595259

research-article2015
JHI0010.1177/1460458215595259Health Informatics JournalEscobar-Pérez et al.

Article

Health Informatics Journal

2016, Vol. 22(4) 878­–896
Integration of healthcare and © The Author(s) 2015
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DOI: 10.1177/1460458215595259
in a public hospital using a jhi.sagepub.com

comprehensive approach

Bernabé Escobar-Pérez
University of Seville, Spain

Tomás Escobar-Rodríguez
University of Huelva, Spain

Lourdes Bartual-Sopena
Alcorcón Foundation University Hospital (HUFA), Spain

Abstract
Public healthcare organisations are moving towards the use of new technologies to automate and improve
their internal processes in order to increase the effectiveness and efficiency of their use of resources. The
aim of this research is to tackle the systematic evaluation of an experience of integrating information in
a healthcare organisation, paying attention to the implications that this entails. The results show that the
integration of the information in the hospital results in higher levels of quality. This study contributes a vision
of interrelated work, in which tasks are shared and aims are jointly established.

Keywords
collaborative work practices and information technology, decision-support systems, information and
knowledge management, information technology healthcare evaluation, organisational change and
information technology

Introduction
The lack of integration of information systems in hospitals – a consequence of using numerous
systems and applications – tends to produce data redundancy and overlapping functionalities. This
makes the coordination of organisational processes difficult.1

Corresponding author:
Tomás Escobar-Rodríguez, University of Huelva, Plaza de la Merced, Huelva 21002, Spain.
Email: tescobar@uhu.es
Escobar-Pérez et al. 879

In recent years, healthcare organisations have been using new technologies to automate and
improve their clinical and business processes. They have increased their interest in investing in
tools that prioritise the integration of clinical, organisational, and management processes.2
With the incessant improvement of computer and information technology, these technologies
have been widely deployed in the medicine manufacturing industry and reveal a great potential for
improving efficiency as well as quality. Enterprise application integration in the medicine manu-
facturing industry is meant to solve the information sharing and interaction between different
application systems.3
A proliferation of literature has emerged offering new organisational and systems models
directed at establishing rationalised services and streamlined organisational structures. Some of the
global forces driving the development of integrated systems include the fragmentation of the
healthcare system. The main reason for this is that a lack of data integration poses a barrier to effec-
tive data reporting and analysis.4
Organisations that go beyond core system integration will be poised to take market share by
virtue of having flexibility to exploit new opportunities and adapt to complex and changing busi-
ness demands.
Two domains – the clinical and financial – have long coexisted within the walls of the nation’s
healthcare facilities. Yet, despite their close proximity, these two worlds traditionally have had lit-
tle direct communication with each other, tending instead to focus on their separate responsibilities
for delivering healthcare. Billers work independently of caregivers and bedside staff members
have little concern for the daily activities of back-office personnel.5
Sooner or later, all expenditures and billings recorded on the clinical side of a healthcare organi-
sation end up in the financial department. Too often, though, clinical and financial applications
operate independently of one another, and early attempts to integrate these disparate systems sel-
dom guaranteed the timely collection and transfer of necessary information.6
To succeed under managed care, healthcare organisations must integrate clinical and financial
information. This integration can help minimise financial risk by improving the ratio of costs to
clinical outcomes. This clinical–financial integration will require healthcare organisations to
improve outcome measurement and cost accounting systems and use tools such as computer-based
patient records to more clearly identify the interventions that produce excellent outcomes at mini-
mal cost.7
Health departments are increasingly recognising the value of sharing information not only
between multiple programmes, but also with private sector providers, policymakers, and the pub-
lic.8 The integration of an organisation’s transactional functions allows it to have a unified data
system instead of a group of isolated applications that offer fragmented data, as well as counting
on updated information. This accelerates the communication flow and drives the organisation’s
internal collaboration. At the same time, it facilitates the decision-making process.
The literature on management in the healthcare sector supports the application of integrated
information systems in healthcare organisations. These contribute to the improvement of processes
and the reduction of operational costs.9
According to Nicolau,10 enterprise resource planning (ERP) systems are well accepted in hospi-
tals insofar as they provide direct benefits in daily work and facilitate tasks; that said, there also
tend to be hostile reactions to ERP systems, because they introduce control mechanisms into daily
work and usually require prominent process re-engineering.11,12
The limitations of achieving the integration of different functions in a healthcare organisation
are both technical and organisational.13 This is the reason why partial integration processes are
frequently carried out.
880 Health Informatics Journal 22(4)

