Journal of Infection and Public Health (2016) 9, 774—780

Understanding Technology and People

Issues in Hospital Information System
(HIS) Adoption: Case study of a tertiary
hospital in Malaysia
Nasriah Zakaria a,∗, Shafiz Affendi Mohd Yusof b

a The Research Chair of Health Informatics and Promotions, King Saud University,
Riyadh, Kingdom Saudi Arabia
b University of Wollongong, Dubai, United Arab Emirates

Received 24 June 2016 ; received in revised form 31 July 2016; accepted 31 August 2016

KEYWORDS Summary
HIS adoption; Background: Hospital Information Systems (HIS) can improve healthcare outcome
Technology and people quality, increase efficiency, and reduce errors. The government of Malaysia imple-
issues; mented HIS across the country to maximize the use of technology to improve
Case study healthcare delivery, however, little is known about the benefits and challenges of HIS
adoption in each institution. This paper looks at the technology and people issues
in adopting such systems.
Methods: The study used a case study approach, using an in-depth interview with
multidisciplinary medical team members who were using the system on a daily basis.
A thematic analysis using Atlas.ti was employed to understand the complex relations
among themes and sub-themes to discover the patterns in the data. .
Results: Users found the new system increased the efficiency of workflows and saved
time. They reported less redundancy of work and improved communication among
medical team members. Data retrieval and storage were also mentioned as positive
results of the new HIS system. Healthcare workers showed positive attitudes during
training and throughout the learning process.
Conclusions: From a technological perspective, it was found that medical workers
using HIS has better access and data management compared to the previously used
manual system. The human issues analysis reveals positive attitudes toward using
HIS among the users especially from the physicians’ side.
© 2016 Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University
for Health Sciences.

∗ Corresponding author.
E-mail addresses: nzakaria@ksu.edu.sa, nasriah.zakaria@gmail.com (N. Zakaria), samohdyu09@gmail.com (S.A. Mohd Yusof).

