Key Success Factors Behind Electronic Medical Record Adoption in Thailand

Journal of Health Organization and Management
Key success factors behind electronic medical record adoption in Thailand

Kanida Narattharaksa Mark Speece Charles Newton Damrongsak Bulyalert
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Kanida Narattharaksa Mark Speece Charles Newton Damrongsak Bulyalert , (2016),"Key success
factors behind electronic medical record adoption in Thailand", Journal of Health Organization and
Management, Vol. 30 Iss 6 pp. 985 - 1008
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Key success factors behind Electronic

medical record
electronic medical record adoption
adoption in Thailand
Kanida Narattharaksa 985
Department of Business Informatics, Received 30 October 2014
Dhurakij Pundit University International College, Bangkok, Thailand Revised 19 June 2015
18 January 2016
Mark Speece 27 February 2016
College of Business and Economics, American University of Kuwait, Accepted 10 March 2016
Salmiya, Kuwait
Charles Newton
International College, Dhurakij Pundit University,
Bangkok, Thailand, and
Damrongsak Bulyalert
Faculty of Medicine, Chiang Mai University,
Chiang Mai, Thailand
Abstract
Purpose – The purpose of this paper is to investigate the elements that health care personnel in
Thailand believe are necessary for successful adoption of electronic medical record (EMR) systems.
Design/methodology/approach – Initial qualitative in-depth interviews with physicians to adapt
key elements from the literature to the Thai context. The 12 elements identified included things related
to managing the implementation and to IT expertise. The nationwide survey was supported by the
Ministry of Public Health and returned 1,069 usable questionnaires (response rate 42 percent) from a
range of medical personnel.
Findings – The key elements clearly separated into a managerial dimension and an IT dimension.
All were considered fairly important, but managerial expertise was more critical. In particular, there
should be clear EMR project goals and scope, adequate budget allocation, clinical staff must be
involved in implementation, and the IT should facilitate good electronic communication.
Research limitations/implications – Thailand is representative of middle-income developing
countries, but there is no guarantee findings can be generalized. National policies differ, as do economic
structures of health care industries. The focus is on management at the organizational level, but future
research must also examine macro-level issues, as well as gain more depth into thinking of individual
health care personnel.
Practical implications – Technical issues of EMR implementation are certainly important. However,
it is clear actual adoption and use of the system also depends very heavily on managerial issues.
Originality/value – Most research on EMR implementation has been in developed countries,
and has often focussed more on technical issues rather than examining managerial issues closely.
Health IT is also critical in developing economies, and management of health IT implementation must
be well understood.
Keywords Thailand, Medical information systems, Electronic health records,
Electronic medical records, EMR implementation, Physician views
Paper type Research paper
Journal of Health Organization and
Management
Vol. 30 No. 6, 2016
An early version of this paper was presented at the 2011 SIBR Conference on Interdisciplinary pp. 985-1008
Business & Economics Research (Society of Interdisciplinary Business Research). Bangkok, © Emerald Group Publishing Limited
1477-7266
Thailand, June 16-18, 2011. DOI 10.1108/JHOM-10-2014-0180
JHOM Introduction
30,6 This study examines factors that personnel in Thailand’s health care industry believe
are necessary for the successful adoption of electronic medical record (EMR) systems
(also often electronic health record, EHR) in Thailand. The concept of EMR started in
the 1970s, and usage of such systems has spread rapidly, although even in most
developed countries, still only a minority of hospitals have fully implemented systems.
986 EMR implementation does not always work well, and there may be resistance to
adoption among key stakeholders. We examine management issues here which can
help improve adoption and implementation success rates.
Such systems go by many names, including EHR, health information technology
(HIT) and many other terms. Technically, different terms sometimes are considered to
cover slightly different content. Occasionally authors argue that the terms must be
carefully distinguished; e.g. Garets and Davis (2006) say EMR and EHR are different in
that EHR is somewhat broader.

However, especially when covering issues like implementation or patient response,
rather than specific content, discussions usually group a range of terms. For example,
Liu et al. (2013) simply talk about “EMR/HER,” rather than choosing one or the other
term; Black et al. (2011) use a wide range these terms in discussing general issues of
impact on health care; and Cresswell and Sheikh (2013) talk about a range of terms
regarding organizational issues in implementation. Our research was specifically on
EMR, but even physicians we interviewed often used many of the terms
interchangeably. In the following discussion we generally stick with EMR, but in
discussing other work, we usually show the term which that work uses.
In gaining effective use of EMR (whatever terminology is used), key issues are not
really about the technology, or even about willingness of doctors to use systems.
They are about management of EMR implementation. Management of the
implementation process needs to be better understood so that implementation can
be better managed:
Organizational issues surrounding technology implementations in healthcare settings are
crucially important, but have as yet not received adequate research attention. This may in
part be due to the subjective nature of factors, but also due to a lack of coordinated efforts
toward more theoretically-informed work (Cresswell and Sheikh, 2013, p. e73).
The impetus for adoption has been a number of critical problems in health care. A few
examples from the USA, which probably has the most extensive data, can
demonstrate the nature of these problems. For example, just a decade ago, the
Institute of Medicine estimated that 44,000-98,000 people died each year because of
medical errors and mistakes that could easily have been prevented (Kohn et al., 2000;
Thompson and Brailer, 2004). The Institute of Medicine also estimated about
1.5 million adverse drug events annually in the USA during the mid-2000s (Aspden
et al., 2007; Appari et al., 2012). It has long been recognized that many medical errors
result from inadequacies in medical records, for example, because of physicians’
illegible handwriting, incorrect dosage selections, and drug-drug or drug-allergy
interactions (Kohn et al., 2000). There is also a looming shortage of health care
personnel in the USA (Agency for Healthcare Research and Quality, 2009; Carrier
et al., 2011), which makes it critical to find ways to make health care provision more
efficient without sacrificing quality.
Both quality and efficiency issues can be at least partially addressed with better
systems of medical records. A summary by the Healthcare Information and
Management Systems Society (HIMSS) defining an EHR shows how the benefits Electronic
would work: medical record
The Electronic Health Record (EHR) is a longitudinal electronic record of patient health adoption
information generated by one or more encounters in any care delivery setting. Included in this
information are patient demographics, progress notes, problems, medications, vital signs, past
medical history, immunizations, laboratory data and radiology reports. The EHR automates
and streamlines the clinician’s workflow. The EHR has the ability to generate a complete 987
record of a clinical patient encounter – as well as supporting other care-related activities
directly or indirectly via interface – including evidence-based decision support, quality
management, and outcomes reporting (Healthcare Information and Management Systems
Society (HIMSS), 2014a).
The USA, which may have the most extensive data about EMR issues, can serve as a
useful example for the developing world, especially middle-income developing