Hospitals are complex and multifunctional institutions,14 and as a result, they require sophisti-
cated clinical and management integration. There are two major approaches to carrying out the
integration of information in hospitals: complete and partial.15 Complete integration means incor-
porating the clinical, administrative, and financial modules into a single system with different
applications, such as the admission and discharge of the patients, wards with first aid kits, and
pharmacy billing. This kind of integration means process re-engineering and produces important
organisational changes that affect both the working of a hospital and the control that comes from
having centralised information. For Anderson,16 this sort of integration tends to produce rejection
from all the personnel – both carers and non-carers – who are usually reluctant to change their way
of working or believe that control by their superiors can cause problems for them. For their part,
Soh and Sia17 argue that this method of implementing an ERP may not be valid for the concrete
case of hospitals because of the need to use specific tools and carry out process re-engineering.
However, this method of integration means efficacy and efficiency for hospital management,
which compensates for the outlay.18
On the other hand, partial integration consists of using the ERP system’s administrative and
financial modules and connecting them to a series of specific applications: radiology, laboratory
uses, and so on. This means, for example, computerising patients’ histories and thus obtaining an
electronic clinical history for each patient. For the medical and nursing staff, this integration is an
important foundation for clinical decision-making, as information can be captured in real time and
can be obtained anywhere (in the doctor’s office, the operating theatre, the intensive care unit, etc.).
Unlike complete integration, there is no thorough process re-engineering and therefore it is not
necessary to modify the working methodology substantially although it still means a greater degree
of control.16,19 This raises the question of whether perceiving that centralised information can be
used to establish control mechanisms could generate rejection although the personnel’s work pro-
cedures will be maintained and improvements in the available information will be achieved.
Systems are being developed along this line in which healthcare information is at least partly
integrated with economic–financial information, such as that carried out in the Alcorcón Foundation
University Hospital (HUFA). However, in parallel to this implementation, evaluation processes are
necessary. These allow the identification of the new systems’ contributions to the organisation. The
success of health information technologies should be evaluated by developing specific tests of
evolutionary fitness,20 as most evaluations are conducted from the point of view of the system’s
efficiency and evidence is only gathered once it has been implemented. This is why they have vari-
ous deficiencies, for example, the lack of a comparison between the situation before and after the
implementation, that is to say, a ‘pre-versus-post’ implementation evaluation.21–24
This research tackles the systematic evaluation of an experience of information integration in a
health organisation, HUFA, paying attention to the implications that this entails. The aims of this
article are as follows:

•• The success of the integrated system depends on the ERP users’ attitudes towards the sys-
tem. Therefore, the first objective is to evaluate the users’ attitude towards the integrated
system and its perceived value.
•• The integrated system should improve the usefulness of the information, making it more
accessible, reliable, and timely. Therefore, the second objective is to identify the changes in
the flows of information and improvement in decision-making with the new system.

The structure of this article is as follows: the next section analyses the role of ERP systems as
tools for integrating business data and presents the evaluation framework. We then describe our
Escobar-Pérez et al. 881

research methodology and present the data analysis and results. We conclude with a summary of
the findings and their implications.

Background
For Newell et al.,25 ERP systems represent a new class of information system that is designed to
help integrate all the key areas of activity of a company, particularly the financial, productive, and
human resource functions. The appearance of ERP marked a trend towards the acquisition of stand-
ardised information systems, rather than tailor-made systems designed to meet the specific needs
of a particular organisation.26
As a consequence of their division into functional areas, traditional information systems focused
on supporting each functional area and only rarely ensured that data flowed smoothly between the
different functional areas. This was aggravated by the fact that the information systems of each
area had, in many cases, been developed independently, with data formats that were incompatible
or did not meet the information needs of the rest of the processes of the business.27
An ERP system overcomes these disadvantages by integrating the information from the differ-
ent departments and subsidiaries of the company into one single database accessible to the whole
organisation.28 When a piece of data is entered into the ERP system by any organisational unit, it
is immediately available for use by the rest of the company’s organisational units. In respect to this
key feature, Gattiker and Goodhue29 state that this integration brings about an improvement in the
flows of information between the various organisational units and reduces administrative costs, as
fewer tasks have to be performed to obtain any particular piece of information.
Thus, for a large multinational firm, an ERP system essentially represents a means of homoge-
nising the work procedures utilised by its units,30 which should lead to greater agility in responding
to market demands and reduced inventory levels.31 However, it is necessary to understand the
impact that individual, group, organisation, and national culture variables have on how the process
of implementing ERP systems unfolds and what may contribute to its final outcome.32,33
Botta-Genoulaz et al.34 carried out a review of the literature on ERP systems during the period
1996–2004, in which they report an increased number of studies published in recent years and
identify different categories in the functions of the area of interest of these studies:

•• Implementation of ERP systems. This category includes those studies associated with the
various stages in the implementation of an ERP system, the problems associated with the
process of implementation, the conditions necessary for the process to be successful, and the
reasons why the process sometimes ends in failure.
•• Optimisation of ERP systems. The idea underlying this type of study is that the process of
implementation does not end when the system is first put into effective operation; in the
post-implementation period, it is essential to analyse the activities that the system is intended
to support in order to optimise the system and thus obtain the expected competitive
advantages.
•• Management by means of the ERP system. These studies focus on considering the ERP
system as a management tool, describing the changes that take place in the management
of companies that install an ERP system against other aspects that do not change as
expected.
•• ERP software. These are studies that approach the topic from the systems perspective, in
which various analyses are made of the aspects associated with the processing of informa-
tion, the inter-operation of the ERP system with the other systems in use in the organisation,
and the adaptation of standard systems to the individual needs of a company.
882 Health Informatics Journal 22(4)

•• ERP and the management of the supply chain. These studies analyse the use of ERP systems
in the context of companies that form an integral part of an existing supply chain.

