03DSSZ01Z0018

the
UNIVERSITY
of
GREENWICH
Dissertation
Title:
“Hospital Information System Evaluation”
Student’s name:
Triantafyllia Doumpa
Supervisor’s name:
Dr. Prodromos Chatzoglou
2009
MSc in Finance and Financial Information Systems
Acknowledgements
I would like to acknowledge the assistance of Dr. Prodromos

Chatzoglou, Professor of the Democritus University of Thrace, Greece,
supervisor of the present dissertation, for his valuable contribution in
supervising my progress in every step, from the beginning until its
completion.
Furthermore, it would be ungrateful not to thank the directors of
the IS departments of the hospitals that participated in the present
research, for our great cooperation during the data collection process.
To conclude, I would like to thank my colleagues and friends, and
especially my family for their help and support that they have given to me
from the begging of the postgraduate programme.
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Table of Contents
ACKNOWLEDGEMENTS ....................................................................... ii
TABLE OF CONTENTS.........................................................................iii
LIST OF FIGURES ............................................................................. v
LIST OF TABLES ..............................................................................vi
ABSTRACT .................................................................................... vii
INTRODUCTION ............................................................................. 1
CHAPTER 1 .................................................................................... 3
HOSPITAL INFORMATION SYSTEMS: THE CASE OF GREECE ........... 3
1.1. IT AND HEALTHCARE .................................................................. 3
1.2. DEFINITIONS, AIM AND STRUCTURE OF HIS ....................................... 6
1.3. THE VALUE OF HOSPITAL INFORMATION SYSTEMS ................................ 8
1.4. THE STATUS OF HIS IN GREEK HOSPITALS ......................................... 9
CHAPTER 2 .................................................................................. 10
INFORMATION SYSTEMS EVALUATION ........................................ 10
2.1. THE IMPORTANCE OF EVALUATION ..................................................10
2.2. THE DELONE AND MCLEAN MODEL OF INFORMATION SYSTEM SUCCESS .....12
2.3. APPROACHES TO IS SUCCESS MEASUREMENT .....................................15
2.3.1. Cost-benefit analysis .......................................................16
2.3.2. System Usage.................................................................16
2.3.3. User Satisfaction .............................................................17
2.4. USER SATISFACTION MEASUREMENT MODELS .....................................17
2.4.1. Bailey and Pearson’s user satisfaction measure....................18
2.4.2. Ives, Olson and Baroudi user satisfaction measure ...............19
2.4.3. Doll and Torkzadeh measurement of EUCS..........................23
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2.4.4. Chin and Lee model of EUCS .............................................26
2.4.5. Mahmood et al., research model of factors affecting IT EUS ..27
CHAPTER 3 .................................................................................. 30
HOSPITAL INFORMATION SYSTEM EVALUATION: THE RESEARCH30
3.1. USER SATISFACTION AS A MEASURE OF SUCCESS ................................30
3.2. THEORETICAL FOUNDATIONS ........................................................32
3.3. THEORETICAL MODEL AND HYPOTHESIS ............................................33
3.3.1. User background .............................................................34
3.3.2. System Quality ...............................................................35
3.3.3. Information Quality .........................................................36
3.3.4. Service quality ................................................................37
3.4. METHODOLOGY RESEARCH...........................................................38
3.4.1. Instrument Development..................................................38
3.4.2. Research Population and Sample .......................................42
3.4.3. Research Procedures .......................................................42
3.4.4. Data analysis..................................................................45
CHAPTER 4 .................................................................................. 54
CONCLUSIONS AND RESEARCH LIMITATIONS ............................. 54
4.1. CONCLUSIONS .........................................................................54
4.2. RESEARCH LIMITATIONS .............................................................55
REFERENCES ................................................................................ 57
APPENDIX A: QUESTIONNAIRE.................................................... 63
APPENDIX B: STATISTICAL ANALYSIS......................................... 66
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List of Figures
FIGURE 1.1: FUNCTIONAL DESIGN FOR THE INTEGRATED HIS ........................... 7
FIGURE 2.1: THE D&M IS SUCCESS MODEL ..............................................13
FIGURE 2.2: UPDATED D&M IS SUCCESS MODEL ........................................14
FIGURE 2.3: A MODEL FOR MEASURING END-USER COMPUTING SATISFACTION .....25
FIGURE 2.4: FORMATION OF END-USER COMPUTING SATISFACTION ..................27
FIGURE 2.5: RESEARCH MODEL OF FACTORS AFFECTING IT END-USER SATISFACTION
.............................................................................................28
FIGURE 3.1: RESEARCH MODEL OF MEASURING USER SATISFACTION ..................34
FIGURE 3.2: USER BACKGROUND ...........................................................50
FIGURE 3.3: SYSTEM QUALITY ...............................................................50
FIGURE 3.4: INFORMATION QUALITY .......................................................50
FIGURE 3.5: SERVICE QUALITY ..............................................................50
FIGURE 3.6: USER SATISFACTION ..........................................................51
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List of Tables
TABLE 1.1: BENEFITS OF USING INFORMATION AND COMMUNICATION TECHNOLOGIES
IN THE HEALTH CARE SECTOR ............................................................ 5
TABLE 2.1: EVALUATION OF ALTERNATIVE UIS MEASURES..............................19
TABLE 2.2: IVES, OLSON AND BAROUDI USER SATISFACTION MEASURE ...............22
TABLE 3.1: DEFINITIONS AND SUPPORTED LITERATURE .................................41
TABLE 3.2: DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS .......................44
TABLE 3.3: FACTOR AND RELIABILITY ANALYSIS ..........................................46
TABLE 3.4: STATISTICS CONCERNING STRUCTURAL EQUATION MODELS ...............51
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ABSTRACT
Abstract
The purpose of this research study is to contribute to the
development of an instrument for the evaluation of Greek Hospital
Information Systems. Information technology has rapidly penetrated into
the healthcare sector with integrated information systems, and it has been
proved that it can lead to better decision support, organizational support
and even influence the patient outcome. This is why the evaluation of
HISs is a very critical issue. After an extended and systematic review of
the existing literature on the basis of published studies, user satisfaction
was chosen as the measurement of IS success. Furthermore, a research
was conducted in order to detect the factors that affect the IS user
satisfaction. This study was based on the DeLone and McLean’s (2003)
model of IS success and, also, on widely validated user satisfaction
models. System quality, information quality, service quality and user
background were selected in order to measure user satisfaction.
Moreover, fourteen factors were chosen with corresponding items that
according to the literature measure the above four factors. A hypothetical
research model was designed and based on this the questionnaire that
was used in the research was generated. The questionnaire was
distributed at 4 Greek hospitals; the General Hospital of Heraklion Crete
“Venizeleio-Pananeio”, the General University Hospital of Alexandroupoli,
the General Hospital of Thessaloniki “Papageorgiou” and, finally, the
General Hospital of Thessaloniki “Georgios Papanikolaou”, that agreed to
participate to the survey. 100 completed questionnaires were collected.
The statistical analysis included factor and reliability analysis in order to
estimate the adequacy of the measurement model and, after that
Structural Equation Modeling was performed to test the structural models
fit. The conclusion is that user background, information quality and service
quality directly and positively affect user satisfaction confirming the initial
three hypotheses (H1, H3, and H4). The diversity concerned H2 which
have shown that system quality influence user satisfaction only indirectly
through information quality and not directly as it was initially stated.
Keywords: user satisfaction, hospital information systems, evaluation
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INTRODUCTION
Introduction
Information technology (IT) has already become one of the most

significant elements that lead to success. Nowadays, IT has entered into
every kind of organizations by making tremendous progress; transition
from personal computing to integrated information systems (IS).
Healthcare sector is one, among many other that have adopted
information systems. Hospital communities have been using information
systems since 1960, where they began with their simplest form, mainly as
financial systems (Zviran M., 1990). Nowadays, Hospital Information
Systems (HIS) have changed dramatically since their first entrance into
the healthcare sector and the continuously development of information
technology. HISs turned out to be multi-functional systems that combine
different subsystems, such as accounting and financial systems, patient
registration applications, medical records etc (Zviran M., 1990). At the
same time, the number of the organizational personnel who directly
interact with computers have also recorded an explosive growth. These
people use information systems in their every day job to accomplish
multiple applications, such as word processing, spreadsheets, statistics,
databases, etc (Harrison, A.W. and Rainer, R.K., 1996). The expanded
range of users and the importance of IS in the healthcare organizations
constitute the evaluation of these systems an extremely important issue,
in order to test the effectiveness of an IS. According to DeLone and
McLean (1992), the most widely known measure of information system
evaluation is user satisfaction. The literature suggests that user
satisfaction can play a vital role and can affect users' behavior toward
computer use, which in turn can also affect the actual usage of the system
(Harrison, A.W. and Rainer, R.K., 1996). Through evaluation the whole
healthcare system can be improved.
The aim of this study is to evaluate Greek hospital information
systems and their success. In order to accomplish this, the present
research focused on the development of an instrument, through which the
evaluation process could take place. More analytically, the factors that
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INTRODUCTION
influence, positively or negatively, users' satisfaction have been detected

based on the literature. The selection of these factors, which the research
model of measuring user satisfaction was based on, was a very critical
issue of this study. Furthermore, the questionnaire that was used for the
purpose of this study was developed according to the measurement
model. The use of questionnaires allows the researcher to survey different
participants and permits respondents to have sufficient time to think
about the questions. The participants in the present survey were the
actual users of 4 Greek hospitals; General Hospital of Heraklion Crete
“Venizeleio-Pananeio”, General Hospital of Thessaloniki “Georgios
Papanikolaou”, General Hospital of Thessaloniki “Papageorgiou”, and
General University Hospital of Alexandroupoli. The data that were
gathered from the selection of the questionnaires were used in order to
run all the appropriate statistical analysis that is going to be discussed in
latter section.
The structure of the present survey consists of 4 Chapters. In
Chapter 1, Hospital Information Systems and their value in healthcare
sector are analysed. Additionally, the penetration and the progress of
information technology in Greek hospitals are also stated. Chapter 2
contains all the relatively theory about information system evaluation.
One of the most known models of information system success is
introduced; the DeLone and McLean model. Furthermore, measurement
models of user satisfaction are also represented. Chapter 3 contains the
research that was conducted for the present survey. The selection of user
satisfaction as the surrogate measure and, the relative theory that the
theoretical model and the research hypothesis were based on are
analysed. Moreover, the research methodology, such as the population
sample approach, the research procedures and the development of the
instrument are also thoroughly analysed. Finally, the data analysis and the
results are demonstrated. Last, Chapter 4 is mainly composed of the
limitations that came up during the research and the most important
conclusions that resulted from the analysis.
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CHAPTER 1 HOSPITAL INFORMATION SYSTEMS: THE CASE OF GREECE
Chapter 1
Hospital Information Systems: the case of Greece
Hospital information systems (HIS) have changed spectacularly

since the introduction of computers in health care organizations, and
these changes were inevitable because of the information technology (IT)
changes, but also because of the realization of the benefits of
computerized hospitals.
The idea of developing a hospital information system began in the
early 1960s and its development mainly concerned of financial and partial
of patient care systems which have failed as being discontinued (Zviran
M., 1990). These systems were designed to provide a money-oriented
return on investment and streamline patient admissions. Another attempt
took place in the mid 1970s, where systems still didn’t focus to patient
care but only on financial applications. In the late 1970s, finally, software
packages expanded, as far as the patient care was concerned, being more
flexible and economic in relation to previous periods (Zviran M., 1990).
However, after years, many hospitals also adopted specialized systems in
other areas, such as laboratory, pharmacy and medical records, with more
emphasis to patient interest, leading to today’s latest form of the hospital
information systems which have become a necessity for a health care unit
to be competitive and to be able to deal with the demands of our days.
When choosing an information system (IS), hospitals must avoid making
mistakes and must consider their actual needs when purchasing a
healthcare software product (Thompson A.M., 1990; Zviran M., 1990).
1.1. IT and Healthcare
Taking into account the rapid development of technology, it was a

matter of time for the information technology to enter in every field of our
daily life and, consequently, in every public and private organization.
Nowadays, it is outstanding to imagine health care sector without
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information technology (IT). The remarkable increase of the use of IT in

health care sector and, especially, in hospitals makes it clear that it is of
vital matter to leave the past behind. Paper-based records and written
documentation are replaced with computer based records and, generally,
with information systems that provide patient safety and improve the
quality and efficiency of health care systems. Different innovations, such
as electronic patient records and especially hospital information systems,
have significantly changed the workflow in healthcare (Aggelidis V.P. and
Chatzoglou P.D., 2008). The benefits that are generated by the use of
information and communication technologies in the health care sector are
categorised and demonstrated in Table (1.1).
Consequently, there is no doubt that paper-based records and
written documentation can no longer follow the needs of the modern
health care and their use reaches its limits as different technological
achievements, such as hospital information systems (HIS), take control
(Uslu, A.M. and Strausberg, J., 2008). It has been said that “given the
fragmented nature of health care, the large volume of transactions in the
system, the need to integrate new scientific evidence into practice, and
other complex information management activities, the limitations of
paper-based information management are intuitively apparent”
(Chaundry, B. et al., 2006; as found in Uslu, A.M. and Strausberg, J.,
2008, pp. 675).
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Health Care
Benefits
Players
• Policy development and decision-making are strongly

supported by effective and on-time information
gathering and distribution.
Administration
• Easier adaptation to eEurope challenges.
units
• Supply control; better budget monitoring.
• Overall improvement in the way citizens are served.
• Increased efficiency in communication between

hospitals, administration units, social security services,
careers, physicians, and citizens.
• Personnel familiarization with information technologies
through Internet-access operations.
• Patient-record traffic support.
• Reinforcement of the need to build health care
Hospitals
information systems (HCISs) and local networks in
hospitals.
• Utilization of the developed Intranets.
• Better information services for the citizens.
• Advanced telematic services (eg, telemedicine
applications in difficult-to-reach regions).
• Meets the increased need for telecommunications not

only for medical, but also for compensation reasons.
• Participation in care chains and relevant coordination.
• Physicians' collaboration.
Health care • Patients'-history data retrieval.
personnel • Continuing education services; familiarization with new
technologies through special training programs.
• Interaction with patients to provide advice or
prescriptions.
• Use of the Internet for health-related information

retrieval.
• Information and communication technologies will
increase interest in citizens' health-issues
management.
Citizens • Creation of the appropriate infrastructure for future
provision of special health services for specific
population groups (eg, in-house services for older
people or patients with long-lasting attendance and
nursing needs).
Table 1.1: Benefits of using information and communication technologies in the health
care sector
(Source: Lampsas, P. et al., 2002, pp. 3)
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1.2. Definitions, aim and structure of HIS
Hospital information systems play a vital role in the quality of care

that is provided in the health care units and in the organization’s daily
operations. In order to understand what an information system is, it is
useful to start with explaining what constitutes a system and information.
First of all, a system consists of inputs, processing and outputs and also
combines different variables that are interrelated, organized and depends
on each other. Secondly, information can be defined as the outcome of
data processing which can be used to aid in decision making (Yusof, M.M.
et al., 2008). Based on the above, and according to Yusof et al. (2008, pp.
378), an information system is defined as “a group of interrelated
processes implemented to aid in enhancing the efficiency and
effectiveness of an organization in performing its functions and attaining
its objectives”. Another definition of an HIS, according to Aggelidis and
Chatzoglou (2008, pp. 101), is: “a hospital information system is a
computer based system designed to facilitate the management of the
administrative and medical information within a hospital”. Furthermore, an
HIS is “an information system used within a healthcare organization to
facilitate communication, perform record-keeping, or otherwise support
the functions of the organization” (Shortliffe, E.H. et al.; as found in Nahm
E.S. et al., 2007, pp. 283). To complete with, according to Ammenwerth
et al. (2007, pp. 216), a HIS can be defined as “the complete information
processing and information storing subsystem of a hospital, including both
computer-based and paper-based information processing tools”.
Due to the complex environment that hospitals function in, the use
of HIS is of great importance. The main aim of HIS is to improve the
quality of care that is provided. This can be achieved by capturing, storing
and retrieving accurate and timely data, by reporting those data in an
effective way and allowing transferability of them to other applications
within the hospital environment (Zviran, M., 1990). According to Zviran
(1990), the most important advantages of HIS are:
a) the capacity of combining data sources in an integrated database
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b) the unique power to shift data among applications

c) the capacity to provide health personnel with a variety of data as
far as the patient treatment is concerned, and
d) the flexibility that is provided to users to move among applications
of their choice.
As mentioned above, hospitals are complex environments that use
integrated information systems. So, it is useful to understand the
structure of HIS and the four major functional groups with the additional
subsystems, that constitute such a system. Figure (1.1) portrays the
functional design of a Hospital Information System.
Figure 1.1: Functional design for the Integrated HIS