countries such as Thailand. The USA is fairly advanced compared to developing
countries but tends to lag behind most developed economies on health quality
indicators (Organization for Economic Co-operation and Development, 2011; World
Health Organization, 2012). Furthermore, “the USA lags significantly behind many of
the developed countries in the adoption of health information technology” (Lewis et al.,
2013, p. 578). Thus, the problems for EMR in the USA seem similar to many of those
which middle-income developing countries face. The USA seems to present a realistic
initial target as some of the more advanced developing countries upgrade their health
care systems toward developed-world standards. Using the USA as an example also
has the advantage that there is an abundance of data for comparison.
The US Government favors the use of EMR systems in theory, but largely lacks
policies to effectively foster wide implementation. The government does not require
use, as do many more EMR-advanced countries, nor does it provide adequate funding,
as do some countries which rely more heavily on the private sector to lead
implementation. The USA did adopt the HIT for Economic and Clinical Health
(HITECH) Act in 2009, but the USA still remained behind most developed countries
several years later (e.g. Schoen et al., 2012). HITECH does include subsidies to
physicians who implement EMR systems, although they do not seem to adequately
cover full costs in most cases. One recent study shows that even among adopters, half
of physicians say that cost is a major barrier to adoption, and continuing maintenance
costs remain a problem for a quarter of adopters. Three-fourth of non-adopters cite
initial cost as a reason not to adopt, and half of non-adopters worried about continuing
annual costs ( Jamoom et al., 2014).
In Jamoom et al. (2014), a majority of those who adopted after the enactment of
HITECH said that HITECH influenced their decision. However, several recent articles
have assessed the impact of HITECH, and found that it has not substantially changed the
rather slow rate of adoption. For example, Schoen et al. (2012) show that the USA still
lagged most developed countries several years after HITECH was adopted. Mennemeyer
et al. (2016) use a Bass innovation diffusion model to assess whether adoption rates
improved after HITECH was adopted. “The model finds that the passage of the HITECH
Act and the subsequent subsidy payments contributed statistically insignificant nudges
to the EHR diffusion curve of less than one percentage point and a half percentage point,
respectively” (Mennemeyer et al., 2016, discussion section).
Both health care provision and health IT vendors are fragmented, which inhibits
adoption of standards applicable nationwide (Healthcare Information and Management
JHOM Systems Society (HIMSS), 2008). “Unfortunately, it seems that fragmentation in the
30,6 USA is at an even higher level than other developed countries, as the private sector and
market forces play more significant roles than other countries. […] [T]he development
and deployment of an ePHR [electronic personal health records] within such a context
is no easy task” (Lewis et al., 2013, p. 578).
Although Thailand is not as advanced as the USA, the situation seems similar.
988 As discussed in more detail below, the country is relatively advanced for the
developing world, but lags somewhat at implementing Health IT compared to many
middle-income developing countries. Careful assessments have found that development
of eHealth is inadequate and needs more government attention. Adoption of various
aspects seems somewhat piecemeal and haphazard, without much coherent national
policy or much coordination (Theera-Ampornpunt, 2011; Kijsanayotin et al., 2010).
For example, this is reflected in a survey showing fairly good IT acceptance at
community health centers for basic care and routine reporting. However, there is
somewhat less use in management and administration, and weak use in communication
and collaboration (Kijsanayotin et al., 2007, 2009), issues that would require more
coordination and standardization.
EMR benefits and EMR performance

Most EMR proponents cite a range of benefits. For example, a recent guide to EMR
implementation by the Texas Medical Association lists a number of “quality benefits of
an EMR,” which can potentially greatly reduce problems noted above. These include
improved access to patient records, quicker turnaround time on various diagnostics
procedures, error reduction, improved diagnostics, all of which ultimately improve
outcomes (Marcus et al., 2009). In recent reviews of published research, Buntin et al. (2011)
and Jones et al. (2014) showed that these sorts of quality and safety improvements
were unambiguously present in the majority (62 and 56 percent, respectively) of recent
studies on EMR implementation. However, the remaining studies show mixed results, or
sometimes mainly negative results.
Many observers also point out efficiency gains. For example, properly implemented,
EMR can streamline a number of routine tasks to allow more time to be shifted to more
substantive aspects of patient care, which is critical for overloaded health care
personnel. In addition, EMR systems can potentially save hospitals and clinics money
in many aspects of their operations so that the same health care can be provided
somewhat less expensively, which, of course, frees resources for addressing quality
and/or shortage issues (Kohn et al., 2000; Thompson and Brailer, 2004; Marcus et al.,
2009; Centers for Medicare & Medicaid Services, 2014; Healthcare Information and
Management Systems Society (HIMSS), 2014b, c). Again, the reviews by Buntin et al.
(2011) and Jones et al. (2014) showed frequent positive efficiency results, but mixed and
negative impacts also turned up in some studies.
Many individual US hospitals use state-of-the-art Health Information Systems (HIS)
technology, and many of these have implemented it well (Haupt, 2011, HIMSS, 2014c).
A number of studies show that, in fact, EMR implementation does improve outcomes as
proponents claim. For example, US hospitals which adopted commercial EMR systems
were more likely to meet a range of quality indicators related specifically to
administering medication (Appari et al., 2012). There is also some evidence that the
systems can improve processes and make them more efficient, ( Jaspers et al., 2011) and
can result in cost savings (Frisse et al., 2012).
Nevertheless, despite all the claimed, and sometimes demonstrated, advantages Electronic
(e.g. Buntin et al., 2011; Jones et al., 2014), EMR implementation is not actually very far medical record
along in the USA. According to HIMSS:
adoption
Many experts [in the USA] agree that the best way to improve healthcare quality and to
reduce medical errors is to fully deploy EHRs. Unfortunately the US lags far behind other
countries documented in this paper” (HIMSS, 2008, p. 112; the study mainly examined
developed countries). 989
Overall, just 3.6 percent of non-federal US hospitals had a comprehensive EHR system
in place in 2010, and another 11.5 percent had a “basic” system, although many others
did show more limited use of some components of EMR systems ( Jha et al., 2010, 2011).
By the end of 2013, only 2.9 percent of US hospitals overall had reached “Stage 7”
in implementation according to HIMSS standards – “Complete EMR.” Another
12.5 percent had reached “Stage 6”(HIMSS, 2014b, c).

