
records to inform their decisions.
A researcher at a rural hospital in Ethiopia described a similar challenge in which patient

registration numbers were replicated, records were lost and patients were assigned new
registration numbers. Also, clinical information was recorded on loose scraps of paper, and
medical records were poor archived (Wong & Bradley, 2009: 13). Another study by Luthuli
and Kalusopa (2017) in South Africa indicated that the patients found their files covered in
dust or torn; sometimes folios or entire files went missing. Furthermore, the clerks required
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patients themselves to buy new folders when their files were full. The patients concurred that
it was the patient’s responsibility to buy folders for their files to prevent records from being
lost. These are the shortcomings of paper-based information management that EMR systems
address.
Of importance to note is the fact that although EMR systems tend to be valuable, their
implementation is a complex matter involving a range of organisational and technical factors
including human skills, organisational structure, culture, technical infrastructure, financial
resources and coordination, amongst other factors (Boonstra, 2014). Therefore, in
implementing EMR systems, assessment, particularly readiness assessment is the first and
most important step prior to implementation (Ammenworth, 2014). Readiness assessment is
defined as an act of ascertaining the availability and magnitude of the range of factors that
influence the successful implementation of an EMR, in an organisation which is
contemplating the adoption of an EMR. The importance of readiness assessment was
highlighted by Muthee et al. (2018) on site readiness assessment preceeding the
implementation of a HIV care and treatment EMR system in Kenya which revealed that
although EMR systems could yield many benefits, facilities need to meet certain
requirements before they are able to successfully implement an EMR.
Durrani et al. (2012) in a study designed to assess the eHealth readiness of AKDN health care
institutions working in Afghanistan in implementing e-health solutions showed that any e-
health programme must consider and address the aforementioned factors before embarking
on a technological solution. The study concluded that rushing into implementing projects
without an assessment of the range of needs and the priorities was a costly experiment, which
poor countries cannot afford. Institutions first need to analyse where health care providers
and other users stand with respect to readiness levels, followed by defining their needs.
Correspondingly, a qualitative study conducted on an EMR trial in Cameroon revealed that

insufficient training of personnel, lack of funding, insufficient leadership and bad
organisational issues, among other issues, led to the failure of the system (Kamadjeu, Tapang,
and Moluh, 2005). Thus, according to Adjorlolo and Ellingsen (2003) in view of some of
these issues, studies on the evaluation of ICT applications and their implementation have
gained dominance in the healthcare industry. In some of these studies, performing an initial
3
or pre-evaluation of the ICT applications as well as considering institutions’ readiness before
the adoption and implementation of ICT related projects were proposed as measures to
reduce the risk of failure (Demarris et al., 2004).
A number of e-health readiness assessment models have been developed specifically to assess
the e-health readiness status of healthcare organisations. These models have different
dimensions and indicators such as network infrastructure, network applications and services,
development of Internet usage, development of skills and human resources and access to ICT.
However, this study will adopt a conceptual framework that was developed by Beebeejaun
and Chittoos (2017) in an assessment of e-health readiness in the public sector of Mauritius.
The strength of this conceptual framework is that it is aligned with a more recent e-health
readiness model, incorporating various determinants at both organisational and individual
levels. The constructs of the model are core readiness, technological readiness, societal
readiness, policy readiness, engagement readiness and acceptance and use readiness as shown
in the Figure 1.1. These constructs will be discussed in detail in chapter 2.
Core readiness Engagement Acceptance and

readiness Use
Technological E-health readiness Effort

readiness Expectancy
Societal Policy
Performance
readiness readiness
Expectancy
Figure 1.1: E-health Readiness Framework (Beebeejaun and Chitoos, 2017)
In brief, the core readiness construct refers to the identification of the core attributes of the
target population that leads to the need for change (Rezai-Rad et al., 2012). Focus under this
construct is on the following attributes: identifying needs for future changes, dissatisfaction
with status quo, awareness about e-health, comfort with technology, trust on the use of ICTs,
planning for e-health project, overall satisfaction and willingness, and integration of
technology.
4
The next construct is technological readiness. This considers attributes related to institutional
and human resource structures. These attributes include ICT regulations and policies, work
ethics and organisational culture, training and availability of resources like speed and quality
of network, hardware and software, compatibility, capability of the ICT support team,
availability of the Internet, reliability of the network, training of users and Internet
accessibility.
Societal readiness construct aims at understanding communication links and collaboration of

healthcare organisations with other institutions. In the context of this study the attributes
include: collaboration with other health institutions, sharing of information, provision of care
to patients and communities in collaboration with other healthcare institutions, socio-cultural
factors among staff, socio-economic position and socio-cultural factors among clients and
communities.
Policy readiness deals with policies at the government and institutional level, which are in
place to address common issues (Khoja et al., 2007). Attention here is placed on policies put
in place for the promotion, support and management of e-health utilisation in health care
institutions. Engagement readiness construct assesses the healthcare providers’ exposure to e-
health readiness systems and willingness to participate in the networking world. In this study,
this will apply to knowledge, benefits of e-health and the willingness of the medical
practitioners to engage actively in training.
Acceptance and use readiness construct assesses the personnel effort expectancy and
performance expectance which attributes include; personal factors like; age, academic
qualification and experience with networking technology; ability to use technology and its
newness; quality of services provided, satisfaction with technology, organizational awareness
and expected benefits.
1.2 Statement of the problem

Globally, all sectors in society are embracing Information and Communication Technologies
to enhance service delivery and competitiveness. Health care is no exception. Electronic
health can transform how health care is delivered and how health systems are run
(Zimbabwe’s National E-Health Strategy 2012-2017). Despite the importance of e-health,
most healthcare institutions in Africa are noted to have failed to conduct an initial assessment
of the institutions’ readiness before the implementation of ICT applications, which
5
contributes to high failure rates (Habibi-Koolaee et al., 2015). Therefore, in light of the
current trends in health information management, to what extent is Ingutsheni Central
Hospital ready to implement an EMR system should it consider EMR system
implementation?
1.3 Purpose of the study

The purpose of this study was to evaluate the readiness of Ingutsheni Central Hospital in
implementing an Electronic Medical Records system. The study is guided by a conceptual
framework developed by Beebeejaun and Chittoos (2017) whose tenets are: core readiness,
technological readiness, societal readiness, policy readiness, engagement readiness and
acceptance and use readiness.
The specific objectives are:
1. To determine the core readiness of key stakeholders at Ingutsheni Hospital in

implementing an EMR system.
2. To find out the technological readiness of Ingutsheni Hospital in implementing an

EMR system.
3. To find out if there are any policies in place that support the implementation of EMR
systems at Ingutsheni Hospital,
4. To determine the societal readiness of Ingutsheni Central Hospital in implementing an
EMR system.
5. To determine the engagement readiness of key stakeholders at Ingutsheni Hospital in

implementing an EMR system.
1.4 Research Questions

1. How core ready are the key stakeholders at Ingutsheni Hospital in implementing an
EMR system?
2. How technologically ready is Ingutsheni Hospital in implementing an EMR system?
3. What policies are in place to support the implementation of an EMR system at

Ingutsheni Hospital?
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4. What sociocultural factors influence the implementation of an EMR system at
Ingutsheni Hospital?
5. How willing are the key stakeholders in implementing an EMR system at the
hospital?
1.5 Significance of the Study

To date, little research that examines EMR implementation in Zimbabwe has been conducted.
Researchers have mainly focused on the need for eHealth policies (Njabulo 2017). Given that
the majority of public hospitals in Zimbabwe have not yet implemented an EMR system or
are only using basic elements of an EMR, this study might be timely. It was hoped that this
study might contribute to the knowledge on the deployment and implementation of EMR
systems in developing countries, which is noted to be limited. As efforts are currently
underway by the Ministry of Health and Child Care to roll out ICT infrastructure in all health
facilities, findings from this study may be valuable for policy formulation and
implementation of EMR systems. It was also hoped that this study would contribute new
information to the body of knowledge in health information management, specifically in the
Zimbabwean context. It might also serve as a benchmark to guide future actions, as well as to
put Ingutsheni Hospital on the map of e-health and ICT users, thereby attracting the attention
of international funding bodies to support the process of e-health adoption. Furthermore, as
the core of librarianship is based on the notion that information does not only need to be
available, but should be the right information, in the right place at the right time, it was hoped
that the results of the study might help the hospital to realise the benefits that come with
incorporating ICTs in the management of patients’ medical records.
1.6 Assumptions of the Study

The study was guided by the assumption that EMR systems improve health information
management.
1.8 Definition of Terms

Hospital
A hospital as defined by McWay (2008) is a healthcare facility that has a governing body, an
organised medical staff and professional staff and inpatient facilities and provides medical,
7
nursing and related services for ill and injured patients 24 hours per day, seven days per
week.
Implementation
According to Carnall (2007:7) implementation refers to those processes needed for designing
and organising the process of change to be effective.
E-readiness is the preparedness to adopt technologies in order to achieve competitive

advantage within a certain field.
E-health
It refers to the use of modern information and communication technologies to meet the needs
of citizens, patients, healthcare professionals, healthcare providers and policy makers.
1.8 Scope (Delimitation of the Study)

The study was done at Ingutsheni Central Hospital which is Zimbabwe’s biggest National
Referral Centre for Psychiatric Disorders. The hospital is located in Bulawayo’s industrial
site, Belmont. The hospital administrators as well as qualified mental health nurses formed
the basis on which results of the study were generalised.
1.9 Limitations of the Study

Time was a major constraint as one semester was not enough to adequately undertake an
extensive research. The researcher had to balance work and research at the same time. To
maximise on the limited time, the Researcher asked for assistance from colleagues and
student nurses to administer questionnaires.
Some of the participants were the Researcher’s workmates. This familiarity may have
influenced the information given. However, since the participants were informed that their
answers, names and place of work would be kept strictly anonymous and highly confidential,
and that the research was to be purely based on their opinion, the Researcher believe that the
participants were objective in their responses.
Since this study was conducted at a public institution, interviewees may have been cautious
in disclosing too much information, withholding some content about the institution. However,
to minimise this, participants were assured that anonymity and confidentiality would be
8
observed. Also, triangulation helped in cross checking as much information as possible from
the participants.
1.10 Summary
The importance of Electronic Medical Records systems in improving healthcare services with
better data management, communication and decision making has seen many governments
making EMR implementation a priority. This is because EMR systems are a growing
cornerstone of modern healthcare systems of the current information age to the extent that
failure to adopt an EMR system may constitute a deviation from the standard of care.
Although EMR systems tend to be valuable, their implementation is a complex matter
involving a range of organisational and technical factors including human skills,
organisational structure, culture, technical infrastructure, financial resources and
coordination, amongst other factors. Despite the importance of e-health, most healthcare
institutions in Africa are noted to have failed to conduct an initial assessment of the
institutions’ readiness before the implementation of ICT applications, which contributes to
high failure rates recorded. Therefore, in light of the current trends in health information
management the study sought to evaluate the e-readiness of Ingutsheni Central Hospital in
implementing an EMR system using a theoretical framework by Beebeejaun and Chittos
(2017). Given that the majority of public hospitals in Zimbabwe have not yet implemented an
EMR system or are only using basic elements of an EMR, the study might have been timely.
It was also hoped that this study would contribute to the knowledge on the deployment and
implementation of EMR systems in developing countries, which was noted to be limited. The
study was guided by the assumption that EMR systems improve health information
management. The Researcher was limited by time, familiarity with the participants as they
were researcher’s workmates and the fact that since this study was conducted at a public
institution, interviewees may have been cautious in disclosing too much information,
withholding some context about the institution.
9
CHAPTER 2
LITERATURE REVIEW
2.1 Introduction
The literature review incorporates the readiness of public hospitals in implementing EMRs.
Attention is also given to the e-readiness frameworks that are used in assessing the readiness
of hospitals in implementing EMRs as well as the benefits of adopting EMRs in hospitals.
The literature review was essential, as its purpose was to place the research in the context of
its contribution to understanding the research problem being studied, and also to locate the
researcher’s own work within the context of existing literature (Hammond and Wellington,
2014). It is the theoretical base which informed the structure of this chapter so as to realise a
sequential presentation. The Researcher obtained a considerable amount of literature for this
study using the NUST Library. The sources for this study include Google Scholar, books,
other scholarly journal articles as well as dissertations that were previously done. The
resulting review provided useful information to respond to the research question and ensured
that this study had a supported research method and design.
2.2 Information Management

The proper management of information is imperative in any organisation. This is because
information is so valuable that it must be well documented, maintained, retrieved and
analysed. Ajami (2011) states that in health management systems, information has the special
role in planning, evaluation, training, legal aspects and research. In this regard, health
information is one of the key factors that contribute to the strengthening of healthcare
delivery in every country (Acquah-Swanzy, 2015). As mentioned by Tevia et al. (2012)
reliable health information lead to timely health policies and planning which improves the
general health status of a country as well as serving as a vital element for individual health
facilities in managing and improving healthcare delivery. The information managed in a
health institution includes financial and administrative information as well as medical
records.
2.3 Medical Records

A medical record is a collection of clinical information pertaining to a patient's physical and
mental health, compiled from different sources (Medical Dictionary, 2012). Medical records
10
are maintained by, or on behalf of, the health professional concerned with the patient's care
and maintained as private documents (Medical Dictionary, 2012). They serve a number of
purposes in a hospital environment. They are a communication tool in the hospital set up:
they communicate patient information such as patient’s medical history and treatment from
physicians (Ngidi, 2016). They also serve as legal documents and can be used as evidence in
a court of law. Additionally, they can be used for billing and medical research purposes
(Weiss, 2000; Wager et al., 2005). Medical records by nature are very sensitive because of
their contents. Patient information usually contains identification details such as names,
contact details, patient medical history, diagnosis and treatment. Thus it is important to adopt
appropriate measures to safeguard the privacy and confidentiality of patient information
found in patient records (Ngidi, 2016).
2.4 The concept of E-Health

The rapid advancements in ICTs and its related applications have seen many governments
globally recognising the prospective benefits of e-health in a bid to improve the health
system. This is confirmed by Lam et al. (2005) who state that the introduction of the e-health
paradigm has been received as an important element in healthcare systems. Authors such as
Juma et al. (2012) and Farzianpur et al. (2015) are of the notion that e-health, one of the
fastest growing sectors in the health care domain, can be used as a resourceful means to
promote and strengthen the health systems and health information. As such, e-health has
gained momentum in areas such as health portals, EMR and HIS, telemedicine and remote
patient monitoring amidst other areas (Busagala and Kawono, 2013).
E-health has been a priority of the World Health Organisation (WHO) since 2005 when the
WHO Assembly Resolution (WHA 58: 28) was adapted (Qureshi and Sha, 2013). The
migration to e-health is necessary to provide quality care because it allows for seamless flow
of information among various entities. Thus, as stated by Mugo (2014), e-health is becoming
a reality in both developed and developing countries and holds great promise in improving
global access to healthcare services and health informatics.
According to Furusa (2018), although e-health has been defined in various forms, its’
constituent concepts operate in the confluence of medical informatics and public health. For
example, by efficiently collecting data in a form that can be shared across multiple health
care organisations and leveraged for quality improvement and prevention activities, EMRs
11
can improve public health reporting and surveillance (Health IT.gov). With more and better
data available, public health organisations can better monitor, prevent, and manage disease.
In New York City, for example, public health officials designed a programme that leverages
EMRs to deploy public health alerts to clinicians (Lurio, 2010). In addition, EMRs help in
improving an organisation’s ability to prevent disease. With electronic health information
about the entire population of patients served, an organisation can look more meaningfully at
the needs of patients and offer better health care (Fiks, 2007). Furthermore, by meaningfully
using EMRs, an organisation can expand its communication and collaboration with public
health officials and thus contribute in public health decisions and policy making (Health
IT.gov).
Mugo (2014) mentions that e-health involves a wide range of actions that use electronic
means to provide health-related information, resources and services. Qureshi and Sha (2013)
simply define e-health as any electronic exchange of information within the health sector.
Although there are so many definitions of it, Kushrinik and Patel (2004) contemplate that any
definition of e-health should encompass the full spectrum of ICTs whilst appreciating the
context of use and the value they bring to the society.
In more practical terms, e-health is the means of ensuring that the right health information is
provided to the right person at the right place and time in a secure, electronic form for the
purpose of optimising the quality and efficiency of health care delivery (Zimbabwe’s
National Health Strategy 2012- 2017). As such, among the various systems introduced in e-
health to increase efficiency in healthcare, EMR systems are considered a vital resource as
they store patients medical events and make them available to medical practitioners at the
point of care.
2.4.1 Electronic Medical Records System