Of the five categories of study identified, we consider the aspects associated with the process
of implementing the ERP system, particularly in a large complex organisation, to be crucial.
Serious problems can arise in organisations with highly differentiated cultural areas; often such
areas have traditionally had a high degree of autonomy, with independent information systems
and independent control over the interests of their area. Hospitals are one example of such organi-
sations. In these sectors, the success of the implementation process depends largely on the top
management giving continuous active support to the project and on the commitment of managers
to the concept of integrating functions and improving operating processes.35 Achieving the par-
ticipation, collaboration, and acceptance of all the members of the organisation is, without a
doubt, one of the principal factors that are critical for the successful implementation of an ERP
system. Akkermans and Van Helden36 state that, during the process of implementation, interde-
partmental collaboration and communication will be reinforced if the top managers, the project
managers, and the software suppliers all demonstrate a positive attitude. In many cases, the tasks
of leadership are particularly important and delicate,37 as the introduction of the ERP system into
the company will modify the procedures within the company and the job functions of some of the
employees, at all levels, will change.
Thus, if the anticipated restructuring that will be required is not properly taken into account in
the process of designing the ERP,38 when the time comes to carry out the campaign of awareness
and training needed, the process of implementation could lead employees to adopt postures of
resistance to the change; this may arise for fear of the unknown or simply due to the sensation of
displacement that some members of the organisation will feel.
However, difficulties arise when the management wishes to extend the scope of the information
system to include all the information that is generated in the hospital. In effect, a hospital needs an
integral system of analysis, planning, and control that allows the procedures that have to be applied
to the patients to be planned and executed in parallel with the provision of the capacity required.39
On this point, according to Khoumbati et al.,13 studies have to be carried out in hospitals to deter-
mine how to increase the capacity of the existing information systems at the same time as reducing
the costs of integrating information.
Integration brings with it an improved flow of information between units.29 The implementation
of ERP enables a firm to reduce the transaction costs of the business and improve its productivity,
customer satisfaction, and profitability.40 A number of empirical studies demonstrate the positive
relationship between expenditures on technology and operational improvements.41,42 More specifi-
cally, findings regarding ERP systems indicate their transactional effectiveness,43 as they provide
databases that are more accessible and which therefore reduce general administration costs while
boosting efficiency.44 Furthermore, ERP systems have been shown to reduce the time required to
complete business processes and help organisations share information,45,46 facilitating an inte-
grated and coordinated workflow.
The aim of previous research has focused on exploring the critical factors related to the success
and failure of the ERP implementation process.35,47–51 These critical factors include top manage-
ment support, user training and education, change management, business process re-engineering,
and effective communication.48,52–54
These critical success factors are helpful and appropriate in explaining both the initial failure and
the eventual success of the implementation.36 However, making an ERP system work is more than an
issue of technical expertise or social accommodation: it is an on-going, dynamic interaction between
the ERP system, different groups in an organisation, and external groups such as vendors, management
Escobar-Pérez et al. 883

Users’ • Resistance to being controlled

• Resistance to change
a tudes • Perceived usefulness
towards the • Perceived ease of use
system • A tude towards use

Usefulness
• Infomaon flows
of the • Decision making
informaon

Figure 1.  Conceptual framework.

Source: adapted from King and Rodriguez.58

consultants, and shareholders.55 ERP systems might be implemented successfully from a technical
perspective, but their success depends on the ERP users’ attitudes towards the system.56,57
Therefore, the evaluation of the success of these integrating technologies is a research question
that should be addressed. In order to carry out a systematic evaluation of the integrated system
implemented in HUFA, we will use the conceptual framework developed by King and Rodriguez58
(Figure 1).
They propose that the comprehensive evaluation of a management information system must
take into account two fundamental aspects. The first is to determine how the new system has
affected the users’ attitudes and the value that they perceive in it. The second refers to the useful-
ness of the information. At the same time, the evaluation tries to identify the extent to which the
new system has improved the quality of the decision-making process. This is both in the sense
of altering the decision-making process itself because of managers having higher-quality infor-
mation and in the sense of proposing new problems or situations due to having information that
did not exist before the implementation of the new system. In other words, it concerns how the
new system has improved the managers’ use of information, making it more accessible, reliable,
and timely.

The implementation of ERP systems in HUFA

Designing, implementing, and using an ERP system constitute a complex task that cannot be
fully understood on its own; it must be analysed within the context of a business environment.32,59
Contrary to other empirical research methods, case studies make it possible to analyse contem-
porary phenomena in their real context, when the demarcations between the two are not very
clear and when multiple evidence sources are used;60 this has been recommended in order to
increase the contact between research and the reality of the business world.15,61 Furthermore, the
case study has been recommended as the ideal research methodology for gaining a better under-
standing of complex phenomena,62,63 and the implementation of an ERP system in an organisa-
tion with sharply divided functional areas and professional cultures is a very complex
phenomenon. Moreover, case studies allow researchers to produce emergent theory in areas in
which knowledge gaps still exist.64
884 Health Informatics Journal 22(4)