In addition, despite strong evidence that EMR systems can and often do deliver the
claimed benefits, there is also plenty of data indicating that they do not always do so
(e.g. Black et al., 2011; Buntin et al., 2011; Jones et al., 2014). Even among adopters of
EMR systems, careful reviews of the evidence often show only limited solid research to
examine whether the claimed benefits have actually materialized, and results have been
mixed. For example: “our systematic review of systematic reviews on the impact of
eHealth has demonstrated that many of the clinical claims made about the most
commonly deployed eHealth technologies cannot be substantiated by the empirical
evidence” (Black et al., 2011). Similarly, a very recent review and meta-analysis shows
that “electronic interventions were not shown to have a substantial effect on mortality,
length of stay, or cost” (Thompson et al., 2015, abstract).
A recent review of the economics in applications to medication management also
demonstrates that there is not actually much careful research to solidly back up claims
of cost savings (O’Reilly et al., 2012). Among the relatively few studies that had been
done, results were mixed. In some cases, implementation did result in reduced costs,
sometimes costs did not change much, and occasionally costs increased. However,
most of these analyses focussed on operating costs, and did not include investment
costs to get systems up and running. “These potential cost savings are speculative and
are not conclusive” (O’Reilly et al., 2012, p. 437). In primary care, a recent review of
evidence in published studies suggests that EMR has contributed only marginally to
improved health outcomes, and sometimes caused slight declines in productivity,
although most studies showed that processes worked better. The researchers did feel
that there are hints at improved performance over the longer term, after initial learning
(Holroyd-Leduc et al., 2011).
This potential for improvement over the “longer-term” does offer grounds for
optimism that remaining problems can be handled. Other evidence also suggests that
part of the problem is not any inherent inability of EMR systems to deliver the benefits.
Rather, some of the difficulties in effective implementation are probably related to
learning how to implement EMR systems more carefully. “The quality of the
implementation process is as important as the quality of the system being
implemented” (Ludwick and Doucette, 2009, p. 29).
For example, while there is not yet very strong evidence that the computerized
decision support systems (CDSS) aspects of EMR systems generally improve outcomes,
there does seem to be a divergence depending on application. Use for diagnostics
generally has not proven effective, but use for routine tasks involved in preventive care
JHOM and basic prescription does seem to be effective ( Jaspers et al., 2011). More
30,6 sophisticated applications take much longer to develop to their full capabilities, and,
until the systems are perfected, they are often more cumbersome to use if one wants the
level of detail necessary for good decisions to improve patient care.
Because implementation has not always been quite what it should be,
many obstacles still exist to widespread adoption of computer technology by
990 all relevant personnel in the health care industry. Not the least of the problems
is getting people to use them. “EMRs are not always perceived as advantageous
from the standpoint of individual clinicians” (Ohno-Machado, 2011). For example,
preventive care and drug-prescription CDSS can be used with few additional
data requirements beyond what is already needed in processing patient visits
or ordering. This causes little extra work or interruption of normal workflow.
However, for diagnostics, using the CDSS often requires more time and effort
( Jaspers et al., 2011). This is a steep price for busy physicians to pay, given that at
the current stage of CDSS development, “clinicians, based on their clinical experience,
are better able to rule out alternative diagnoses than diagnostic CDSS” ( Jaspers et al.,
2011, p. 332).
Many observers think getting usage of the EMR systems is one of the key issues,
often more important than specific technical details of the IT itself. A survey of 302 IT
professionals in the US health care industry showed that more than one-third said the
top priority was achieving “meaningful use” of their EHR systems (Healthcare
Information and Management Systems Society (HIMSS), 2012). (“Meaningful use” is a
technical term used in the American Recovery and Reinvestment Act, which mandates
progressively greater use of Health IT, and defines a number of specific functions and
targets for usage of those functions (Blumenthal and Tavenner, 2010; HealthIT.gov,
2014). This does represent progress compared to the survey results in the previous
year, when half said achieving meaningful use was a top priority (HIMSS, 2012).
This discussion suggests that it is necessary to have a good understanding of user
thinking about the key factors needed to make EMR systems work. Even good
technology will fail if the intended users do not use it. Discussing their review, Buntin
et al. (2011) say that:
In fact, the stronger finding may be that the “human element” is critical to health IT
implementation. The association between the assessment of provider satisfaction and
negative findings is a strong one. This highlights the importance of strong leadership and
staff “buy-in” if systems are to successfully manage and see benefit from health information
technology (Buntin et al., 2011, p. 470).
Current discussion has called for more focus on how to make implementation
work better, rather than simply showing that well implemented EMR does provide
benefits. “With the increasing adoption of EHRs and other forms of health IT, it is no
longer sufficient to ask whether health IT creates value; going forward, the most
useful studies will help us understand how to realize value from health IT” ( Jones
et al., 2014, p. 52).
This is particularly important in developing countries, which mostly still need to
catch up to the developed world in terms of availability and quality of health care.
We examine this in Thailand and note that:
[…] the current body of literature comes from developed nations. As access to technology
expands, and the associated costs decline, the potential role and impact of the EMR/EHR
within developing countries need to be explored” (Holroyd-Leduc et al., 2011, p. 736).
It is hard enough to fully implement systems and get users to adopt them where there Electronic
is, relatively, an abundance of resources. The difficulties noted above in getting medical record
effective EMR adoption are compounded in developing countries.
adoption
EMR in Thailand
Thailand can represent conditions in middle-income developing countries fairly well;
the World Bank classifies it as an “upper middle income” country (World Bank, 2014). 991
Within this category of developing countries, Thailand compares similarly to how the
USA compares to developed countries. Thailand ranks 32nd overall in global
competitiveness, above most middle-income countries. However, it ranks somewhat
lower on infrastructure (44th) than many countries at similar development levels, and
much lower on health and primary education (67th) (World Economic Forum (WEF),
2015a). Thailand’s rank on “Impact of ICTs on access to basic services” (including
health) is 69th, behind many developing economies, including several in ASEAN