(Source: Zviran, M., 1990, pp 34-37)
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1.3. The Value of Hospital Information Systems
To begin with, it can be said that nowadays no one can imagine

health care sector without the use of information technology. Information
technology is constantly growing, and more and more hospitals embed
innovations which are always improved, due to requirements of modern
society. Someone could appraise the value of HISs by recording the
multiple benefits that are generated by their use and comparing them with
the old and historical paper based records.
Generally, integrated HISs are estimated as the mean through
which patient’s safety and the quality of health care systems are always
improved. In relation to paper based records, it is for sure that they
prevail because they provide to clinicians real-time decision support, with
a full patient profile available, leading them to the correct decisions (Jha,
A.K. et al., 2008). With the use of information technology, clinicians
achieve the reduction of unnecessary testing to patients and avoid wrong
prescriptions that would lead to undesirable results. In other words, the
use of an integrated information system allows the creation of a well
organised historical patient profile, with information about allergies,
treatment results, and medication given which lead to a better patient
care (Bakker, A.R., 2007). Another important factor is that the use of
HISs positively affect personnel’s productivity and diagnostic quality due
to well designed and well informed databases that function within the
system. It has also been proved that the use of information technology
can improve revenues. According to some researchers, “one clinic realised
a 12% increase in their revenues the 12-month period post-
implementation compared to pre-implementation” (Clayton, P.D. et al.; as
found in Handel, D.A. and Hackman, J.L., 2008, pp. 2). Another institution
realised “a savings of $1.67 for every dollar invested in their information
system” (Souther, E., 2001; as found in Handel, D.A. and Hackman, J.L.,
2008, pp. 2).
At this point, and having mentioned all the above, it must be stated
that a HIS is nothing more than a tool that it is useless without human
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interference. The information produced by the system is always related to

the available data of the system and to the software quality, but at the
end all kinds of decision and different solutions to problems always
depend on humans and their capabilities.
1.4. The status of HIS in Greek hospitals
National governments have treated healthcare as a matter of great

importance. Technological innovations such as HISs are the mean through
which the service quality that is provided by the health care units can be
improved. Well organized efforts began at the end of 1980s in Greece with
the first Community Support Framework (1st CSF) that aimed to introduce
information technology in health care sector, and continued with the 2nd
CSF, in the mid-1990s. Finally, in 2000, and through the 3rd CSF, a great
attempt took place with the purpose of creating information-oriented
organizations by introducing integrated information systems into public
Greek hospitals (Aggelidis, V.P. and Chatzoglou, P.D., 2008).
According to a survey of the Information Society of Greece that was
conducted in 2008, although the penetration of information technology in
health care sector was satisfied to a great level, their use was surprisingly
very low. Furthermore, the outcomes of another survey have also shown
that despite the high penetration of IT in the administrative sector of the
hospitals, the medical and the nursing sector faces a low level of
computerization (Vagelatos, A. et al., 2002).
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CHAPTER 2 INFORMATION SYSTEMS EVALUATION
Chapter 2
Information Systems Evaluation
In this part, issues related to Hospital Information System

evaluation and the relative theories are going to be analysed. At the
beginning, basic terms such as the real meaning of evaluation, the
reasons why it is so important to evaluate and the time when this takes
place will be discussed. Furthermore, the most important and common
used methods and theories are going also to be discussed.
2.1. The importance of evaluation
Nowadays, it is generally accepted that the use of information

technology has become a necessity for the health care sector. As it have
been mentioned in previous sections, many advantages derive from its
use. The most important are the reduction of errors which are caused by
humans, well informed patient records, and the improved quality of the
health care system (Jha, A.K., et al., 2008; Hayrinen, K., et al., 2008).
On the other hand, there are some disadvantages that can also
derive from the use of information technology. First of all, integrated
information systems are very expensive to implement (Kluge, E.H.W.,
2007). Additionally, the loss of productivity and efficiency by the staff is
another disadvantage that derives from the fact that at the beginning the
system is time-consuming, which can also lead to patient neglect
(Edwards, P.J., et al., 2008).
To sum up, and with all the above stated, someone can realise that
the evaluation of Hospital Information Systems is a very important issue
and the procedure must be as accurate as possible. Through evaluation,
disadvantages are reduced and improvements are achieved;
improvements that will remake the system itself more friendly to the user,
and help them realise the importance of its usage, that consequently may
contribute to an upgraded structure of a health care unit (Burkle, T., et
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al., 2001). It is of vital importance that during the evaluation process both
the technology that is used and the role of the users that participate and
their relation to the technology must be taken into account (Ammenwerth,
E., et al., 2003).
The term “evaluation” has been given by different researchers.
According to Aggelidis, V.P. and Chatzoglou, P.D. (2008, pp. 100),: “an
evaluation research is the systematic collection and analysis of
information in order to support decision-making concerning projects,
processes or methods”. Based on Aggelidis and Chatzoglou (2008), the
evaluation process is initially composed of the explanation of the criteria
the researcher sets for the evaluation, then the collection of the
appropriate information as far as the evaluated object is concerned and,
finally, the determination of the value of the results. Another definition is
the following: “evaluation can be defined as the decisive assessment of
defined objects, based on a set of criteria to solve a given problem”
(Heinrich, L., 1999; as found in Ammenwerth, E., et al., 2003, pp. 126).
Evaluation studies can be distinguished in two categories;
summative and formative. Summative evaluation tries to illustrate and
examine the result of an information technology in clinical routine, while
formative evaluation tries to positively improve the information technology
used by providing the developers with useful comments (Ammenwerth, E.,
et al., 2003). Furthermore, the evaluation of Hospital Information
Systems can take place at different phases and by different people at each
phase (Nahm, E.S., et al., 2007):
- During the development of the system, where the evaluation is
initially conducted by the vendor.
- During the implementation of the system, where the system is
evaluated by the organization.
- After the implementation of the system, where the evaluation is
conducted by various, internal and external, users.
Indeed, evaluation starts during the development of the system and
it can be categorised into verification, validation, assessment of human
factor and clinical assessment of clinical effect (Burkle, T., et al., 2001):
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Verification is taking place during the development of the system

and it examines whether the system is being structured according to its
primary specification requirements and verifies the level of
appropriateness, completeness, and consistency of the system.
Validation is the process that takes place later and confirms if the
system functions according to its initial design in real working conditions.
Assessment of human factor is the next process that takes place,
and tries to check whether the system is acceptable by the users. Even if
a system has passed the phases of verification and validation, its design
might not be easy in use, and thus difficult to handle in real time. The
usefulness and the usability of the system are checked.
Clinical assessment of clinical effect is the last phase, and from this
answers derive; answers that concern the patient outcome.
To conclude, different approaches have been developed concerning
information systems evaluation and each of them have both positive
characteristics and flaws as well. According to Ammenwerth, E., et al.
(2003), there is no standard method of how to evaluate an integrated
information system. Bokhari, R.H. (2005, pp. 211) stated that “the
evaluation of a system in terms of its success is an inherently complex
phenomenon”. In the next section, one of the most well known model of
information systems success and three basic measures of success are
analysed.
2.2. The DeLone and McLean Model of Information System Success
In 1992, DeLone and McLean published a paper in which they have

tried to present some subsistence and structure to the depended variable
of an IS success. Thus, they proposed a taxonomy and an interactional
model, known as the D&M Model, as a basic structure and instrument for
understanding the concept and the functionality of IS success. The D&M
Model targeted to combine previous research about IS success in order to
offer a more precise guidance for further analysis (DeLone, W.H., and
McLean, E.R., 2003). As mentioned above, based on previous theories, a
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multidimensional model of IS success was postulated. According to

DeLone and McLean (1992), the six dimensions of IS success are the
following:
• “system quality”, which measures technical success
• “information quality”, which measures semantic success, and
• “use”, “user satisfaction”, “individual impacts”, and “organizational
impacts”, which measure effectiveness success.
It is very important to be stated that although these dimensions
come from very old theories, they are still very powerful and they are still
used in our days. It must become clear that these dimensions are
mutually connected and not independent (Pitt, L.F., et al., 1995).
According to the theory described in DeLone and McLean (2003), a model
proposes that an IS is firstly produced enclosing all the characteristics that
demonstrate the level of the system quality and information quality. In
turn, all end-users that consume their daily time with these characteristics
can either be satisfied or dissatisfied from the information that is provided
to them or by the system itself. The use of the system and the
information generated by the system, subsequently influence each user
individually as far as their every day job is concerned, and at the end
positive or negative organizational impact arise. The resultant D&M IS
Success Model is demonstrated in Figure (2.1).
Figure 2.1: The D&M IS Success Model

(Source: DeLone and McLean, 2003, pp. 12)
In few words, the best system quality is expected to lead to greater

user satisfaction and more use of the system, which would entail positive
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effects on individual productivity and consequently to improved

productivity of the organization. The purpose of combining success
taxonomy with the model of IS success was to assist the understanding of
the possible causal correlations of the dimensions of success and to
provide a more in-depth presentation of these correlations. Finally, it must
be said that the D&M IS Success Model is one of the most well known,
which is proved by the fact that during the period 1993 to 2002,
approximately 285 surveys used the model as a basis to their theory, a
number that with no doubt reveals the level of its success (DeLone, W.H.,
and McLean, E.R., 2003).
Relying on different researches and the changes in the
management of information systems, followed in the period after the
presentation of their first version of the model, in 2003 McLean and
DeLone presented a revised and Updated Model of IS Success, and this is
stated below in Figure (2.2):
Information
Quality
Intention
Use
To Use
System Net
Quality Benefits
User
Satisfaction
Service
Quality
Figure 2.2: Updated D&M IS Success Model

(Source: DeLone and McLean, 2003, pp. 24)
According to the D&M updated model, in the already known

dimensions: “information quality” and “system quality”, has been added
one more; “service quality”. Pitt et al., (1995) have stated that “the most
common used measures of IS success focus on the products and not so
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much on the services that the IS provides. If the measure of service

quality is excluded from the survey, there is a major risk for the
researchers to assess the IS success incorrect”. Another change in the
updated model is the existence of another measure; “intention to use”.
The difference between “intention to use” and “use” is that the first is an
attitude and the second is a behavior. Furthermore, the measure of “use”
and “user satisfaction” still exist and remain closely correlated. “Use”
precedes “user satisfaction”, but positive “use” will lead to greater “user
satisfaction”. In turn, this will lead to greater “intention to use” and,
consequently, to greater “use”. As a result of all these interrelated
measures, specific “net benefits” will occur (DeLone, W.H., and McLean,
E.R., 2003).
2.3. Approaches to IS success measurement
A large number of possible measurements of IS success exists and

this is because an information system can be viewed from many different
angles. Specifically, there are two perspectives: the organizational
viewpoint and the socio-technical viewpoint (Au, N., et al., 2002). From
the organizational point of view, emphasis is given to the information that
is provided from the IS and the way this interface with the user. This
perspective has been criticized claiming that ignores the human element.
On the other hand, the socio-technical viewpoint focuses on individual
needs. Furthermore, as it has been mentioned above, six dimensions of IS
success have been identified by DeLoan and McLean, (1992): system
quality, information quality, information use, individual impact, and
organizational impact. All of these six dimensions characterise the IS both
from the organizational viewpoint and the socio-technical viewpoint.
DeLoan and McLean (2003) later added one more dimension; service
quality.
To continue with, in latest years the discussion has primarily
focused around three different measures of success:
1. Cost-benefit analysis
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2. System usage
3. User satisfaction
In the next sections these approaches are thoroughly analised.
2.3.1. Cost-benefit analysis
In a cost-benefit analysis procedure, the actual value of the IS, as

far as the organization is concerned, can be described as the difference
between the benefits in terms of the organizational effectiveness. The
cost-benefit analysis has been subjected under great criticism because it
is difficult to prove that benefits are connected to the information system
and because the costs and benefits are difficult to be measured in terms
of monetary value (Au N. et al., 2002).
2.3.2. System Usage
Another measure of IS success is system usage. This measure

shows in which level users trust the effectiveness of the system. Systems
usage is much easier to put into operation and it can be defined as “either
the amount of effort expended interacting with an information system or,
less frequently, as the numbers of reports or other information products
generated by the information system per unit time” (Trice A.W. et al.,
1988; as found in Bokhari R.H., 2005, pp. 213). There are different ways
of measuring the IS success, and these are (Au N. et al., 2002):
• The actual time that the users are linked with the system
• The amount of patient or client records that have been registered
• The amount of computer functions that have been used
Criticism is also applied to this method because it is relevant only
when it is voluntary (Ives, B., et al., 1983).
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2.3.3. User Satisfaction
The other measure of IS success that is considered to be the most