http://dx.doi.org/10.1016/j.jiph.2016.08.017
1876-0341/© 2016 Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences.
Case study of a tertiary hospital in Malaysia
Introduction
The Ministry of Health (MOH) in Malaysia has stated
that its vision is to lead the nation to work together
for better health well-being, services, and infras-
tructure through technological advances. Since its
Seventh Malaysian Plan (1996—2000), the govern-
ment has not only embarked on rigorous initiatives
but also adopted various innovations to integrate
health information systems (HIS) into local health-
care. The plan stated that 33 paperless public
hospitals would be established within the five-
year period. Building on this vision, technology
has totally changed the way organizations operate,
both in practices and policies [1]. A few countries in
East Asia such as Singapore, Taiwan, and Hong Kong
are in the intermediate stages of adoption [2], com-
pared to high-adoption countries such as England,
Australia and Denmark [3].
HIS implementation can improve healthcare
quality, increase efficiency [4] and enable easy
data retrieval and reporting [5]. HIS can also
reduce errors compared to a more manual system
[6] and increase communication among healthcare
providers [7].
Today, patients are technologically savvy due to
the rapid growth of and innovations in medical
technology, and the health disparity gap is shrink-
ing [8]. Because of this, patients expect similar
electronic services from their healthcare providers.
Unfortunately, providers are making slow progress
in meeting this demand due to obstacles such as the
limited number of successful programs, financial
costs, lack of technology advocates [9], and neg-
ative staff attitudes which affect intentions toward
and adoption of work practices using HIS [10].
A report published in National Center for Health
Statistics, reported that 78% physicians in office-
based practices (physician office that is used to
deliver primary and specialty care) are using elec-
tronic medical record, which is an increment of
18% in 2001 [11]. Moreover, with high competitive-
ness in the healthcare industry, physicians and their
medical teams are facing intensified pressures to
use state-of-the-art technology to provide quality
patient care [4]. In the past, physician frustration
stemmed from heavy patient loads, administrative
tasks, and loss of control over patient care decisions
[12].
Other factors that may influence staff attitudes
toward new technology systems include individual
characteristics such as age, gender, and computer
literacy, and contextual factors such as work-
flow impact, involvement in system selection, and
autonomy [10]. Features of the technology itself,
775
such as user-system interaction, usability, speed
and reliability can also influence people’s attitude
toward using the system [10].
Our research question is what are the benefits
and challenges of HIS adoption by healthcare insti-
tutions in Malaysia, in terms of both technology and
people?
Methodology
This research used a case study to examine the
interplay of potential variables in order to provide
a holistic and in-depth understanding of the issues
related to adoption of HIS by medical teams. The
case study approach was chosen because it was
best-suited to answer the research question, ‘‘What
are the technological and human issues encoun-
tered during HIS adoption?’’ The case study method
allowed the researchers to approach the field as
closely as possible, to develop a deep understand-
ing of HIS, the circumstances under which HIS is
used, and the characteristics of the medical team
that affect their working with the system.
Data Collection Procedures
A convenience sampling strategy was used to
recruit medical team members from a tertiary hos-
pital. We visited the institution for 2 consecutive
days and the administrator identified those med-
ical workers who were willing to participate in
the study. Twenty-seven medical workers agreed
to participate in this interview to explore adoption
behavior related to HIS use in practice. Participants
came from different departments of the hospital
and had experience using HIS in their practice.
Interviews were carried out by three researchers
who were trained in qualitative interviewing, sup-
ported by two research assistants. Each interview
lasted 40—55 min and each interviewee gave con-
sent for the interview and to be audio-recorded.
The study received approval from the director of
the hospital.
Before interviewing began, researchers brain-
stormed possible issues related to HIS adoption in
Malaysia. The researchers chose to conduct face-to-
face interviews using a mostly unstructured format
consisting of two parts, with the goal of elicit-
ing interviewees’ beliefs and opinions about their
adoption behavior related to the use of HIS. In the
first part of the interview, participants were told
the objective of the study: to understand physi-
cians’ adoption behavior related to the use of HIS
in practice. Then, each respondent was asked to
776
describe his or her role in the hospital, their work
experiences, their usage of ICT in hospital and dur-
ing leisure time, and how they became involved
with the HIS. During the process, respondents were
encouraged to talk freely about their attitudes
and behaviors toward HIS usage. The respondents’
initial replies and probing for further elaboration
guided the flow of the interview process. In the sec-
ond part of the interview, participants were asked
more direct questions about the difficulties and
troubles they encountered when using HIS. Finally,
they were asked whether they solved these prob-
lems, and if so, how.
Data analysis
Audio recordings of the interviews were transcribed
after each session. Thematic analysis was then per-
formed as follows. First, the researcher read the
transcription while listening to the audio recording
(repeatedly, if necessary), and made memos and
summaries during the process.
Next, the transcribed interviews were coded
using computer software packages designed for
qualitative analysis, in this case Atlas.ti version 5.0.
Open coding was used, wherein common themes
related to issues of HIS adoption were identified
and passages from the interviews were attached
to their corresponding thematic codes (e.g., the
interview statement ‘‘What particular information
I want, I can get in seconds. But with a manual sys-
tem, this is not possible.’’ [P7] is attached to the
code ‘‘easy access to information’’). In-vivo coding
was also used, wherein words or terms used by the
interviewees are employed as codes (e.g., given the
statement ‘‘System A changed my activity, it defi-
nitely saved time’’ [P7], the term ‘‘saved time’’ is
used as a code). Finally, memos were also recorded
throughout the process of coding to document the
insights and ideas generated during the coding pro-
cess; these memos can serve as extra data to be
analyzed.