Several acronyms and definitions have been used to define EMR, such as electronic patient
health record (EPHR), Electronic Patient Record (EPR), Computerised Patient Record (CPR)
and Electronic Health Record (EHR). Laerum and Fauxberg (2004) give a general definition
describing EMRs as information systems that manage both the distribution and processing of
information necessary for the healthcare delivery system. Angst and Agrawal (2009) define
EMRs as a software programme developed for the storage, processing and data exchange of
12
medical information by healthcare providers. However, as Waegmann (2002) said, “whatever
you call it, the vision is of superior care through uniform, accessible health records”.
2.4.1.1 Advantages of EMR in developing countries

Many scholars have highlighted the potential benefits deriving from the adoption of EMR
systems, assessing different dimensions of impact either in theoretical terms or supporting
their discussion with empirical evidence. Of importance to note is that the rapid progress
within the ICT field makes the problems of paper based medical records all the more
apparent as stated by Uslu and Stausberg (2011). They further state that the only thing that is
certain is that the conventional paper-based patient management is rapidly reaching its limits.
Therefore, in revealing the benefits of adopting EMRs, the limitations of paper based systems
manifest.
One of the major limitations of paper-based systems that the adoption of EMRs seeks to
address is that paper-based systems make the identification, storage, and retrieval of
information cumbersome. Romanow (2012) comments that paper records limit the flow of
information, insufficiently document patient care, impede the integration of health care
delivery, create barriers to research, and limit the flow of information available for
administration and decision making.
A common ground of prominent authors on the use of EMRs in hospitals such as Khoja et.al
(2007), Chaudhry (2006) and Sridhar (2009) provide a more comprehensive review on the
limitations of traditional paper-based records systems. They outline that paper records are a
very fragile medium that require big space purposely for storage and must be properly
organised to be accessible; data recorded may not be in uniform standard and only one person
can access at a time; paper may be missing or lost, misplaced or it can lead to complexity and
frequent illegibility in clinical notes.
Arriffin (2018) mentions that the most significant problem on dealing with paper records is
about the timing process. This is because usually medical professionals need the patient data
instantly and time is very critical in healthcare organisations. Paper is not a stable media
format, and by nature is easily affected by both water and fire. All medical records need to be
locked away in a storage area in order to protect confidentiality, integrity and security of the
information. As argued by Currie and Finnegan (2009), these are the problems that eHealth,
through electronic medical records system seek to address. Mugo (2014) supports this by
13
stating that it is these limitations of paper –based records that are influencing a transition
across the globe towards EMRs and in general eHealth. In particular, Chaudhry et al. (2006)
noted that EMR applications can prompt for completeness, provide better ordering for
searching and retrieval, and permit validity checks for data quality, research, and especially
decision support.
As far back as 1994, Van Der Loo et al. argued that EMRs reduce the time for collecting
information since the data is not collected and recorded on multiple occasions and patient
health information can be shared quickly (Thompson et al., 2009). A study by Joos et al.
(2006) found that the implementation of EMRs resulted in less time needed to develop a
patient synopsis and improved communication which could lead to cost savings. Li-kourezos
(2007) did almost a similar study and found that nurses were able to finish tasks much faster
than before when using EMRs.
Pagiari et al. (2007) adds on by stating that sharing information between different healthcare
providers may also reduce geographical barriers and serve as a point of record integration,
particularly in fragmented health systems and consequently improving the quality of care.
EMRs have the capability to capture and store a huge amount of information of patient
information and such a large database results in quality improvement and cost effectiveness
(Sidorov, 2006).
Cucinello (2011) having realised that EMRs have a huge impact on healthcare organisations
summarises the key dimensions of impact based on the literature as shown in Figure 2.1:
14
Figure 2.1: Impact of EMRs on Healthcare Organisations (Cuccinello, 2011)
As shown in figure 2.1, EMRs have an impact on the daily activities, commitment and
communication on people working within the organisation. It also improved information
sharing and communication within departments. Medical errors as well as risk for any
malpractice can be reduced also through the use of EMRs, hence improving patient
confidence in the hospital services. Also, EMRs have an impact on the health care delivery
process as they enhance continuity of service.
2.5 E-Health Implementation in Developing Countries

Inspite of the well-defined benefits of e-health, its implementation remains low in developing
countries, especially in public hospitals with little research that explains this phenomenon
(Juma et al., 2012; Mugo, 2014). Kgasi and Kalema (2014) in an assessment of e-health
records in rural South Africa found that n as much as there were numerous expected benefits
from the implementation of e-health in developing countries, the anticipated challenges were
immense. Recently, Katurura (2018) found that studies that were conducted analysing the
EMR efforts across the African continent proved that there are some challenges hindering
EMR implementation.
One notable observation from literature is that countries use unique approaches towards the
implementation of e-health (Mugo, 2014). This explains why the implementation of e-health
is not the same globally. Regardless of the unique approach towards e-health, the factors that
influence the implementation of e-health seem to be universal but their effect is contextual.
15
According to Kagsi and Kalema (2014) these challenges may arise from different angles that
may include though not limited to poor infrastructure, lack and unevenly distributed
government subsidies and services, lack of qualified personnel to implement and run the
services and political instability. The authors note that, for example, Malawi and Ghana had
made attempts to implement national EMRs, but challenges such as a lack of government
support and necessary infrastructure, unavailability of continuous electricity supply and
resistance from healthcare workers caused these projects to be unsuccessful. Thus, readiness
assessment becomes imperative before rolling out any ICT initiative.
2.5 E-health readiness assessment

About two decades ago, research found that large IT projects were associated with 30% or
more failure rates (More, 1990) and the problem was more serious and visible in developing
countries. Adjorlolo and Ellingsen (2016) remarking on the challenges facing developing
countries in the implementation of e-health projects are of the view that challenges
confronting developing countries are not of the same magnitude and for that matter the
problems that hamper the operations of ICTs in healthcare industry are not the same for all
developing countries. One area in which discussions have been advanced for purposes of
initiating and sustaining health related ICT projects in the e-health sectors of developing
countries as mentioned by Adjorlolo and Ellingsen (2016) is readiness assessment.
Readiness assessment is important in that, as an information infrastructure, EMRs have

several characteristics such as enabling, shared, open, socio-technical, heterogenous and
installed base that make them unique and whose implementation can appear more
challenging. These characteristics make EMRs more complex and require that its
implementation is preceeded by readiness assessment to determine success factors (Adjorlolo
and Ellingsen, 2016). This is supported by Demiris et al. (2004) and Jennet et al. (2003) who
state that e-health readiness assessment is associated with pre-implementation evaluation
hence it is an important requirement before the implementation.
Readiness, which is an earlier aspect of change (Lewin, 1951), is described as a cognitive

precursor to the behaviour of either resistance to or support for any change. Ali et al. (2017)
makes an important contribution by outlining that readiness in the context of e-health requires
organisational readiness together with health workers preparedness. Organisational readiness
pertains to organisational resources for instance finance, ICT infrastructure, ICT department
16
essential for e-health implementation. Rezai-Rad et al. (2012) gives a simpler definition of e-
health readiness assessment as the readiness of communities and healthcare institutions for
the expected changes brought about by programmes related to the implementation of ICTs. In
this regard, an important consideration of e-health readiness is that it is related to the concept
that the successful implementation and use of ICTs in health is a social process rather than
purely a technical one (Qureshi et al., 2014).
DeGaetano (2015) states that e-health readiness assessment can be a process for identifying
and addressing gaps between current and desired results. Kasraain (2008) adds on by citing
the advantages of e-health readiness assessment as avoiding huge losses on time, money and
effort; avoiding delays and disappointments among planners, staff and users of services. He
also adds that e-health readiness assessments help in facilitating the process of change in the
institutions and communities from the initial stage- resistance to change; through
contemplation-acceptance of new ideas; and preparation for ICT implementation.
In line with the above, Demiris et al. (2004) states that the assessment of readiness is one of
the methods of decreasing the failure risks in organisational projects such as EMR. Ali et al.
(2017) further elaborates that the necessary technical and social readiness assessments tend to
be of much relevance for e-health which is generally capital intensive in addition to whose
failures symbolise an important financial loss to the employing organisations.
Weiner et al. (2008) gives another benefit of having e-health readiness assessments by stating
that it acts as a method for knowing customer profiles and preparedness together with
organisational weaknesses and strengths. This in turn assists decision makers in a healthcare
institution to become well informed of areas lacking in readiness and consequently serve as
instruction for preventive actions to combat the innovative failure (Li et al., 2012).
Despite the benefits of having an e-health readiness assessment, Ali et al. (2017) take
cognisant of the fact that in many African countries where health-related IT projects are a
priority, preparedness assessment studies are not carried out and even where this kind of
studies are performed they are not publicised to serve like a guide to potential
implementations. Toure et al. (2012) supports this by stating that readiness assessments
toward the implementation of ICT projects in health sector can be often neglected for
political and other socio-cultural reasons.
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2.6 eReadiness Theoretical Frameworks
In order to ground understanding of readiness in e-health implementation and sustainability in
a developing country context, a review of literature on existing theoretical frameworks on
readiness such as the Technology Readiness Index, Campbell et al. (2001), Demiritis et al.
(2004), and Jennett et al. (2005) was done.
2.6.1 Technology Readiness Index (TRI)

Technology Readiness Index (TRI) has been widely accepted as a theoretical foundation in
the domain of technology readiness. However, TRI initially referred to people’s openness to
technology rather than their proficiency in using it. TRI’s four constructs of optimism,
innovativeness, discomfort and insecurity targeted individuals rather than the technology and
other factors that could influence readiness. This gap has seen researchers such as Heeks
(2008) and Himmelstein (2005) modifying and extending TRI to suit their studies. However,
Heeks (2008) and Himmelstein (2005) argued that in as much as the extended models of TRI
have been proved to be good predictors of readiness, assessment frameworks should be
adequately complex to integrate the multitude organisation’s characteristics, changing needs
and the structural composition of the organisation.
2.6.2 Campbell et al. (2001) Readiness Framework

Campbell et al. (2001) developed a readiness framework by conducting semi-structured
interviews followed by a thematic analysis in order to investigate the multiple healthcare
providers’ view for the readiness evaluation of e-health applications. Results of thematic
analysis revealed six themes:
 Turf: a threat to healthcare providers’ livelihood professional autonomy or both;
 Efficacy: desire to know that e-health applications will fill a functional need in
healthcare providers’ practice before they invest time and money in making such a big
change;
 Practice context: barriers to adopting e-health applications.
 Apprehension: as a human aversion to change
 Time to learn: hesitancy among the providers to take the time to learn a new
technology and to persuade patients of its worth;
 Ownership: participants who were professionally and emotionally invested in the
technology – stakeholders who acknowledged its benefits, adapted it to their needs,
and tried to help others learn.
18
These six themes comprise the framework to understand three categorised organisational
stings, that is, “fertile soil”, somewhat fertile soil, and “barren soil” (Campbell et al., 2001).
Change strategies are also suggested to every readiness setting (Li et al., 2008. Campbell et
al. (2001) provided a mechanism for determining and then dealing with three different levels
of readiness for implementing e-health applications. Nevertheless, the mechanism does not
involve organisational, public or patient readiness for e-health, only from healthcare
providers’ view, hence not suitable for this study.
2.6.3 Demiris et al. (2004) Readiness Framework

Demiris et al. (2004) used two existing readiness scales: the Organizational Information
Technology/Systems Innovation Readiness Scale (OITIRS) and the organizational and
functioning readiness for change (ORC). The framework assesses staffs’ exposure to
technology and institutional resources. The problem with this framework is that it assesses
practitioner readiness instead of organisational readiness, with an emphasis on staff
competency using technology, hence not suitable for this study.
2.6.4 Jennett et al. (2005) Readiness Framework

Jennett et al. (2005) developed a readiness framework which is applauded for its
comprehensiveness in terms of the evaluation scope. It consists of four types of readiness;
core readiness, engagement readiness, structural readiness and concern of non-readiness.
Core readiness refers to the realisation of needs and expressed satisfaction with the present
situation and conditions; engagement readiness involves the active participation of people in
the idea of e-health. In the process, people weigh the advantages and disadvantages of e-
health, assess risk, and question e-health as a solution; structural readiness focuses on the
establishment of efficient structures as a foundation for successful e-health projects within an
organisation; for example, human, technical, training, policy and funding. Concern for non-
readiness is expressed as a perceived lack of need or a failure to recognise a need for change
and implementation of e-health technology (Jennett et al., 2005). However, Beebeejaun and
Chittoos (2017) mention that the major weakness of this framework is that it provides very
little information regarding demographics or current technological practices.
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2.7 Beebeejaun and Chittoos Theoretical Framework
Hammond and Wellington (2014) define a conceptual framework as a general orientation to a
topic using a mix of published literature, personal knowledge and speculations on the kind of
relationships that might emerge in the main study.
There are several other e-health readiness frameworks in addition to the ones mentioned
above, however of great concern to note is that several studies such as those done by Li and
Seal (2012); Ojo et al., (2008); Jennet et al. (2005) and Reza-Raid (2012) recommended the
importance of considering context when developing a model for e-health assessment in
developing countries; hence, the adoption of a conceptual framework that was developed by
Beebeejaun and Chittoos (2017) in an assessment of e-health readiness in the public sector of
Mauritius. Their study was a cross-sectional quantitative study whereby the target population
comprised four groups including the physicians, nursing personnel, health records officers
and pharmacy personnel from the five regional hospitals in Mauritius. The sample was
selected using a proportional stratified sampling ensuring that the particular categories of
individuals including physicians, nursing officers, health record officers and pharmacy
personnel were represented.
The constructs of the theory discussed below include core readiness, engagement readiness,
policy readiness, technological readiness and societal readiness.
2.7.1 Core Readiness Construct

Core readiness construct refers to the identification of the core attributes of the target
population that leads to the need for change (Rezai-Rad et al., 2012). Provision of care
requires the documentation of clinical information as an intrinsic aspect of routine clinical
activity and is essential from both professional and legal standpoints (Allan et al., 2000).
Accordingly, core readiness assessment is concerned about patients’ records generation,
storage and retrieval with paper-bases health records systems. In particular, it involves
documentation efficiency of patient records (Warshawsky et al. 1994; Allan et al. 2000),
patient privacy (Gritzalis et al. 2004; Blobel, 2004) and the degree of physicians’ satisfaction
with completeness and accuracy of paper-based health records (Staroselky et al., 2006) and
with sharing of patient records (Bakker, 2007).
20
Core Readiness
Realisation of Providers’
Problems Satisfaction with
PHR
Inefficient Breached Incompleteness Poor Sharing of

Documentation Patient Privacy & Inaccuracy Records
Figure 2.2: Core readiness construct (Li et.al, 2008)
Core readiness affects e-health readiness in that when the realised problems are more serious
and dissatisfaction expressed by physicians is higher, the healthcare organisations and
providers are more ready to adopt new practices (EMR) to create change (Jennett et al., 2002;
Jennett et al. 2005) and vice versa.
In an institution based cross-sectional quantitative study on health professionals readiness to

implement EMR systems at 3 hospitals in Ethiopia, Biruk et al. (2014) noted that if health
professionals mark at least two problems, like inefficient documentation of patient records,
dissatisfaction with the completeness and accuracy of patient data, as well as difficulty in
sharing patient records in the questionnaire they would be core ready for EMR system
implementation.
2.7.2 Technological Readiness Construct