widely known among the researchers is user satisfaction. According to Au
N. et al. (2002, pp. 453), user satisfaction is defined as “the IS end-user’s
overall affective and cognitive evaluation of the pleasurable level of
consumption-related fulfillment experienced with the IS. IS end-users
refer to non-technical personnel who use or interact with the system
directly”. User satisfaction is a multiple validated measure by many
researchers unlike the other two measures mentioned above (Bailey, J.E.,
and Pearson, S.W., 1983; DeLone, W.H., and McLean, E.R., 2003; Chin,
W.W., and Lee, M.K.O., 2000). Information system users evaluate the
quality of the system in their daily life. If users are not satisfied with the
quality and the functions provided by the system, the quality of the
information generated and, generally, by the services of the system, they
will not use it, or they will not use it correctly (Ribiere, V., et al., 1999).
More specific, in hospitals, which are highly sensitive environments, if the
personnel is not satisfied with the information system it is very likely to
reject it. Therefore, for a hospital information system to be successful, it
must not be very complicated in use, it must be adapted based on user’s
needs, it must be friendly in use and meet user expectations (Ribiere, V.,
et al., 1999).
2.4. User satisfaction measurement models
According to the literature, the most important user satisfaction

measurement models, which are used for the evaluation of Hospital
Information Systems, are the following:
• Bailey and Pearson, 1983
• Ives et al., 1983
• Doll and Torkzadeh, 1988
• Chin and Lee, 2000
• Mahmood et al., 2000
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2.4.1. Bailey and Pearson’s user satisfaction measure
The Bailey and Pearson (1983) model of computer user satisfaction

is the first essential model, which is referred as the basis for the
development of further research on the measurement of end-user
satisfaction, with the ultimate aim of creating instruments for measuring
the IS success. Although the specific model is quite old, still remains one
of the most widely known and used. Bailey and Pearson (1983) created
the model based on the definition of user satisfaction in relation to a given
situation. They defined satisfaction as “the sum of the user’s weighed
reactions to a set of factors”,
n
Si = ∑R W
j =1
ij ij
where
Rij = the reaction to factor j by individual i
Wij = the importance of factor j to individual i
This equation calculates the satisfaction as the sum of a user’s
positive or negative reaction in relation to each factor, and on the
significance that is defined by the user for a specific factor.
After reviewing 22 studies of the computer/user interface, Bailey
and Pearson identified and suggested 36 factors that affect user
satisfaction. Having the list completed, these authors proceeded to
different tests in order to examine the completeness and the accuracy of
the list. Two more factors were added after recommendations by some
professionals. This new and expanded list was then distributed to 32
middle manager users in 8 different organizations to comment on the
importance of each factor. All factors turned out to be more or less
important for each interviewer, based on their jobs. Through the analysis,
one factor was brought up four times from the interviewers and because
of the frequency that has been mentioned, that factor was added in the
list, which was then constituted from 39 factors. The questionnaire, which
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included all the 39 factors was analytically tested and revealed that it is a
reliable instrument to use for measuring user satisfaction (Bailey, J.E.,
and Pearson, S.W., 1983).
2.4.2. Ives, Olson and Baroudi user satisfaction measure
Ives et al. (1983) had introduced their own instrument of user

satisfaction at the same year with Bailey and Pearson’s model (1983). At
the beginning Ives et al. reviewed and analysed all the existing models of
user satisfaction measurement in order to develop their own instrument.
For this reason the following measures of Gallapher (1974), Jenkins and
Richetts (1979), Lacker and Lessig (1980), and Bailey and Pearson (1983)
were studied. Through extended analysis for each model and after
locating their dominant characteristics, as well as their advantages and
disadvantages, a classification of those 4 measures was generated in
relation to (Ives, B., et al., 1983):
• Derivation (empirical or otherwise)
• Amount of empirical support
• Level of coverage (product, system services)
• Number of indicators in the measure
Table (2.1) encompasses a summary of the four measures reviewed:
Measure Derived Empirical Level of Number of

From Support Coverage Indicators
Gallapher Empirical Adequate Product 18

Jenkins and Literature and
Ricketts interviews Inadequate Product 5
Larcker and
Lessig Interviews Adequate Product 2
Literature,
Bailey and interviews, Adequate Product and 39
Pearson and empirical support
Table 2.1: Evaluation of Alternative UIS Measures
(Source: Ives, B., et al., 1983, pp. 787)
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In order to decide which one of the four models mentioned above

would be used for further research, Ives et al. (1983) assumed that the
chosen model should embrace the experience with sufficient support,
which should cover satisfaction in relation to information system product
and the support services offered, and generally should provide multiple
indicators. Based on the above criteria, the Bailey and Pearson measure
was selected. The aim of the study was to reproduce and duplicate Bailey
and Pearson’s findings as far as the validity of the instrument is
concerned, to proceed in further testing of the validity, to lessen the
overall measure in a way of maintaining its credibility, and to produce a
short form of the instrument for further research (Ives, B., et al., 1983).
The research that was conducted referred to 800 production
managers of manufacturing organizations in U.S. Two questionnaires were
sent to them in different timing (Ives, B., et al., 1983). The first was the
Bailey and Pearson information system satisfaction measure, while the
second was a 4-item measure for overall satisfaction. All the appropriate
tests took place, such as a) reliability of the measure, b) content validity
of the questionnaire, c) predictive validity, and d) construct validity of the
measure. A sort form of the instrument was generated according to two
phases; the first contained the elimination of the factors that showed
undesirable psychometric qualities, and the second contained the
elimination of some items within factors in order to reduce the completion
time of the questionnaire. The elimination of the appropriate factors was
depended upon an extended analysis and judgment. All scales were
classified according to reliability, content validity, and construct validity.
Continuously, 6 factors of the initial 39 were chosen for elimination, and
those were (Ives, B., et al., 1983):
1. Competition with EDP unit
2. Chargeback method
3. Vendor support
4. Computer language used
5. Security of data
6. Format of output
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Furthermore, the reduction of the 4-items for each factor to 2-items

took place, for the short form of the instrument to be finally a reality. But
still the questionnaire was too big to be completed in a quick way. For this
reason Ives et al. (1983) continued the process by eliminating factors with
undesirable psychometric characteristics, and by keeping those scales
with factor loadings of 0.50 or higher. Table (2.2) shows the factors
composing the original UIS instrument of Bailey and Pearson (1983), and
the Ives et al. (1983) short form questionnaire, and the factors that
consists the instrument.
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1. Relationship with the EDP staff*

2. Processing of requests for changes to existing systems *
3. Means of input/output with the EDP centre
4. Interdepartmental competition with the EDP unit
5. Confidence in systems
6. Timeliness of output information
7. Chargeback method of payment for services
8. Perceived utility (worth versus cost)
9. Vendor support of hardware and software
10. Computer language used to interact with systems
11. Expectation (expected versus actual level of computer based support)
12. Correction of errors
13. Security of data
14. Degree of EDP training provided to users *
15. Users' understanding of systems *
16. Users' feelings of participation *
17. Currency (up-to-dateness) of the output information
18. Attitude of the EDP staff*
19. Reliability of output information*
20. Top management involvement in EDP activities
21. Format of output
22. Response/turnaround time
23. Determination of priorities for allocation of EDP resources
24. Convenience of access (to utilize the computer capability)
25. Relevancy of output information (to intended function)*
26. Volume of output information
27. Personal job effects resulting from the computer-based support
28. Accuracy of output information *
29. Precision of output information *
30. Communication with the EDP staff *
31. Organizational position of the EDP function
32. Time required for new systems development *
33. Personal control of EDP service received
34. Schedule of recurring output products and services
35. Documentation
36. Completeness of the output information *
37. Technical competence of the EDP staff
38. Flexibility of systems
39. Integration (automated sharing of information) of system database
Table 2.2: Ives, Olson and Baroudi user satisfaction measure

(Source: Ives, B., et al., 1983, pp. 793)
(*) Factors conserved in the Ives et al. (1983) short form questionnaire
To conclude with, it can be said that the Bailey and Pearson (1983)
measure, and the sort form by Ives et al. (1983), still remain two of the
most common used measures of IS user satisfaction, in order to value IS
success. It would be considered as a slight not to state that there are also
some negative perspectives for both instruments, especially when
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someone attempts to apply them into HIS evaluation procedures. These

disadvantages are mentioned below (Ribiere, V., et al., 1999):
• The original factors of Bailey and Pearson (1983) are relatively old;
they were developed in 1977, and because of the rapid
development in computer technologies they can be considered as
invalid.
• The health care environment is completely different from other
organizations, and so the factors and the structure of the
questionnaires must be adapted to them.
• Costumers or users do not have the potentiality to make comments
or to suggest any changes.
• No research takes place for the user’s profile.
• Improvement directions are not prioritised.
2.4.3. Doll and Torkzadeh measurement of EUCS
To start with, the rapid growth in technologies and the different

changes in the way a user interact with the IS, were the main reasons
that drove Doll and Torkzadeh (1988) to the development of a new model
of measuring user satisfaction. After 1988 users had direct relationship
toward the IS, and the already existed models were accommodated to
support indirect interaction. They measured the overall user satisfaction
without evaluating user satisfaction according to the different
characteristics of the IS, such as ease of use. According to Doll and
Torkzadeh (1988), the main reasons for the development of an instrument
are the following:
• to focus on the satisfaction with the information provided by the
system
• to contain items in order to evaluate the ease of use of an
application
• to provide Likert-type scales
• to be a new, short, and easy to use for both practice and academic
research
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• to be able to use it across many applications

• to enable researchers to examine the relationship between end-user
computing satisfaction (EUCS) with independent variables.
Taking all the above into consideration, Doll and Torkzadeh (1991)
emphasised that one major goal for the development of the proposed
model, was to contribute to the IS evaluation, in order to improve the IS
itself. Furthermore, Doll and Torkzadeh’s proposed model (1988) aims to
revise and validate Ives et al., (1983) model. Initially, and taken into
consideration the fact that many items from Ives et al. instrument seemed
less appropriate in an end-user environment, they subtracted them from
the new proposed instrument. These are:
• Relationship with the EDP staff
• Processing of requests for system changes
• Attitude of EDP staff
• Communication with EDP staff
• Time required for system development
• Personal control of EDP services
Additionally, the EDP staff/services and user knowledge/ involvement
were also excluded from the revised instrument.
For the development of the new instrument, previous surveys
related to the end-user computer satisfaction measurement were
thoroughly reviewed and based on them, Doll and Torkzadeh (1988) end
up with a 40-item instrument, where 7 of them were related to ease of
use, and 2 more measured perceived overall satisfaction. The initial
questionnaire, which was composed of these 40-items, was handed out to
96 end-users of five different firms. The instrument was supported by the
end-users overall satisfaction and by the specific aspects that satisfied or
dissatisfied them. Furthermore, through multiple tests and by eliminating
items according to the researchers ended up with 23 items. Five more
items were also subtracted from the instrument because their differences
were meaningful. To continue with, the new 18-item questionnaire was
administrated to 44 firms, and the results were that 618 appropriate
questionnaires were gathered for further analysis. Factor analysis
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identified 12 new items categorised into 5 factors which constituted the

overall end-user satisfaction factor. Figure (2.3) modifies the model for
measuring EUCS and reveals the coded items of the instrument:
CONTENT
C1: Does the system provide the precise information you need?
C2: Does the information content meet your needs?
C3: Does the system provide reports that seem to be just about exactly what you
need?
C4: Does the system provide sufficient information?
ACCURACY
A1: Is the system accurate?
A2: Are you satisfied with the accuracy of the system?
FORMAT
F1: Do you think the output is presented in a useful format?
F2: Is the information clear?
EASE OF USE
E1: Is the system user friendly?
E2: Is the system easy to use?
TIMELINESS
T1: Do you get the information you need in time?
T2: Does the system provide up-to-date information?
Figure 2.3: A Model for Measuring End-User Computing Satisfaction

(Source: Doll and Torkzadeh, 1988, pp. 268)
Doll and Torkzadeh (1988) model is referred to be as one of the

most common used which has been tested into different environments,
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and appears to have adequate reliability and validity across a variety of

applications.
2.4.4. Chin and Lee model of EUCS
In this section, Chin and Lee’s (2000) model is going to be

analysed. It is a model which has been based on Doll and Torkzadeh’s
(1988) instrument and its upgrade. Chin and Lee (2000) presented a new
set of measures focusing on five factors that already existed and by
adding one more factor; the operating speed. The researchers claimed
that according to the theory, there should be a strong correlation between
the operating speed of the system and overall user satisfaction.
Furthermore, in the already existed five factors, researchers added more
measures on each factor focusing most on satisfaction.
In the proposed model, except of the measure of the overall user
satisfaction, prior expectations and subsequent results from using the
system, and also how well the system fulfills users’ desires, were also
taken into consideration (Chin, W.W., and Lee, M.K.O., 2000). In figure
(2.4) the proposed model is represented:
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D. Overall
A. Prior Discrepancy
Expectations With
Expectations
Direct and H. Expectation
multiplicative Based
combination Satisfaction
E. Overall
Evaluation of
Expectation
Discrepancy
C. Post-Hoc
Perceptions
J. Overall
Direct and
End-User
multiplicative
combination Satisfaction
with an IS
F. Overall
B. Prior
Discrepancy
Desires
With Desires
Direct and I. Desire
multiplicative Based
G. Overall combination Satisfaction
Evaluation of
Desire
Discrepancy
Figure 2.4: Formation of End-User Computing Satisfaction

(Source: Chin, W.W., and Lee, M.K.O., 2000, pp. 556)
The terms expectations and desires are concepts that must not be
confused. According to Chin and Lee (2000), expectations are what the
user expects to get by the system, and desires are what the user wants to
get by the system. For example, the user may expect low performance
from the IS, which is supported by the IS department which in turn lack of
knowledge, but he also actually desire a lot more from the IS, and vice
versa. To conclude, the Chin and Lee (2000) proposed model assumes
that satisfaction appears from both direct and multiplicative combinations
of expectation and desire based satisfaction.
2.4.5. Mahmood et al., research model of factors affecting IT EUS
Through an extended literature review of 45 surveys that have been

published between 1986 and 1998, Mahmood et al., (2000) attempted to
gather the factors that act as determinants of user satisfaction. The aim of
their study was to determine the extent on which 9 variables, which were
-27-
identified in these surveys, influence user satisfaction. These 9 variables

are the following:
1. User expectations
2. Ease of use
3. Perceived usefulness
4. User attitude towards information system
5. Organizational support
6. Perceived attitude of top management
7. User experience
8. User skills
9. User involvement in system development
The literature revealed that these variables fell into three major
categories: a) perceived benefits, b) organizational support, and c) user
background. All the above are demonstrated in Figure (2.5):
Figure 2.5: Research model of factors affecting IT end-user satisfaction