Research on ERPs based on survey studies has previously been used to identify ERP success
factors and provide statistics on ERP adoption and benefits.65,66 On the other hand, case study
research has explored the nature and role of these ERP success factors.67,68 However, since public
hospitals’ characteristics differ from those of other organisations, these studies may not fully
explain the implementation process in public hospitals. For that reason, we chose to carry out in-
depth case study research to provide insight into the implementation process and use of ERP sys-
tems in public hospitals, which might not be possible with other methods.69 In order to lend validity
to our data, this study used the triangulation method recommended by Yin.70 Therefore, multiple
techniques were used to collect data for this study:

•• Two surveys were conducted at two moments in time to identify how both the users’ attitude
and the perceived value had evolved.
•• Informal conversations with personnel from different areas were held away from the work
environment in a relaxed setting to avoid more official behaviour that might have affected
the information (short or insincere replies).
•• Direct observation of general hospital functioning as well as each of the specific service
areas in order to become familiar with its personnel, peculiarities, management, and so on.
These observations were mostly carried out during the morning hours, as this is when the
hospital is most active.

Context – the integration of information in HUFA

Due to the informational nature of this study, the selection of the unit to be studied was not random,
but specific in nature.71 This case study was carried out in HUFA due to its public nature, as well
as its autonomous administration and economic management departments; its directors showed
interest in seeking efficient solutions to assist in decision-making. HUFA, assigned to the Madrid
Health Service, was founded under Law 15/1997, of 25 April, which deals with new ways of man-
aging the National Health System. It started operations in December 1997 and currently serves a
population of more than 250,000 inhabitants.
Practically from the beginning, the members of the Foundation were convinced that the hospital
needed an ERP. Due to this, the integration of clinical and economic-financial information was
established as one of the main aims in the strategic plan for information systems.
The HUFA Information System currently has three major modules, interconnected via a series
of interfaces (Figure 2).
The functions included in each module and the 11 applications are as follows:

•• Module 1. Human Resources (Personnel Management and Management of Shifts) and

Payroll.
•• Module 2 (SAP R/3). Financial and Cost Management (Supplies, General Accounting,
Analytical Management and Management of Costs, Payment of Suppliers’ Invoices,
Inventory Management, and Maintenance), Supporting Services (Catering, Dietetics, and
Kitchen), and the Executive Information System.
•• Module 3. Patient Care Management (Admission of In-patients, Waiting Lists, Emergencies
and Emergency Boxes, External Consultations, Electronic Clinical History, and Invoicing to
the Customer), and Clinical Management (Management of Operating Theatres, Radiology,
Outpatients, Ward Control Points, Control Infrastructure, Generation of Medical Reports,
Pharmacy, Pathology and Nursing Units, Document Manager, Medical Protocols, and the
Laboratory).
Escobar-Pérez et al. 885

MODULE 2
MODULE 1
Financial and cost management

Human Resources
I-2 Supplies General
Accounting
Personal Shifts

Analytical
Maintenance
Management

Payroll
I-3 Invoicing Inventory
Payroll by suppliers Control

Support
Executive
Catering, Information
Dietetics & System
Kitchen
Balanced
I-1 Scorecard
Library

I-5 I-8 I-9 I-10

I-6

MODULE 3
Patient Care Management Waiting Lists Emergency & External Consultations
Accidents
Client Invoicing
Clinical Electronic
Admissions Patient Care Histories I-11 Files
I-4
I-7
Clinical management Out-patients Pathology Nursing Units

Operating Theatre Pharmacy/Unidose

Management Laboratory Specific Modules
Radiology

Figure 2.  The health information system at HUFA.

SAP is the world’s largest ERP manufacturer. SAP’s traditional ERP solution, named R/3, pro-
vides ERP functionalities that help businesses to manage areas such as product planning, purchas-
ing, warehousing, transportation, and human resources. HUFA tries to resolve this complexity
from a technological perspective using a sophisticated set of interfaces. Although all interfaces
were considered when the system was designed, not all were developed. In particular, the inter-
faces connecting Modules 2 and 3 were not utilised. These interfaces would allow the Invoicing
886 Health Informatics Journal 22(4)

module to be related to General Accounting and Analytical Management and are fundamental to
the correct integration of information between Modules 2 and 3.
To develop its activity, HUFA is financed by the Madrid Health Service and regulated by an
agreement signed by both parties. Additionally, the hospital provides healthcare to third parties
who are required to pay, such as collaborating and private entities (mutual companies), private
insurance entities (traffic accidents), and individuals. Moreover, to contribute to the operation of
the Foundation’s typical activities, HUFA provides services for collaborations that correspond to
sums received from sponsors and business collaborators. These are mostly for clinical trials.
Regarding HUFA’s non-healthcare service provision, there is a payment for the assignment of
the Foundation’s physical spaces for exploitation by third parties of different businesses, such as
the restaurant or employee cafeteria, as well as the income from different courses provided by the
Foundation. To sum up, HUFA’s service provision gives rise to different billable elements which
can be classified according to the following typology:

1. Patient with patient guarantor;

2. Patient with private guarantor;
3. Patient with firm guarantor;
4. Firm.

Implementation of the integrated system in HUFA

For those responsible for managing the HUFA, the information systems are a set of procedures and
functions directed towards the collection, production, assessment, storage, recovery, and distribu-
tion of items of information within the organisation, and which are oriented towards promoting the
flow of these items from the points where they are generated to the final intended recipients.
Therefore, the information systems should be an integral part of HUFA’s corporate strategy, as
today all organisations are information-based.
The managers think that the management of information is one of the bases on which the organi-
sation operates (in addition to its human and financial resources) and that the incorporation of
technology is essential in order to handle the information adequately, not only at the strategic and
tactical levels to serve as the support for decision-making, but also at the operating level to facili-
tate daily clinical activity.
The implementation of the healthcare and financial information project in HUFA has allowed
the healthcare activity, supported by the clinical information systems (so-called SELENE), to be
connected to the hospital’s SAP R/3 through the hospital’s billing tool, which is called AURORA.
This last tool will enable the hospital to reduce its transaction costs and improve its productivity
by reducing the time it takes to complete some business processes and by helping users to share
information.
A differentiated file structure has been defined according to the typology of bills in the hospital
and for each one of them. These files are transmitted through the HUFA information system.
The integration process begins when a bill is generated in the AURORA system, as a file is
automatically created with the text structure defined and a file with the image of the bill. Once the
directory has produced the file, it makes a call via an event to an SAP R/3 job. This validates the
file, records the document, and attaches the image of the bill to the account document or produces
a file with the error log. This is notified via a warning sent to the email client of the assigned users.
As a result, to achieve the integration of the healthcare and economic information in the hospi-
tal, it is compulsory to establish agreements and restrictions between the two systems in order to
homogenise the structure of the data coming from the different applications.
Escobar-Pérez et al. 887

From these restrictions and from the records of the healthcare activity corresponding to
‘Financier’ (Private, Social, Muface – one of the most important private health insurance firms for
civil servants in Spain – International Agreements, etc.) and ‘Area’ (Emergencies, Hospitalisation,
Outpatients, etc.) in SAP R/3, the economic record of the service provided is obtained. In this
record, the cost centre or the project Personnel Expenditure Projection (PEP) assigned is obligato-
rily reported in each bill. The PEP elements are objects to which the budget is assigned, having an
availability control when recording or committing expenditure. In this way, it can be assured that
more is not spent than is received for the activity carried out.
The centre to which the cost is assigned corresponds to the structure of the Homogeneous
Functional Groups (HFGs) approved in HUFA.
On the other hand, the management of the research projects in HUFA requires information to be
obtained about collections and payments related to the projects that are carried out in the hospital
and that are managed in SAP R/3 via the PEP elements.
In both cases, the master data at the centre of the PEP cost or element correspond to a single
table that is kept in SAP R/3. This is updated in real time via another interface between the two
systems. A second table is used for the billing of non-healthcare activities. This has, according to
the kind of ‘firm’ bill issued, the type of value-added tax, the account, and the allocation to the
corresponding cost centre or PEP element.

Results: evaluation of the integrated system

Users’ attitudes and perceived value
A field study was conducted in HUFA to compare users’ attitudes and their perceived value of
the system. The study was carried out with all the users of this new interface connecting Modules
2 and 3. Two surveys were carried out at two moments in time to identify both how the users’
attitude and how the perceived value had evolved. The data of the first survey were gathered in
September 2011, before the integration of the economic–financial and healthcare information
was undertaken. The second survey took place in April 2013, once the integration was complete.
On both occasions, the response rate obtained was 80 per cent, with a total of 59 valid responses
in each case.
The questionnaire included the items related to a series of constructs that allow the evaluation
of the users’ attitudes and perceived value of the system. These are described in Table 1. The theo-
retical constructs were designed from previous research by Carr et al.,72 Davis,73,74 Davis et al.,75
Dasgupta et al.,76 Mathieson,77 and Moore and Benbasat.78 The items that make up each of the
constructs were quantified via a 7-point Likert scale, in which 1 meant ‘completely disagree’ and
7 ‘completely agree’.
Once the data had been obtained, the results of the two surveys were compared using Student’s
t-test.79,80 The results obtained are shown in Table 2.
The results (resistance to being controlled (RBC1), p < 0.05; RBC2, p < 0.01; RBC3, p < 0.01)
confirm that RBC is a significant factor in evaluating the users’ attitudes and their perceived value
of the system. The study shows that RBC varies according to the progress in the project’s imple-
mentation. After the implementation of the project in the hospital, the average values of each item
show an increase with respect to the first consultation, which was carried out in the tool’s pre-
implementation phase. The comparison of the results obtained in the two phases confirms that as
the implementation of an integrated information system advances, there is a progress in the reduc-
tion of time spent controlling the workers, the quality of the information improves, and the tasks
and control systems are facilitated. The users consider the lack of compatibility of the system with
888 Health Informatics Journal 22(4)

Table 1.  Constructs and items.