This construct considers the attributes related to institutional and human resources structures
shown in Figure 2.3. The attributes include ICT regulations and policies, work ethics and
organisational culture, training and availability of resources like, speed and quality of
network; hardware and software; compatibility; capability of the ICT support team;
availability of the Internet; reliability of the network; training of users and internet
accessibility.
21
. Technological
Readiness
Hardware Network EMR related IT support Healthcare

software Personnel Providers’ past IT
experience
Figure 2.3: Technological Readiness (Li et al., 2008)
2.7.2.1 Infrastructure
E-health infrastructure pertinently affects adoption of e-health (Kundi et al., 2013).
Remarking on this, authors such as Qureshi and Sha (2013) observed that infrastructural
issues are dominating the research on e-projects in all organisations including the health
sector. E-health infrastructure is seen to be a critical factor (Coleman and Furusa, 2018). E-
health infrastructure relates to the hardware and software necessary for the implementation of
systems such as EMR.
Adoption of appropriate hardware and software are crucial for successful implementation of
e-health systems. Before launching the e-projects, required hardware and software must be
detected, ascertained and put in place in order to avoid user related problems (Kundi et al.,
2013). Furusa and Coleman (2018) conducted a study on factors influencing e-health
implementation by medical doctors in public hospitals in Zimbabwe and found that although
the application of e-health is dependent on various technologies and ICT infrastructure, there
was a lack of ICT infrastructure that supported e-health in Zimbabwe. According to Furusa
and Coleman (2018), a number of hospitals in Zimbabwe did not have enough technologies
in place for e-health. The present ICT tools available were meant for administration and
procurement functions.
2.7.2.2 ICT Support

The implementation of an IT project depends on the technical support from IT specialist.
Technical support is important to maintain a system and keep it running. According to Ross
et al. (2016), the presence of technical staff has been suggested as a strategy to reduce
barriers related to disruptions in workflows, roles and responsibilities that e-health
implementation might bring. Hence, hospitals should have ICT structures in place and IT
officers should be conversant with technology used in healthcare centres.
22
In Zimbabwe, as noted by Coleman and Furusa (2018), there was inadequate technical
support for the majority of hospitals. Participants in Coleman and Furusa’s (2018) research
indicated that they were not getting adequate technical support from the IT personnel because
of the unavailability of IT departments, the attitude of IT personnel or lack of expertise
technical support which is needed for the functioning of ICT personnel. Coleman and Furusa
(2018) also observed that only central hospitals had between two to five IT support officers.
2.7.3 Societal readiness construct

This construct aims at understanding communication links and collaboration of healthcare
organisations with other institutions. The attributes include; collaboration with other health
institutions, sharing of information, provision of care to patients and communities in
collaboration with other healthcare institutions; socio-cultural factors among clients and
communities (Khoja et al., 2007).
If a healthcare organisation where healthcare providers use multiple mediums to

communicate with another and the communication frequency is high, also has
communication links to both hospitals and administrative centres and provides care in
collaboration with other healthcare organisations, societal readiness is high; and vice versa
(Li et al., 2007).
Nguyen (2018) conducted a study to determine the societal readiness of a hospital in

implementing an EMR system and found that the healthcare workers only used the phone or
mobile to contact other hospitals. IT staff sometimes used email while others never used
email for their work at the hospital. There was no exchange of information. Exchange and
sharing medical documents by using an online repository of health staffs was very low. This
in turn resulted in a low societal readiness. However, other researchers such as Qureshi et al.
(2014) and Waithera (2017) are of the view that societal readiness has very little impact on an
organisation’s overall readiness in implementing EMR systems compared to the influence of
other constructs.
The external environment has an impact on the implementation of EMR systems in hospitals.
Commenting on this, Xue and Liang (2007) state that another major challenge, which
hampers the implementing of e-health related ICT projects like EMR in developing countries,
is the issue relating to financial cost. The cost incurred in purchasing the necessary software
and hardware together with the cost of transport and installation, the cost of maintenance, the
23
cost of training of the hospital staff (Durrani, and Khoja, 2009) as well as other unanticipated
costs might be too high to deter governmental and institutional commitment towards the
implementation of EHR. Hence the implementation of EHR comes with huge financial
responsibilities and commitments that often worsen already existing financial predicament of
health institutions in developing countries (Bedeley & Palvia, 2014).
A study by Jaana et al. (2012) found that financial resources were one of the main barriers
reported in the literature facing the adoption of EMRs in hospitals. According to Jaana et al.
(2012), prior research had found significant relationships between the level of EMR
capabilities in hospitals and the financial capacity in those hospitals. The feeling of instability
in securing financial support to implement the EMR influences the enthusiasm of the users
and leads to frustration; this could lead the system to fail (Hendy et al., 2007). Furthermore,
hospitals simply cannot afford to introduce EMRs owing to their limited budgets. Although
may countries have introduced some financial support and incentives to encourage small
hospitals to adopt EMRs, these countries remained at a disadvantage given their inability to
afford the core requirements before the implementation, such as IT infrastructure,
professionals and training (Jaana et al., 2012). Additionally, financial problems and economic
downturns may affect the budget allocated to EMR implementation, even in countries like the
UK (Hendy et al., 2007).
In public institutions, the government also influences the implementation of EMR systems
(Qureshi, 2013). This was also observed by Simbini (2013) who commented on the influence
of the Zimbabwean government on hospitals in implementing e-health systems. He observed
that the system of authority found in the health sector was very stringent and not highly
flexible. According to Simbini (2013) the utilisation of e-health in hospitals was determined
by the Ministry of Health itself. Hospitals had no right, especially district and central
hospitals, to institute e-health systems at their level. There was a lack of initiative with regard
to e-health from the part of the Ministry in terms of medical service delivery. Also, poor
government support could constitute a significant barrier to the adoption of EMRs as the
highest standard of governance is requited to ensure that hospitals support change, and
maintain the security and accuracy of their records (Parente and Van Horn, 2006).
24
2.7.4 Acceptance and Use Readiness
This construct assesses the personnel effort expectancy and performance expectance whose
attributes include; personal factors like; age, academic qualification and experience with
networking technology; ability to use technology and its newness; quality of services
provided, satisfaction with technology, organisational awareness and expected benefits.
Habibi- Koolaee et al. (2015), state that the role, of manpower readiness is a critical factor for
the successful implementation of EMR systems. Ahmadi (2011) concurs by stating that
nurses have an important role to provide clinical care, thus they have a valuable role in
successful implementation of electronic systems. Without their acceptance and in turn use of
EMR systems, all efforts to implement an EMR system would be ineffective. Hence, as part
of assessing an organisation’s readiness for EMR system implementation, it is important to
address acceptance and use issues.
In a descriptive-cross sectional study conducted in 2013 by Habibi-Koolaee on the readiness

of nurses in a teaching hospital at Tehran University of Medical Sciences, readiness was
computed by computer skills and knowledge and attitude of nurses. The level of computer
skill was assessed based on ICDL training. Amatayacul (2005) believes that to assess
readiness of healthcare providers for implementing EMR, healthcare providers’ computer
skills, knowledge and attitude should be surveyed.
Terry et al. (2008) showed that the readiness of healthcare workers is related to their
computer skills and knowledge about EMR. The authors stated that the physicians, nurses
and other health provides who have high computer skills would welcome the implementation
of EMR. This is supported by Coleman and Furusa (2018) who note that healthcare workers
with the necessary ICT skills and knowledge ae able to appreciate the possible benefits of e-
health in the workplace, and thus increase the chances of acceptance and use of e-health.
In countries that have assimilated ICT training for clinicians, acceptance of e-health and
actual use is relatively high (Khan et al., 2012). Training boosts awareness and confidence
levels as users are able to overcome technophobia while relating usage to expected benefits
(Sahay & Walsham, 2006). Abraham et al. (2006) add their voice by arguing that optimal use
of IT towards the transformation of healthcare requires IT knowledge in the medical
communities. The correlation between ICT skills and adoption of e-health is also discusses by
Juma et al. (2012) who point out that inadequate ICT skills in the health sector in Kenya
25
explains the low adoption of e-health. Hogan and Palmer (2005) are of the opinion that those
healthcare professionals who lack the ICT skills of processing the online health end up
spending too much time on the same. Without adequate ICT skills, user involvement in
selection and development of OCTs becomes difficult and if it happens, it is only to
rubberstamp the experts’ decisions. This might lead to having e-health technologies that are
not widely accepted.
In line with the above, Marques et al. (2011) states that ICT training among clinicians is cited
as a key determinant of electronic health. According to Ochieng and Hosoi (2005) on a study
that sought to establish the factors influencing diffusion of electronic medical records in
Japan, ICT skills are required to foster positive attitudes about electronic medical records.
Therefore, developed countries in an effort to raise ICT skills among clinicians have
incorporated ICT training in health courses offered at various academic levels. New courses
such as medical informatics, bioinformatics, computational biology, and health informatics
have been started. Sood et al. (2008) notes that the developed countries are using cutting edge
technologies like 3D simulations, virtual reality and robotics to rain clinicians and that ICT is
included in the curriculum of medical courses. Availability of ICT skills among clinicians is
likely to lead to the acceptance and actual use of e-health in primary healthcare (Mugo,
2014).
In a systematic review study, Hobbs (2002) indicated that the healthcare providers have little
interest in using computers, but there is a positive correlation between their knowledge and
attitude towards the use of computer. In the study of Jebraeily et al. (2010) there was not ant
significance between knowledge, attitude and computer skills. However, the findings of
Habibi-Koolaee et al. (2015) were not consistent with Hobbs and Jebraeily’s studies. The
reason may be because people’s awareness of the advantages and disadvantages of the system
has no equilibrium. This means that healthcare providers may be more concerned about the
potential disadvantages of the system and therefore have negative attitudes.
Other demographic factors such as age and the level of education also play an important role
in assessing the readiness of an organisation in implementing an e-health solution. Coleman
and Furusa (2017) state that by its very nature age is a source of digital divide because the
acceptance and use of technology is correlated to age. In their study, Coleman and Furusa
(2017) found that, the participating doctors, especially the young ones, expressed concern
26
over the older doctors who went to medical school during the paper era. The young doctors
noted that old doctors lacked enthusiasm to work in an environment that is embedded in
technology.
This corroborates Beebeejaun and Chitoos’ (2017) findings of a study that revealed
significant difference among age of healthcare providers and their readiness for adopting e-
health system. The younger groups are likely to have more positive attitudes regarding the
adoption of e-health than older age groups. This is in contrast to the findings of a study by
Arning and Ziefle (2016) who found that older age groups had more positive attitudes
regarding the usefulness of technologies than younger age groups.
2.7.5 Engagement Readiness Construct

Engagement readiness assessment result is dependent on healthcare providers’ fear or
concern about potentially negative impacts, recognition of benefits of EMR and their
willingness to accept EMR training. The construct is as illustrated in Figure 2.4.
Engagement Readiness
Potential Negative Impact Recognition of Benefits Willingness to Accept

EMR Training
High Limitation Time Worries Efficient Protection Better Provision & Willingne
investment of IT cost about Medical of patients’ provision of sharing of ss to
and poor knowledge change in Practice privacy patients’ timely accept
reimburse workflow information information EHR
ment training
Figure 2.4: Engagement Readiness (Li et al., 2008)
If healthcare providers over-express their fear or concern about potentially negative impacts,
but have not recognised the benefits of EMR and are not willing to accept EMR training, the
engagement readiness is low. In contrast, high readiness is for the organisations, where
healthcare providers do not over-express their fear or concern about potentially negative
27
impacts, and they have recognised the benefits of EMR and are willing to accept EMR
training.
Users’ perceptions on technology can affect how a technology is conceptualised and of it will
be accepted and further used. In a study that involved exploring hopes and fears in the
implementation of electronic health records in Bangladesh (Khan et al., 2012) found that
most actors who were afraid to use ICTs in the health sector had negative perceptions on
ICTs. In the study for instance, some physicians thought that using an EMR would be more
time consuming, which would negatively influence the time they could spend with patients.
This indicates that for successful adoption of e-health to be witnessed in developing countries
various stakeholders must change their attitudes on e-health. Patients must be ready to allow
that their health information be shared using ICTs, they should be able to use mobile devices
to search health information and must develop trust towards electronic medical records. The
clinicians must perceive ICTs positively by encouraging each other to use them in the
provision of health services. Where there are challenges with technologies, healthcare
providers should have those challenges addressed other than dismissing the whole concept of
e-health (Qureshi, 2013). Governments must also be in the forefront in raising awareness of
ICTs in the health sectors by organising seminars, conferences that bring together academics,
clinicians, hospital administrators and other policy makers (Mugo, 2014).
Training on the use of ICTs among clinicians is cited as a key determinant of electronic
health (Ochieng and Hosoi, 2005). According to Ochieng and Hosoi (2005) in a study that
sought to establish the factors influencing the diffusion of electronic medical records in
Japan, ICT skills were required to foster positive attitudes about electronic medical records
which translate to higher adoption of electronic medical records. Therefore, developed
countries in an effort to raise ICT skills among clinicians have incorporated ICT training in
health courses offered at various academic levels. New courses such as medical informatics,
bioinformatics, computational biology, and health informatics have been started. Sood et al.
(2008) notes that the developed countries are using cutting edge technologies like 3D
simulations, virtual reality and robotics to rain clinicians and that ICT is included in the
curriculum of medical courses. Availability of ICT skills among clinicians is likely to lead to
the acceptance and actual use of e-health in primary healthcare. This is because clinicians wit
ICT skills are able to appreciate the possible advantages of implementing e-health solutions.
28
2.7.6 Policy Readiness Construct
Policy readiness deals with policies, at the government and institutional level, which are in
place to address common issues (Khoja et al., 2007). Attention here is placed on policies put
in place for the promotion, support and management of e-health utilization in the health care
institutions. Of interest is the role played by government policy in the support and sustenance
of e-health initiatives. In support of this, Beebeejaun and Chittoos (2017) state that
government policies play a crucial role to maximise the probability of success in
implementing information systems. Shaqrah (2010) adds on by mentioning that the
government e-health policies make an environment where the likelihood of using resources
effectively is increased, the professionals find their suitable places and exercise faithfully and
the future of IT application in healthcare becomes clearly identifiable.
Mokhtar and Yusof (2009) conducted a study to examine EMR implementation in the
Malaysian public sector and especially the existence of a policy. The authors mention that
EMR implementation is not just a challenge that has to do with technology but the secret of
success is hiding behind the strategic planning of the activity. This is not wrong but when
talking about a transition from manual to electronic era then technology is a challenging issue
for the coordinators (Henriksen and Andersen, 2008). Naturally, for effective and proper
implementation of an EMR system it is vital to pay attention to the legislative and policy
environment (Henriksen and Andersen, 2008).
In a qualitative study conducted by Chikuni (2016) it was revealed that developing a robust e-
health system requires a suitable health policy. Chikuni (2016) notes that in Zimbabwe, an
ICT policy (MICT, 2010) and a national e-health strategy policy (MoHCC, Zimbabwe’s E-
Health Strategy, 2012- 2017) are in existence. According to him, policies are in place but
their implementation seems to be the biggest challenge hence most attempt to implement e-
health systems are usually standalone systems which are not evaluated for effectiveness of
even properly supported for effectiveness. Coleman and Furusa (2017) commenting on the
influence of government policy and implementation of EMR systems comment that the
problem with government policies is that the policies are drafted in isolation with one
another.
29
2.8 Summary
This chapter gave a detailed literature review on the readiness of hospitals in implementing
Electronic Medical Records systems. To minimise the risk of wasting resources and system
failure; risks that hospitals in resource strained economies cannot afford to take, a
comprehensive assessment of the readiness is mandatory before system implementation.
Implementation of EMRs is socio-technical in nature and therefore the requirements of
establishing such services should be established from different angles. A wide range of
factors such as core readiness, technological readiness, engagement readiness, societal
readiness, policy readiness, and acceptance and use must be addressed by hospitals before
implementing EMR systems. Literature revealed that core readiness determines the extent to
which the hospital is likely to adopt and use an EMR system as the higher the levels of
dissatisfaction with the status quo results in the likelihood of EMR system implementation. It
was also revealed that in terms of technological readiness, there is need to have adequate ICT
infrastructure, ICT support and ICT skills. However, government hospitals within developing
countries are characterised with a critical shortage in these. Literature also revealed that
policy readiness creates an enabling environment for EMR system implementation. Lack of a
clearly defined policy in EMR implementation has serious negative consequences on the
implementation and adoption of EMRs. Societal readiness, which includes partly factors from
the macro-environment greatly influences EMR system implementation. The economic
environments, including government support, are some of the factors that can enable or
hamper e-health implementation and adoption.
30
CHAPTER 3
RESEARCH METHODOLOGY
3.1 Introduction
This chapter covers the research design and methodology that was used to address the
research problem (Khothari, 2004). Research methodology is the overall approach to a
problem which could be put into practice in a research process, from the theoretical
underpinning to the collection and analysis of data (Remenyi et al., 2003). The methodology
brings out the strategies that were employed by the researcher to answer the research
questions. The chapter provides the research philosophy, research approach, research strategy,
data collection methods, sampling and sampling technique, ethical considerations, data
analysis and interpretation procedures. Methodology chosen was seen befitting to answer the
research questions for the study which required the use of both qualitative and quantitative
techniques.
3.2 Research Philosophy