(World Economic Forum (WEF), 2015b). The USA is in a similar position relative to
other developed economies. It ranks 3rd overall in global competitiveness, but
somewhat lower on infrastructure (11th), and much lower on health and primary
education (46th) (WEF, 2015a). The USA ranks 30th on “Impact of ICTs on access to
basic services” (including health) (WEF, 2015b). Careful comparison of Thailand’s
profile on eHealth with other countries indicates that it seems to have made a serious
commitment to eHealth, but is still relatively early in implementing things (World
Health Organization, 2006, 2011).
Thailand has a system of both public and private health care provision. In recent
decades it has been national policy to gradually make public coverage more widely
available with relatively cheap patient costs. The tax-financed Civil Servant Medical
Benefit Scheme started in 1980 to cover active and retired government employees. The
Social Security Scheme started in 1990, covering private sector employees, with
financing by employee, employer, and government contributions. In 2001, government-
funded Universal Coverage was implemented, with nominal payments for many basic
services, provided they were delivered at designated public hospitals and community
health centers (Theera-Ampornpunt, 2011).
These conditions suggest that the benefits of Health IT systems would be useful in
Thailand, and indeed, Thailand is one of leaders among developing world countries at
implementing Health IT. Nevertheless, as noted in the introduction, adoption has been
scattered, with little coherent national policy or coordination (Theera-Ampornpunt,
2011; Kijsanayotin et al., 2010). Community health centers use IT to support basic care
and routine reporting, but management and administration use it less, and
communication and collaboration across organizations is weak (Kijsanayotin et al.,
2007, 2009).
Similarly, about three-fourth of hospitals in a recent nationwide survey (n ¼ 883)
reported high to very high utilization of IT. This may be an overestimate, because
response rate among the smaller hospitals was lower than among larger ones, but it
shows fairly extensive Health IT usage for a developing country. About 80 percent of the
responding hospitals have adopted some basic EMR for operations dealing with out-
patients, and many specific basic administrative functions show even higher rates.
However, only about half use EMR functions for inpatient work, which requires much
more data. Basic internal information sharing is moderately good, but there is not much
information sharing outside the hospital. Only about 5-10 percent of hospitals report
making use of a full range of comprehensive EMR functions (Theera-Ampornpunt, 2011).
JHOM Another survey of 728 health care professionals across Thailand in 2004 showed
30,6 that “integration and utilization of information” ranked as the second most cited major
obstacle to implementing quality management in Thai hospitals (out of 24 key issues
included on the questionnaire). Nearly 27 percent said it was a major obstacle, and 95.5
percent cited it as a problem to at least some degree. The very specific “medical
recording process” ranked eighth as a major obstacle, and was cited as a problem to
992 some degree by 88 percent. The same survey was given to surveyors, who conduct
external evaluations to assure that Thai hospitals meet Government accreditation
standards. They cited “integration and utilization of information” and “medical
recording process” as the first and third most critical major obstacles, respectively.
These two things were cited first and second most frequently as constituting at least
some degree of problem (Pongpirul et al., 2006).
At the level of individual health care organizations, health care personnel also face a
number of difficulties in being able to use systems even when they are implemented.
Workload is a key issue (e.g. Parket al., 2015). With a very heavy patient load, doctors in
particular find it difficult to devote time to learning new systems, or to taking on
additional reporting duties to feed data into the systems; this has also sometimes been a
problem even for nurses. In addition, organizational support in terms of such things as
adequate budget and project coordination are important, as well as some lack of depth
in IT knowledge for the systems (Theera-Ampornpunt, 2011; Kijsanayotin et al., 2007,
2009, 2010; Srakoopunet al., 2010). Such problems are not much different from those
noted above in research on developed country EMR implementation.
Method
A major survey was used to assess views broadly in Thailand’s health care industry
about critical success factors in EMR implementation. The questionnaire was adapted
for the situation in Thailand, based on the general literature and the literature
specifically about EMR in Thailand, as discussed above. A very small scale qualitative
pilot was conducted to confirm that the issues on the questionnaire reflected the things
health care personnel are actually currently concerned with. The sample returned 1,066
valid responses.
Developing the questionnaire for Thailand

A survey of current literature was used to identify key factors facilitating adoption.
There is little point in belaboring this, since there are already several recent reviews of
the literature (e.g. Ciemins et al., 2009; Kaplan and Harris-Salamone, 2009). We
specifically used the issues in Cresswell and Sheikh (2013), which is one of the most
recent reviews to broadly examine various factors. They note that there is no
overarching conceptual framework; and say that one of their key contributions is
summarizing and organizing the range of issues which the literature has looked at so
far. Cresswell and Sheikh (2013) categorized factors affecting adoption of health IT
innovations into three interrelated dimensions: adequate technology, stakeholder
involvement, and organizational leadership. Some of the factors are related to the
technology itself, rather than to what the organization does, so they were not included
in this study. Similarly, some were about social aspects of the technology use, and were
not included.
Here, we focussed specifically on managerial issues. However, the managerial issues
could include technology and social issues if management could make substantial
decisions about them. For example, Cresswell and Sheikh (2013) classify IT literacy and Electronic
competency as a social issue; as they do stakeholder involvement in implementation. medical record
We included those issues; clearly management has some direct control over these
things through hiring criteria and training policies, as well as over the degree of
adoption
consultation with staff during implementation.
Cresswell and Sheikh (2013) note that there is no “prescriptive” approach to
successful implementation; i.e., basically, context is critical. Applied to questionnaire 993
development, this implies that we needed to focus on the conceptual issues, not specific
questions developed in some other context. At any rate, as Cresswell and Sheikh (2013)
note, much of the evidence is anecdotal, i.e., case studies. There are few large-scale
surveys which cover the whole set of managerial issues discussed here.
The main issues in Cresswell and Sheikh (2013) which get fairly extensive
discussion (because the literature covers them to some extent) are:
• adequate finances, budgets;

• clear organizational goals, avoid “mission creep”;
• fit into and support organizational processes;
• fit into and support medical decisions;
• good communications about the project and among various stakeholders;
• involvement of key stakeholders throughout implementation;
• the system facilitates communication flows;
• the system fits user needs;
• basic computer skills are adequate, which may require training;
• training on the EMR systems; and
• strong vendor relations and vendor responsiveness.
Cresswell and Sheikh (2013) do not directly talk about the internal IT staff at the hospital,
but much of the discussion on the other factors imply strong internal IT support.
In Thailand, only a few studies look at these management issues, and usually from a
case study approach. Kijsanayotin et al. (2009) do report on a survey which included
questions that represent many of our concepts. They call these issues “facilitating
conditions:” for adoption of the HIT systems: necessary resources, compatibility with
current processes, systems fit needs, adequate documentation (i.e. communication
about the system), necessary knowledge and skills to use the system, and (explicitly),
adequate IT personnel available for assistance.
Initial in-depth interviews