(Source: Mahmood et al., 2000, pp. 753)
The figure reveals that the first factor, perceived benefits, includes
the job-related benefits the user believes that will gain by using the
system, which in turn will affect the overall usage of the system. The
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second factor includes characteristics of the user, such as user experience,

skills, and user involvement in the system development. Finally, the third
factor includes organizational support, and user and top management
attitude toward information systems.
The results of Mahmood et al., (2000) research revealed that
perceived benefits, such as user expectations, ease of use, and perceived
usefulness are strongly correlated to end-user satisfaction. Additionally,
end-user satisfaction was found to be strongly affected by user
background, and variables such as user experience and skills, and user
involvement. Finally, the relationship between end-user satisfaction and
organizational support were found to be statistically significant.
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CHAPTER 3 HOSPITAL INFORMATION SYSTEM EVALUATION: THE RESEARCH
Chapter 3
Hospital Information System Evaluation: The research
The present chapter contains the research that took place for the
evaluation of hospital information systems, based on the replies to the
structured questionnaires, which will be described in the following
sections. After studying the research framework which concerns the
specific research, all the theory concerning user satisfaction, as a
surrogate measure of IS success, is summarised. Furthermore, all the
models and relative instruments on which our hypothetical model, and
consequently the questionnaire, was based are also discussed.
Additionally, the procedure for the selection of the population sample, the
research procedures for the detection of the hospitals that participated in
the survey, and the development of the instrument that was used in the
research are thoroughly analised. Last, the statistical analysis that took
place is thoroughly discussed with the appropriate data analysis, and with
the most important measures of the construct validity and reliability, and
factor analysis. After that and with the use of the Structural Equation
Modeling approach, the overall model with the extracted path coefficients
are also demonstrated.
3.1. User satisfaction as a measure of success
The selection of the evaluation method is the first thing a

researcher has to do, before starting any survey. Initially, the method that
is considered to be the most appropriate for the case of IS in Greek
hospitals, has been chosen. According to the literature (Au, N. et al.,
2002), there are three main approaches to evaluate IS effectiveness, and
these are: a) cost-benefit analysis, b) system usage, and c) end-user
satisfaction measurement. To start with, the cost-benefit analysis was the
first to be rejected, because it is difficult to prove that a specific benefit is
a result of an information system itself. More precisely, this method is too
-30-
hard to get implemented into Greek hospitals, because of the lack of

appropriate data (before after the implementation and the usage of the
IS). On the other hand, the method of system usage has also been
rejected as an option, because of the fact that system usage is not always
voluntarily, but most of the times personnel is forced to use the IS. So,
system usage is not able to generate valuable results for the IS
effectiveness and success. According to Ives et al., (1983), an information
system is not considered as a success when its users are dissatisfied with
its functionality. It is for sure that when users are not satisfied with the
quality of the system, the quality of the information and the services
provided, the system will be rejected or not used correctly (Ribiere et. al.,
1999). This is valid especially into hospitals where the personnel may be
suspicious towards new technologies and easily neglect them (Anderson,
J.G., 1997).
At this point, and having had the term user satisfaction explained, it
is of great importance to determine the users of IS as well. Users are all
the stakeholders of an HIS that are involved in its operation and
functionality. According to Ribiere et al. (1999), HIS users can be
categorised into internal and external. As internal users can be
characterised the nursing staff, doctors, the administrative staff, and
generally all those directly related to the use of an HIS. On the opposite
side, external users are the patients, suppliers, insurance providers, and
everyone that is indirectly related to an HIS. The present research focuses
on internal users only.
To sum up, user satisfaction is the most common sited method to
evaluate IS effectiveness and the one that it has been used by many
researchers. It is the measure that through the evaluation helps different
problems during the functionality or the use of the system to be located
(Salmela, H., and Turunen, P., 1997), and it is the one that is going to be
used in the present research.
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3.2. Theoretical foundations
In the previous chapter all the models that measure the IS success
and the factors that affect computer user satisfaction were studied, in
order to a model for the measurement of IS success with user satisfaction
as the surrogate measure to be developed.
Furthermore, the up-dated IS success model of DeLone and McLean
(2003) refers to three major dimensions that affect the quality and
effectiveness of an IS and have great impact on user satisfaction: “system
quality”, “information quality” and “service quality”. The D&M IS success
model has been empirically tested and validated and has indicated
significant relationships between system quality and user satisfaction,
between information quality and user satisfaction, and between service
quality and user satisfaction (DeLone W.H. and McLean E., 2003).
Another evaluation instrument of measurement user information
satisfaction is the Doll and Torkzadeh (1988) instrument which is the most
widely known and the one that has been validated several times (Xiao L.
and Dasgupta S., 2002; Deng X. et al., 2008). They developed a 12 item
instrument which is comprised of 5 components: content, accuracy,
format, ease of use, and timeliness. Chin and Lee (2000) extended the
model by adding another factor; system speed, and by filling in more
questions in each factor.
Finally, according to Mahmood M.A. et al., (2000) the factors that
affect IT user satisfaction are spited into categories: perceived benefits
and convenience, user background and involvement and organizational
attitude and support. To continue with, nine variables have been identified
for each one of the above factors: perceived usefulness, ease of use, user
expectations, user skills, user involvement in system development,
organizational support, perceived attitude of top management toward the
project, and user attitude toward information systems. The results were
positive support for the influence of all nine variables on user satisfaction
but not to varying degrees. The most significant relationships were found
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to be user involvement in systems development, perceived usefulness,

user experience, organizational support and user attitude towards the IS.
3.3. Theoretical model and hypothesis
As it has been mentioned above there are three measures of IS

success: cost-benefit analysis, system usage and user satisfaction. In this
study the evaluation of Greek hospitals information systems is going to be
conducted with the measurement of user satisfaction because it is proved
to be the most accurate measure according to different researchers.
According to DeLone and McLean (2003) model there are three
dimensions that are related to user satisfaction: a) system quality, b)
information quality and c) service quality, and also according to Mahmood
et al. (2000) another big dimension that is related to user satisfaction is
d) user background. Initially, from the Mahmood et al., (2000) model the
variables that measure “user background” have been selected, and these
are: user experience, user skills, and user training. Furthermore, from
DeLone and McLean (2003) model, internal support and external support
were selected as the variables that compose the factor “service quality”.
The measure of “information quality” is comprised by content, accuracy,
format, and timeliness that were chosen from Doll and Torkzadeh (1988)
model, and by data security that was chosen from Ives et al. (1983)
model. Finally, ease of use, system speed, screen interface, and error
recovery were also selected to compose the typical measures of the factor
“system quality” (Doll and Torkzadeh, 1988; Chin W.W. and Lee M.K.O.,
2000; Ribiere V. et al. 1999; Ives B. et al. 1983). To conclude with, these
four dimensions are going to be used in the theoretical model as the four
main factors that positively influence user satisfaction. The model is
presented in Figure (3.1).
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Experience
Training User Background
Skills
Ease of Use
System Speed H1
Screen Interface System Quality
Error recovery
H2
User Satisfaction
Content
Accuracy
H3
Format Information Quality
Timeliness
H4
Data security
Internal Support
Service Quality
External Support
Figure 3.1: Research model of measuring user satisfaction
3.3.1. User background
According to the literature, user background can be measured with

experience, training, and user’s skills (Mahmood, M.A. et al., 2000;
Igbaria, M. and Nachman, S.A., 1990). It has been recognised that user’s
experience is, among others, an important factor, which can be associated
to IS success by leading to greater satisfaction. Igbaria (1990) points out
the need of continuously educated and experienced personnel as far as
computers are concerned. This comes from the findings that computer
experience is related to computer anxiety decrease and, thus to the
enhancement of user’s confidence and satisfaction (Igbaria, M., 1990).
Many researchers have shown that user experience can positively affect
-34-
user satisfaction even though it is hard to measure (Guimaraes, T. et al.,

1992). Of course, some researchers have found that computer experience
is not significantly correlated to user satisfaction (Lawrence, M, and Low,
G., 1993), others have found some correlation with satisfaction (Palvia,
P.C., 1996), and others have indicated that previous experience with
computers is a significant factor related to user satisfaction (Mahmood,
M.A. et al., 2000). Furthermore, training has also been identified as a
factor that affects IS effectiveness and user satisfaction (Igbaria, M.,
1990; Davis, S.A., and Bostrom, R.P., 1992). Given the fact that, user
training is directly connected to satisfaction and, thus, to system usage, it
is of vital matter that organizations should provide their personnel with
continuously training on new technologies by encouraging them to
participate in different seminars and presentations (Igbaria, M., 1990).
Last but not least, user’s skills with computers and, generally with IT
technology have also been identified as a factor that is directly associated
with user satisfaction and performance (Torkzadeh, G., and Lee, J., 2003).
Their findings have shown that user’s computing skills can help the user to
accept new computer applications and, increase their involvement with
information systems and, thus, user satisfaction.
Based on the above and the hypothetical model developed, the first
research hypothesis that has to be tested is formulated as following:
H1. User background will positively affect the hospital personnel
satisfaction.
3.3.2. System Quality
According to the literature, system quality is one of the most

important factors that influence user satisfaction and it can be measured
with ease of use, system speed, screen interface, and error recovery
(DeLone W.H. and McLean E., 2003; Doll, W.J., and Torkzadeh, G., 1988;
Chin W.W. and Lee M.K.O., 2000; Ribiere V. et al. 1999; Ives B. et al.
1983; Bailey, J.E., and Pearson, S.W., 1983). When a system is easy to
use, and complex procedures do not exist, it is more likely to be accepted
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by the users (Davis, F.D., 1989). According to Igbaria et al., (1995), it is

very important for the organizations to be very careful when designing an
information system. A system must be developed based on user’s abilities
and needs, in order to succeed ease of use and, then, user satisfaction.
Furthermore, another variable that leads to high levels of user satisfaction
with an IS is system speed. The rapid development of technology, and the
constantly increased demands by the organizations to their staff constitute
the speed that the applications are executed one of the most important
variable that influence IS success (Chin W.W. and Lee M.K.O., 2000). To
continue with, screen interface and error recovery are also stated among
the most significant variables that affect user satisfaction (Ribiere V. et al.
1999). The work environment that is offered to the user by the system on
the one hand and, the ability to correct a false information or mistake on
the other hand are key factors that lead to IS success (Ribiere V. et al.
1999).
Based on the above and the hypothetical model developed, the
second research hypothesis that has to be tested is formulated as
following:
H2. System Quality will positively affect the hospital personnel
satisfaction.
3.3.3. Information Quality
According to the literature, information quality mostly refers to

measures of information systems output (Pitt, L.F. et al., 1995). Typical
measures of information quality contain content, accuracy, format,
timeliness, and data security (Etenazi-Amoli, J., and Farhoomand, A.F.,
1996; Chin W.W. and Lee M.K.O., 2000; Doll, W.J., and Torkzadeh, G.,
1988). To begin with, the content of the information provided by the
system will satisfy the users if it fits to their needs (Doll, W.J., and
Torkzadeh, G., 1988; Chin W.W. and Lee M.K.O., 2000). At the same way,
researchers have shown that, measures that refers to information product
items, such as the accuracy of the output information, the format and the
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material design of the layout, and the timeliness of the information

available to the users, positively influence user satisfaction (Chin W.W.
and Lee M.K.O., 2000, Doll, W.J., and Torkzadeh, G., 1988; Bailey, J.E.,
and Pearson, S.W., 1983). Finally, the confirmation and the confidence
that data are secured from unauthorised alteration or loss leads to greater
user satisfaction (Etenazi-Amoli, J., and Farhoomand, A.F., 1996; Bailey,
J.E., and Pearson, S.W., 1983).
following:
H3. Information Quality will positively affect the hospital
personnel satisfaction.
3.3.4. Service quality
Service quality is another major factor that, according to DeLone

and McLean (2003), affects user satisfaction and IS effectiveness. Typical
measures of service quality mainly include internal and external support
(Etenazi-Amoli, J., and Farhoomand, A.F., 1996; Thompson, R.L. et al.,
1991). It is for certain that, when the IS department (internal support),
and the external vendor (external support) provide help and solutions to
different problems that derive from computer usage, users feel more
confident towards obstacles, which, in turn, leads to greater satisfaction
and system usage as well (Thompson, R.L. et al., 1991; Etenazi-Amoli, J.,
and Farhoomand, A.F., 1996).
following:
H4. Service Quality will positively affect the hospital personnel
satisfaction.
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3.4. Methodology Research
3.4.1. Instrument Development
Many researchers have spent a lot of time to find a valid instrument

for user satisfaction. Among these researchers, Bailey and Pearson (1983)
were the first to develop an instrument that was composed of 39 items
that measure user satisfaction. Later on, Ives et al. (1983) created a short
form version of 13 items from the initial Bailey and Pearson’s (1983)
instrument. Furthermore, Doll and Torkzadeh (1988) revised the Ives et
al. (1983) instrument and created a 12 item, which measured end-user
computing satisfaction based on five factors: content, accuracy, format,
ease of use, and timeliness. Their instrument is one of the most common
used in the field of user satisfaction and the one that has been validated
by many researchers. To continue with, Doll and Torkzadeh’s (1988)
instrument was later enhanced and revised by Chin and Lee (2000). They
added one more factor; system speed, and enriched each factor with more
items in the instrument. The present research uses the revised Doll and
Torkzadeh’s (1988) tool by Chin and Lee (2000) as a basis, because it is
an instrument that is well validated and widely used, and it has been
developed especially for end-user computing applications (Chen, L-da et
al., 2000). Furthermore, the factors and the items that compose the
instrument are suitable for the present research in Greek hospitals.
The rapid development of technology in all organizations, and the
great responsibilities that users face in their every day working life when
handling large amounts of data, classify previous experience, user skills,
and training in computers very important factors that lead to user
satisfaction and, thus, IS success (Mahmood, M.A. et al., 2000; Lawrence,
M, and Low, G., 1993; Etenazi-Amoli, J., and Farhoomand, A.F., 1996;
Igbaria, M., 1990; Mosley, I.T., 2001). Additionally, the work environment
(screen interface) that is offered by the system, the abilities of the system
to correct mistakes and to protect data from loss are considered to be
factors that play significant role on user satisfaction and IS effectiveness
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(Etenazi-Amoli, J., and Farhoomand, A.F., 1996; Bailey, J.E., and Pearson,
S.W., 1983; Ribiere V. et al. 1999). Furthermore, many researchers
claimed that the support that is offered to the users, either by the IS
department of the organization, or by the vendor of the IS, has great
effect on user satisfaction (Chen, L-da et al., 2000; Etenazi-Amoli, J., and
Farhoomand, A.F., 1996; Thompson, R.L. et al., 1991).
Therefore, the present research includes all the above aspects. All
the definitions and their supported literature of the variables that were
used for the research model of measuring user satisfaction are
demonstrated at Table (3.1). The literature review that was mentioned
resulted in the structure of the questionnaire that has been distributed to
the Greek hospitals (see Appendix A).
The questionnaire was divided in two parts. Part I contained 6
questions which concerned general information (demographic
characteristics) about the respondents. Questions 1 to 4 involved
information about the sex and the age of the respondents, their
educational level, and their position at the hospital that they were
occupied. Questions 5 and 6 determined the length of time the respondent
has been working in the healthcare field, and the length of time the
respondent has been using the hospital’s information system.
In part II the respondent were asked to rate the statements on a
five-point Likert scale, where 1 = strongly disagree, 2 = disagree
somewhat, 3 = neutral, 4 = agree somewhat, and 5 = strongly agree. The
five-point Likert scale was selected because it gives the opportunity to the
respondents to chose to state neutral, as opposed to other Likert scale
types. This part consisted of five sets of items.
The first set, from item A1.1 to item A3.3, requested the
respondents to rate each statement, which consisted information about
the user background, as far as their previous experience, their skills, and
their training were concerned. A strongly agree response suggested a high
level of satisfaction an, a strongly disagree response suggested a low level
of satisfaction to all items of the questionnaire.
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In the second set, items B1.1 to B1.5 referred to their level of