Joubish et al. (2011) states that a research philosophy or paradigm is essentially a worldview,
a whole framework of beliefs, values and methods within which research takes place. In any
particular field, normal research is performed in accordance with a set of rules, concepts and
procedures called a paradigm, which is well accepted by scientists working in that field
(Rajasekar et al., 2013).
A pragmatic worldview was adopted for the study, given the research problem at hand. A
pragmatic approach is one which takes a practical orientation to a problem and finds a
solution that is fit for a particular context (Hammond and Wellington, 2014). It is based on
the premise that knowledge is both socially constructed and based upon the reality of the
world we experience and live in (Gray, 2014). This mode of inquiry makes use of induction
(to identify patterns), deduction (testing theories) and abductions (uncovering and relying on
the best explanations for understanding one’s results (Johnson and Onwuegbuze, 2004).
These qualities of pragmatism made it suitable for adoption in this study.
The pragmatic worldview was most suitable because it uses all approaches available to
31
examine the problem. Objectives of the study required pluralistic approaches to fulfill them
and this implied more than one system of philosophy and reality. This is supported by
Thomas (2009) who notes that what appears as the case is that the two paradigms, positivism
and intepretivism, are co-existing with each other and each is recognised as having its own
part to play in social inquiry – one paradigm will be right for one kind of question, the other
one right for another.
Pragmatism was also chosen because instead of focusing on methods, pragmatic researchers
put a lot of emphasis on the research problem and use all approaches available to understand
the problem. In this regard, without using both qualitative and quantitative data collection
methods, the researcher could have been overwhelmed by the population of healthcare
workers under study, and thus miss out on collecting information pertinent in the attainment
of objectives. Therefore, use of questionnaires to collect information from the healthcare
workers and interviews from the hospital administrators facilitated the collection of
quantitative data fulfilling the positivists and interpretivists approaches. Here, an advantage
of going pragmatic as revealed by Creswell (2014) is that pragmatism provides choices to
multiple methods, different worldviews, and different assumptions, as well as different forms
of data collection and data analysis.
3.3 Research Approach

Babbie (2012) identified research approach as a “systematic and orderly approach taken
towards the collection and analysis of data so that information can be obtained from those
data”. Since the study was guided by a pragmatic approach, a mixed methods approach where
quantitative and qualitative data was simultaneously collected and then merged at
presentation by way of relating the results of each type to produce conclusions based on data
collected from both approaches was adopted. Hammond and Wellington (2014) define mixed
methods approach as a combination of typically quantitative and qualitative methods in order
to provide complementary and perhaps contrasting perspectives on a phenomenon.
Specifically, mixed methods adopted in this study is the concurrent mixed method which
according to Caruth (2013) involves gathering quantitative and qualitative data at the same
time while one’s design purpose is to support the findings of the other design.
The researcher based the inquiry on the assumption that collecting diverse types of data
provided a more complete understanding of a problem than either quantitative or qualitative
32
data alone. As such, mixing was done on data collection, data analysis and data interpretation.
Some questions were addressed using a quantitative methodology, and some such as on
policy and societal readiness were addressed mostly in qualitative terms.
Mixed methods research is particularly useful for research projects where no single approach
can fully explain or explore the phenomenon being investigated, especially when this
phenomenon is complex and multifaceted (Fidel, 2008). Hence, this approach was deemed to
be particularly suitable to study information systems issues which are always
multidimensional and involve a wide range of socio-economic, socio-political, socio-
technical, regional and organizational factors (Peng, 2011).
Choice of the mixed methods approach was also inspired by the fact that mixed methods
approach is the only way to be certain of findings as it combines the strengths of each
methodology and minimizes the weaknesses (Mckim, 2017). This expands on Schulze’s
(2003) findings that mixed methods approach provides more breath, depth and richness as
compared with either quantitative or qualitative methods alone. This is because it is evident
that when multiple methods are used to collect data in mixed research, triangulation would be
achieved. Triangulation, in turn allows the researcher to be more confident of their results.
3.4 Research Strategy

Saunders et al. (2009) defined research strategy as the general plan of how the researcher will
go about answering the research questions. The main strategy that was employed by this
study is the survey strategy within a case study, with Ingutsheni being the case. Yin (2009)
highlights that in mixed methods, there are two nested arrangements, which are a case study
within a survey strategy and a survey within a case study.
A survey within a case study design was used for the purposes of triangulating both the
research methods and data collection. Questionnaires and semi-structured interviews were
used as data collection methods. Mathers and Hunn (2007) cited in Topodzi (2017) call the
survey a very traditional way of conducting research. They praise surveys for being
particularly useful for non-experimental descriptive designs. The best design that suited this
study was the descriptive survey method by virtue of its background. Also, the survey
strategy has been appreciated as a strategy suitable for the deductive approach, which permits
the collection of large amounts of data from a sizeable population economically. The study
was carried out deductively as it tested Beebeejaun and Chitto’s conceptual framework on e-
33
readiness of hospitals in implementing EMR systems. This model also influenced the
objectives and questions.
Survey research allows the use of more than one data collection techniques for the generation
of both qualitative and quantitative data. To achieve this, the researcher used questionnaires
to gather data from the healthcare workers and interviews from the hospital administration.
Where surveys are used, they take several forms. Depending on the aims and objectives of a
study, researchers can make use of either cross-sectional or longitudinal surveys.
Longitudinal surveys, according to Creswell (2014), are an approach in which data are
collected from people at different points over a period of time. These can either be
correlational or explanatory. Thus, in this study a cross sectional study was used. According
to Creswell (2014), a cross sectional survey is a research technique in which data are gathered
from a sample of people at one point usually using a questionnaire. It is a single, unrepeated
survey.
Advantages of the cross-sectional survey for this study included: the economy of the design
and the ability of the author to have quick and inexpensive means of collecting data.
Consequently, these advantages allowed the generation of data on more than one case at a
single point in time, allowing the researcher to generate data from the healthcare workers and
the hospital administrators at the same time thus, eliminating inconsistencies that may result
through variations in time for data collection.
The fact that the survey strategy can easily be used in mixed methods approach where
quantitative and qualitative data are obtained made it suitable for this study, which also had to
send questionnaires to a sample of a large population as well as interviewing hospital
administrators. Utilisation of the survey technique empowered the researcher to gather a lot
of data relating to the study; subsequently, allowing the researcher to examine issues
surrounding the e-Readiness of Ingutsheni Central Hospital holistically.
There are ethical advantages in surveys in that surveys are not likely to expose individuals to
the extent that they may be evasive or withhold treatment (Mather, Fox, and Hunn, 2007).
The argument by Mather, Fox and Hunn (2007) is based on the premise that the individuals
included in a study will merely be exposed to events that occur in the real world and would
have taken place anyway.
34
3.5 Population
This refers to the total group of people that a researcher wants to study. For this study,
participants were drawn from qualified mental health nurses referred to as healthcare workers
in the study and the hospital administrators. Healthcare workers were drawn from 14 wards
within the hospital. Target population of the study was 178 nurses from the selected wards,
and 7 hospital administrators. There are different categories of healthcare workers at
Ingutsheni Central Hospital, inclusive of psychologists, social workers, occupational
therapists. However, this study focused on qualified mental health nurses since they
constituted a large number of the hospital workers expected to use the EMR system.
3.6 Sampling and Sampling Frame

It was impossible for the researcher to collect data from all the healthcare workers due to
feasibility issues, hence sampling was done. Sampling made the research more accurate and
economical. Sampling is the act, process or technique of selecting a suitable sample of a
representative part of the population for the purpose of determining parameters or
characteristics of the whole population (Mugo, 2010). The researcher used both quota
sampling and judgemental sampling techniques to select study participants, which are non-
probability sampling techniques. Non-probability sampling is a sampling technique where
the samples are gathered in a process that does not give all the individuals in the population
equal chances of being selected.
3.6.1 Stratified Random Sampling

Stratified random sampling was used for the selection of participants from the healthcare
workers. This was done to ensure that each healthcare worker from each of the 14 wards had
a known probability of being selected. Healthcare workers were placed in different strata and
thereafter respondents were selected using simple random sampling from each ward. The
researcher used a computer program known as Research Randomiser to generate random
numbers to assign to participants. This reduced the potential for human bias in the selection
of cases to be included in the sample. To calculate sample size, an online sample size
calculator (https://www.surveymonkey,com/mp/sample-sizecalculator) was used. From a
population of 178 qualified mental health nurses, with a confidence interval of 95%, and a
margin error of 5%, a sample size of 124 was calculated. This sample size is typically big for
a survey. This was seen to be reasonable as the larger the sample size the more statistically
significant it is.
35
The number of cases that were to be included in each strata was dependant on the make-up of
each strata within the population. This involved using a sampling fraction that was
proportional to the total population to ensure that each strata contributed an evenly significant
percentage towards the total population. The formula for the sampling fraction was:
k = n/N
whereby n= sample size

N = population size
K =sampling fraction
The table below depicts the calculations for the sample size for each ward
Table 3.1 Sample size calculations for each ward

Name of the Number of Percentage Sample Size
hospital ward healthcare workers contribution in the
in the ward sample size
Dawson 12 7% 9
St. Lukes 2 11 6% 7
St. Lukes 1 12 7% 9
Juvenille 12 7% 9
St. Francis 11 6% 7
Mambo 11 6% 7
Nandi 11 6% 7
St. Mary’s 2 14 8% 10
Khumalo 22 12% 15
Mzilikazi 2 12 7% 9
J. W Villa 7 4% 5
Mzikazi 1 13 7% 9
Annexe 9 5% 6
St Mary’s 1 21 12% 15
178 100% 124
3.6.2 Judgemental Sampling

This is a non-probability sampling technique also known as purposive sampling. This was
36
done in the selection of hospital administrators who in this case included the, one person from
the ICT Department, one person from the Health Information Department as well as 5
matrons. Patton (2015: 264), states that,
“the logic and power of purposive sampling lie in selecting information-rich

cases for in-depth study. Information-rich cases are those from which one can
learn a great deal about issues of central importance to the purpose of the
inquiry…Studying information-rich cases yields insights and in-depth
understanding”.
3.7 Data Collection Instruments

The main instruments used in mixed method researches consist of close-ended and open-
ended questionnaires, interviews and classroom observations (Zohrabi, 2013). In this study,
the Researcher made use of questionnaires with both closed-ended and open-ended questions
and semi-structured interviews for data collection. These different ways of gathering
information supplemented each other and hence boosted the validity and dependability of the
data. In the main, the quantitative data were obtained through closed-ended questions and the
qualitative data through open-ended questions and interviews.
3.7.1 Questionnaires
As the study adopted a mixed methods design, it was binding that there be a data collection
method capable of collecting quantitative data that would be used together with qualitative
data from interviews. Thus, the Researcher adopted a questionnaire based on research design
as well as the advantages presented by questionnaires. Questionnaires were used to collect
data from healthcare workers.
The items of the questionnaires were developed based on the research objectives and research
questions. As such, the questionnaire was divided into 5 sections, with each section
addressing a specific objective. A combination of closed-ended and open-ended questions
was adopted in the development of the questionnaire. Closed-ended questions provided the
Researcher with quantitative or numerical data and open-ended questionnaires with
qualitative or text information. Seliger and Shohamy (1989 quoted in Zohrabi, 2013) are of
the opinion that closed-ended questionnaires are more efficient because of their ease of
analysis. On the other hand, Gillham (2000:5) argues that open questions can lead to a greater
level of discovery. He too admits the difficulty of analysing open-ended questionnaires. The
important issue in open-ended questions is that the responses to these types of questions more
accurately reflect what the respondents wanted to say. Therefore, it is better that any
37
questionnaire include both closed-ended and open-ended questions to complement each other
(Zohrabi, 2013).
Questionnaires are seen as one of the efficient means of collecting data on a large scale basis
in a cost effective way. As a result, questionnaires were used to gather large amounts of data
on the readiness of healthcare workers in implementation of EMR system at Ingutsheni
Central Hospital. Furthermore, respondent’s anonymity made the respondents’ share
information easily.
On the other hand, questionnaires have some disadvantages which should be kept in mind
whenever and wherever they are used (Gillham, 2000). Some of these shortcomings include
the fact that ambiguity and unclearness of some questions might lead to inaccurate and
unrelated responses, some questions may cause misunderstanding and the wording of the
questions might affect the respondents’ responses. Also it might be difficult to ascertain
whether the respondent would be the one who would have completed the questionnaire.
The above limitation however was mitigated by doing a pilot study. This is supported by
Williams (2003) who states that ideally, every questionnaire should undergo a formal pilot
during which the acceptability, validity, and reliability of the measure is tested. The best
method of piloting is to test the questionnaire with persons who have relative expertise in the
field, to anticipate any issues or any sources of confusion (Walliman, 2008).
Piloting of the questionnaire was done through presenting the questionnaire to peers. The
Researcher asked the peers to express their views concerning clarity of phrasing and integrity
of questionnaire formulation, appropriate phrase axis to which it belongs, proposals for
amendment, addition and deletion. This was expected to give additional value to the
questionnaire before final administration.
Also, another method of pre-testing the questionnaire that was done was having the
draft questionnaire tried out on a group that was selected on convenience and that was similar
in make-up to the one that ultimately was to be sampled. Specifically, the questionnaire was
pretested on the Researcher’s colleagues who are qualified mental health nurses, but
employed as nurse tutors. Here, factors such as discovering errors in the instrument,
evaluating procedure for data processing and analysis and checking for the reaction of
respondents were considered. On administration, contact details of the Researcher were
38
provided so that those with questions could make follow- ups.
3.7.2 Interviews
Data was collected from hospital administrators through semi-structured interviews. Semi-
structured interviews consist of several key questions that help to define the areas to be
explored, but also allow the interviewer or interviewee to diverge in order to pursue an idea
or response in more detail. This interview format is used most frequently in healthcare, as it
provides participants with some guidance on what to talk about, which many find helpful.
The flexibility of this approach, particularly compared to structured interviews was that it
allowed for the discovery or elaboration of information that was important to participants but
not have previously thought of as pertinent by the researcher.
The Researcher had 7 interviews with the hospital administrators, who in this case included
the health information manager, ICT person, and 5 matrons. In a semi structured interview
the Researcher asks a predetermined set of questions guided by the interview schedule.
While it is possible to try to jot notes to capture respondents' answers, it is difficult to focus
on conducting an interview and jotting notes. This approach would result in poor notes and
also detract for the development of rapport between interviewer and interviewee; hence the
researcher recorded the interviews. Development of rapport and dialogue is essential in
unstructured interviews. If tape-recording an interview was out of the question, the researcher
considered having a note-taker present during the interview.
To enhance reliability and validity, the researcher used member checking by offering each
participant the opportunity to review partial transcripts and verify accuracy of individual
interview upon completion. Qualitative investigators often depend on member checking to
ensure reliability of data by suggesting each participant examine transcripts and amend
recognised inaccuracies (Reilly, 2013).
The researcher opted for semi-structured interviews because questions can be prepared ahead
of time. This allowed the researcher to be prepared and appear competent during the
interview. Semi-structured interviews also allowed informants the freedom to express their
views in their own terms. They also provided reliable, comparable qualitative data. However,
there was the possibility of researcher bias and failure to manage time appropriately. To curb
39
this, the researcher conducted the interviews while maintaining an impartial and objective
stance throughout the interviews. The researcher also tried to adhere strictly to proposed
timeline. Also, this form of interview is neither too rigid nor too open. It is a moderate form
in which a great amount of data can be elicited from the interviewee.
3.8 Reliability and Validity