For our project, a small qualitative pilot was carried out in a Thai 350-bed hospital that
has successfully been using an EMR system for almost a decade. This in-depth work
was done to make sure we understood the concepts related to these success factors in
the Thai context, i.e., it aimed to assure external validity of the measures on the
questionnaire. Even if some concepts are quite well developed in the western world,
there is no guarantee that they will fit other cultural contexts (Douglas and Nijssen,
2003), and specific measures need to represent the cultural context (e.g. Harzing et al.,
2013), as well as specific industry context. This focus on concepts first, and then
JHOM developing questions based on specific context, worked well in comparing satisfaction
30,6 with interpersonal service vs internet-based self-service in two very different financial
services contexts in Thailand, retail stockbrokerage and corporate banking (Srijumpa
et al., 2007). The same conceptual issues had to be measured for these two different
financial services, but the questions had to be relevant to the specific context.
The hospital was chosen because it was using commercial EMR with relatively
994 advanced functions in nearly all departments of the hospital. Theera-Ampornpunt
(2011) says that about 80 percent of Thai hospitals have adopted EMR to some degree,
but many do not have very full coverage of EMR functions. This particular hospital
would qualify as having nearly full implementation of the range of EMR functions, so
that we would not be exploring the concepts with users who had little actual experience
on some aspects of EMR.
In addition, access to this hospital through connections was assured. Access is often
critical for meaningful research in large organizations in any context (Eriksson and
Kovalainen, 2008, p. 52), and is invariably a key consideration for getting quality data
in Asia’s relationship-oriented cultures (e.g. Srijumpa et al., 2004). This connections
network is important for access to health professionals, to whom outsiders often
havelimited access (Liu and Ma, 2006).
The in-depth interviews were conducted with ten physicians scattered across a
range of departments in the hospital. The procedures generally followed
recommendations from a discussion that specifically addressed using in-depth
qualitative methods to assess concepts relating to customer acceptance of internet
technology in financial services in Thailand (Srijumpa et al., 2004). Interviews were
semi-structured, following a topics list of the success factors, but discussing them
only as respondents brought them up, without imposing the researchers’
conceptualization onto respondents. We used probing questions to get additional
depth when necessary for understanding any of the success factors (Eriksson and
Kovalainen, 2008, Chapter 7).
The list of factors from the literature did not change much, but was slightly refined
to reflect the Thai context, and condensed because the respondents did not see much
distinction between some sets of factors. For example, while Cresswell and Sheikh
(2013) do talk about both fitting organizational/administrative needs and processes,
and specifically fitting physicians’ needs, they do not distinguish these very strongly.
Our respondents felt that administrative processes and medical decisions were entirely
separate issues, and the EMR system needed to support both. On the other hand,
Cresswell and Sheikh (2013) talked about several aspects of “communication”
separately, but our respondents tended to consider various modes (such as
interpersonal, documentation, etc.) all as “communication.” The need for IT staff
support, implicit in Cresswell and Sheikh (2013), was explicit in our interviews.
Ultimately, we ended up with 12 key factors, noted in the bullet points above, and
the respondents tended to see only two key dimensions, one related to managerial
competence (roughly organizational vision and support), and one oriented toward
management of the technical side. Respondents in the large-scale survey were asked
whether they agreed that each of these 12 factors was important in implementing the
EMR system. A ten-point Likert scale from strongly agree (10) to strongly disagree (1)
was used. They are listed in Table I, according to whether the factors seemed to be
mainly more broadly managerial (q1-q6) or mainly about managing the IT support
competently (q7-q12). The tables show representative quotes from the small qualitative
pilot to illustrate the nature of thinking about the factors.
Managerial issues
Electronic
q1. The organization has adequate budget allocation medical record
Top management has to allocate a reasonable budget and view this implementation is for adoption
improving patient care. I think top management is the most (cost-) factor person on EMR
initiation
q2. The organization has clear EMR project goals and scope
Top management has to decide about health care IT, and plan for long-term operation, e.g., home 995
monitoring. The reference should have a common health IT system to enable the patient
information to be shared, and hospitals can generate some statistics by type of patients
q3. The EMR functions support administrative processes for patient management
The functionality of the decision support systems for general administrative processes such as
resource scheduling. Data from EMR should also be used for managing our hospital, forecasting
and planning for better patient services
q4. The EMR functions support medical decisions
I will use if it allows me to access patient data quickly and correctly, that data needs to be
integrated among departments. I think the awareness of how EMR supports with nurse’s routine
(is important), e.g., for medication administration
q5. The organization has effective EMR project communications
EMR data should be in the same data standard and can be used by hospital referrals as a
communication means. Some data in hospital still being mostly isolated, e.g., X-ray tests, cannot share
with other departments. If it is shared, it will reduce health care cost, human resources, and budget
q6. Development of the system has substantial clinical staff involvement
Development of a system like EMR is not a big deal, but it is needed in modern hospitals. But
changing new user’s attitudes who have never used any system is quite difficult. I think
(management has to consult doctors about) workload and time to pay attention to health IT, (which)
affects so much on using. EMR has to facilitate the changes from paper record to electronic
IT support issues
q7. The system has good electronic communications and connectivity
The system need to be stable, easy to use, and physicians can access it whenever they want. All
points of care should be included in EMR network, and make it accessible, and physicians can
track patient’s condition
q8. The EMR suits department user needs
Easy to modify some functions to fit with hospitals operation. This also serves us to collect a
variety of data types in the future. EMR should allow physicians to add patient details after
patient goes home, e.g., adding pictures of fracture area
q9. The organization has training to improve computer skills
Computer training to increase computer skills
q10. The organization has training in the EMR system
Staff should be eager to learn and improve their jobs using health IT
q11. The EMR vendors provide strong support
About EMR adoption, we want the vendor or IT department quickly response to our requirement,
fix problems quickly
q12. Knowledge and experience of internal IT staff is high Table I.
Modern hospital should have a chief information officer with clear role and responsibly and scope Representative
of work. They should have a good income and a considerable fringe benefit. Position of CIO quotes about the
should be filled by a clinician rather than a technology-based person measures
Other questions on the questionnaire addressed basic respondent demographics,

including their education, job category, and experience using health care IT.
Sampling
There is potential concern that observing or questioning of the physicians using the
EMR system while they are working might negatively affect patient confidentiality.
JHOM Thus, interviews did not ask about and did not have access to information about
30,6 patients, either in aggregate or at the individual patient level. The names of the doctors
interviewed are also kept confidential and no information is disclosed which could
possibly link to individual respondents or individual hospitals. The survey procedure
was discussed with the Thai Ministry of Public Health (MoPH).We received written
approval from MoPH to sample from MoPH hospitals, and this approval letter was
996 included with the cover letter and questionnaire.
The Thai MoPH classifies hospitals into three levels. In practice, they can be
distinguished by size, but key characteristics, such as the depth of specialist care
available, is closely correlated with this. Lists we used included 820 hospitals throughout
Thailand. At this stage, endorsement from MoPH was considered sufficient to overcome
lack of connections, and random sampling was used to choose approximately 20 percent
of the hospitals from the list, roughly in proportion to the number in the three levels. This
resulted in 169 hospitals that received questionnaires. In each hospital, 15 people received
questionnaires, the breakdown of which was (as much as it was possible to identify the
appropriate positions): one policy maker, two information systems managers, four
physicians, two dentists, two pharmacists, two professional nurses, and two technical
nurses. A total of 2,535 questionnaires were distributed:
• primary care hospitals (90-120 beds): 79 hospitals 1,185 questionnaires;
• secondary care hospitals (121-500 beds): 65 hospitals 975 questionnaires; and
• tertiary care hospitals ( W 500 beds): 25 hospitals 375 questionnaires.
A total of 1,066 usable questionnaires were returned, and the data were analyzed using
SPSS, using basic descriptive statistics, factor analysis, and regression. The overall
response rate of 42 percent. However, the response rate differed somewhat by
professional category, with higher return rates from professional nurses, followed by
pharmacists, and the lowest rates by information systems managers (Table II). Some of
these response rates would be somewhat higher, as professional category could not be
determined with certainty on about 14 percent of the questionnaires. A few respondents
did not answer this question (about 2.2 percent), but most of the inability to be sure about
professional category was because respondents answered more than one. Often, this was
either doctors or nurses who also held some administrative responsibilities.
About 56 percent of respondents were female, and 80 percent were more than
30 years old. As might be expected in this target population, 96 percent of respondents
had at least a bachelor degree; physicians, of course, also held a graduate medical
degree. In total, 95 percent reported experience in using computers, and nearly
Professional category Sent Returned Response rate
Policy maker 169 49 29.0