agreement to statements that concerned the ease of use of the system;
items B2.1 to B2.4 consisted statements about the level of satisfaction
with the speed of the system; items B3.1 to B3.4 referred to screen
interface of the work environment of the system; B4.1 to B4.3 consisted
statements about the way the system controlled the error recovery. Items
B1.1 to B4.3 of the second set of the questionnaire measured the quality
of the system.
The third set indicated the respondents to state their level of
satisfaction with the quality of the information that the system offered to
them. Items C1.1 to C1.5 referred to the quality of the information
content offered by the system; items C2.1 to C2.4 consisted statements
about the accuracy of the information provided; items C3.1 to C3.5
consisted statements about the format of the information; items C4.1 to
C4.5 referred to the respondents level of agreement to statements that
concerned the timeliness of the information available to them; items C5.1
to C5.3 referred to the security of the data generated by the system.
The fourth set of the questionnaire indicated the respondents to
state their level of satisfaction as far as the service quality was concerned.
Items D1.1 to D1.3 referred to internal support provided to the users by
the IS department, and items D2.1 to D2.3 referred to external support
provided to the users by the vendor of the IS.
Last but not least, the sixth set of the questionnaire indicated three
statements about the overall satisfaction with the use of the information
system, rating them to a five-point Likert scale, where 1 = very
dissatisfied or extremely dissatisfied, and 5 = very satisfied or extremely
satisfied.
All the data that were gathered from the collected questionnaires
and, the statistical analysis that was generated by them and follows in the
next section resulted with the use of the statistical SPSS program. At the
beginning, confirmatory factor analysis was conducted in order to
estimate the adequacy of the measurement model (Chang, M.K. 1998)
and, after that, Structural Equation Modelling (SEM) was also performed in
order to test the structural model’s fit (Anderson, J.C., and Gerbing, G.W.,
1998) with the use of the AMOS software.
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Factor Definition Items Supporting

“The level of previous experience with
Experience computer systems” 3 Lawrence & Low (1993)
(Lawrence & Low, 1993)
“The amount of specialized instruction A2.1: Etenazi &
and practice that is offered to the Farhoomand (1996)
Training user to increase the user’s proficiency 4 A2.2-A2.4: Igbaria
in utilizing the computer capability (1990)
that is unavailable” (Bailey & Pearson,
1983)
“The ability to use computer-based
systems in the specific functional
areas of information acquisition,
Skills storage retrieval, analysis, 3 Mosley, I.T. (2001)
interpretation, and presentation by
using software applications” (Mosley,
2001)
B1.1-B1.2: Doll &
“The degree to which a person Torkzadeh (1988)
Ease of Use believes that using a particular 5 B1.3: Chin & Lee (2000)
system would be free of effort” B1.4-B1.5: Venkatesh et
(Davis, 1989) al., (2003)
“The speed with which a computer
System Speed system responds to different tasks” 4 Chin & Lee (2000)
(Chin & Lee, 2000)
“The work environment which the
systems offers to the user for the
Screen Interface importing, processing as well as 4 Ribiere et al., (1999)
exporting of the information”
(Ribiere et al., 1999)
“The ability of the system to offer you B4.1-B4.2: Ribiere et
Error Recovery a chance to correct a mistake 3 al., (1999)
(incorrect information)” (Ribiere et B4.3: Bailey & Pearson
al., 1999) (1983)
“The extent of the information C1.1-C1.3: Doll &
Content content provided by the system that 5 Torkzadeh (1988)
fits the users need” (Chin & Lee, C1.4-C1.5: Chin & Lee
2000) (2000)
C2.1- C2.2: Doll &
Accuracy “The correctness of the output 4 Torkzadeh (1988)
information” (Bailey & Pearson, 1983) C2.3-C2.4: Chin & Lee
(2000)
“The material design of the layout C3.1-C3.2: Doll &
Format and display of the output content” 5 Torkzadeh (1988)
(Bailey & Pearson, 1983) C3.3-C3.5: Chin & Lee
(2000)
“The availability of the output C4.1-C4.2: Doll &
Timeliness information at a time suitable for its 5 Torkzadeh (1988)
use” (Bailey & Pearson, 1983) C4.3-C4.5: Chin & Lee
(2000)
“The safeguarding of data from
Data Security misappropriation or unauthorized 3 Etenazi & Farhoomand
alteration or loss” (Bailey & Pearson, (1996)
1983)
“The amount of support provided to D1.1-D1.2: Chen et al.
Internal Support the users of the system from the IS 3 (2000)
department of the organization” D1.3: Etenazi &
(Chen et al., 2000) Farhoomand (1996)
“The amount of support provided to D2.1: Etenazi &
External Support the users of the system from the staff 3 Farhoomand (1996)
of the vendor of the IS” D2.2-D2.3: Thompson et
(Etenazi & Farhoomand, 1996) al., (1991)
Table 3.1: Definitions and Supported Literature
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3.4.2. Research Population and Sample
For the purpose of this survey, the first thing that should be
determined is the selection of the population that will participate on the
research. Although the idea of hospital information systems began in the
early 1960s (Zviran M., 1990), the first well organised attempt in Greece
began at the end of 1980s. That means that HISs are still in progress in
Greece, in relation to other nations, and ISs are not used by the whole
personnel of the hospitals, but mainly by the administrative staff.
According to the chief of the IS department from the General Hospital of
Xanthi, by the end of 2009 and through the fourth Community Support
Framework (4th CSF), schedules have been organised for the introduction
of a system, part of the integrated HIS, to the whole nursing staff of the
hospitals. It is very important that the population sample must not include
people that generally work in hospitals, but the actual users of the ISs,
the ones that use the system in their every day life at work. These are all
the stakeholders that participate in the IS functionality. Thus, the
population sample was restricted to healthcare personnel, such as medical
staff, nursing staff, and administrative staff from every department of the
hospital. Additionally, the research was limited to hospitals in Greece,
which were randomly selected to participate in the research.
3.4.3. Research Procedures
The gathering of all the appropriate data was performed in different

phases. At the beginning, a letter was sent and a week later a telephone
contact with the chief of the IS department of 6 Greek Hospitals took
place. The hospitals were the followings: General Hospital of Xanthi,
General Hospital of Heraklion Crete “Venizeleio-Pananeio”, General
Hospital of Thessaloniki “Georgios Papanikolaou”, General Hospital of
Thessaloniki “Papageorgiou”, General Panarkadiko Hospital of Tripolis, and
General University Hospital of Alexandroupoli. In the present research, we
wanted to include hospitals that are not located in the Athens (capital)
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region. This is why hospitals from different and diverse regions of Greece
were selected. The discussion concerned their willingness to participate in
the survey. After the initial contact, a preliminary questionnaire was sent
to the chief of the IS department of each hospital, in order to ascertain
the quality and the meaning of the questions that composed the
questionnaire, and to rate the relevance of the items in terms of user
satisfaction with the IS. After that the initial questionnaire was partly
adjusted to end up with the final form (see Appendix A).
The next phase started with the postage of the questionnaires by
mail, accompanied with the formal letter that was sent at the beginning. A
self-addressed, stamped envelope was enclosed for the convenience of
the IS department, in order to return the completed questionnaires back
to the researcher. The questionnaires were sent in 22nd of June to all
hospitals simultaneously and the collecting date was arranged to be after
2 weeks. Unfortunately, a small delay was inevitable because of the
summer months, where the most staff is on holidays in Greece. The
collection ended at the first week of August. From the 140 questionnaires
that initially were sent, a total number of 100 questionnaires were finally
gathered from 4 hospitals. The General Panarkadiko Hospital of Tripolis
and the General Hospital of Xanthi were not able to continue participating
in the research. More precisely, 41 questionnaires were gathered from the
General Hospital of Heraklion Crete “Venizeleio-Pananeio”, 29 from the
General University Hospital of Alexandroupoli, 18 from the General
Hospital of Thessaloniki “Papageorgiou” and, finally, 12 from the General
Hospital of Thessaloniki “Georgios Papanikolaou”. All of the 100
questionnaires found to be complete and usable for research, achieving a
rate response of 71.40% percent. The demographic profile of the
respondents is demonstrated in Table (3.2). The Table shows that the
research sample is composed of 39% nursing staff, 8% doctors and 53%
administrative staff. Furthermore, the sample consists mainly of female,
between the ages of 31-50, well educated, reaching a 10 year experience
with using an information system.
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Frequency Frequency (%)

(persons)
Sex Female 73 73%
Male 27 27%
20-30 13 13%
31-40 31 31%
Age 41-50 37 37%
>50 11 11%
missing 8 8%
High School 19 19%
Educational Bachelor’s Degree 69 69%
level Master’s Degree 10 10%
Doctoral Degree 2 2%
Nursing Staff 39 39%
Personnel Doctors 8 8%
Administrative Staff 53 53%
Years in the <15 years 68 68%
present job ≥15 years 27 27%
missing 5 5%
Years using the <10 years 57 57%
IS ≥10 years 18 18%
missing 25 25%
Table 3.2: Demographic characteristics of respondents
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3.4.4. Data analysis
i) Construct validity and construct reliability

It must be stated that it is very important to verify that the items
which composed the questionnaire explicate defined ideas through
analysis of validity and reliability. In the present survey, a factor analysis
was performed (see Appendix B) by using the Kaiser-Meyer-Olkin (KMO)
measure of sampling adequacy and the Bartlett’s Test of Sphericity, which
are recommended for measuring construct validity (Hair, J. et al., 1995).
Additionally, the Cronbach’s (a) reliability test was used in order to
estimate the internal consistency of measurements (Straub, D.W. et al.,
2004). Finally, the Total Variance Explained (TVE) score was also used in
order to measure the cumulative percentage of the variance that is
explained by all factors. The results of the factor and reliability analysis,
and the results of the descriptive statistics are summarised at Table (3.3).
To begin with, through the statistical analysis and as Table (3.3)
reveals, the results of the descriptive statistics show that items A1.1 to
A1.3 that constitute the factor “experience” have mean scores between 3
and 4 indicating that the respondents have a relatively positive perception
toward these constructs. The same indications are also revealed for items
A3.1 to A3.3 that compose the factor “skills”, items A2.1 and A2.4, B1.1
to B1.5, B2.1 to B2.4, B3.1 to B.3.4, B4.1 to B4.3 that compose the
factors “training”, “ease of use”, “system speed”, “screen interface”, and
“error recovery” respectively. Mean scores of items C1.1 to C1.5, C2.1 to
C2.4, C3.1 to C3.5, C4.1 to C4.3, and C5.1 to C5.3 that constitute the
factors “content”, “accuracy”, “format”, “timeliness”, and “data security”
respectively are also between 3 and 4, expect from items C4.4 and C4.5
that are below 3. Items A2.2 and A2.3 are also below 3 showing that
training is a result of personal effort. Last, items D1.1 to D1.3 of the
factor “internal support”, D2.1 to D2.3 of the “external support”, and
items SAT1 to SAT3 of the overall satisfaction factor resulted mean scores
between 3 and 4, also showing the high positive perception by the
respondents.
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1 2 3 4 5 Statistics Mean Std. Loadings