The researcher paid attention to both quantitative and qualitative dimensions of validity and
reliability. Reliability measures consistency, precision, repeatability, and trustworthiness of a
research (Chakrabartty, 2013). Riege (2003) states that it is a demonstration that the
operations and procedures of the research inquiry can be repeated by other researchers who
then achieve similar findings. Zohrabi (2013) states that obtaining similar results in
quantitative research is rather more straightforward than is with qualitative data due to the
fact that qualitative data is in narrative form and subjective. Thus, instead of focusing on
obtaining the same results, it is better to think about the dependability and consistency of the
data. In this case, the purpose is not to attain the same results, but to agree that based on the
data collection processes the findings and results are consistent and dependable.
In order to increase the reliability of the research, the researcher explained explicitly the
different processes and phases of the inquiry. This means that there was elaboration on every
aspect of the study. The rationale of the study, design of the study and the subjects were
described in detail. The researcher also described in detail how the data was collected, how it
was analysed, how different themes were derived and how the results were obtained. This
detailed information can help replicate the research and contribute to its reliability.
Furthermore, the interviews were recorded and preserved. This guarantees confirmability of
the interview data. Also, the reanalysis or the replication of the data can be rather easily
implemented by any independent investigator. This procedure can increase the internal
reliability of the data and findings.
Validity is concerned with whether the research is believable and true and whether it is
evaluating what it is supposed or purports to evaluate (Zohrabi, 2013). In this regard, Burns
(2010:160) stresses that “validity is an essential criterion for evaluating the quality and
acceptability of research. The quality of research instruments is very critical because “the
conclusions researchers draw are based on the information they obtain using these
40
instruments” (Fraenkel & Wallen, 2003, p. 158). Accordingly, it is imperative that the data
were used to validate the instruments and the data.
When dealing with content validity, the researcher is concerned with determining whether all
areas or domains are appropriately covered. To this end, as mentioned before, the research
instruments and the data were reviewed by the experts in the field of research. Based on
reviewer’ comments, the unclear and obscure questions were revised and the complex items
reworded. The ineffective and nonfunctioning questions were discarded altogether. Also, the
design of questionnaires and interview schedule was guided by the research objectives.
Mainly, internal validity is concerned with the congruence of the research findings with the
reality. Also, it deals with the degree to which the researcher observes and measures what is
supposed to be measured (Creswell, 2005). On the whole, to boost the internal validity of the
research data and instruments, the researcher applied the following methods recommended by
Merriam (1998): triangulation, member checks, peer examination, and minimisation of
researcher’s bias.
i. Triangulation. In order to strengthen the validity of data and findings, the Researcher
collected data through questionnaires and semi-structured interviews. Gathering data
through one technique can be questionable, biased and weak. However, collecting
information from a variety of sources and in this case from healthcare workers and
hospital administrators with a variety of techniques can confirm findings. Through
triangulation the researcher gained qualitative and quantitative data in order to
corroborate findings.
2. Member checks. Through member checks the results and interpretations were taken
back to the participants in order to be confirmed and validated. Therefore, the results
and interpretations of interviews were handed over to the interviewees in order to
confirm the content of what they would have stated during the interview encounter. In
this way the plausibility and truthfulness of the information was recognized and
supported.
3. Peer examination. In a peer examination process, the research data and findings are
reviewed and commented on by several nonparticipants in the field. However, these
peers need to be familiar with the subject under study and possess enough background
information in it. Therefore, the researcher asked two experienced professionals who
41
had the necessary expertise in health information management research to review and
comment on the interview and questionnaire data and findings. It is certain that the
plausibility of data analysis and interpretations by these peers tremendously
augmented the validity of the research.
4. Researcher’s bias. It is clear that every researcher has his/her own particular values,
beliefs and worldviews. To minimise bias, the Researcher tried to collect, analyse and
interpret data as impartially as possible. The Researcher was also explicit, critical and
faithful at different phases of the inquiry process. Also, the Researcher followed the
ethical rules and principles, performed the evaluation as accurately as possible and
reported the findings honestly.
3.9 Data Collection Procedures

Data was collected using questionnaires and semi structured interviews. The researcher asked
the First Line Nurse Managers to assist with the distribution of questionnaires. This was
meant to ensure a higher response rate considering that the nurses work on shifts. To collect
qualitative data through interviews, the Researcher had to schedule appointments with each
participant. The Researcher then followed the eight steps recommended by Turner (2010) to
follow before starting an interview:
1. choosing a setting with little distraction,

2. explaining the purpose of the meeting,
3. addressing terms of confidentiality,
4. explaining the format of the interview,
5. indicating how long the interview usually takes,
6. telling participants how to get in touch with the researcher later if they wish to,
7. asking participants if they have questions before starting the interview, and
8. not relying on memory to recall respondents answers.
3.10 Data Presentation and Analysis Procedures

Since the study used a mixed methods approach, qualitative and quantitative data
presentation and analysis procedures were taken into consideration. The researcher conducted
separate qualitative and quantitative analysis; merged the two data sets either through data
transformation. Data transformation involves the converting of one form of data into the other
form, for example qualitative into quantitative or vice versa, so that it is easily merged.
42
Quantitative data was presented using descriptive statistics, graphs, and tables. Qualitative
data was presented using narratives and themes to records responses from the interviews.
SPSS was used for quantitative data analysis and Microsoft Excel was used too to generate
graphs for data presentation.
3.11 Ethical Considerations

Polit and Hungler (2006) say that ethics are concerned with the degree to which research
procedures adhere to professional, legal and social obligations to research subjects. Ethics
relate to two groups of people, those carrying out the research who should be aware of their
obligations and responsibilities in the way they carry out their activities and the researched
upon who have basic human rights that should be protected. Research subjects had the right
to be informed about research, to consent, or to withdraw from it if they were not content.
Ethical issues were taken into consideration by the researcher throughout the research process
(right from the formulation of the research questions to the dissemination of the research.
Creswell (2009) notes that in formulation of a research problem, it is important to identify a
problem that will benefit the individuals being studied, one that will be meaningful for others
besides the researcher. As such, the researcher observed this by identifying a research
problem, whose study was expected to benefit Ingutsheni Central Hospital in the
implementation of an Electronic Records System. It was hoped that from the results of the
study, the hospital would identify those factors that might negatively impact the
implementation of an EMR system, and address them before rolling out an EMR initiative.
On addressing ethical issues in the purpose and questions, Sarankatos (2013), states that in
developing the purpose and research questions of the study, the researcher needs to convey
the purpose of the study that will be described to the participants. In compliance with this
ethical consideration, the researcher clearly explained the purpose of the research to the
participants, thus avoiding deception which might be evident in research whereby,
“participants might understand one purpose, but the researcher has a different purpose in
mind” (Creswell, 2009).
There are also many ethical issues that were addressed during data collection. Ethical
clearance was sought from Ingutsheni Central Hospital authorities through writing a letter
that identified the extent of time, the potential impact, and the outcome of the research. Also,
a supporting letter from the Department of Library and Information Science requesting for
43
authorisation to conduct a study was presented to the hospital authorities.
All the information obtained was kept in confidence by the researcher and the faculty. No
names of the participants was indicated anywhere. All participants were required to give an
informed consent of their willingness to participate. During the study each participant was
given a consent form to read and understand before signing and getting involved in the study.
Elements of the consent form included:
 Identification of the researcher

 Identification of how the participants were selected
 Identification of the purpose of research
 Identification of the level and type of participant involvement
 Assurance that the participant can withdraw at any time
 Provision of contact names if questions arise.
In data analysis and interpretation, the researcher dissociated names from responses. Also, in
interpretation of data, the researcher provided an accurate account of information. As the
study was based on pragmatism, the researcher did some debriefing with the participants to
check accuracy in the quantitative aspect of the research. For the qualitative aspect, the
researcher employed one or more strategies, for example member checking, and peer
debriefing to check the accuracy of the results.
In writing and dissemination of the research, the writer avoided the potential of suppressing,
falsifying, or inventing findings to meet the hospital’s needs or her needs. Scientific
misconduct such as plagiarism was also avoided by acknowledging the work of others.
3.12 Summary
The chapter highlights the research philosophy, research design, the research strategy,
population and sampling, the instruments, data collection, analysis and presentation
procedures as well as ethical considerations. The research adopted a pragmatic worldview as
it accommodates multiple stances. Mixed methods approach was adopted because of its
ability to enhance the validity and credibility of the research findings by comparing
information obtained from different methods of data collection. Cross sectional survey design
was opted for with the hospital as the unit of analysis, and EMR system readiness as the
44
subject of inquiry. The study population included the hospital administrators and qualified
mental health nurses. These participants were selected using purposive sampling and
stratified random sampling respectively. The chapter also looked at how validity and
reliability issues were enhanced through triangulation, member checking, and pretesting of
the research instruments. Ethical issues were also considered throughout the research process.
45
CHAPTER 4
DATA PRESENTATION AND ANALYSIS
4.1 Introduction
This chapter focuses on the presentation, analysis and interpretation of the study findings.
The presentation and analysis of the results was guided by the mixed methods methodology
which was adopted by this study. Quantitative findings from the healthcare workers were
presented together with qualitative results of the interviews. Quantitative data was gathered
from the closed ended questions of the questionnaire and it was analysed using SPSS. Data is
presented in themes guided by the research objectives which were outlined in chapter one.
The presentation of the quantitative data is done in graphs, charts, tables and descriptive
statistical narratives. Qualitative data was grouped into themes and represented as narratives.
4.2 Demographic Data

A total of 124 questionnaires were administered by the researcher across the 14 wards of the
hospital and 98 questionnaires were returned giving a 79% response rate. Table 4.1 highlights
the response rate by gender, qualification, age and work experience. Of the 98 respondents,
57.1% (56) were female and 42.9% (42) were male. The majority of the respondents 39.8%
(39) were within the 31-40 years age range, followed by 26.5% (26) within the 21-30 years
age range. 25.5% (25) were aged between 41 -50 years and only 8.2 % (8) belonged to the
51-60 age range. None of the respondents were above 61 years.
The results show that the highest number of respondents; 77.6% (76) have been in the nursing
profession for a period of 1-5 years, followed by 16.3% (16) with a period of 6-10 years.
Only 6 respondents (6.1%) have been in the nursing profession for a period of more than 10
years.
46
Table 4.1 Response Rate by Gender, Age and Years of Experience
Gender
Cumulative
Frequency Percent Valid Percent Percent
Valid Male 42 42.9 42.9 42.9
Female 56 57.1 57.1 100.0
Total 98 100.0 100.0
Age
Cumulative
Valid 21-30 26 26.5 26.5 26.5
31-40 39 39.8 39.8 66.3
41-50 25 25.5 25.5 91.8
51-60 8 8.2 8.2 100.0
Total 98 100.0 100.0
Experience
Frequency Percent Valid Percent Cumulative Percent
Valid 1-5 76 77.6 77.6 77.6
6-10 16 16.3 16.3 93.9
10+ 6 6.1 6.1 100.0
Total 98 100.0 100.0
The researcher managed to conduct interviews with all the targeted interviewees who
comprised 5 matrons, ICT manager and the Health Information manager.
Presentation of Findings
4.3 Acceptance and Use

It was necessary to collect data on socio-demographic factors such as age, gender,
qualification and work experience as there were believed to be some of the factors that might
influence acceptance and use of EMR systems.
4.3.1 Age and Knowledge in Computer Use

Twenty point four percent respondents (20) within the 21-30 age group indicated that they
were novices in computer use; 22.4% (22) respondents within the 31-40 age group also
indicated that they rated their knowledge in computer use as novice. 12.2% (12 respondents)
47
from the 41-50 age group indicated the same, with only 6.1% respondents from the 51-60 age
group saying they were novices.
The highest number of respondents (12.2%) who rated their knowledge in computer use as
average were those between 31 and 40 years, followed by 6.1% (6) respondents from the 21-
30 age group. Only 4% (4) respondents from the 41-50 age group rated their knowledge in
computer use as average. From the 51-60 age group, only 2.2% (2) respondents rated their
knowledge in computer use as average.
None of the respondents from the 21-30 age group and 51-60 indicated to be experienced
computer users. The highest number of respondents 9.1% (9) who indicated that they were
experienced computer users were within the 41-50 age range followed by 5.1% (5)
respondents from the 31-40 age group. Table 4.2 illustrates this.
Table 4.2 Age * Knowledge Cross tabulation

Knowledge
Experience
Novice Average d Total
Age 21-30 20 6 0 26
31-40 22 12 5 39
41-50 12 4 9 25
51-60 6 2 0 8
Total 60 24 14 98
A chi-square analysis was also done to determine the relationship between age and
knowledge in computer use. P value was 3.325 as shown in Table 4.3 below.
Table 4.3. Chi-Square Tests of Age and Knowledge in

Computer Use.
Asymptotic
Significance
Value Df (2-sided)
a
Pearson Chi-Square 16.709 6 .010
Likelihood Ratio 19.119 6 .004
Linear-by-Linear
3.325 1 .068
Association
N of Valid Cases 98
48
4.3.2 Age and Commitment
All the respondents across all age groups indicated that they were committed to the training
and use of EMR systems.
4.3.3 Gender and Awareness in EMR systems

A chi-square test on gender and awareness in EMR systems was done to see if gender has any
influence on healthcare awareness of EMR systems. Results are as shown in Table 4.4 below:
Table 4.4 Chi-Square Tests on Gender and Awareness in
EMR systems
Asymptotic
Significance
Value Df (2-sided)
a
Pearson Chi-Square .643 2 .725
Likelihood Ratio .641 2 .726
Linear-by-Linear
.151 1 .698
Association
N of Valid Cases 98
A p value of .151 was noted.
4.3.4 Experience and Commitment to Dedicate to the Training and Use of EMR systems
All the respondents (100%) indicated that they were committed to dedicate to the training and
use of EMR regardless of their years of experience.
4.4 Core readiness

Core readiness in implementing an EMR system was addressed from healthcare workers
awareness of EMR systems, previous use of EMR, healthcare workers’ satisfaction with the
current medical records management services offered by the hospital, as well as the
realisation of problems faced in using paper-based medical records.
4.4.1 Awareness of EMR systems

The healthcare workers were asked about their level of awareness of EMR systems.
Participants were presented with four choices; nothing, a little, very little and a great deal.
The results are as shown in Figure 4.1.
49
Awareness of EMR systems
Very Little
10%
Little
34% Nothing
56%
Figure 4.1 Awareness of EMR systems