Construct
Resistance to being
controlled (RBC)
Resistance to change (RC)
Perceived usefulness (PU)
Perceived ease of use (PEU)
Attitude towards use (A)
Item
RBC01. The ERP system allows the management to improve the
quality of the control systems.
RBC02. Implementing an ERP system reduces the time needed to
control the behaviour of the workers.
RBC03. As a result of its single database and its analysis capacity, the
ERP system facilitates the control tasks.
RC01. The use of an ERP system is not completely compatible with my
current work.
RC02. I believe the use of the ERP system does not fit the way I like
to work.
RC03. The use of an ERP system does not fit my way of working.
PU1. The use of ERP systems improves my performance.
PU2. The use of ERP systems helps me to improve the most important
aspects of my work.
PU3. The use of ERP systems allows me to do more work than would
otherwise be possible.
PEU1. The use of ERP systems is frequently confusing.
PEU2. Mistakes are frequently made when ERP systems are used.
PEU3. Interacting with ERP systems is frequently frustrating.
A1. The use of ERP systems in the hospital is a good idea.
A2. The use of ERP systems at work is pleasant.
A3. The use of ERP systems is beneficial, improving both the attention
to the patient and the hospital management.

their tasks, preferences, and ways of working to be significant (RC01, p < 0.05; RC02, p < 0.05;
RC03, p < 0.05). The item resistance to change (RC) shows a decrease in its values between the
periods compared. The average of the results obtained in September 2011 and April 2013 varies
considerably in the samples observed. As the project advances, the users perceive a greater fit
between the new system’s tools and their needs.
Measuring specific variables related to the users’ attitude towards the new system (A) – such as
in the case of perceived usefulness (PU) and perceived ease of use (PEU) – has allowed the users’
emotional values to be incorporated into this study.
The results of the users’ perceptions of the system’s usefulness show a significant relationship
(PU01, p < 0.05; PU02, p < 0.01; PU03, p < 0.05). Thus, the users’ perceptions of the usefulness of
the new information system are consolidated as an influential factor in the employees’ attitude
regarding the introduction of innovations into the hospital’s information system.
The study’s findings show an average increase in the PU values of the items consulted (PU01,
PU02, and PU03) between the periods compared. This result upholds the idea that with the consoli-
dation of the implementation of the project, the users perceive improvements in performance and
in the main aspects of their work. This brings about a reduction of their RC, as has been com-
mented previously.
The PEU results adjust to the standard proposed by the model (PEU01, p < 0.01; PEU02,
p < 0.01; PEU03, p < 0.01), while the decrease in the value of the items is broadly noted in the com-
parative data between the two periods. The users appreciate the improvements achieved with the
new tool, as using the new application has allowed them to reduce the errors in their daily work.
Escobar-Pérez et al. 889

Table 2. Results.

Item September 2011 April 2013 t value p value Significant

Average Standard Average Standard

before Deviation after Deviation
before after
RBC01 3.27118644 1.62767561 3.84745763 1.34950258 2.09351263 0.0384822 Yes, p < 0.05
RBC02 2.74576271 1.67736678 3.54237288 1.59007736 2.64742557 0.00923837 Yes, p < 0.01
RBC03 2.69491525 1.79322708 3.72881356 1.59558127 3.30852505 0.00124958 Yes, p < 0.01
RC01 4.40677966 2.03519587 3.6779661 1.79501876 2.06291903 0.04135254 Yes, p < 0.05
RC02 3.94915254 1.60197861 3.38983051 1.43859305 1.99536149 0.04834724 Yes, p < 0.05
RC03 3.81355932 1.64499844 3.22033898 1.42717223 2.09229434 0.03859313 Yes, p < 0.05
PU01 4.57627119 1.59960545 5.25423729 1.29446062 2.53069493 0.01272332 Yes, p < 0.05
PU02 4.6779661 1.58049183 5.54237288 1.03926423 3.51012443 0.00063871 Yes, p < 0.001
PU03 4.76271186 1.66442475 5.3559322 1.33600939 2.13494574 0.03486945 Yes, p < 0.05
PEU01 4.42372881 2.09435522 3.25423729 1.34668457 3.60770762 0.00045706 Yes, p < 0.001
PEU02 4.74576271 2.18610992 3.76271186 1.535095 2.82674704 0.00553967 Yes, p < 0.01
PEU03 4.71186441 2.09309907 3.6779661 1.71645864 2.93381025 0.00403637 Yes, p < 0.01
A01 5.49152542 1.63341066 6.08474576 0.95209634 2.41009025 0.0175201 Yes, p < 0.05
A02 5.22033898 1.64072941 5.89830508 0.90391706 2.77996065 0.00634494 Yes, p < 0.01
A03 5.23728814 1.55739596 5.88135593 0.93004905 2.72727165 0.00737854 Yes, p < 0.01

After the implementation and experiencing the new system, the users feel greater satisfaction and
are clearer about the new system’s advantages.
Finally, the results note a significant increase related to the users’ attitude. Once the system had
been implemented, the users were satisfied with the benefits it had brought them in their daily
work, as well as with the improvements that it offers to the organisation as a whole (strategic plan-
ning and results obtained by the hospital, work atmosphere, etc.).
The results show that one of the key factors for the implementation process to be satisfactory is
the users’ attitudes and their perceived value of the new system.
The answers on the users’ behaviour and emotiveness towards the innovations of the infor-
mation systems are a critical factor to be taken into account in any implementation project.
The positive attitude detected in the second period of the project increases the willingness to
use the tool.
This study has allowed the verification of the hypothesis that, through their behaviour, users’
attitudes play an important role in the implementation process of any technological innovation.