Info systems managers 338 39 11.5
Physicians 676 232 34.3
Dentists 338 135 39.9
Pharmacists 338 163 48.2
Table II. Professional nurses 338 193 57.1
Professional Technical nurses 338 100 29.6
category of Category cannot be determined 155
respondents Total questionnaires 2,535 1,066 42.1
90 percent had experience specifically on the medical IT system in their hospital. Electronic
We checked for differences on the 12 key factors by professional category, but found medical record
few significant differences; in particular, none of the factors showed any significant
difference by whether the respondent was a physician or a nurse. Thus, in further
adoption
analysis here, we discuss the factors using the whole sample, without breaking things
down by professional category.
997
Results
Our initial step in the analysis was an exploratory factor analysis, to examine whether
the health care personnel perceived an overriding dimensional structure in the set of
necessary factors for implementing EMR systems. Using the most common orthogonal
varimax rotation (Churchill and Iacobucci, 2005), we found two distinct factors that
accounted for 69 percent of variance (Table III). These two factors had nearly equal
weight in the factor solution, as indicated by the proportion of variance accounted for.
The third factor in the initial solution had an eigenvalue substantially below 1.0,
indicating that only two factors are required to capture the main dimensional structure
of the data. We call factor 1 “managerial expertise,” and factor 2 “technical expertise.”
All questionnaire items had communalities above 0.5, indicating that the majority of
variance in each of the 12 items was captured in these two factors. There was negligible
cross-loading on most items, although Q8 “EMR suits department user needs” loaded
only slightly more strongly on “technical expertise” than on “managerial expertise.”
This issue seems to be perceived as both a managerial and a technical issue. Similarly,
Q7 “good electronic communications & connectivity,” while stronger on the “technical
expertise” dimension, did seem to be perceived as also somewhat representing
“managerial expertise.”
Table IV shows the means of each of the 12 questionnaire items representing key
success factors, organized to indicate the two factors in Table III. It is clear that, in
general, respondents felt that managerial expertise was slightly more important than
technical expertise in implementing the EMR system. Respondents considered all of the
Question Fac1 Fac2 Communality
q1. Adequate budget allocation 0.771 0.644

q2. Clear EMR project goals and scope 0.839 0.747
q3. EMR functions support administrative processes 0.663 0.544
q4. EMR functions support medical decisions 0.783 0.690
q5. Effective EMR project communications 0.741 0.713
q6. Clinical staff Involvement 0.696 0.644
q7. Good electronic communications and connectivity 0.509 0.617 0.639
q8. EMR suits department user needs 0.543 0.592 0.646
q9. Training to improve computer skills 0.870 0.822
q10. Training in the EMR system 0.872 0.848
q11. EMR vendors 0.762 0.637
q12. Knowledge and experience of IT staff 0.787 0.751
Initial eigenvalue 7.101 1.224
Proportion of variance (after rotation) 35.652 33.720 Table III.
Cumulative variance 35.652 69.372 Factor results for the
Notes: Principal component analysis, varimax rotation with Kaiser normalization; factor loadings importance ratings
o0.50 are not reported on success factors
JHOM Dimension from factor analysis question n mean SD
30,6
Dimension 1 managerial expertise
q2 clear EMR project goals and scope 1,002 8.49 1.646
q1 adequate budget allocation 999 8.44 1.674
q6 clinical staff involvement 1,002 8.37 1.691
q5 effective EMR project communications 1,001 8.27 1.593
998 q4 EMR functions support medical decisions 996 7.87 1.677
q3 EMR functions support administrative processes 993 7.66 1.793
Dimension 2 technical expertise
q7 good electronic communications and connectivity 998 8.42 1.650
q12 knowledge and experience of IT staff 1,000 8.24 1.770
q8 EMR suits department user needs 996 8.15 1.713
q9 training to improve computer skills 1,000 7.91 1.831

Table IV. q10 training in the EMR system 1,001 7.84 1.843
Means of the 12 q11 EMR vendors 988 6.97 2.068
key factors for Valid n (listwise) 960
implementing EMR Notes: Scale: 10 ¼ strongly agree; 1 ¼ strongly disagree
questionnaire items important; all were rated, on average, well above the scale midpoint
of 5.5. However, generally they felt “clear EMR project goals and scope,” “adequate
budget allocation,” “good electric communications & connectivity,” and “clinical staff
involvement” rated highest. Most of these seem to be about managing the
implementation process, rather than about technical expertise.
It is interesting to note that Q11 “the EMR vendors provide strong support” rates
substantially (and significantly) lower in importance than any other questionnaire item.
This suggests a relatively weak relationship with suppliers, which has been noted in
other industries in Thailand (e.g. Suwannaporn and Speece, 2003; Kritchanchai and
Wasusri, 2007). In the US health care industry, poor communications between health IT
suppliers and health care providers is not uncommon, sometimes because health care
administrators often stand between the supplier and the health care professionals.
“A key challenge for the development and deployment of ePHRs is the highly
fragmented nature of the health care industry, which can disrupt information flows
across the many constituents that make up the patient-delivery-care process” (Lewis
et al., 2013, p. 578; ePHR ¼ electronic personal health record). In the initial qualitative
validity check discussed above, several comments suggested that some respondents in
the hospital were skeptical of vendor commitment.
Simple visual observation of the means in Table IV suggests that overall,
professionals in Thailand’s health care industry do not believe that the most critical
issues in EMR system implementation are technical. They do, of course, recognize that
technical expertise is important, but do not feel it is as important as managerial
expertise. The project must have clear goals and scope, an adequate budget, and have
user involvement. The technical item that ranked highest was actually about electronic
communication and connectivity, a technical aspect which facilitates the managerial
elements (and which had a cross-loading on the managerial factor). Table V simply
shows that there is a small but significant difference in the perceived importance of the
overall dimension.
Figure 1 graphically shows percentage divergence of the mean on each questionnaire
item from the overall grand mean across all the items. There is a clear tendency to perceive
most elements of managerial expertise as more important than elements of technical Electronic
expertise. However, the third managerial expertise element, “support administrative medical record
processes for patient management,” is notably below other managerial elements. This
likely reflects the nature of the sample which is mostly medical personnel in some
adoption
capacity. The literature shows that patient management is one of the more common
implementations in Thailand. However, it may simply be that this function generally
works moderately well, so respondents do not notice it very much. In addition, as noted, 999
vendor support scores very low comparatively. As noted, this probably reflects the
Dimension Mean Significance of difference