The results showed that 56.1% (55) of the respondents knew nothing about EMR systems,
33.7% (33) knew a little, and 10.2% (10) knew very little. None of the healthcare workers
knew a great deal about EMR systems.
Similarly, a question that tested the awareness of the matrons, ICT Manager and the Health
Information Manager, herein referred to as the hospital administrators, was asked. The results
of the interviews showed that all the interviewed respondents were aware of the existence of
EMR systems in the medical field with the most popular response being:
“I have heard about EMR systems, but I haven’t used them before….I got to
know of them theoretically when we were doing our Diploma in Nursing
Administration. Unfortunately, we haven’t had any hands on experience in
using these systems”
However, only 2 of the respondents, demonstrated much knowledge on EMRs and stated that
the hospital currently had one such system ‘ePMS’, that catered for a special type of clientele,
that is, HIV patients, and thus was run at a very small scale. They further explained that this
was also used for disease surveillance and to track these HIV patients. However, as one
interviewee put it,
“Ingutsheni Hospital does not have a system that caters for the whole hospital
as is the case at many private hospitals as well a few government owned
hospitals.”
50
4.4.2 Previous use of EMR systems
The healthcare workers were also asked on previous use of electronic medical records. The
results indicated that only a few of the respondents 13.3% (13) had used EMR systems
before, with the majority, 86.7% (85) having not used EMR systems before. Those who had
used EMR systems before indicated that they had experience in using such systems from the
part time jobs they did at private hospitals.
Of the 7 respondents who were interviewed, only 2 said that they had previous use of the
EMR systems.
4.4.3 Satisfaction with the current medical records management services

The respondents were also asked the extent to which they were satisfied with the way
medical records were managed at Ingutsheni Central Hospital. The majority of the
respondents, 58.2% (57) indicated that they were very dissatisfied with the way medical
records were managed whilst 36.7% (36) were dissatisfied, and 5.1% (5) were indifferent. Of
interest to note was the fact none of the respondents indicated that they were either very
satisfied or satisfied with the way medical records were managed.
Likewise, the hospital administrators were asked whether they were satisfied with the way
medical records were managed. Four of the interviewed respondents indicated much
dissatisfaction as one respondent expressed it,
“Actually, I am not happy at all about how things are done here because we are
mainly doing it on paper and this is an old way of doing things. We need to be
computerised and Ingutsheni Central Hospital is lagging behind in terms of
ICTs. We need to be computerised so that we lessen the burden of
recordkeeping and reduce duplication of effort.”
However, on a different note, only one respondent was neutral. The respondent indicated that
she could not say that she was not satisfied although she knew that the hospital was behind in
terms of technology. The other 2 respondents indicated that they were satisfied with the way
the medical records were managed as they had not had any challenges associated with the
way medical records were managed.
4.4.4 Challenges faced

In response to a question that was asked on whether the healthcare workers had ever faced
any challenges in the way medical records were managed, 95.9% (94) respondents pointed
51
that they had faced challenges in the way medical records were stored. Only 4 respondents
denied to have ever faced any challenges in the way medical records were stored as shown in
Table 4.5.
Table 4.5: Existence of challenges faced by healthcare workers as a result of the way
medical records are stored
Cumulative
Valid Yes 94 95.9 95.9 95.9
No 4 4.1 4.1 100.0
Total 98 100.0 100.0
Those who had faced challenges before were asked to state the challenges they had faced
with the paper-based medical records management in a qualitative way. A similar question
was asked to all the interviewees. The responses are as narrated below.
Paper is fragile
All respondents reported that paper medical records are easily broken and there could be
information loss. Regarding this, one of the female respondents who had 5 years of service
experience denoted as follows;
“Paper based medical records are just proving to be a challenge in the treatment
of patients here. Considering the type of patients that we have here, most of the
cards they bring from home will be showing lack of proper care for example,
they are exposed to water, get torn and in the end vital information is rubbed
off. Others will simply be not in the right state of mind to be taking care of
these records.”
Storage problem
Another common problem of paper based medical record system indicated by the respondents
was storage problem. They indicated that paper medical records took a lot of space for
storage and it became a problem when they accumulated and became a pile. They added that,
papers were not durable and easily damaged naturally during storage.
52
Other problems that were mentioned included the fact that paper-based medical records were
expensive to use and did not easily facilitate the addition of new information. As one
respondent indicated,
“The hospital is running out of paper…..and the information becomes too big
because we will be filing a lot of papers in one file and our patients are chronic
patients and we end up with 2 or more than 2 volumes of files for one patient,
and in the end the old information might be lost.”
Other problems indicated were those related to missing files, misplaced files and the long-
time taken to retrieve a patient’s file, especially when that patient came to the hospital for
treatment after a very long time.
To assess core readiness, the healthcare workers were also asked to indicate their opinion on
the implementation of EMR in their wards, and the results indicated that all the respondents
(100%) viewed the implementation of EMR systems in their wards as a requirement.
4.5 Technological Readiness

Technological Readiness was addressed based on the availability of ICT infrastructure such
as computers, printers, PDAs, laptops and printers; relevant software; Internet and the
availability of skilled human resources in ICTs.
4.5.1 Availability of ICT infrastructure

A question was asked to the ICT Department on the technological infrastructure required for
the implementation of EMRs and it was indicated that EMR implementation requires basic
ICT infrastructure such as computers, servers, reliable Internet and printers, just to mention a
few of the resources needed. Asked on the adequacy of the infrastructure available at the
hospital to implement an EMR system, it was noted that the ICT infrastructure that the
hospital had at the time was inadequate for the implementation of an EMR system, for
example, there were no computers at the wards. The few computers that were at the hospital
were used for administration purposes only, and not every office had computers.
All the healthcare workers indicated that they do not have access to computers in their wards.
Also, the results indicated the absence of hardware such as desktops, laptops, PDAs, printers
needed for EMR implementation at the wards.
53
4.5.2 Training on the use of EMRs
On the issue of training or direct experience in using EMRs, only 8.2% (8) respondents said
that they had been previously trained in using EMRs, and the majority, 91.8% indicated not
to have been previously trained in the use of EMRs.
Similarly, the hospital administrators were asked whether any training on EMRs and ICTs in
general had been provided by the hospital. One respondent with 9 years of service at the
hospital mentioned that since he joined the hospital in 2010, the hospital had never offered
any training in ICTs to the nurses.
However, prior to 2010, the hospital offered some training in ICTs to the senior members of
staff. As one respondent put it,
“Yes there was a time when the senior nurses were taken to Speciss College,
but unfortunately all of the nurses who went for training are gone, maybe we
are left with one only. The training was going to cascade downwards but the
hospital must have probably run out of funds, and the programme stopped at
that time”.
4.5.3 ICT Skills

A question on the technical skills that are required for one to be able to use EMR systems was
asked. The response was that basic computer literacy skills such as data capturing skills and
ICDL were a requirement.
“Without these, one cannot use an EMR system effectively, however, no

special skill is required”.
The healthcare workers were also asked to rate their knowledge of computer usage and the
results are as shown in the Figure 4.2
54
Figure 4.2: Knowledege in computer use
The majority of the respondents 61.2% (60) rated their knowledge in computer use as novice,
whilst 24.5% (24) said that it was average. Only 14.3% (14) rated their knowledge in
computer use as experienced.
4.5.3 Adequacy of ICT support

A question was asked about whether the hospital had enough human resources in terms of
skill and expertise to support the implementation and sustenance of an EMR system. It was
found that the hospital’s ICT Department was at the time run by only one qualified ICT
person. The response was as follows:
“..if only the hospital would employ another ICT personnel, I think that I would
have safely said that we have enough human resources in terms of skill and
expertise in the ICT Department. At the moment, I just do everything by
myself and of course with the help of 2 student interns. The department also
has hospital equipment technicians,however, their area of expertise is not on
ICTs but on hosputal equipment such as X-Rays, Boilers, and CT Scanners”.
55
4.6 Engagement Readiness
Engagement readiness assessment result were based on healthcare workers’ opinion on the
importance of EMRs, their fear or concern about potentially negative impacts, recognition of
benefits of EMR and their willingness to accept EHR training.
4.6.1 Importance of EMR

In order to get to know the healthcare workers’ perception on the importance of EMR
implementation, a question was asked on how they ranked the importance of EMRs basing on
a scale ranging from ‘Not Important at all’ to ‘Very Important’. Table 4.6 shows the results.
Table 4.6 Perceptions on significance of EMR implementation

Cumulative
Valid Somewhat
26 26.5 26.5 26.5
Important
Neutral 13 13.3 13.3 39.8
Important 23 23.5 23.5 63.3
Very Important 36 36.7 36.7 100.0
Total 98 100.0 100.0
As shown in Table 4.6 above, most respondents 36.7% (36) ranked EMR implementation as
very important, followed by 26.5 % (26) respondents who ranked the EMR implementation
as somewhat important. 23.5% (23) respondents said that it was important, whilst only 13.3%
were neutral.
4.6.2 Perceived benefits of EMR implementation

Healthcare workers were asked to rate the perceived benefits that they believed would occur
as a result of EMR system implementation in order of importance. The results are as shown
in Figure 4.3.
56
Figure 4.3 Benefits of EMR implementation
Improving workflow
The majority of the respondents 74.5% (73) agreed that EMR implementation was very
important in improving workflow, whilst 15.3% (15) said that it was fairly important and
10.2% (10) said that it was just important. None of the respondents showed that EMR
implementation was slightly important in improving workflow.
Reducing Medical Errors

The majority of the respondents 39.8% (39) said that EMR implementation is fairly important
in reducing medical errors, 30.6% (30) said that it was very important in minimising medical
errors. Eighteen point four percent (18) indicated that it was important whilst 11.2% (11)
indicated that EMR implementation is slightly important in reducing medical errors.
Reducing Costs
The majority of the respondents, 30.6% (30) indicated that EMR implementation would help
reduce costs, whilst 28.6% (28) reported that EMR implementation was fairly important. The
least number of respondents, 14.3% (14) said that EMR implementation was slightly
important in cost reduction. 26.5% (26) respondents, however, were of the view that EMR
implementation was very important in cost reduction.
57
Improving Information Retrieval
All the respondents (100%) perceived information retrieval to be a very important benefit
derived from EMR implementation.
Minimising malpractice claims

Twenty three point five percent (23) respondents indicated that EMR implementation was
very important in minimising malpractice claims, 38.8% (38) showed that it is fairly
important, whilst 35.7% (35) respondents indicated that it was important. However, only
(2%) 2 respondents were of the view that EMR implementation was slightly important in the
reduction of medical errors.
The hospital administrators were also asked a question on the benefits of implementing an
EMR system and indicated that an EMR system would improve service quality at the
hospital, and would also improve information retrieval as one respondent put it,
“for example, at Khumalo ward there, which is an admission ward, if EMR

systems are implemented it would be a matter of clicking the button and getting
the information at hand, rather than waiting for the records officers to open
their office on whatever day. Maybe it would be a weekend and you really need
that information, you have to wait for Monday, and then go to their archives
and start paper hunting”.
Another respondent added that,
“with the implementation of an EMR system life becomes easy both for the
nurse and the administrator”.
4.6.3 Fear about potential negative impacts

The information on the fear about potentially negative impacts was collected in a purely
qualitative manner. The majority of respondents indicated that the fear that they had was
linked to the nurses’ low computer literacy skills and a general phobia for computers. Others
indicated a fear for the loss of information in the event of system failure and they hinted that
the hospital might even fail to attend to such failures due to financial challenges that were
typically faced by the hospital.
58
4.6.4 Willingness to dedicate to training
None of the respondents refuted the idea of receiving training on the use of EMRs should the
hospital implement the system. The reason they gave was that they felt that it was necessary
to move with the times, especially in this technological era where one has to be up to date
with new technologies. Thus, training would be a great advantage to them.
4.7 Societal Readiness

Societal readiness was assessed from the collaboration of Ingutsheni hospital with other
health institutions; sharing of information, provision of care to patients and communities in
collaboration with other healthcare institutions; socio-cultural factors among staff; socio-
economic position and socio-cultural factors among clients and communities.
Respondents were asked how the hospital shared patient care information with other hospitals
or service providers, and all the respondents indicated that they used telephone mainly to
communicate with other hospitals. None of the respondents showed that the hospital used any
electronic means such as email or fax when communicating with other hospitals, as shown by
Table 4.7.
Table 4.7 Other Medium of communication

Cumulative
Valid Ambulance 4 4.1 4.1 4.1
Hospital Transfer letters 1 1.0 1.0 5.1
Hospital Transfer
3 3.1 3.1 8.2
Letters
Mails 3 3.1 3.1 11.2
Nurse 1 1.0 1.0 12.2
Patient Notes 21 21.4 21.4 33.7
Patient Records 1 1.0 1.0 34.7
Physically through
1 1.0 1.0 35.7
ambulance
Written records 1 1.0 1.0 36.7
Written Records 62 63.3 63.3 100.0
Total 98 100.0 100.0
The researcher also asked the respondents whether they used email in any work related
communication and none of the respondents used email in work-related communication.
59
Inter-transfer hospital notes whereby “the doctor writes detailed notes, reports on
investigation, management they expect the other doctor to do on the patient” was the main
mode of communication used by the hospital.
On the socio-economic position of the hospital, all the respondents interviewed indicated that
unlike other hospitals, Ingutsheni Central Hospital is a non-income generating hospital, that
is, the clients get all the services free of charge. One interviewed respondent emphasised that,
“One of our drawbacks is that we depend on the government budget and we do

not generate any income… we depend on the national budget…..we are just
incapacitated to put for example, computers in every ward”.
As a public institution the hospital relied on annual government fund allocations which were
usually not enough to cater for every other expense that the hospital incurred. This in turn
affected the rate at which ICTs were adopted in the hospital, as many departments competed
for the little resources that the hospital received. To add on to that, another respondent said
that,
“Our economic situation is the one that is making us lag behind in terms of
ICTs, this system should have been implemented yesterday than today,
however, we need to appreciate that we cannot start to run before we crawl”.
Another respondent indicated that the ICT Department was not viewed as a priority in
relation to other departments in the hospital. The respondent said that the importance of ICTs
was only realised after a problem that requires an ICT solution would have been faced, other
than that, the department came bottom on the list. This was the case with fund allocation
within the hospital. As reported;
“Although some funds are allocated to the department yearly… should any
need arise in other departments, ICT Department is always the sacrificial lamb
of the hospital…immediately funds will be diverted for other uses”.
The other challenge that the hospital faced as reported by one respondent was that, as a non-
income generating public institution, Ingutsheni Central Hospital had to wait for the Ministry
of Health and Child Care to initiate the implementation. “This involves a lot of bureaucracies
and thus decisions take time to be made”, reported one respondent.
60
In terms of community readiness, all the respondents said that the community was ready for
EMR implementation, considering the age group of the majority of the hospital’s clients.
They also indicated that very few people these days do not understand the value of
computers. However, emphasis was put on the importance of communicating change to the
patients should the hospital implement the system.
4.8 Policy Readiness

A question was asked to the respondents about whether there were either governmental or
institutional policies they knew of that governed the implementation of ICTs in hospitals. The
majority of the respondents were not aware of any such policies. However, those who were
aware, indicated the existence of the Ministry of Health and Child Care ICT policy but
pointed out that the provisions of the policy were not clear on the implementation of EMR
systems in hospitals. Also, another respondent indicated that there was no coherence of the
existing policies that governed the management of medical records.
“For example, the hospital’s health information department relies on the

Records and Archiving Act of 1986 and this does not cater for any use of ICTs
in medical records management”.
4.9 Data Interpretation and Discussion

This section interprets the major research findings and shows how the results fit into previous
studies. It also links the results with literature reviewed.
4.9.1 Acceptance and Use

It was necessary to examine socio-demographic factors such as age, gender and work
experience as there were believed to be some of the factors that might influence acceptance
and use of EMR systems. As such a chi-square analysis of the socio-demographic factors and
knowledge in use of computers, awareness and willingness to dedicate to training on EMR
systems was done.
The results showed that there was no association (p=3.325) between age and knowledge in
computer use. This is in contradiction with Coleman and Furusa (2017) who state that by its
61
very nature age is a source of digital divide because the acceptance and use of technology is
correlated to age.
All the respondents were willing to dedicate to the training and use of EMR systems. These
findings are consistent with those reported in a study by Nour (2005) who found that health
worker age was not associated with EMR versus paper record use preferences. However,
these findings contradicted results from several studies that found that younger health
workers preferred EMRs more than older health workers (Olufunmilayo et al. 2017; Lakbala
and Dindarloo, 2014). Also, findings from a study conducted in Kuwait indicated that
younger health professionals had better readiness for EMR system. This may be due to the
fact that younger people natural tend to have more motive, interest, and readiness to accept
new technology developments than aged people ( Al-Azmi , 2008)
The findings revealed that there was no association (p=0.151) between gender and awareness
in EMR systems. Similarly, findings from a study that was done in Kenya showed that there
was no significant difference between males and females in terms knowledge levels in EMR
(P = 0.35). This was probably because males and females have equal exposure to technology
in modern contexts.
Also, the number of years of work experience did not have any influence on willingness to
use EMR system. This was in contrast with findings of a study by Baron (2005) where there
was a significant association between the years of experience and willingness to use
electronic medical records systems.
4.9.2 Core Readiness