Next, analysis was performed wherein similar-
ities and differences among codes are identified
and codes are categorized into themes. A broader
theme might contain sub-themes, and those sub-
themes might contain further sub-themes (e.g., the
code ‘‘easy access to information’’ is categorized
under the theme ‘‘relative advantages of HIS’’).
Relationships between the themes and sub-themes
are examined and compared constantly to form
a network that serves as a basis of a conceptual
framework. The coding process stops when no sig-
nificant or new themes emerge.
After all themes have been identified, verifica-
tion and validation of the results were performed
N. Zakaria, S.A. Mohd Yusof
through peer debriefing by three researchers, in
which the analyzed results and conceptual abstrac-
tions are presented to other qualitative researchers
to identify any hidden biases and clarify the mean-
ing and interpretation of the quotations. Many
researchers agree that peer debriefing is a good way
to enhance the credibility and validity of qualitative
research [13,14].
Results
Two distinct themes emerged with regards to the
issues experienced by the medical team in adopt-
ing HIS in practice: those related to technology and
those related to people (human).
Technological issues
Results of the study showed that, in general, physi-
cians believed that using HIS would bring many
benefits. One of the most significant benefits was
improved efficiency of the clinical process. Time is
saved in the sense that the number of steps required
for a patient to finish his or her visit to the hos-
pital is reduced through the use of HIS in clinical
practice. Physicians reduce their walking distance
with a decreased need to carry prescriptions to the
pharmacy or other departments. This is supported
by physician statements such as the following:
‘‘HIS is quick compared to the old system; patients
do not need to wait long, they can come and collect
their medication faster.’’ [P7]
Improved workflow for patients to receive their
medication is a key indicator of healthcare qual-
ity. Reduced patient waiting time means that more
patients can be seen by the doctor in a day. As one
doctor said:
‘‘We can see more patients in a shorter period of
time; this is very important; patients do not have
to wait for a long time outside.’’ [P7]
Another important benefit of using HIS was
improved communication among physicians. They
could get immediate access to updated information
from their supervisor or senior staff. As two of the
physicians said:
‘‘If we used memos as we used to, we need to read
and sign them. We need to leave our job and go
read what is updated. It is very time consuming.
But now [after installation of the HIS] we can read
whenever we are free, it is very easy.’’ [P1]
Case study of a tertiary hospital in Malaysia
‘‘If we want to prepare some document or pro-
posal, we just draft it and send it via email to the
director, and the director sends it back to us after
it’s edited. It is very convenient and effective.’’
[P6]
Doctors can also send prescriptions directly to
the pharmacy via HIS instead of using personnel
to transfer the order manually. Improved commu-
nication channels allow more time to be saved and
increase the efficiency of hospital work flows.
Physicians also stated that using HIS improved
their information management compared to the
previous paper-based method.
‘‘I think it’s better to have HIS, because we have
statistics, every case needs to be recorded, so at
the end of the month, I can get the statistics infor-
mation at anytime I wish.’’ [P6]
‘‘What particular information I want, I can get in
seconds. But with a manual system, that is not
possible. I have to search go to the particular chap-
ter.’’ [P7]
Information is more organized and can be
retrieved in many formats. Statistical charts make
raw data more meaningful and increase the medi-
cal team’s knowledge compared with preparing in
other systems or manually. A reduced workload is
believed to contribute to the provision of a more
caring healthcare service. Physicians reported that
much more information was available to them in
one place compared to the previous paper-based
method.
‘‘After I used HIS, it was really good. Once I enter a
patient’s identity card number, the information is
complete and ready, and we have no need to search
for files.’’ [P10]
Information retrieved from HIS is also more leg-
ible and can be comprehended more easily:
‘‘Some handwriting is difficult to read, espe-
cially for new physicians. But with HIS everything
becomes easy because it’s standardized and can be
printed out, so the patients and physicians won’t
be confused.’’ [P8]
Use of HIS also improved data storage. Compared
to the paper-based method, HIS requires a smaller
space to install the server, and a large amount of
patient records can be stored inside it. Physicians
recognized this benefit of HIS over a paper-based
method by saying that:
‘‘[A] computerized system is better than a paper-
based method because we do not need to store so
many paper files, and the patients’ records need
777
to be stored forever, so you can just imagine how
many files we need to store for a period of ten
years.’’ [P13]
‘‘Using paper will cause many problems like miss-
ing records, lost records, etc. but this wouldn’t
happen if HIS is used, records will become more
organized.’’ [P13]
Human issues: physicians’ attitudes toward
HIS
Physician attitude toward HIS refers to a doctor’s
positive or negative feeling about using HIS [15]. In
this study, we found that physicians showed three
types of attitudes: pre-usage, post-usage, and per-
sonal attitude. Personal attitude is differentiated
from pre- and post-usage attitude in that personal
attitude is unrelated to work obligations and physi-
cians are free to speak their feelings regarding the
HIS.
With respect to pre-usage attitude toward HIS,
the findings were almost unanimous: most of the
physicians had a negative feeling toward HIS:
‘‘I feel like I freeze, don’t know where to start.’’
[P1]
‘‘We see the system as very troublesome.’’ [P3]
‘‘At the beginning it is not very clear about the
system.’’ [P5]
‘‘It is quite a shock to use HIS because we used to
use paper previously.’’ [P9]
Other words commonly used include
‘‘complicated’’, ‘‘worse’’, and ‘‘dizzy’’. This
indicates that in their first exposure to HIS,
physicians feel great stress about adopting the
system due to uncertainty and a lack of sufficient
knowledge about the system.
After a few months of usage, however, physi-
cians’ attitudes toward HIS usage showed a
dramatic change. Most reported a positive feeling
about HIS usage:
‘‘The system is not that complicated actually’’ [P9]
‘‘Integration of IT in healthcare is really good’’
[P14]
Physicians clearly felt that the system improved
the efficiency of their work and reduced the time
needed to finish their daily tasks. However, physi-
cians did seem to feel that age was a factor