Dev.
A1.1 2,0 5,1 15,2 47,5 30,3 K.M.O.=0,704 3,99 0,920 0,858
Experience A1.2 3,1 9,2 22,4 40,8 24,5 Bartlett’s Sig=0,000 3,74 1,029 0,885
A1.3 11,2 14,3 27,6 27,6 19,4 (TVE)=73,279 3,30 1,254 0,825
Cronbach (a)=0,806
A2.1 8,4 10,5 16,8 32,6 31,6 K.M.O.=0,500 3,68 1,257 Dropped
Training A2.2 48,4 17,9 10,5 14,7 8,4 Bartlett’s Sig=0,000 2,17 1,389 0,895
A2.3 36,7 8,2 9,2 29,6 16,3 (TVE)=80,090 2,81 1,577 0,895
A2.4 4,1 12,2 29,6 54,1 Cronbach (a)=0,748 4,34 0,849 Dropped
A3.1 3,1 5,1 16,3 44,9 30,6 K.M.O.=0,692 3,95 0,978 0,840
Skills A3.2 3,1 10,2 15,3 32,7 38,8 Bartlett’s Sig=0,000 3,94 1,111 0,881
A3.3 16,2 18,2 21,2 23,2 21,2 (TVE)=71,430 3,15 1,380 0,813
Cronbach (a)=0,785
B1.1 2,0 10,0 20,0 48,0 20,0 K.M.O.=0,805 3,74 0,960 0,759
B1.2 1,0 12,2 15,3 50,0 21,4 Bartlett’s Sig=0,000 3,79 0,955 0,896
Ease B1.3 2,0 12,1 23,1 45,5 17,2 (TVE)=67,052 3,64 0,974 0,855
of Use B1.4 7,1 4,0 18,2 42,4 28,3 Cronbach (a)=0,874 3,81 1,113 0,810
B1.5 3,1 12,4 20,6 44,3 19,6 3,65 1,031 0,767
B2.1 2,1 13,5 20,8 46,9 16,7 K.M.O.=0,714 3,63 0,987 0,840
System B2.2 7,1 9,2 24,5 44,9 14,3 Bartlett’s Sig=0,000 3,50 1,077 0,887
Speed B2.3 7,1 6,1 24,2 42,4 20,2 (TVE)=74,686 3,63 1,093 0,865
B2.4 12,2 18,4 24,5 26,5 18,4 Cronbach (a)=0,634 3,20 1,284 Dropped
B3.1 4,1 10,3 26,8 40,2 18,6 K.M.O.=0,853 3,59 1,038 0,889
Screen B3.2 2,0 10,2 22,4 40,8 24,5 Bartlett’s Sig=0,000 3,76 1,006 0,887
Interface B3.3 4,1 9,2 25,5 37,8 23,5 (TVE)=79,980 3,67 1,063 0,896
B3.4 4,0 10,1 31,3 26,3 28,3 Cronbach (a)=0,916 3,65 1,119 0,905
B4.1 10,2 15,3 25,5 34,7 14,3 K.M.O.=0,754 3,28 1,191 0,931
Error B4.2 9,1 20,2 27,3 27,3 16,2 Bartlett’s Sig=0,000 3,21 1,206 0,947
Recovery B4.3 7.3 16,7 28,1 39,6 8,3 (TVE)=87,037 3,25 1,066 0,920
Cronbach (a)=0,925
C1.1 7,1 8,2 22,4 45,9 16,3 K.M.O.=0,847 3,56 1,085 0,866
C1.2 6,1 10,2 18,4 44,9 20,4 Bartlett’s Sig=0,000 3,63 1,107 0,934
Content C1.3 7,1 7,1 24,5 38,8 22,4 (TVE)=83,246 3,62 1,126 0,906
C1.4 7,2 15,5 15,5 41,2 20,6 Cronbach (a)=0,949 3,53 1,191 0,938
C1.5 5,2 10,4 20,8 45,8 17,7 3,60 1,061 0,916
C2.1 7,1 8,2 25,5 41,8 17,3 K.M.O.=0,817 3,54 1,095 0,895
Accuracy C2.2 7,1 8,2 23,5 39,8 21,4 Bartlett’s Sig=0,000 3,60 1,128 0,961
C2.3 3,1 9,2 22,4 38,8 26,5 (TVE)=84,305 3,77 1,043 0,934
C2.4 4,1 10,3 21,6 37,1 26,8 Cronbach (a)=0,937 3,72 1,097 0,880
C3.1 7,1 8,2 29,6 48,0 7,1 K.M.O.=0,870 3,40 0,992 0,918
C3.2 7,1 7,1 24,5 39,8 21,4 Bartlett’s Sig=0,000 3,61 1,118 0,931
Format C3.3 8,2 4,1 20,4 51,0 16,3 (TVE)=86,448 3,63 1,069 0,939
C3.4 7,1 12,2 19,4 49,0 12,2 Cronbach (a)=0,960 3,47 1,086 0,931
C3.5 7,1 13,3 14,3 51,0 14,3 3,52 1,114 0,930
C4.1 3,1 11,2 17,3 45,9 22,4 K.M.O.=0,695 3,73 1,031 0,923
C4.2 5,1 10,2 16,3 40,8 27,6 Bartlett’s Sig=0,000 3,76 1,122 0,955
C4.3 5,5 6,6 22,0 42,9 23,1 (TVE)=52,178 3,71 1,068 0,912
Timeliness
84,354
C4.4 26,5 21,4 27,6 18,4 6,1 Cronbach (a)=0,740 2,56 1,236 0,896
C4.5 18,9 21,1 24,2 25,3 10,5 2,87 1,282 0,887
C5.1 6,2 8,2 38,1 22,7 24,7 K.M.O.=0,706 3,52 1,138 0,863
Data C5.2 4,1 15,3 30,6 27,6 22,4 Bartlett’s Sig=0,000 3,49 1,124 0,947
Security C5.3 3,1 14,4 36,1 26,8 19,6 (TVE)=83,739 3,45 1,061 0,934
Cronbach (a)=0,901
D1.1 4,0 12,1 8,1 42,4 33,3 K.M.O.=0,737 3,89 1,124 0,926
Internal D1.2 8,1 7,1 13,1 40,4 31,3 Bartlett’s Sig=0,000 3,80 1,195 0,934
Support D1.3 5,1 16,2 14,1 43,4 21,2 (TVE)=83,825 3,60 1,142 0,886
Cronbach (a)=0,903
D2.1 4,0 15,2 35,4 29,3 16,2 K.M.O.=0,722 3,38 1,057 0,908
External D2.2 3,1 14,3 41,8 23,5 17,3 Bartlett’s Sig=0,000 3,38 1,031 0,900
Support D2.3 5,1 11,1 49,5 21,2 13,1 (TVE)=78,710 3,26 0,996 0,853
Cronbach (a)=0,865
SAT1 4,0 4,0 47,5 30,3 14,1 K.M.O.=0,754 3,46 0,929 0,949
Overall SAT2 4,0 2,0 47,5 34,3 12,1 Bartlett’s Sig=0,000 3,48 0,885 0,964
Satisfactio SAT3 3,0 2,0 50,5 32,3 12,1 (TVE)=90,051 3,48 0,850 0,934
n Cronbach (a)=0,944
Table 3.3: Factor and reliability analysis
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Starting with the factor analysis, it can be stated that KMO is above
the 0,500 threshold for all factors (Hair, J. et al., 1995). More precisely,
KMO varies between 0,500 and 0,870. The Cronbach’s (a) reliability test
revealed values more than the 0,600 threshold (Malhotra, N., 1999), while
TVE score is above 0,500 for all factors (Straub, D.W., 1989). Last but not
least, the analysis has shown that factor loadings are at acceptable levels
for all items. At this point, it must be pointed out that 3 out of 52 items
were dropped out of the analysis. Additionally, it must stated that the
statistical analysis has indicated that the items originally composed the
factor “timeliness” have loadings in two factors (see Appendix B),
separating this way items C4.1 to C4.3 from items C4.4 to C4.5. This may
have happened because of the reverse meaning of the C4.4 and C4.5
items.
The results demonstrated at Table (3.3) suggest that, users have a
very satisfactory background with acceptable experience in programs for
personal computing and information systems as well. As far as the
training factor is concerned, it is obvious that, it is a result of personal
effort and self study rather than a privilege that should be provided to
them by the IS department of the organization or the vendor of the IS.
Furthermore, and as far as factor skills is concerned, users believe that
they have a satisfactory level of the ability to interact and execute
software packages very easy, such as entering data, formulas and
generating calculations.
To continue with, users are highly satisfied with their interaction
with the system which is understandable, friendly in use and easy to
handle; highly satisfied with the speed that the system operates; highly
satisfied with the screen interface of the system, such as the screen
layout and colors which are pleasant to the user. Moreover, users are
satisfied with the ability that the system offers to correct different
mistakes in a simply way.
It is very interesting to see that most of the users are very satisfied
as far as the information provided to them by the system. They believe
that the information delivered to them covers their needs with regards to
-47-
the content, the accuracy, and the way that the information is presented
to them. As far as the factor timeliness is concerned, it can be stated that
generally users are satisfied with the time that takes to generate useful
information from the system. The factor data security is the one that most
users are neutral towards it, revealing this way that they are not very
sure or convinced that the system secures data against unauthorised
alteration or physical damage.
Furthermore, as far as the internal and external support factors are
concerned, it cab be said that most of the support provided to the users
comes from the IS department of the organization and then from the
vendor of the system.
Finally, the results from the factor overall satisfaction reveals that
most of the users hold a neutral position. This may mean that the system
needs improvements so that users to become more satisfied with their
whole operation of the system.
ii) Structural Model Fit

At the beginning of this section it is necessary to revise some basic
models that were used in the present survey. To begin with, it must be
said that DeLone and McLean (1992) claimed that user satisfaction can be
measured with three factors: information quality, system quality and
service quality. Furthermore, according to Mahmood et al., (2000) another
dimension that is related to user satisfaction is user background. Finally,
from DeLone and McLean (2003) revised model service quality is
considered to be another factor that is directly connected with user
satisfaction. To continue with, in this part of the survey it has been tested
whether the 14 items that were demonstrated in figure (3.1) measure the
4 factors stated above and, in turn, whether these 4 factors measure user
satisfaction. In few words, the hypothetical model (figure 3.1) of this
research was tested. The hypothetical model was tested using the
Structural Equation Modeling approach. For this reason and according to
the needs of this study five fit measures were used in order to evaluate
the overall model fit. These were the following: chi-square/degree of
-48-
freedom (x2/df), goodness-of-fit index (GFI), comparative fit index (CFI),

normed fit index (NFI), and root mean square residual (RMR). In the first
part, “user background” was tested whether it can be measured with
experience, training and skills; “system quality” with ease of use, system
speed, screen interface, and error recovery; “information quality” with
content, accuracy, format, timeliness and error recovery; “service quality”
with internal and external support. The results that were generated with
the use of the AMOS software package are demonstrated at Figures (3.2),
(3.3), (3.4) and (3.5).
To begin with, Figure (3.2) which refers to user background shows
that experience is strongly related to user background (0,87), skills is also
strongly related to user background (0,77) and training is related in an
acceptable level (0,50) also with user background. Furthermore, Figure
(3.3) reveals that ease of use (0,84), system speed (0,55), screen
interface (0,71) and error recovery (0,63) are strongly related to the
factor system quality. In Figure (3.4), it can be observed that the four first
factors, meaning content (0,88), accuracy (0,89), format (0,90) and
timeliness (0,60) are strongly related to information quality, and data
security (0,43) reveals that it is related to the factor in an acceptable
level. Finally, internal support with a loading of 0,77 and external support
with 0,90 shows that they are also strongly related to service quality, as it
can be seen in Figure (3.5). Here it can be stated that there is no change
from the initial hypothetical model.
As far as the second part is concerned, Figure (3.6) represents the
overall model and Table (3.4) the summarised results from the testing of
the models with the use of the Structural Equation Modeling approach.
-49-
Figure 3.2: User Background
Figure 3.3: System Quality
Figure 3.4: Information Quality
Figure 3.5: Service Quality
-50-
Figure 3.6: User Satisfaction
CMIN/DF GFI NFI CFI RMR

User
Background 2,022 0,964 0,965 0,981 0,027
System
Quality 8,956 0,929 0,858 0,868 0,051
Information
Quality 3,579 0,912 0,941 0,908 0,038
Service
Quality 1,022 0,977 0,962 0,984 0,006
User
Satisfaction 5,762 0,893 0,842 0,853 0,119
Table 3.4: Statistics concerning structural equation models
-51-
As it can be observed, the CMIN/DF score is within the acceptable

levels, below 5 (Harrison, A.W. and Rainer, R.K., 1996) except from the
system quality which is at 8,956. However, it is still acceptable. GFI score
is above the 0,90 threshold (Bollen, K.A. and Long, J.S., 1993), CFI score
is also close to the 0,90 threshold (Smith, T.D. and McMillian, B.F., 2001),
while NFI is close to 0,90. Last, RMR score is below the 0,1 threshold
(Bollen, K.A., 1989; Hair, J.F. et al., 1992) except from users satisfaction
value which is very close (0,119). Furthermore, Figure (3.6) represents
both the overall model and the extracted path coeffients within the model
and the adjusted R2 score, which explains 53% of the variance in user
satisfaction. As it can be noticed, examining the relationship between user
background and user satisfaction, it is obvious that there is a weak
positive (0,23) relationship. This relation reveals that the more
experienced the user is, with adequate skills and training provided by the
organization itself or by the vendor may improve satisfaction with the
system. As far as the relationship between information quality and user
satisfaction is concerned, it can be said that there is a highly positive
relation (0,54). This relation shows that if the information provided to the
users covers their needs, such as accuracy of the information and content
which satisfies their daily needs, on time delivered information, then their
satisfaction with the of the system will be improved. Furthermore, the
model reveals that there is a highly positive impact between service
quality and user satisfaction (0,43). This relation shows that the better
service provided to the user when needed, internal or external, generates
more confidence to the users and, thus, higher satisfaction. Finally, it can
be observed that there is a very high relationship between system quality
and information quality (0,88).
Summarising, from the initial four hypotheses Figure (3.1) three of
them have been proved through this present survey. Hypothesis 1 (H1)
showing that user background positively affect user satisfaction;
hypothesis 3 (H3) showing that information quality positively affect user
satisfaction, and hypothesis 4 (H4) showing that service quality positively
-52-
affect user satisfaction. Hypothesis 2 (H2) which was referred to the direct
positive relationship between system quality and user satisfaction has
been rejected. At this point, it must be said that it has been found that
system quality indirectly affect user satisfaction through information
quality.
-53-
CHAPTER 4 CONCLUSIONS AND RESEARCH LIMITATIONS
Chapter 4
Conclusions and research limitations
4.1. Conclusions
This survey has examined the relationship between user satisfaction

and user background, user satisfaction and system quality, user
satisfaction and information quality and, finally, user satisfaction and
service quality. For this purpose all the relative theory and previous
studies were thoroughly analysed and the testing hypothesis were easily
generated. It is useful to remind of the sample’s characteristics that were
used in the present survey. The sample was composed of 4 Greek Hospital
from different and diverse regions of Greece. The demographic
characteristics have indicated that most users of hospital information
systems are occupied at the administrative sector of their organization
reaching a 53 percentage among the 100 respondents that participated in
the research. In order to test whether the relationship between the
dependent variable and the independent variables that were demonstrated
at Figure (3.1) exist and confirm the results from previous researchers,
the statistical program SPSS was used as the basic instrument in this
study. Firstly, factor analysis was conducted in order to estimate the
adequacy of the measurement model, and the construct validity and
reliability of the instrument. Secondly, Structural Equation Modeling was
performed in order to test the structural model fit and examine the paths
of the model, with the use of the AMOS software package. The statistical
analysis has indicated that the four initial hypotheses (see Figure 3.1) of
the research model have been slightly modified. The present survey have
shown that user background directly positively affect user satisfaction
(H1), confirming this way the research of Mahmood et al., (2000) in which
the first hypothesis was based on. The modification concerns the DeLone
and McLean (2003) three factors that have been proved to affect user
satisfaction. Information quality (H3) and service quality (H4) have been
-54-
tested and have shown that directly positively affect user satisfaction. The
diversity concerns the factor system quality and its relationship to user
satisfaction. The results from the Structural Equation Modeling approach
have shown that hypothesis 2 (H2) is rejected in this present research,
meaning that system quality does not affect user satisfaction directly, but
affects it indirectly through information quality (see Figure 3.6). This
change may have occurred because of the misunderstanding of the
questions by the respondents of the questionnaire, since system quality
have been proved to be one of the major factors that has direct impact on
user satisfaction by other researchers (DeLone, W.H. and McLean, E.R.
1992; DeLone, W.H. and McLean, E.R. 2003).
Summarising, it can be stated that the evaluation of Hospital
Information Systems through the user satisfaction measurement is a
major research field, especially in Greece where it still remains in primary
stage. Further research is necessary and critical in order to reveal the
factors that really affect user satisfaction with information systems. The
results of these findings may lead hospital organizations to realise that the
use of information technology is, nowadays, very important and its use
may lead to better operation of the healthcare sector. But, information
technology is useless, if the users that daily interact with information
systems are dissatisfied with their functionality and reject them.
4.2. Research Limitations
This research embraced different limitations. The limitations

involved the sample size, which is considered as a small one (100
respondents) that was gathered from four Greek hospitals. Furthermore,
the respondent’s completion of the questionnaire and the questionnaire
itself may be considered as limitation as well, meaning that the responses
might have been biased because of the time pressure, and some of the
statements of the questionnaire might have been unclear. Moreover,
many critical factors that have direct influence to user satisfaction, such
as system flexibility, user’s expectations, relevancy, user’s anxiety etc,
-55-
were omitted to keep the research simple. Finally, as a limitation can be

considered the fact that in Greek hospitals most of the IS users come from
the administrative staff and little from the nursing staff, where in other
nations the situation is completely different.
-56-
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APPENDIX A: QUESTIONNAIRE
Appendix A: Questionnaire
QUESTIONNAIRE
Directions
This questionnaire contains two parts. Part I asks some general information about you. Part II asks
you to rate your agreement or disagreement on a variety of issues. Please rate the statements based
upon the job in relation to the IS of the Hospital.
Thank you very much for your opinion and time. Please be assured this information will remain strictly
confidential and that the questionnaire is anonymous.
Part I
1. Select your sex
Male Female
2. Age: ____
3. Select your education level
High School Master’s Degree
Bachelor’s Degree Doctoral Degree
Else: ________
4. Position at the hospital
Nursing Staff
Doctors
Administrative staff
5. Number of years in the present job: ......year(s) ......month(s)
6. Number of years using the IS: ......year(s) ......month(s)
Part II
A) User Background
1 2 3 4 5
Strongly Disagree Neutral Agree Strongly
Disagree Somewhat Somewhat Agree
A1.1 The level of my computer experience with
packages developed for personal 1 2 3 4 5
computer (excel, word etc) is satisfactory
A1.2 The level of my computer experience with
1 2 3 4 5
information systems is satisfactory
A1.3 The nature of my previous encounters
with information systems was very 1 2 3 4 5
satisfactory
A2.1 Adequacy of computer training was
1 2 3 4 5
provided to me
A2.2 The training was provided to me by
1 2 3 4 5
vendors or outside consultants
A2.3 The training was provided to me by the IS
1 2 3 4 5
department
A2.4 Self study was the way of accomplishing
1 2 3 4 5
my training
A3.1 Loading, interacting, and executing
1 2 3 4 5
software packages is easy for me
A3.2 Formatting and producing useful reports
1 2 3 4 5
is easy for me
A3.3 Entering data, formulas, and calculations
1 2 3 4 5
is easy for me
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B) System Quality
1 2 3 4 5
B1.1 The system is friendly to the user 1 2 3 4 5
B1.2 The system is easy to use 1 2 3 4 5
B1.3 I believe that the it is easy to get the