The study findings showed that more than half of the healthcare workers, 56.1% (55) knew
nothing about EMR systems, 33.7% (33) knew a little, and 10.2% (10) knew very little. None
of the healthcare workers knew a great deal about EMR systems. The findings are in contrast
with a study conducted by Lakbala (2014) testing the perception and attitude of physician’s
toward electronic medical records whereby all the respondents (100%) knew a great deal
about electronic medical records. However, they are almost similar to the findings by Biruk
(2014) whereby more than half of the participants (86%) did not have any know-how about
EMR systems. The reason for this might be that the idea of e-health is relatively new to
healthcare centres in Zimbabwe (Coleman and Furusa, 2018). It might also be attributed to
62
the fact that schools of nursing do not teach computer application although some nurse
administrators are expected to be computer literate (Madya and Chinamasa, 2012).
On previous use of EMRs, findings revealed that only a few of the respondents 13.3% (13)
had used EMR systems before, with the majority, 86.7% (85) having not used EMR systems
before. Those who had used EMR systems before indicated that they had experience in using
such systems from the part time jobs they did at private hospitals. The reason for this might
be that the state of e-health in Zimbabwe is low and very unsatisfactory in public healthcare
institutions. E-health systems are mainly focused on selected central hospitals, thereby
neglecting other hospitals. Thus, its state in public hospitals can be described as nascent
(Coleman and Furusa, 2018).
The majority of the respondents, 58.2% (57) indicated that they were very dissatisfied with
the way medical records were managed whilst 36.7% (36) were dissatisfied, and 5.1% (5)
were indifferent. Of interest was the fact none of the respondents indicated that they were
either very satisfied or satisfied with the way medical records were managed. Likewise, the
hospital administrators were asked whether they were satisfied with the way medical records
were managed. Four of the interviewed respondents indicated much dissatisfaction.
In accordance with the present results, a study by Marutha and Ngaope (2017) showed that
when asked to rate the state of records management, 15% (24) of respondents indicated that
the state of records management in their institutions was very poor, 58% (94) stated that it
was poor while 1% (2) were unsure about the state of records. Additionally, 22% (36)
indicated that it was in a good state, while 4% (6) were of the view that the state of records in
their institutions was very good. Those indicated unsure, poor and very poor justified that at
times records were requested in bulk, which made the retrieval process lengthy. It was stated
that there was too much paperwork, no proper filing/archiving system, poor planning, poor
organisation and supervision, files were inexplicably lost as well as a lack of filing space.
Similarly, Luthuli and Kalusopa (2017) conducted a study and their findings revealed that the
majority of respondents from Ngwelezana Hospital said that they were not happy with the
way their records were managed at the Outpatient Department (OPD). The study revealed
patients finding their files covered in dust or torn; sometimes folios or entire files missing and
patients not told where they could be located. As a result of dissatisfaction in use of paper
63
based medical records, all the respondents in the study regarded EMR system implementation
to be a requirement; hence they were core ready for implementation.
4.9.3 Technological Readiness

Study findings showed that there was no adequate information technology infrastructure
needed for the implementation of EMR system at the hospital. It was revealed that the few
computers that the hospital had were used mainly for administrative purposes. This
corroborates recent findings by Coleman and Furusa (2018) that a number of hospitals in
Zimbabwe and other developing countries did not have enough technologies in place for e-
health. The present ICT tools are meant for administration and procurement functions. This is
also consistent with the findings from an empirical study by Bedeley & Palvia (2014), which
rated lack of ICT infrastructure as the major challenge of e-Health. Thus limited access to
computers and other ICT facilities remain a challenge to the successful implementation of
EHR (Martinez, Villarroel, Seoane & del Pozo, 2005).
The findings also confirm Qureshi’s (2013) observation that other essential IT accessories
that are basic element for successful implementation of EHR systems are just not available in
most health institutions in developing countries (Qureshi, 2013). However, this is not the case
in developed countries. Sood et.al (2018) states that in most developed countries like United
State, United Kingdom, Norway, Denmark and Australia, there was a growing and robust
healthcare infrastructure that received ample financial support from their governments (Sood
et al., 2008). This is however not the situation in most developing countries. In particular,
professionals in various health facilities who implement healthcare information technology
based solutions like EHR systems in developing countries are overwhelmed with the lack of
ICT resources, such as unavailability of computers, and weak healthcare infrastructure (Ibid).
The results also showed that in terms of training in ICTs and or EMRs only 8.2% (8)
respondents had been previously trained, and the majority (91.8%) had not been trained. The
findings also revealed that prior to 2010, the hospital had once offered training in ICTs to
senior members of staff, although presently most of the members who were trained had left
for other jobs.
64
In terms of computer knowledge and skills, the findings revealed that the majority of the
respondents 61.2% (60) rated their knowledge in computer use as novice, whilst 24.5% (24)
said that it was average. Only 14.3% (14) rated their knowledge in computer use as
experienced. This resonates with an observation that the majority of health professionals in
developing countries lack the basic ICT knowledge or skills that are needed to effectively use
the EMR systems (Alverson et al., 2009).
It was also found that the hospital’s ICT Department was being run by only one qualified
ICT person. This confirmed what was revealed by literature. Adjorlolo and Ellingsen (2013)
mentioned the institutional success of EMR also depends largely on the availability of a well
-functioning ICT Department. However, this is usually not the case with hospitals in
developing countries. They are usually run by one ICT personnel who is overburdened with
problems in the hospital (Adjorlolo and Ellingsen, 2013). Similarly, generally in Zimbabwe,
as noted by Coleman and Furusa (2018) there is inadequate technical support for the majority
of hospitals, with only central hospitals having between two to five IT support officers.
4.9.4 Engagement Readiness

Findings revealed that most respondents 36.7% (36) ranked EMR implementation as very
important, followed by 26.5 % (26) respondents who ranked the EMR implementation as
somewhat important. Twenty-three point five percent (23) respondents said that it was
important, whilst only 13.3% were neutral. None of the respondents said that it was not
important. This might be because people generally have different perceptions regarding ICTs
in the medical field (Terry, et.al 2008).
On the benefits of EMR implementation, findings revealed that 74.5% (73) respondents
agreed that EMR implementation was very important in improving workflow, whilst 15.3%
(15) said that it was fairly important and 10.2% (10) said that it was just important. None of
the respondents showed that EMR implementation was slightly important in improving
workflow. This supports literature which reports that various studies conducted across a
variety of heathcare settings have claimed that the introduction of EMR systems can lead to
an improvement in quality and improve operational efficiency and workflow (Ramaiah,
2012).
65
On the issue of EMR implementation having an impact on cost reduction, the majority of the
respondents, 30.6% (30) indicated that EMR implementation would help reduce costs, whilst
28.6% (28) reported that EMR implementation was fairly important. The least number of
respondents, 14.3% (14) said that EMR implementation was slightly important in cost
reduction. Twenty-six point five percent (26) respondents, however, were of the view that
EMR implementation was very important in cost reduction. The differences in their views are
in line with Choi’s (2013) observation that there are several debates surrounding the
importance of EMR systems in cost reduction, hence the need for further analysis to
determine whether EMR is financially cost-effective in real-life clinical settings.
All the respondents (100%) perceived information retrieval to be a very important benefit
derived from EMR implementation. This is in agreement with Arriffin (2018) who mentions
that the most significant problem on dealing with paper records is about the timing process.
This is because usually medical professionals need the patient data instantly and time is very
critical in healthcare organisations.
Findings also revealed that 23.5% (23) respondents indicated that EMR implementation was
very important in minimising malpractice claims, 38.8% (38) showed that it was fairly
important, whilst 35.7% (35) respondents indicated that it was important. However, only 2%
(2) respondents were of the view that EMR implementation was slightly important in the
reduction of malpractice claims. These findings are almost similar with findings by Aswad
(2015) in Saudi Arabia where a strongly positive belief that EMR decreased medical errors
was revealed. Fewer than 5% of the respondents disagreed with this whereas 95% of the
responses fell between “neither” and “strongly agree”.
The findings from the interviews that were held also showed that the most perceived benefits
of EMR implementation were easy information retrieval and a minimisation in duplication of
work. Users’ perceptions on technology can affect how a new technology is conceptualized
and if it will be accepted and further used. In a study that involved exploring hopes and fears
in the implementation of electronic health records in Bangladesh (Khan et al., 2012), it was
found that most actors were only afraid of use of ICTs in health sector based on their
perceptions about it. In the study, for instance, some physicians thought that using an EMR
66
would be more time consuming, which would negatively influence the time they could spend
with patients
The fears that the majority of the respondents had on EMR implementation were linked to the
nurses’ low computer literacy skills and a general phobia for computers. Others indicated a
fear for the loss of information in the event of system failure and they hinted that the hospital
might even fail to attend to such failures due to financial challenges that were typically faced
by the hospital. This contradicts the findings by Jebraeily et al. (2010) whereby the most
negative attitude was endangering work position (42.4%), increasing workload and time
wasting (49.8%) and endangering information confidentiality and security (54.6%).
It was noted from the findings that all the participants were willing to dedicate to training on
the use of EMR systems. These findings almost match with findings by Onigbogi et al.
(2018), whereby 90.10% respondents expressed willingness to devote time for training in
order to facilitate their use of EMRs. However, this finding is in contrast with a study
conducted in Bandar Abbas, Iran where only 30% of the respondents said they would devote
the time required for training on the use of EMRs (Lakbala and Dindarloo, 2014).
4.9.5 Societal Readiness

Findings showed that the hospital did not use any electronic means of communication when
sharing patient information with other hospitals. Telephone and inter-hospital transfer letters
were the main modes of communication. It was also found that none of the health care
workers used email when communicating with other hospitals. Similarly, Nguyen (2018)
conducted a study to determine the societal readiness of a hospital in implementing an EMR
system and found that the healthcare workers only used the phone or mobile to contact other
hospitals. This in turn resulted in a low societal readiness.
The findings also revealed that the hospital worked on very limited funds from the annual
government budget allocation and this affected the rate of adoption of ICTs. This confirms
what was revealed in literature. Jaana et al. (2012) mentioned that prior research has found
significant relationships between the level of EMR capabilities in hospitals and the financial
capacity in those hospitals. The feeling of instability in securing financial support to
implement the EMR influences the enthusiasm of the users and leads to frustration. They
67
further stated that furthermore, hospitals often simply cannot afford to introduce EMRs
owing to their limited budgets. Additionally, financial problems and economic downturns
may affect the budget allocated to the EMR implementation, even in countries like the UK
(Hendy et al., 2007).
It was also revealed that the hospital alone could not initiate the implementation of EMR
systems due to incapacitation issues and also because of the bureaucratic nature of the
government. This agrees with the statement that systems of authority found in the health
sector are very stringent and not highly flexible (Simbini, 2013). The utilisation of e-health in
hospitals is determined by the ministry itself. Hospitals have no right, especially district and
central hospitals, to institute e-health systems at their level (Coleman and Furusa, 2018).
Findings also revealed that the hospital’s clients would welcome the innovation without any
resistance as the majority of the hospital’s clientele comprised the young generation. Only the
need of communicating change to the patients if the EMR system was to be implemented was
deemed to be necessary. This is supported by Khoja et al. (2007) who state that it is
important to empower patients whenever systems such as EMR systems are to be
implemented because some patients value and idolise the hard-copied, hand-written
treatment forms from their doctors.
4.9.6 Policy Readiness

The findings of the study showed that there was an absence of a policy that supported the
implementation of an EMR system. It was revealed that the Ministry of Health and Child
Care ICT policy that the government hospitals relied on did not have any clearly defined
provisions on the implementation of EMR systems. These findings are in line with the
observation that adds on by mentioning that the government e-health policies make an
environment where the likelihood of using resources effectively is increased, the
professionals find their suitable places and exercise faithfully and the future of IT application
in healthcare becomes clearly identifiable (Shaqrah, 2010). Also, as revealed in literature, the
absence of a clearly defined health policy may obstruct the implementation of e-health
systems at all levels of healthcare.
It was also revealed that the hospital’s health information management department relied on
the Records and Archives Act of 1986 and there was no coherence of this policy with the
68
Ministry of Health and Child Care ICT policy. These findings are supported by Coleman and
Furusa (2017) who state that the problem with government policies is that the policies are
drafted in isolation from one another.
5. Summary
This chapter showed the presentation, analysis and interpretation of the research findings.
Research findings were presented in tables, graphs, descriptive statistics and narratives. They
were organised into themes around research objectives. The findings showed that in terms of
core readiness, despite low levels of knowledge in EMR systems, participants were
enthusiastic on the implementation of an EMR system. They expressed much dissatisfaction
with the paper based medical records management. Findings on technological readiness
indicated that the hospital did not have adequate ICT infrastructure, support and skills needed
for the implementation of an EMR system. In terms of engagement readiness, findings
revealed that all the participants were willing to undertake and dedicate to raining on the use
of EMR systems. The most perceived benefit of EMR implementation was information
retrieval. Results from societal readiness assessment showed that the major drawback that the
hospital faced was linked to the dire economic crisis in the country and the bureaucratic
nature of government owned institutions that were not conducive for ICT implementations.
Findings also showed that there was absence of a policy that supports the implementation of
EMR systems in hospitals. The existing policies that the hospital relied on were disintegrated
and did not have any clearly defined provisions on the implementation of EMR systems.
69
CHAPTER 5
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
5.1 Summary
The study was conducted under the background that the advancements in ICTs have
witnessed different systems such as EMR systems being implemented in healthcare
organisations to improve healthcare services. Despite the importance of these systems, most
healthcare institutions in Africa are noted to have failed to conduct an initial readiness
assessment of the institution’s readiness before implementation, which contributes to high
failure rates. Failure to conduct a readiness assessment also is very costly in terms of time
and resources. It is against this background that the study sought to examine the eReadiness
of Ingutsheni Central Hospital in implementing an EMR system.
The study was guided by a conceptual framework adopted rom Beebeejaun and Chittos
(2017) whose tenets include: core readiness, technological readiness, engagement readiness,
societal readiness and policy readiness. It was hoped that the findings of the study would
contribute to the knowledge on the deployment and implementation of EMR systems in the
developing countries, which is noted to be limited. It was also hoped that the study would
contribute new information to the body of knowledge in health information management,
specifically in the Zimbabwean context. Literature was reviewed to set the tone for the study
and to orient the researcher on previous studies on eReadiness of hospitals in implementing
EMR systems.
A pragmatic worldview, mixed methods design and a survey strategy were adopted by this
study to answer the research questions. Questionnaires and semi-structured interviews were
used as the data collection methods. The study population was drawn from 178 healthcare
workers and the study participants (124) were selected using stratified random sampling from
the 14 hospital wards. Purposive sampling was used for the selection of hospital
administrators who were to be interviewed.
The findings revealed that Ingutsheni Hospital was core ready for EMR implementation. The
findings also revealed that the hospital did not have the technological infrastructure, skills
and ICT support needed for EMR system implementation. It was also revealed that although
70
the healthcare workers have limited knowledge on EMR systems, they indicated a high
degree of willingness to commit to training on the use of EMR systems. Also, the perceived
benefits of EMR implementation they had were more than the fears they had. Findings on
societal readiness showed that the hospital did not use any electronic means of
communication when sharing patient information with other hospitals. It was also revealed
that the hospital alone could not initiate the implementation of an EMR system due to
incapacitation issues and also because of the bureaucratic nature of the government
departments. Findings showed that no community resistance was anticipated. On policy
readiness, findings showed that the available policies on information management were
disintegrated and there was no policy that had clearly defined provisions on the
implementation of EMR systems.
5.2 Conclusions
Based on the research findings, the study made the following conclusions:
5.2.1 Core Readiness