Table V.
Dimension 1 managerial expertise 8.18 0.000 Means of the two
Dimension 2 technical expertise 7.92 dimensions
7.50 technical
5.00
2.50
0.00
Mean
–2.50
–5.00
–7.50
managerial
–10.00
–12.50
pctQ1diff
pctQ2diff
pctQ3diff
pctQ4diff
pctQ5diff
pctQ6diff
pctQ7diff
pctQ8diff
pctQ9diff
pctQ10diff
pctQ11diff
pctQ12diff
Notes: “PctQ1diff”=percentage difference of q1 to the overall mean across all

questions. q1, the organization has adequate budget allocation; q2, the
organization has clear EMR project goals and scope; q3, the EMR functions
support administrative processes for patient management; q4, the EMR functions
support medical decisions; q5, the organization has effective EMR project
communications; q6, development of the system has substantial clinical staff
Involvement; q7, the system has good electronic communications and Figure 1.
connectivity; q8, the EMR suits department user needs; q9, the organization has Mean percentage
training to improve computer skills; q10, the organization has training in the difference from the
grand mean by
EMR system; q11, the EMR vendors provide strong support; q12, knowledge and importance item
experience of internal IT staff is high
JHOM generally poor supplier linkages across most industries in Thailand. If there were many
30,6 cases of strong vendor support, presumably it would be more apparent that it was
important. Finally, among IT elements, the knowledge and experience of internal IT staff
is considered comparatively important.
Discussion
1000 It is clear from these results that implementing an EMR system is not purely a technical
issue. Substantial attention must be given to managing the implementation of EMR
systems, and to managing the technical support. These are not two disjoint sets of
isolated actions, i.e., they cannot be approached “question by question” in terms of the
items on the questionnaire. Rather, these issues form coherent packages, as the strong
factor analysis results show. The set of 12 “success factor” items contains only two
underlying dimensions – in other words, these issues are strongly interrelated. Poor
performance on one is going to affect the other factors.

The EMR implementation must have coherent scope and well defined goals, and
must show clear clinical benefits. EMR users view these issues, and communication
about these issues, as important management responsibilities. Clear scope and goals
need to be understood and communicated throughout the project. That scope includes
the requirement that EMR supports administrative processes for patient management,
as applied to admissions, in-patients, out-patients, and workflows. However, clinical
professionals want EMR to go beyond simply serving administrative needs, to support
medical decisions. Usage of most advanced functions depends mainly on acceptance by
these health care personnel themselves.
Effective communication is essential – in both directions – to keep EMR
implementation on track. Basically, managers need to know what users think, and
users need to know exactly what the system can do, so that they can advise on whether
modifications might make it more effective and efficient. Physicians generally agree
that their involvement is required, but they are also usually very busy. Health care
managers must encourage clinical staff to join the implementation, contributing their
requirements for making EMR fit best into their work. Physician department managers
need to allocate time and resources to learn new technologies and implementation
methodologies from vendors. New physicians need to have some basic knowledge
about EMR before working it into their practices.
There must be sufficient budget allocation, not only for the initial set-up of the
system, but also for recurring costs after installation for maintenance and possibly
modification. Health care personnel should be involved in the project beyond initial
start-up, to keep it oriented toward the needs of health care personnel.
Technical support for users is about making sure that there is sufficient knowledge
and training available, but more than that, about making sure that plenty of personnel
are around to handle any problems and support needs. In a broad sense, “technical
support” includes orientation of the EMR effort toward user needs, including using it to
facilitate communication among relevant health care personnel.
Managerial implications
This research has been directed towards better understanding the concepts related to
success factors for EMR adoption in the Thai context. The research examined views
from a much broader population than only policy makers in health care facilities, but
focussed mainly on users (physicians and nurses) and IT developers to identify the
issues to be overcome for successful adoption of EMR systems. The research has
confirmed that health care professionals perceive some important issues with EMR Electronic
adoption. Key points from this research include. medical record
First, policy makers and stakeholders need to use information about users’ attitudes.
The EMR system cannot fully deliver benefits if many potential users fail to actually use
adoption
it. These research findings highlight users’ attitudes that HIT may well help improve
work conditions and patient care. But it is clear that this is not easy – a number of issues
must be addressed to implement EMR systems and make them responsive to user needs. 1001
Users conceptualize the issues broadly into two dimensions, relating to managerial
expertise in implementing the system, and IT expertise.User views here indicate that
managing the EMR implementation is an even more critical issue than the IT support.
This is consistent with some of the literature. Although management of implementation
is not a very common topic in discussions of health IT systems, some studies have
indicated the importance of some of the issues included here (e.g. Edwards, 2006;
Carayon et al., 2009; Kaplan and Harris-Salamone, 2009; Jaana et al., 2011; Cresswell and
Sheikh, 2013). This study is further evidence that careful management of the process
must be a high priority, and furthermore, that the range of management issues should
not be considered individually as isolated issues, but as an interconnected package.
Second, the key managerial issues seem to be about adaptation to the context of the
specific organization. General capabilities, especially supporting the administrative
process, and to some extent, supporting medical decisions, are not the most critical
parts of managing the system well. Presumably, these are perceived as rather generic.
Rather, the EMR implementation project must be carefully defined with clear goals and
scope and needs sufficient budgetary support. Clinical users must have substantial
involvement in defining system features and functions and communications must work
effectively. These things make sure that the system will fit user needs well.
Note that this implies two-way communications, both keeping everyone informed and
bringing in user views. The importance of user involvement has been an occasional
theme in studies for quite some time (e.g. Anderson, 1997; Edwards, 2006; Carayon et al.,
2009), as has the importance of good communications to achieve this (e.g. Kaplan and
Harris-Salamone, 2009; Cresswell and Sheikh, 2013). However, the fact that this issue
still needs to be pointed out in studies suggests that users are not always involved
in meaningful ways. In general, involving users in the development and implementation
of IT systems is just a specific case of customer involvement in the new product
development process. It has been demonstrated in many industries that such
involvement greatly improves success rates in new product/new service introduction
(e.g. in Thailand, Rajatanavin and Speece, 2006; Suwannaporn and Speece, 2010).
Third, among IT issues, the electronic communications are considered the most
important. The literature on IT implementations does not often examine the
communications infrastructure; however, the health IT manager should be aware of the
importance of the communications network. This, of course, supports the managerial
factors just discussed above. Knowledge and experience of internal IT staff is also
relatively important, again an issue related to the ability to adapt the EMR system to
the specific context of the organization. Jaana et al. (2011) noted that hospital IT
directors in Canada cited the importance of a skilled IT support staff; the research here
among (mostly) doctors and nurses confirms this. A few prior studies have also cited
the need for training in general computer skills and specifically on the EMR system
(e.g. Edwards, 2006; Kaplan and Harris-Salamone, 2009; Cresswell and Sheikh, 2013).
While respondents here do not discount these needs, these are not relatively among the
most critical issues.
JHOM Finally, and quite notably, vendor support was relatively by far the least important
30,6 individual element. Since vendors are the developers of the system, or represent the
developers, and have a big role in implementing EMR in the organization, this is
noteworthy and deserves additional research in the future. It could possibly suggest
that vendors are generally doing so well that users in Thailand do not bother worrying
about this issue as much. More likely, it reflects the somewhat poor linkage between
1002 suppliers and customers which is characteristic of other industries in Thailand
(e.g. Suwannaporn and Speece, 2003; Kritchanchai and Wasusri, 2007), and sometimes
characteristic in the EMR industry in the west (e.g. Lewis et al., 2013).
This would indicate a need for EMR vendors to learn to communicate more
effectively with the customers for their systems. This, of course, would include
recognition that the cooperation needs to be much broader than just the technical
aspects of the system. Claybaugh and Srite (2009) show that good communication on a
broad set of issues is important for customer perceptions of a good relationship with IT
vendors. This study further demonstrates that vendors need strong customer
relationships, beyond simply setting up the system.
Conclusion
Much research about implementation of EMR systems examines how characteristics of
users and their attitudes toward the system affect usage of such IT systems. This work
often uses some version of the Technology Acceptance Model (e.g. Edwards 2006;
Ketikidis et al., 2012; Kijsanayotin et al., 2009). Other work focusses on characteristics of
organizations or technology. In their extensive review of recent research, Cresswell and
Sheikh (2013) found that a range of technical, social, and organizational issues have
important impacts on successful implementation. Many of their issues are about the
nature of the context, such as government HIT policy, characteristics of the adopting
organization, or characteristics of available technology. Certainly managerial decisions
must account for such issues, so it is important to understand them, but they are not
themselves things which managers control.
Even when some managerial issues are included, few discussions carefully
distinguish the managerial issues from various characteristics of users or systems. For
example, some factors in Cresswell and Sheikh (2013) are clearly managerial, but they
are not specifically distinguished from other issues, and managerial issues are not
examined as a package. There is not very much focus specifically on how management
of the EMR implementation process influences adoption. This research shows that a
range of main users in Thai hospitals feel that management of the implementation
process is even more important than technical issues. Clearly, we need to know more
about this, and especially need to demonstrate that these sorts of management
expertise issues, along with technical expertise, do actually improve perceptions
toward using the EMR systems.
This research provides a good beginning at understanding the range of managerial
issues needed for successful adoption of EMR systems. One strength of the research is
that it covers a large random sample of health care workers, including mostly doctors
and nurses who would actually be using the system, i.e., the adopters. Support for the
research by the Thai MoPHensured that the response rate was fairly high, 42 percent.
The research process was careful to pull the main concepts (but not specific questions)
from the literature, and to confirm that the concepts are indeed relevant in Thailand. In
other words, the data used here to begin examining the issues seems to have fairly high
reliability and external validity.
On the other hand, adaptation of the questionnaire to context makes easy direct Electronic
comparison to other countries slightly problematic, although careful proceedure can medical record
reduce this difficulty. In addition, while Thailand is fairly representative of middle-
income developing countries, there is, of course, no guarantee that findings can be
adoption
generalized to other such countries. National policies differ, as do economic structures
of the health care industry. Thailand does show a standing among developing
countries which is similar to how the USA fits with developed countries – generally 1003
highly competitive within their groups overall, but lagging on implementation of HIT,
at least partly because of lack of coherent policy.
Perhaps a middle-income developing country with more coherent policy would show
somewhat different results. Better policy and more expereince in implementation might
lead to better management practice so that the issues here could be considered routine
rather than very important. Our focus has been on management issues at the
organizational level, but future research certainly must also examine macro-level
factors such as policy, as well as gain more depth into thinking of individual health
care personnel.
As Ketikidis et al. (2012) already noted, research is needed in a wide range of cultural
(and economic development) contexts to confirm generalizability. Some countries are
less advanced than Thailand, while some are advanced developed countries, and
success factors may shift. Notably, the role of budgets and infrastructure may shift in
more advanced economies, or may be even more prominent in countries that are
substantially less developed than Thailand. Less developed countries may lack the
technical expertise which is generally available to Thai public hospitals.
EMR systems, when used well to their full extent, can improve the safety and
effectiveness of the public health care delivery system. However, the rate of
successful implementation worldwide is not very high. This study on the key
success factors for EMR systems should benefit managers, administrators, other
stakeholders in public health care and vendors of health care IT. Managerial
actions do indeed play an important role in EMR implementation. It is hoped
that this study, and others like it, can help improve successful implementation
of EMR systems. The whole range of managerial issues should be further studied
to see how management of the implementation process can affect the uptake and
use of the EMR.
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About the authors