1 2 3 4 5
system to do what I want to do
B1.4 My interaction with the system is clear
1 2 3 4 5
and understandable
B1.5 Learning to operate the system is easy for
1 2 3 4 5
me
B2.1 The operational speed of the system is
1 2 3 4 5
satisfactory
B2.2 The system operates at a satisfactory
1 2 3 4 5
pace
B2.3 The systems runs very quickly 1 2 3 4 5
B2.4 The speed of the system is satisfactory 1 2 3 4 5
B3.1 I believe that the screen layout of the

1 2 3 4 5
system are well designed
B3.2 I believe that the screen colours of the
1 2 3 4 5
system are pleasant
B3.3 I believe that the volume of output per
1 2 3 4 5
screen is suitable
B3.4 I generally believe that the screen
1 2 3 4 5
interface is easy to customize
B4.1 The function of the system to correct a
1 2 3 4 5
mistake is simple
B4.2 The system has the ability to correct a
1 2 3 4 5
incorrect information in a fast way
B4.3 The methods and policies governing
correction and rerun of system outputs 1 2 3 4 5
that are incorrect are complete
C) Information Quality
C1.1 I believe that the system provides the
1 2 3 4 5
precise information I need
C1.2 I believe that the information content
1 2 3 4 5
meet my needs
C1.3 I believe that the systems provides
reports that seems to be just about 1 2 3 4 5
exactly to what I need
C1.4 The information provided by the system
1 2 3 4 5
fit my needs
C1.5 The system provides me the right amount
1 2 3 4 5
of information for my needs
C2.1 I believe that the system is accurate
1 2 3 4 5
C2.2 The accuracy of the system is satisfactory

1 2 3 4 5
C2.3 I believe that the system provides

1 2 3 4 5
accurate information
C2.4 I believe that the system provides reliable
1 2 3 4 5
information
C3.1 I believe that the output is presented in a
1 2 3 4 5
useful format
C3.2 I believe that the information provided is
1 2 3 4 5
clear
C3.3 The layout of the output is satisfactory
1 2 3 4 5
C3.4 The format of the output is satisfactory

1 2 3 4 5
C3.5 I believe that the information is presented

1 2 3 4 5
to me with a satisfactory way
-64-
1 2 3 4 5
C4.1 I believe that I get the information I need
1 2 3 4 5
in time
C4.2 The system provides up-to-date
1 2 3 4 5
information
C4.3 I believe that the system provides me
1 2 3 4 5
with the information in a timely manner
C4.4 The system provides information that it is
1 2 3 4 5
to old to be useful
C4.5 I believe that the system provide some
information that it is too late for my 1 2 3 4 5
needs
C5.1 The system secures data against physical
1 2 3 4 5
loss or damage
C5.2 The system secures data against
1 2 3 4 5
unauthorized alteration
C5.3 Generally, the safeguarding of the
system from unauthorized access is 1 2 3 4 5
satisfactory
D) Service Quality
D1.1 I believe that the IS department provides
satisfactory support to all users of the 1 2 3 4 5
system
D1.2 I believe that staffs suggestions for future
enhancements of the system are
1 2 3 4 5
responded by IS department
cooperatively
D1.3 I believe that there is availability of IS
1 2 3 4 5
staff for consultation
D2.1 I believe that the amount of support
1 2 3 4 5
provided by the vendor is satisfactory
D2.2 The vendor is available for assistance
1 2 3 4 5
with software difficulties
D2.3 The vendor is available for assistance
1 2 3 4 5
with hardware difficulties
Overall Satisfaction
Rate your satisfaction with the use of the system
1 2 3 4 5
very dissatisfied neutral very satisfied
Using the system makes me feel:
1 2 3 4 5
extremely neutral extremely satisfied
dissatisfied
All things considered, I am:
1 2 3 4 5
very dissatisfied neutral very satisfied
with using the system.
-65-
APPENDIX B: STATISTICAL ANALYSIS
Appendix B: Statistical Analysis

Factor Analysis
KMO and Bartlett's Test

Kaiser-Meyer-Olkin Measure of Sampling
Adequacy. ,704
Bartlett's Test of Approx. Chi-Square 98,966

Sphericity df 3
Sig. ,000
Anti-image Matrices
A1.1 A1.2 A1.3

Anti-image Covariance A1.1 ,531 -,254 -,133
A1.2 -,254 ,480 -,207
A1.3 -,133 -,207 ,608
Anti-image Correlation A1.1 ,701a -,504 -,235
A1.2 -,504 ,665a -,383
A1.3 -,235 -,383 ,761a
a. Measures of Sampling Adequacy(MSA)
Communalities
Initial Extraction
A1.1 1,000 ,735
A1.2 1,000 ,783
A1.3 1,000 ,680
Extraction Method: Principal Component Analysis.
Total Variance Explained
Initial Eigenvalues Extraction Sums of Squared Loadings

Component Total % of Variance Cumulative % Total % of Variance Cumulative %
1 2,198 73,279 73,279 2,198 73,279 73,279
2 ,473 15,767 89,046
3 ,329 10,954 100,000
Component Matrixa
Compone
nt
1
A1.1 ,858
A1.2 ,885
A1.3 ,825
a. 1 components extracted.
a
Rotated Component Matrix
a. Only one component was extracted.

The solution cannot be rotated.
-66-
RELIABILITY
/VARIABLES=A1.1 A1.2 A1.3
/SCALE('ALL VARIABLES') ALL/MODEL=ALPHA.
Reliability
Scale: ALL VARIABLES
Case Processing Summary
N %
Cases Valid 95 95,0
Excludeda 5 5,0
Total 100 100,0
a. Listwise deletion based on all
variables in the procedure.
Reliability Statistics
Cronbach's
Alpha N of Items
,806 3
Factor Analysis

Adequacy. ,500

Sphericity df 1
Sig. ,000
Anti-image Matrices
A2.2 A2.3
Anti-image Covariance A2.2 ,638 -,384
A2.3 -,384 ,638
Anti-image Correlation A2.2 ,500a -,602
A2.3 -,602 ,500a
Communalities
Initial Extraction
A2.2 1,000 ,801
A2.3 1,000 ,801
-67-

1 1,602 80,090 80,090 1,602 80,090 80,090
2 ,398 19,910 100,000
Component Matrixa
Compone
nt
1
A2.2 ,895
A2.3 ,895
Rotated Component Matrixa

RELIABILITY
/VARIABLES=A2.2 A2.3
Reliability
N %
Cases Valid 95 95,0
Excludeda 5 5,0
Total 100 100,0
Cronbach's
Alpha N of Items
,748 2
-68-
Factor Analysis

Adequacy. ,692

Sphericity df 3
Sig. ,000
Anti-image Matrices
A3.1 A3.2 A3.3

Anti-image Covariance A3.1 ,576 -,262 -,120
A3.2 -,262 ,502 -,227
A3.3 -,120 -,227 ,633
Anti-image Correlation A3.1 ,699a -,488 -,198
A3.2 -,488 ,649a -,403
A3.3 -,198 -,403 ,744a
Communalities
Initial Extraction
A3.1 1,000 ,705
A3.2 1,000 ,776
A3.3 1,000 ,662

1 2,143 71,430 71,430 2,143 71,430 71,430
2 ,510 17,009 88,439
3 ,347 11,561 100,000
Component Matrixa
Compone
nt
1
A3.1 ,840
A3.2 ,881
A3.3 ,813

-69-
RELIABILITY
/VARIABLES=A3.1 A3.2 A3.3
Reliability

N %
Cases Valid 98 98,0
Excludeda 2 2,0
Total 100 100,0
Cronbach's
Alpha N of Items
,785 3
-70-
Factor Analysis

Adequacy. ,805

Sphericity df 10
Sig. ,000
Anti-image Matrices
B1.1 B1.2 B1.3 B1.4 B1.5

Anti-image Covariance B1.1 ,473 -,191 -,128 ,092 ,009
B1.2 -,191 ,296 -,046 -,174 -,066
B1.3 -,128 -,046 ,424 -,106 -,149
B1.4 ,092 -,174 -,106 ,430 -,082
B1.5 ,009 -,066 -,149 -,082 ,562
Anti-image Correlation B1.1 ,753a -,512 -,286 ,204 ,018
B1.2 -,512 ,763a -,129 -,489 -,161
B1.3 -,286 -,129 ,859a -,248 -,305
B1.4 ,204 -,489 -,248 ,787a -,166
B1.5 ,018 -,161 -,305 -,166 ,890a
Communalities
Initial Extraction
B1.1 1,000 ,576
B1.2 1,000 ,803
B1.3 1,000 ,731
B1.4 1,000 ,655
B1.5 1,000 ,588

1 3,353 67,052 67,052 3,353 67,052 67,052
2 ,636 12,714 79,766
3 ,471 9,413 89,180
4 ,343 6,855 96,034
5 ,198 3,966 100,000
-71-
Component Matrixa
Compone
nt
1
B1.1 ,759
B1.2 ,896
B1.3 ,855
B1.4 ,810
B1.5 ,767

RELIABILITY
/VARIABLES=B1.1 B1.2 B1.3 B1.4 B1.5
Reliability
N %
Cases Valid 94 94,0
Excludeda 6 6,0
Total 100 100,0
Cronbach's
Alpha N of Items
,874 5
-72-
Factor Analysis

Adequacy. ,714

Sphericity df 3
Sig. ,000
Anti-image Matrices
B2.1 B2.2 B2.3

Anti-image Covariance B2.1 ,573 -,201 -,144
B2.2 -,201 ,467 -,241
B2.3 -,144 -,241 ,512
Anti-image Correlation B2.1 ,762a -,389 -,265
B2.2 -,389 ,679a -,493
B2.3 -,265 -,493 ,712a
Communalities
Initial Extraction
B2.1 1,000 ,706
B2.2 1,000 ,787
B2.3 1,000 ,748

1 2,241 74,686 74,686 2,241 74,686 74,686
2 ,438 14,600 89,286
3 ,321 10,714 100,000
Component Matrixa
Compone
nt
1
B2.1 ,840
B2.2 ,887
B2.3 ,865

-73-
RELIABILITY
/VARIABLES=B2.1 B2.2 B2.3 B2.4
Reliability
N %
Cases Valid 94 94,0
Excludeda 6 6,0
Total 100 100,0
Cronbach's
Alpha N of Items
,634 4
Factor Analysis

Adequacy. ,853

Sphericity df 6
Sig. ,000
Anti-image Matrices
B3.1 B3.2 B3.3 B3.4

Anti-image Covariance B3.1 ,358 -,123 -,091 -,085
B3.2 -,123 ,362 -,074 -,098
B3.3 -,091 -,074 ,335 -,137
B3.4 -,085 -,098 -,137 ,314
Anti-image Correlation B3.1 ,864a -,343 -,262 -,252
B3.2 -,343 ,865a -,213 -,290
B3.3 -,262 -,213 ,847a -,423
B3.4 -,252 -,290 -,423 ,836a
Communalities
Initial Extraction
B3.1 1,000 ,790
B3.2 1,000 ,787
B3.3 1,000 ,803
B3.4 1,000 ,819
-74-

1 3,199 79,980 79,980 3,199 79,980 79,980
2 ,306 7,646 87,625
3 ,269 6,737 94,362
4 ,226 5,638 100,000
Component Matrixa
Compone
nt
1
B3.1 ,889
B3.2 ,887
B3.3 ,896
B3.4 ,905

RELIABILITY
/VARIABLES=B3.1 B3.2 B3.3 B3.4
Reliability
N %
Cases Valid 95 95,0
Excludeda 5 5,0
Total 100 100,0
Cronbach's
Alpha N of Items
,916 4
-75-
Factor Analysis

Adequacy. ,754

Sphericity df 3
Sig. ,000
Anti-image Matrices
B4.1 B4.2 B4.3

Anti-image Covariance B4.1 ,275 -,144 -,082
B4.2 -,144 ,230 -,129
B4.3 -,082 -,129 ,316
Anti-image Correlation B4.1 ,761a -,574 -,278
B4.2 -,574 ,709a -,479
B4.3 -,278 -,479 ,803a
Communalities
Initial Extraction
B4.1 1,000 ,867
B4.2 1,000 ,897
B4.3 1,000 ,847

1 2,611 87,037 87,037 2,611 87,037 87,037
2 ,235 7,838 94,875
3 ,154 5,125 100,000
Component Matrixa
Compone
nt
1
B4.1 ,931
B4.2 ,947
B4.3 ,920

-76-
RELIABILITY
/VARIABLES=B4.1 B4.2 B4.3
Reliability
N %
Cases Valid 95 95,0
Excludeda 5 5,0
Total 100 100,0
Cronbach's
Alpha N of Items
,925 3
-77-
Factor Analysis