in a favorable attitude toward HIS. Those who
categorized themselves as veteran users reported
it was difficult for them to learn new skills
778
to operate the HIS. Although physicians showed
different attitudes pre- and post-usage, person-
ally they showed a positive attitude toward ICT
integration in healthcare in general. Words used
included ‘‘important’’, ‘‘like’’, and ‘‘good’’ when
physicians were requested to express their personal
feelings toward employing HIS in a hospital setting.
Some of the physicians even thought that future
physicians should be IT-trained so that they can
adopt future innovations in healthcare smoothly
and quickly.
Discussion
Hu et al. suggested that there are three categories
of characteristic that affect technology accep-
tance: individual, technological, and organizational
[16]. Zakaria et al. also suggest that ICT adoption
challenges can be categorized into three groups:
organizational, human, and technological [17].
In this study, we found that generally physicians
favor ICT integration in their clinical workflow.
Before performing the study, we expected physi-
cians to show a negative attitude toward ICT
integration. This belief was based on predicted
physician unwillingness to move out of their com-
fort zone, since ICT integration might create
changes to the status quo. They might be uneasy
with such changes and perceive them as threaten-
ing, resulting in a high level of intolerant behavior.
This turned out not to be true.
From the technological perspective, HIS brings
many benefits to the physician. HIS improves
physician performance, productivity and efficiency.
Physicians recognize benefits in terms of improved
access and data management. Once connected with
the system, physicians can retrieve a great deal of
information. They can collect statistical data eas-
ily and monitor a patient’s biometrics with just a
simple click through the HIS.
Using an HIS which appropriately matches the
patient’s and medical worker’s needs will enhance
the process of HIS adoption, but it is important
that the system also address the issue of med-
ical workers’ attitude toward ICT integration in
healthcare. The technology may be good in improv-
ing the hospital’s workflows, but if it is unstable
and not user friendly, it will demand increased
mental effort to operate and staff will likely feel
negatively toward it. Therefore, any HIS software
development should include time spent in the hos-
pital to observe the daily routines of the medical
teams and collection of team members’ opinions on
how technology can help them. Active conversation
N. Zakaria, S.A. Mohd Yusof
should be encouraged through frequent meetings
and feedback sessions; this will enhance HIS devel-
opment and ensure that bugs and errors are fixed
quickly.
In addition to ensuring that an HIS meets med-
ical teams’ needs, the hospital needs to create a
supportive environment to present HIS adoption in
the work setting as a proactive step. In addition
to top-down encouragement to adopt HIS, hospital
administration should address individual concerns
and work to achieve physician buy-in and support
of HIS. The hospital can identify a change leader to
champion the process of HIS adoption. This leader
can be instrumental in positioning the adoption of
HIS as a progressive method of preventing medical
mishaps and promoting patient-focused practices.
A successful change leader can instill in the minds of
medical team members the belief that HIS adoption
will improve the healthcare service provided and
reduce their current workload. This can be done
through education interventions such as publicity
campaigns and discussion groups, together with
role modeling by superiors and organized staff visits
to advanced medical institutes which are already
enjoying the benefits of early deployment of
HIS.
Development of a comprehensive training pro-
gram to increase medical teams’ computer compe-
tency is necessary, and should be tailored to include
every stakeholder in the hospital. Specific train-
ing should be targeted to help medical workers
acquire different skills at different phases of HIS
adoption. For example, at the introduction phase,
medical workers should be trained in basic com-
puter skills such as typing and accessing/navigating
the HIS. The training program can be improved sub-
sequently with additional content and medical staff
can return for more training as new features of
the HIS are brought online. More importantly, the
training program should not be a one-shot strat-
egy but rather integrated into the hospital’s usual
practices, especially for new staff as they join the
hospital. This could address the human factor issues
of self-efficacy, computer competency, and atti-
tudes toward adopting HIS.
Limitation of this study include looking at the
technology adoption at only one point of time
and not longitudinally. Longitudinal research can
improve the observation of the progress of tech-
nology adoption among medical workers over time.
Conclusion and future direction
This study identified the technology and people
issues related to medical team attitudes toward
Case study of a tertiary hospital in Malaysia
HIS. Although this study was focused on the fac-
tors related to attitudes toward technology use in
the healthcare sector, the results can be a use-
ful reference in examining IT adoption in other
sectors. It should be noted that this study exam-
ined one HIS adoption in Malaysia. From the 7th
to the 10th Malaysia plan, the government con-
tinues to acknowledge the role of technology to
improve healthcare delivery. The government is
proposing to use sophisticated technology such as
mobile clinics and drones to help serve inaccessi-
ble communities [18]. Future research can explore
whether the results of the study could be applied
in different countries or to different types of HIS.
Future research could also combine both qualita-
tive and quantitative methods to examine the issue
of ICT integration in healthcare but also in other
sectors. Such research might include a case study
as its first stage in order to understand the inter-
play of variables in the real-world situation and
then perform survey-based work to measure the
strength of the variables and identify any causal
relationships among them. Future research can also
focus on how HIS adoption could benefit patients
rather than medical teams; how perceived barri-
ers change over time; what are the differences
in adoption by various groups (e.g., nurses, doc-
tors, top management, support staff); or how the
design of the system and/or organizational sup-
port affect pre- and post-adoption attitudes and
behavior.
Funding
No funding sources .
Competing interests
None declared.
Ethical approval
Not required.
Acknowledgment
The project was financially supported by King Saud
University, Deanship of Scientific Research, through
the research group project No. 73214.
779
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