Kanida Narattharaksa is currently completing her PhD dissertation in the Business Informatics
PhD Program, Dhurakij Pundit University International College, Bangkok, Thailand. She was
formerly a health IT Project Director and Co-owner of a major Thai medical informatics vendor
which was sole Thailand distributor of EMR systems for a number of vendors worldwide.
She has implemented EMR systems in over 30 major public and private hospitals throughout
Thailand over the past decade. She sold her share in the company several years ago to pursue her
PhD studies full time. Kanida Narattharaksa is the corresponding author and can be contacted at:
nk1689@icloud.com
Mark Speece is Associate Professor of Marketing at the American University of Kuwait.
Earlier, he spent 16 years in Southeast Asia, much of it at the Asian Institute of Technology in
Bangkok, and he continues as an adjunct in PhD programs at the Dhurakij Pundit University
in Bangkok. His PhD in marketing is from the University of Washington. He also has a PhD in
Middle East economic geography from the University of Arizona. Much of his research is on
customer acceptance of internet technologies and services.
Charles Newton is emeritus Professor, School of Engineering and Information Technology,
University of New South Wales, Canberra. He was the Dean at the Dhurakij Pundit University
International College, Bangkok, for most of the past decade and is now Emeritus Dean and Senior
Advisor to DPUIC. His PhD is in nuclear physics from the Australian National University.
Much of his teaching and research has been in the field of operations research and decision
support systems.
Damrongsak Bulyalert is an Assistant Professor in the Department of Internal Medicine and
Assistant Dean of the Faculty of Medicine, Chiang Mai University. He also practices in Maharaj
Nakorn Chiang Mai Hospital at the Chiang Mai University. His PhD in Physiology is from the
Emory University, Atlanta, Georgia, and his MD is from the Chiang Mai University. He has a
long-standing interest in medical informatics, and has completed a number training programs in
medical informatics, TQM, and information security policy.
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Key success factors behind Electronic

that EHR is somewhat broader.

useful example for the developing world, especially middle-income developing

EMR benefits and EMR performance

12.5 percent had reached “Stage 6”(HIMSS, 2014b, c).

health) is 69th, behind many developing economies, including several in ASEAN

Developing the questionnaire for Thailand

• adequate finances, budgets;

Initial in-depth interviews

Other questions on the questionnaire addressed basic respondent demographics,

Professional category Sent Returned Response rate

Policy maker 169 49 29.0

Question Fac1 Fac2 Communality

q1. Adequate budget allocation 0.771 0.644

q9 training to improve computer skills 1,000 7.91 1.831

Dimension Mean Significance of difference

Dimension 2 technical expertise 7.92 dimensions

Notes: “PctQ1diff”=percentage difference of q1 to the overall mean across all

performance on one is going to affect the other factors.

records”, available at: www.himss.org/ASP/topics_ehr.asp(accessed February 2014).

About the authors

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