Management of the information and improvement in decision-making

The plan to open the hospital relied on the implementation of management strategies focused on
improving efficiency. The ERP system was opted for as being the most suitable for providing com-
puter support to the organisation. It is clear that in the investments carried out by the hospital since
its inauguration, priority has been given to the implementation of new technologies and the devel-
opment of applications and tools. These allow the integration of processes that are clinical, organi-
sational, and related to hospital management.
From the beginning, HUFA was conceived as a modern organisation with a system that inte-
grates clinical and economic–financial information:
890 Health Informatics Journal 22(4)

The integrated system […] was a hospital ambition; in other words, it was a priority to have an integrated
management system providing information. (Nursing)

… when I started, the Foundation was quite clear that it wanted an integrated management system; this
was evident from the outset. (Economic–Financial)

The decision was considered justified because, based on experience, the members initially com-
prising HUFA were firmly convinced that it would be very positive to be able to integrate different
department data; therefore, they decided unanimously to do so.
From the outset, three factors were decisive in settling on installing the ERP system:

•• To stop using isolated information systems. ‘The Foundation’s members were a bit tired of
having different information systems, each managed by independent persons or businesses
with little or no contact between them’ (Economic–Financial).
•• Involve clinics in management. ‘… clinical management – that is, the involvement of the
clinic in running the hospital with set objectives, not in the role of top management, but as
an active participant in achieving the goals set by those in charge …’ (Nursing).
•• Use the hospital as a political point of reference to demonstrate that self-management is
indeed possible ‘… HUFA was the Government’s flagship at the time; I think that after
10 years, most of the government has changed, yet we are still here; in other words, we were
on the right path …’ (Nursing).

As the hospital was new, so were its staff and its work arrangement. Setting up an integrated
information system as well as the necessary tools to prepare data was not problematic, at first, and
to a point management viewed it as a challenge:

The need for integrated information was not evident until we had it. (Medical)

I come from a hospital in which information systems were practically not used. When I got here to all of
this I said, ‘This is great – I love it!’. (Nursing)

As the hospital is practically new, HUFA’s Accounting and Treasury Department is practically
automated and almost all the processes are computerised. It has a digital system for issuing and
receiving bills, which is available online.
The solution adopted in HUFA implies the use of financial and administrative modules, but
keeps the specific applications that have traditionally been utilised in the healthcare industry. In
this case, it works with SAP R/3 connected to specific healthcare applications that contain eco-
nomic information through interfaces. For this reason, it does not have modules that are unified in
a single platform. This is what is known as a partial solution.
There is an access to the clinical episodes, which are subject to monetary compensation through
the integration of the healthcare activity with billing.
The implementation of this innovation is integrated with the hospital’s ERP and its main contri-
butions to the information management are detailed below. Thus, the renovation of the receiving,
recording, and validation processes of the bills received; automating the comparison of the prices
of the orders to suppliers with what these suppliers bill; the reconciliations of the units of goods
received with the units billed; and the recording (entering) in the bill’s data system have contrib-
uted the following advantages:
Escobar-Pérez et al. 891

•• The management of the different formats of documents of bills received in accordance with
the precise financial, legal, and accounting requirements.
•• The conversion of paper into digital images. The bill’s image is exportable and is available
throughout the bill’s processing. It integrates the bill’s digital image with the accounting
record in the hospital’s ERP.
•• It captures the information of any kind of bill at the level of lines of detail, allowing the
automatic reconciliation with the order and the delivery note without the user’s
intervention.

Regarding the bills issued, the implementation of this research project of integrating healthcare
and financial information has allowed the hospital to establish a gateway between AURORA, the
billing tool of the healthcare activity (SELENE), and the hospital’s economic information system,
SAP R/3.
Concerning the capturing, recording, and exactitude of the information, the main advantages in
the implementation of this tool are as follows:

•• An increase in capacity and shorter response–reaction times in the seeking, recording, col-
lection, and payment of bills.
•• An increase in the efficiency of the handling process of bills that have been issued, the
elimination of bills in paper archives, the introduction of single data from a single module,
and the automatic posting of the bills.
•• Improvements in the access to information, and the synchronisation and updating of infor-
mation simultaneously in all the related areas. There is a link from the SAP R/3 system to
each posted document.
•• The reduction of errors.