Adequacy. ,847

Sphericity df 10
Sig. ,000
Anti-image Matrices
C1.1 C1.2 C1.3 C1.4 C1.5

Anti-image Covariance C1.1 ,325 -,110 -,010 ,013 -,049
C1.2 -,110 ,170 -,083 -,067 ,027
C1.3 -,010 -,083 ,257 -,012 -,056
C1.4 ,013 -,067 -,012 ,141 -,104
C1.5 -,049 ,027 -,056 -,104 ,181
Anti-image Correlation C1.1 ,893a -,466 -,036 ,062 -,203
C1.2 -,466 ,819a -,397 -,436 ,155
C1.3 -,036 -,397 ,914a -,065 -,260
C1.4 ,062 -,436 -,065 ,811a -,654
C1.5 -,203 ,155 -,260 -,654 ,819a
Communalities
Initial Extraction
C1.1 1,000 ,750
C1.2 1,000 ,873
C1.3 1,000 ,821
C1.4 1,000 ,880
C1.5 1,000 ,838

1 4,162 83,246 83,246 4,162 83,246 83,246
2 ,346 6,919 90,164
3 ,244 4,871 95,036
4 ,167 3,331 98,367
5 ,082 1,633 100,000
-78-
Component Matrixa
Compone
nt
1
C1.1 ,866
C1.2 ,934
C1.3 ,906
C1.4 ,938
C1.5 ,916

RELIABILITY
/VARIABLES=C1.1 C1.2 C1.3 C1.4 C1.5
Reliability
N %
Cases Valid 93 93,0
Excludeda 7 7,0
Total 100 100,0
Cronbach's
Alpha N of Items
,949 5
-79-
Factor Analysis

Adequacy. ,817

Sphericity df 6
Sig. ,000
Anti-image Matrices
C2.1 C2.2 C2.3 C2.4

Anti-image Covariance C2.1 ,252 -,113 -,014 ,023
C2.2 -,113 ,131 -,079 -,064
C2.3 -,014 -,079 ,211 -,093
C2.4 ,023 -,064 -,093 ,331
Anti-image Correlation C2.1 ,815a -,624 -,059 ,081
C2.2 -,624 ,750a -,477 -,305
C2.3 -,059 -,477 ,847a -,352
C2.4 ,081 -,305 -,352 ,883a
Communalities
Initial Extraction
C2.1 1,000 ,801
C2.2 1,000 ,924
C2.3 1,000 ,872
C2.4 1,000 ,775

1 3,372 84,305 84,305 3,372 84,305 84,305
2 ,352 8,806 93,111
3 ,182 4,560 97,671
4 ,093 2,329 100,000
Component Matrixa
Compone
nt
1
C2.1 ,895
C2.2 ,961
C2.3 ,934
C2.4 ,880
-80-

RELIABILITY
/VARIABLES=C2.1 C2.2 C2.3 C2.4
Reliability
N %
Cases Valid 95 95,0
Excludeda 5 5,0
Total 100 100,0
Cronbach's
Alpha N of Items
,937 4
-81-
Factor Analysis

Adequacy. ,870

Sphericity df 10
Sig. ,000
Anti-image Matrices
C3.1 C3.2 C3.3 C3.4 C3.5

Anti-image Covariance C3.1 ,216 -,092 -,029 -,012 -,025
C3.2 -,092 ,172 -,071 -,039 ,017
C3.3 -,029 -,071 ,174 -,006 -,059
C3.4 -,012 -,039 -,006 ,163 -,099
C3.5 -,025 ,017 -,059 -,099 ,154
Anti-image Correlation C3.1 ,908a -,475 -,152 -,066 -,135
C3.2 -,475 ,858a -,411 -,233 ,104
C3.3 -,152 -,411 ,897a -,035 -,361
C3.4 -,066 -,233 -,035 ,860a -,626
C3.5 -,135 ,104 -,361 -,626 ,834a
Communalities
Initial Extraction
C3.1 1,000 ,843
C3.2 1,000 ,867
C3.3 1,000 ,881
C3.4 1,000 ,866
C3.5 1,000 ,865

1 4,322 86,448 86,448 4,322 86,448 86,448
2 ,292 5,847 92,295
3 ,165 3,299 95,594
4 ,134 2,689 98,282
5 ,086 1,718 100,000
-82-
Component Matrixa
Compone
nt
1
C3.1 ,918
C3.2 ,931
C3.3 ,939
C3.4 ,931
C3.5 ,930

RELIABILITY
Reliability
N %
Cases Valid 97 97,0
Excludeda 3 3,0
Total 100 100,0
Cronbach's
Alpha N of Items
,960 5
-83-
Factor Analysis

Adequacy. ,695

Sphericity df 10
Sig. ,000
Anti-image Matrices
C4.1 C4.2 C4.3 C4.4 C4.5

Anti-image Covariance C4.1 ,264 -,144 -,049 -,024 -,027
C4.2 -,144 ,201 -,131 ,005 ,032
C4.3 -,049 -,131 ,314 ,016 -,056
C4.4 -,024 ,005 ,016 ,638 -,370
C4.5 -,027 ,032 -,056 -,370 ,620
Anti-image Correlation C4.1 ,758a -,624 -,170 -,058 -,066
C4.2 -,624 ,678a -,522 ,014 ,090
C4.3 -,170 -,522 ,801a ,037 -,127
C4.4 -,058 ,014 ,037 ,531a -,587
C4.5 -,066 ,090 -,127 -,587 ,542a
Communalities
Initial Extraction
C4.1 1,000 ,863
C4.2 1,000 ,912
C4.3 1,000 ,841
C4.4 1,000 ,803
C4.5 1,000 ,798
Compo Initial Eigenvalues Extraction Sums of Squared Rotation Sums of Squared

nent Loadings Loadings
Total % of Cumulative Total % of Cumulative Total % of Cumulative
Variance % Variance % Variance %
1 2,714 54,276 54,276 2,714 54,276 54,276 2,609 52,178 52,178
2 1,504 30,078 84,354 1,504 30,078 84,354 1,609 32,176 84,354
3 ,402 8,038 92,392
4 ,248 4,968 97,360
5 ,132 2,640 100,000
-84-
Component Matrixa
Component
1 2
C4.1 ,913 -,171
C4.2 ,921 -,251
C4.3 ,899 -,181
C4.4 ,300 ,845
C4.5 ,364 ,816
Component
1 2
C4.1 ,923 ,106
C4.2 ,955 ,031
C4.3 ,912 ,091
C4.4 ,038 ,896
C4.5 ,108 ,887
Rotation Method: Varimax with Kaiser Normalization.
a. Rotation converged in 3 iterations.
Component Transformation Matrix
Component 1 2
1 ,956 ,294
2 -,294 ,956
Rotation Method: Varimax with Kaiser Normalization.
RELIABILITY
Reliability
N %
Cases Valid 89 89,0
Excludeda 11 11,0
Total 100 100,0
Cronbach's
Alpha N of Items
,740 5
-85-
Factor Analysis

Adequacy. ,706

Sphericity df 3
Sig. ,000
Anti-image Matrices
C5.1 C5.2 C5.3

Anti-image Covariance C5.1 ,482 -,106 -,051
C5.2 -,106 ,206 -,165
C5.3 -,051 -,165 ,227
Anti-image Correlation C5.1 ,875a -,338 -,153
C5.2 -,338 ,647a -,763
C5.3 -,153 -,763 ,669a
Communalities
Initial Extraction
C5.1 1,000 ,744
C5.2 1,000 ,896
C5.3 1,000 ,872

1 2,512 83,739 83,739 2,512 83,739 83,739
2 ,366 12,190 95,930
3 ,122 4,070 100,000
Component Matrixa
Compone
nt
1
C5.1 ,863
C5.2 ,947
C5.3 ,934

-86-
RELIABILITY
/VARIABLES=C5.1 C5.2 C5.3
Reliability
N %
Cases Valid 96 96,0
Excludeda 4 4,0
Total 100 100,0
Cronbach's
Alpha N of Items
,901 3
Factor Analysis

Adequacy. ,737

Sphericity df 3
Sig. ,000
Anti-image Matrices
D1.1 D1.2 D1.3

Anti-image Covariance D1.1 ,292 -,181 -,099
D1.2 -,181 ,275 -,125
D1.3 -,099 -,125 ,428
Anti-image Correlation D1.1 ,710a -,638 -,279
D1.2 -,638 ,693a -,363
D1.3 -,279 -,363 ,833a
-87-
Communalities
Initial Extraction
D1.1 1,000 ,857
D1.2 1,000 ,872
D1.3 1,000 ,786

1 2,515 83,825 83,825 2,515 83,825 83,825
2 ,313 10,424 94,249
3 ,173 5,751 100,000
Component Matrixa
Compone
nt
1
D1.1 ,926
D1.2 ,934
D1.3 ,886

RELIABILITY
/VARIABLES=D1.1 D1.2 D1.3
Reliability
N %
Cases Valid 99 99,0
Excludeda 1 1,0
Total 100 100,0
Cronbach's
Alpha N of Items
,903 3
-88-
Factor Analysis

Adequacy. ,722

Sphericity df 3
Sig. ,000
Anti-image Matrices
D2.1 D2.2 D2.3

Anti-image Covariance D2.1 ,378 -,226 -,155
D2.2 -,226 ,396 -,128
D2.3 -,155 -,128 ,529
Anti-image Correlation D2.1 ,684a -,584 -,346
D2.2 -,584 ,698a -,279
D2.3 -,346 -,279 ,807a
Communalities
Initial Extraction
D2.1 1,000 ,825
D2.2 1,000 ,809
D2.3 1,000 ,728

1 2,361 78,710 78,710 2,361 78,710 78,710
2 ,395 13,162 91,872
3 ,244 8,128 100,000
Component Matrixa
Compone
nt
1
D2.1 ,908
D2.2 ,900
D2.3 ,853

-89-
RELIABILITY
/VARIABLES=D2.1 D2.2 D2.3
Reliability
N %
Cases Valid 98 98,0
Excludeda 2 2,0
Total 100 100,0
Cronbach's
Alpha N of Items
,865 3
-90-
Factor Analysis

Adequacy. ,754

Sphericity df 3
Sig. ,000
Anti-image Matrices
SAT1 SAT2 SAT3

Anti-image Covariance SAT1 ,198 -,115 -,050
SAT2 -,115 ,159 -,099
SAT3 -,050 -,099 ,262
Anti-image Correlation SAT1 ,755a -,650 -,220
SAT2 -,650 ,697a -,488
SAT3 -,220 -,488 ,828a
Communalities
Initial Extraction
SAT1 1,000 ,900
SAT2 1,000 ,929
SAT3 1,000 ,873

1 2,702 90,051 90,051 2,702 90,051 90,051
2 ,195 6,503 96,553
3 ,103 3,447 100,000
Component Matrixa
Compone
nt
1
SAT1 ,949
SAT2 ,964
SAT3 ,934

-91-
RELIABILITY
/VARIABLES=SAT1 SAT2 SAT3
Reliability
N %
Cases Valid 99 99,0
Excludeda 1 1,0
Total 100 100,0
Cronbach's
Alpha N of Items
,944 3
-92-

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I would like to acknowledge the assistance of Dr. Prodromos

LIST OF FIGURES ............................................................................. v

LIST OF TABLES ..............................................................................vi

ABSTRACT .................................................................................... vii

HOSPITAL INFORMATION SYSTEMS: THE CASE OF GREECE ........... 3

1.1. IT AND HEALTHCARE .................................................................. 3

1.2. DEFINITIONS, AIM AND STRUCTURE OF HIS ....................................... 6

1.3. THE VALUE OF HOSPITAL INFORMATION SYSTEMS ................................ 8

1.4. THE STATUS OF HIS IN GREEK HOSPITALS ......................................... 9

INFORMATION SYSTEMS EVALUATION ........................................ 10

2.1. THE IMPORTANCE OF EVALUATION ..................................................10

2.3. APPROACHES TO IS SUCCESS MEASUREMENT .....................................15

2.3.1. Cost-benefit analysis .......................................................16

2.3.2. System Usage.................................................................16

2.3.3. User Satisfaction .............................................................17

2.4. USER SATISFACTION MEASUREMENT MODELS .....................................17

2.4.1. Bailey and Pearson’s user satisfaction measure....................18

2.4.2. Ives, Olson and Baroudi user satisfaction measure ...............19

2.4.3. Doll and Torkzadeh measurement of EUCS..........................23

2.4.5. Mahmood et al., research model of factors affecting IT EUS ..27

HOSPITAL INFORMATION SYSTEM EVALUATION: THE RESEARCH30

3.1. USER SATISFACTION AS A MEASURE OF SUCCESS ................................30

3.2. THEORETICAL FOUNDATIONS ........................................................32

3.3. THEORETICAL MODEL AND HYPOTHESIS ............................................33

3.3.1. User background .............................................................34

3.3.2. System Quality ...............................................................35

3.3.3. Information Quality .........................................................36

3.3.4. Service quality ................................................................37

3.4. METHODOLOGY RESEARCH...........................................................38

3.4.1. Instrument Development..................................................38

3.4.2. Research Population and Sample .......................................42

3.4.3. Research Procedures .......................................................42

3.4.4. Data analysis..................................................................45

CONCLUSIONS AND RESEARCH LIMITATIONS ............................. 54

4.1. CONCLUSIONS .........................................................................54

4.2. RESEARCH LIMITATIONS .............................................................55

APPENDIX B: STATISTICAL ANALYSIS......................................... 66

FIGURE 1.1: FUNCTIONAL DESIGN FOR THE INTEGRATED HIS ........................... 7

FIGURE 2.1: THE D&M IS SUCCESS MODEL ..............................................13

FIGURE 2.2: UPDATED D&M IS SUCCESS MODEL ........................................14

FIGURE 2.3: A MODEL FOR MEASURING END-USER COMPUTING SATISFACTION .....25

FIGURE 2.4: FORMATION OF END-USER COMPUTING SATISFACTION ..................27

FIGURE 2.5: RESEARCH MODEL OF FACTORS AFFECTING IT END-USER SATISFACTION

FIGURE 3.1: RESEARCH MODEL OF MEASURING USER SATISFACTION ..................34

FIGURE 3.2: USER BACKGROUND ...........................................................50

FIGURE 3.3: SYSTEM QUALITY ...............................................................50

FIGURE 3.4: INFORMATION QUALITY .......................................................50

FIGURE 3.5: SERVICE QUALITY ..............................................................50

FIGURE 3.6: USER SATISFACTION ..........................................................51

TABLE 1.1: BENEFITS OF USING INFORMATION AND COMMUNICATION TECHNOLOGIES

IN THE HEALTH CARE SECTOR ............................................................ 5

TABLE 2.1: EVALUATION OF ALTERNATIVE UIS MEASURES..............................19

TABLE 3.1: DEFINITIONS AND SUPPORTED LITERATURE .................................41

TABLE 3.2: DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS .......................44

TABLE 3.3: FACTOR AND RELIABILITY ANALYSIS ..........................................46

TABLE 3.4: STATISTICS CONCERNING STRUCTURAL EQUATION MODELS ...............51

Keywords: user satisfaction, hospital information systems, evaluation

Information technology (IT) has already become one of the most

influence, positively or negatively, users' satisfaction have been detected

Hospital Information Systems: the case of Greece

Hospital information systems (HIS) have changed spectacularly

1.1. IT and Healthcare

Taking into account the rapid development of technology, it was a