Although none of the healthcare workers indicated that they knew a great deal on EMR
systems, and only 13.3% had used EMR systems before, they showed much dissatisfaction
with the paper-based medical records management. The study therefore concluded that
regardless of one’s knowledge on EMR systems, paper-based medical records management
have so many limitations that manifest in the form of missing files, misplaced files and
difficulties in information retrieval. It was therefore concluded that despite the low levels of
knowledge in EMR systems, the healthcare workers were ready for the adoption of an EMR
system in the hospital.
5.2.2 Technological Readiness

It was concluded that Ingutsheni Central Hospital is not technologically ready for the
implementation of an EMR system. The findings showed that the hospital’s currently
available ICT infrastructure, support and skills cannot accommodate EMR implementation.
5.2.3 Engagement Readiness

The researcher concluded that besides the low levels of knowledge in EMRs, all the
participants acknowledged the importance of EMR system implementation at Ingutsheni
Central Hospital. The most perceived benefits of EMR implementation were easy information
retrieval and a minimisation in the duplication of work. The only fears regarding EMR
71
implementation were linked to healthcare worker’s low computer literacy skills and a general
phobia for computers. It was therefore concluded that training in ICTs was necessary to boost
healthcare worker’s knowledge in EMR systems and to eliminate technophobia.
5.2.4 Societal Readiness

The researcher concluded that the external environment, that is the country’s economic
situation, in which the hospital operated in, had a great influence on eReadiness of the
hospital in implementing an EMR system. This affected even the mode of communication
that the hospital used when communicating with other hospitals in that the inadequate
infrastructure did not accommodate electronic means of communication. Furthermore, it was
concluded that the highly stringent centralised structure of public hospitals make it difficult
for any ICT change to be implemented. As shown by literature, government-owned hospitals
have no right to institute e-health systems at their level.
5.2.5 Policy Readiness

The findings of the study showed that there was an absence of a policy that supported the
implementation of an EMR system. It was revealed that the Ministry of Health and Child
Care ICT policy that the government hospitals relied on did not have any clearly defined
provisions on the implementation of EMR systems. It was therefore concluded that the policy
environment has a great impact on the implementation of EMR systems in hospitals. Poor
government support through policy on e-health implementation seriously hampers the
adoption of ICTs in government hospitals.
5.3 Recommendations
Based on the findings, the following recommendations were suggested;
1. The Zimbabwe Ministry of Health and Child Care

Teaching programmes for computer and knowledge on EMR system should be incorporated
into the curriculum of medical education and nursing education. If EMR systems are
introduced in the Schools of Medicine, they will increase awareness and development of
competent health professionals to safeguard the future of the medical services.
The government needs to increase subsidies for the healthcare facilities, especially the non-
income generating hospitals like Ingutsheni Central Hospital.
72
Since e-health cannot be implemented in isolation, to foster e-health growth in the public
sector an attentive policy needs to be considered. Hence, health policy should compel public
hospitals to implement e-health systems.
2. Ingutsheni Central Hospital

An EMR system implementation position paper should be prepared and presented to the
hospital executive so that when the hospital requests for funding from the Zimbabwe
Ministry of Health and Child Care all stakeholders would be all in a clear position.
Ingutsheni Hospital should have other income generating projects aimed at improving the
technological infrastructure available at the hospital.
The hospital also needs to form strategic partnerships with other government and private
hospitals that have already implemented and adopted EMR systems so that they can learn
from best practices.
3. Recommendations for further study

Since the findings of this study were based on the opinion of qualified mental health nurses
referred to as healthcare workers, it is recommended that further studies be done inclusive of
other medical professionals such as doctors, occupational health therapists and pharmacists,
as well as the non-medical staff.
73
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88
APPENDIX A
QUESTIONNAIRE FOR HEALTHCARE WORKERS
My name is Gamuchirai Bonde, a Master of Science student in Library and Information

Science at the National University of Science and Technology. I am undertaking a research
aimed at evaluating the e-Readiness of Ingutsheni Central Hospital in implementing an
Electronic Medical Records system. I kindly invite you to participate in the study. The
findings of the study will be strictly for academic purposes and all efforts will be made to
protect your identity and keep the information provided confidential. Please feel free to ask
questions regarding this study. You may contact me at gamubonde150389@gmail.com if you
have any questions or use the Library’s extension on 2113. It should take you approximately
15 minutes to complete this questionnaire. Thank you for your participation.
Informed Consent
Please read the following statements carefully before agreeing to take part in this study; I
understand that;
 All results from this study will be anonymous. Information extracted from this
questionnaire will not under any circumstances contain names or identifying
characteristics of participants.
 I am free to withdraw from this study at any time without penalty
 I am free to decline to answer to particular questions
I consent to take part in this study on terms described above; Yes No
89
Please tick in the appropriate box, and provide further explanation where necessary
SECTION A: DEMOGRAPHC CHARACTERISTICS
1. Gender: Male
Female
2. Age: 20-30 years

31-40
41-50
51-60
61-70
3. Years of experience in nursing

0-5
6-10
More than 10
SECTION B: CORE READINESS
Electronic Medical Records systems are information systems that manage both the
distribution and processing of information necessary for the healthcare delivery system. They
can also be defined as software programs developed for the storage, processing and data
exchange of medical information by healthcare providers.
4. How much do you know about Electronic Medical Records Systems?
Nothing
A little
Very Little
A great deal
5. Have you ever used such records before?

Yes No
90
6. If your answer to number 6 was Yes, please indicate where you have used Electronic
Medical Records before, If No, proceed to number 8
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
…………………………………………………………………………………………...
7. To what extent are you satisfied with the current medical records management services
provided by Ingutsheni hospital?
Very Dissatisfied Satisfied
Dissatisfied Very Satisfied
Neutral
8. During your term of service at Ingutsheni, have you ever faced any challenge with how
medical records are stored? Yes No
9. If your answer to number 7 was Yes, what are the challenges you have faced with the
paper based medical records management? If No, proceed to number 9
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
10. In your opinion, the use of electronic medical records systems in my ward is:
Optional
Required
I do not know
SECTION C: TECHONOLOGICAL READINESS
11. Do you have access to computers in your ward? Yes No
12. How frequently do you use computers in executing your duties as a nurse?
A lot Sometimes Never
91
13. How will you rate your knowledge of computer usage?
Novice
Average
Experienced
Other (Please Specify)…………………………………………
14. Have you ever had any training or direct experience in using Electronic Medical
Records Systems.
Yes No
15. Do you have access to internet in your ward?

Yes No
16. Please indicate the information and communication technologies in place within your
ward that may be used to support Electronic Medical Records Implementation
Number of ICTs in place 0-5 6-10 11-15
Desktop
Laptop
PDAs
Printers
SECTION D: ENGAGEMENT READINESS

16. How do you rank the importance of an Electronic Medical Records System
Not important at all
Somewhat important
Neutral
Important
Very important
17. The hospital should implement an Electronic Medical Records System in preference
to paper-based medical records management.
Strongly Disagree
92
Disagree
Neutral
Agree
Strongly Agree
18. Please rate each of the following perceived benefits that you believe will occur as a
result of Electronic Medical Records system implementation in order of importance.
1=Most important, 6= Least important.
1 2 3 4 5 6
Improve workflow
Reduce medical errors
Reduce costs
Improve information retrieval
Minimise malpractice claims
19. What fears do you have in the adoption of an Electronic Medical Records system for
use in your ward?
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
20. Are you willing to dedicate to training on the use of Electronic Medical Records
Systems should the hospital implement the system?
Yes No
21. Please support your answer to Question 20 …………………………………………..

…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
93
SECTION E: SOCIETAL READINESS
22. How do you exchange or share patient care information with other hospitals or
service providers?
Through the telephone
Via email
Other means (Please Specify)………………………………..
23. Do you ever use email in work-related communication?

Yes No
24. If an EMR system was to be implemented, do you think that gender issues will have
an impact on the use of the system?
Yes No
94
APPENDIX B
INTERVIEW GUIDE FOR THE MATRONS

protect your identity and keep the information provided confidential. Thank you for your
participation.
Electronic Medical Records systems are information systems that manage both the
distribution and processing of information necessary for the healthcare delivery system. They
can also be defined as software programs developed for the storage, processing and data
exchange of medical information by healthcare providers.
1. Do you have experience in using Electronic Medical Records Systems or have you
ever heard about them?
2. To what extent are you satisfied with the way medical records are managed in this
institute?
3. Do the nurses report any challenges that stem from the use of paper-based medical
records in the treatment of patients?
4. What measures has the hospital put in place to deal with such queries?
5. In your opinion, do you think it is mandatory for the hospital to implement an
Electronic Medical Records system?
6. What would be the benefits of implementing such a system?
7. What fears may hinder the implementation of Electronic Medical Records system?
8. The implementation of Electronic Medical Records Systems requires hardware such
as computers, printers, mobiles, relevant software and internet availability. Does
95
Ingutsheni have the necessary ICT infrastructure needed for the implementation of an
Electronic Medical Records System?
9. If No, are there mechanisms to acquire additional ICT resources that support
Electronic Medical Records implementation?
10. Do you think the nurses have the knowledge and skills on Electronic Medical Records
systems?
11. Has the hospital offered any form of training in ICTs to nurses before?
12. Do you have any institutional policies that govern the management of medical
records?
13. In your opinion, what socio-cultural factors might influence the implementation of
Electronic Medical Records in hospitals?
14. Which communication channels are used by the hospital when sharing patient
information with other hospitals?
15. How frequently do you communicate with other hospitals?
16. Do you have any other information that you think is useful to this study?
96
APPENDIX C
INTERVIEW GUIDE FOR THE HEALTH INFORMATION DEPARTMENT

protect your identity and keep the information provided confidential. Thank you for your
participation.
1. What do you understand by the term Electronic Medical Records?

2. To what extent are you satisfied with the way medical records are managed in this
hospital?
3. What are the challenges that stem from the use of paper-based medical records?
4. What measures has the hospital put in place to deal with the challenges?
5. In your opinion, do you think it is mandatory for the hospital to implement an
Electronic Medical Records system?
6. What would be the benefits of implementing such a system?
7. What fears may hinder the implementation of Electronic Medical Records system?
8. Do you think the nurses have the knowledge and skills on Electronic Medical Records
systems?
9. Do you have any institutional policies that govern the management of medical
records? How about government policies?
10. In your opinion, what socio-cultural factors might influence the implementation of
Electronic Medical Records in hospitals?
11. Do you have any other information that you think is useful to this study?
Thank You.
97
APPENDIX D
INTERVIEW GUIDE FOR THE ICT DEPARTMENT

Science at the National University of Science and Technology. I am doing a research aimed
at evaluating the e-Readiness of Ingutsheni Central Hospital in implementing an Electronic
Medical Records system. I kindly invite you to participate in the study. The findings of the
study will be strictly for academic purposes and all efforts will be made to protect your
identity and keep the information provided confidential. Thank you for your participation.
1. What do you understand about the concept of Electronic Medical Records System
2. What are the technological requirements for implementing such a system here at
Ingutsheni?
3. To what extent is the current information communication infrastructure adequate for
implementing an EMR system?
4. What are the technical skills needed for one to be able to use the system?
5. Do you have enough human resources, in terms of skill and expertise in your
department, to support the implementation and sustenance of an Electronic Medical
Records System?
6. Are there any institutional/ governmental ICT policies that guide the management of
medical records that you know of?
7. To what extent is the hospital administration supportive of any ICT initiatives? Are
there any funds allocated to your department for the maintenance of the hospitals’
information and communication infrastructure?
8. In your opinion, what challenges might be faced by the hospital in implementing an
EMR system.
9. Do you have any other information you think is useful to this study?
98
APPENDIX E: LETTER OF AUTHORISATION TO CONDUCT RESEARCH
99

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NATIONAL UNIVERSITY OF SCIENCE AND TECHNOLOGY

FACULTY OF COMMUNICATION AND INFORMATION SCIENCE

DEPARTMENT OF LIBRARY AND INFORMATION SCIENCE

E-READINESS OF INGUTSHENI CENTRAL HOSPITAL IN IMPLEMENTING AN

A RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILMENT OF THE

LIBRARY AND INFORMATION SCIENCE

Academic Supervisor Mrs. E. Maisiri

NAME OF AUTHOR: Bonde Gamuchirai

TITLE OF PROJECT: E-Readiness of Ingutsheni Central Hospital in

PROGRAMME: Master of Science Degree in Library and

YEAR THIS DEGREE GRANTED: 2019

PERMANENT ADDRESS: No. 12 Cawston Road, Northend

FACULTY OF COMMUNICATION AND INFORMATION SCIENCE

I therefore release the student to submit her dissertation for marking.

To my family, for never giving up on me.

I am heartily thankful to my supervisor, Mrs. E. Maisiri, for her encouragement, guidance

CHAPTER 1: INTRODUCTION ........................................................................................... 1

1.2 Statement of the problem ................................................................................................. 5

1.3 Purpose of the study ......................................................................................................... 6

1.4 Research Questions .......................................................................................................... 6

1.5 Significance of the Study ................................................................................................. 7

1.6 Assumptions of the Study ................................................................................................ 7

1.8 Definition of terms ........................................................................................................... 7

1.8 Scope (Delimitation of the Study) .................................................................................... 8

1.9 Limitations of the Study .............................................................................................. 8

1.10 Summary ........................................................................................................................ 9

CHAPTER 2: LITERATURE REVIEW ............................................................................ 10

2.2 Information Management ............................................................................................... 10

2.4 The concept of E-Health ................................................................................................ 11

2.4.1 Electronic Medical Records System ........................................................................ 12

2.5 E-Health Implementation in Developing Countries ....................................................... 15

2.5 E-health readiness assessment ........................................................................................ 16

2.6 eReadiness Theoretical Frameworks .............................................................................. 18

2.6.1 Technology Readiness Index (TRI) ......................................................................... 18

2.6.2 Campbell et al. (2001) Readiness Framework......................................................... 18

2.6.3 Demiris et al. (2004) Readiness Framework ........................................................... 19

2.6.4 Jennett et al. (2005) Readiness Framework ............................................................. 19

2.7 Beebeejaun and Chittoos Theoretical Framework ......................................................... 20

2.7.1 Core Readiness Construct ........................................................................................ 20

2.7.2 Technological Readiness Construct......................................................................... 21

2.7.3 Societal readiness construct ..................................................................................... 23

2.7.4 Acceptance and Use Readiness ............................................................................... 25

2.7.5 Engagement Readiness Construct ........................................................................... 27

2.7.6 Policy Readiness Construct ..................................................................................... 29

2.8 Summary ........................................................................................................................ 30

CHAPTER 3: RESEARCH METHODOLOGY ................................................................ 31

3.2 Research Philosophy ...................................................................................................... 31

3.3 Research Approach ........................................................................................................ 32

3.4 Research Strategy ........................................................................................................... 33

3.6 Sampling and Sampling Frame ...................................................................................... 35

3.6.1 Stratified Random Sampling ................................................................................... 35

3.7 Data Collection Instruments ........................................................................................... 37

3.7.1 Questionnaires ......................................................................................................... 37

3.7.2 Interviews ................................................................................................................ 39

3.8 Reliability and Validity .................................................................................................. 40

3.9 Data Collection Procedures ............................................................................................ 42

3.10 Data Presentation and Analysis Procedures ................................................................. 42

3.11 Ethical Considerations.................................................................................................. 43

3.12 Summary ...................................................................................................................... 44

CHAPTER 4: DATA PRESENTATION AND ANALYSIS .............................................. 46

4.2 Demographic Data.......................................................................................................... 46

4.3 Acceptance and Use ....................................................................................................... 47

4.3.1 Age and Knowledge in Computer Use .................................................................... 47