With the solution adapted by the hospital – based on the SAP R/3 connection with specific
healthcare applications – the information is totally integrated. This accelerates the flow of informa-
tion and drives internal collaboration. For example, it decreases the response time for solving any
problem related to the information transmitted. Furthermore, the personnel are more committed to
a real-time philosophy, as they have less repetitive work, have digitalised information, and do not
have to carry out tedious paper archive searches.
Moreover, the connection of the data between the different functions developed in the hospital
facilitates the analysis of the information for decision-making. The integration makes it possible to
optimise the process of obtaining information. In the past, this used to be extremely complex and
laborious due to the time needed to acquire solid and connected information.
On the other hand, the integration of the financial and healthcare information has allowed pro-
cess re-engineering to be carried out to increase efficiency. Thus, the work procedures have been
revised while the resulting tasks have been reassigned along the line discussed by Davenport and
Stoddard.81 This was achieved by taking into consideration the alignment of the technological tools
with the organisation’s skills, strategy, and environment.82
The integration of the information in the hospital has involved the automation of the processes
implicated. As a result, numerous routine tasks that the staff performed manually have been sup-
pressed. The integration has allowed the staff involved to be reassigned to other tasks and activities
in the hospital with greater value added.
At the same time, with the integration of the information, greater ease and speed in accessing
information has been achieved: information is available in real time and the organisational man-
agement is more transparent. All this allows not only to increase deficiency in the financial and
892 Health Informatics Journal 22(4)

administrative processes but also to improve efficacy in the decision-making process and the hos-
pital’s corporate process.
There are a number of advantages to amassing information into a single database, all of which
favour managing and decision-making. It is evident that
•• Information can be contrasted and decisions can be made with a feeling of certainty:
The problem in hospitals is that information from different departments (for example, Dermatology, OB/
GYN, etc.) is that information is not compared and contrasted. Therefore, the ability to make decisions
based on total certainty is always doubtful. On the other hand, once data is integrated, the decision-making
process is less risky. (Nursing)

•• The data obtained are clear and objective:

The biggest benefit of an integrated system is that decisions can be made based on information, rather than
suppositions. (Nursing)

•• Reliability is increased while errors are reduced, which makes it easier to prepare ratios and
compare data:

Data obtained from an integrated system are reliable, with a reduced margin of error […] and represent a
unique opportunity to control economic and patient information to be able to prepare ratios and
comparatives. (Economic–Financial)

•• Saves time and increases security:

Integrated systems save you from excess work, and provide peace of mind and reliability.
(Economic–Financial)

… I switch on the ‘on’ button in the morning and can see everything that has occurred. (Nursing)

•• This is efficient since data are introduced just once and are checked by the internal system
controls:

Integration does not only represent efficiency when introducing data, but also ensures solid information,
as it can be cross-checked […]. This is great for the Accounting Department. (Accounting)

•• Doctors and patients also benefit (peace of mind and agility) since patient file management
is centralised, providing an electronic clinical history that makes it less likely that tests will
be lost (such as analyses, X-rays, etc.). Patient files are lost less frequently, and medication
is not incorrectly dispensed as often. Long waits for test results are a thing of the past, even
in cases in which several are needed, resulting in considerable savings in consumables:

In this case, having an integrated management system allows us to have most information at hand and to
be able to use it in an agile, clear, and connected fashion to handle our patients […]. Doctors and patients
do not have to wait for results which are going from one end of the hospital to another, and a great deal is
saved in the way of consumables. (Medical)

To sum up, it may be said that the implementation of the integrated information system has
allowed HUFA to attain higher quality levels in its service provision. In the hospital’s case, this is
centred on the improvement of healthcare service provision.
Escobar-Pérez et al. 893

Conclusion
The presentation of the specific case of HUFA is an example of the integration of different agents
of a hospital’s inherent activity, as well as the automation of the processes involved in this integra-
tion. The new system in HUFA fosters a cultural change towards interrelated work systems in
which tasks are shared and common aims are established. This in turn allows the organisation to
improve the quality of the information handled.
Sometimes, it is not easy to deal with this integration process in hospitals because of their
organisational issues. The major problems arise in most ERP adoptions because of organisational
rather than technical issues, for example, social and cultural barriers and user resistance.
Furthermore, the business processes of the company are often substituted for the business pro-
cesses implemented in the ERP. In hospitals, ERP systems are welcomed as long as they provide
direct benefits to users’ work and ease their work practices. At the same time, hostile reactions to
the ERP system were evident in HUFA, as it implied control mechanisms of the users’ work and
introduced new work tasks previously performed by others.
This study has conducted a systematic evaluation of the solution adopted to carry out integration.
The results show how the users’ attitudes and the perceived value of the information system improved
overtime. In this particular case, the users do not perceive the higher integration level of the information
system to be a negative issue. Therefore, hostile reactions could partially be reduced using the system
and by showing that a higher level of integration usually implies a higher level of performance.
On the other hand, the quality of the decision-making process has also improved, both in the
sense of altering the decision-making process – due to the managers having higher quality informa-
tion – and in the sense of being able to pose new problems and situations.
Now that the project is finished, HUFA is continuing to advance towards the design of systems
based on the complete integration of information. This last goal would allow HUFA to have a com-
plete description of all its internal and external processes with users, institutions, suppliers, and
customers in a common platform.
In this way, all the hospital’s team would function with the same tool. This would allow all the
users to be interconnected and the information to be shared through the same tool.
The organisational complexity that is characteristic of hospitals – mainly due to the cultural dif-
ferences between the different areas – can make advancing down this road difficult. Nevertheless,
the need to manage economic resources in an increasingly efficient manner means achieving the
complete integration of information through a single platform.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publi-
cation of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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