Accepted Manuscript Title: Organizational decision to adopt hospital information system: An empirical investigation in the case of Malaysian public hospitals Author: Hossein Ahmadi Mehrbakhsh Nilashi Othman Ibrahim PII: DOI: Reference:
S1386-5056(14)00249-4 http://dx.doi.org/doi:10.1016/j.ijmedinf.2014.12.004 IJB 3148
To appear in:
International Journal of Medical Informatics
Received date: Revised date: Accepted date:
1-10-2014 11-12-2014 26-12-2014
Please cite this article as: H. Ahmadi, M. Nilashi, O. Ibrahim, Organizational decision to adopt hospital information system: An empirical investigation in the case of Malaysian public hospitals, International Journal of Medical Informatics (2015), http://dx.doi.org/10.1016/j.ijmedinf.2014.12.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Highlights
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An integrated model is developed to facilitate the adoption decision of HIS. The integrated model is based on TOE framework and HOT-fit model. We test interdependencies among the dimensions and variables using ANP and DEMATEL. The results show that Environment and Technology are the most important factors. Hospital decision makers can refer to the study findings to make a better decision.
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Organizational decision to adopt hospital information system: An empirical investigation in the case of Malaysian public hospitals
Hossein Ahmadi a, Mehrbakhsh Nilashi a,*, Othman Ibrahim a a Faculty of Computing, Universiti Technologi Malaysia, Johor, Malaysia
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Corresponding author email address: [email protected]
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3 Organizational decision to adopt hospital information system: An empirical investigation in the case of Malaysian public hospitals Abstract. Objectives: This study mainly integrates the mature Technology-Organization-Environment (TOE) framework
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and recently developed Human-Organization-Technology (HOT) fit model to identify factors that affect the hospital decision in adopting of Hospital Information System (HIS).
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Methods: Accordingly, a hybrid Multi-Criteria Decision-Making (MCDM) model is used to address the dependence relationships of factors with the aid of Analytic Network Processes (ANP) and Decision Making Trial
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and Evaluation Laboratory (DEMATEL) approaches. The initial model of the study is designed by considering four main dimensions with thirteen variables as organizational innovation adoption factors with respect to HIS. By
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using DEMATEL, the interdependencies strength among the dimensions and variables are tested. The ANP method is then adopted in order to determine the relative importance of the adoption factors, and used to identify
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how these factors are weighted and prioritized by the public hospital professionals, who are wholly familiar with the HIS and have years of experience in decision making in hospitals’ Information System (IS) department. Results: The results of this study indicate that from the experts’ viewpoint "Perceived Technical Competence" is
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the most important factor in the Human dimension. In the Technology dimension, the experts agree that the
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"Relative Advantage" is more important in relation to the other factors. In the Organization dimension, “Hospital
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Size" is considered more important rather than others. And, in the Environment dimension, according to the experts judgment, "Government Policy " is the most important factor. The results of ANP survey from experts also reveale that the experts in the HIS field believed, these factors should not be overlooked by managers of hospitals and the adoption of HIS is more related to more considering of these factors. In addition, from the results, it is found that the experts are more concerned about Environment and Technology for the adoption HIS. Conclusions: The findings of this study make a novel contribution in the context of healthcare industry that is to improve the decision process of innovation in adoption stage and help to enhance more the diffusion of IS in the hospital setting, which by doing so, can provide plenty of profits to the patient community and the hospitals. Keywords. Public hospital, Hospital Information System, Adoption, Organizational decision, HumanTechnology-Organization-Environment, Multi-Criteria Decision Making
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4 hindrance to increasing organizational performance in
Physicians and patients today are encountering great
terms of providing fast and efficient health services
pressures from the healthcare setting. In the perspective
[17]. Nevertheless, these innovations have not escaped
of physicians, their irritation is originating from heavy
from various challenges and issues both from internal
patient’s loads, administrative tasks, and losing patient
and external factors [7,15,40].
care
are
In Malaysia, the healthcare system consists of both a
complaining that during the medical interaction, more
public and a private sector. Also the rural areas are
consideration should be provided on them [2,4].
mostly served by government health clinics and
Obviously, medical service all the days of a week are
hospitals [6,17]. The people are acquiring a broad
required to be given specially from the public hospitals,
range of healthcare services in a low price. But, for
effective
and
some reason such as, population structure, increased
individual electronic access to personal medical health
life expectancy, healthcare service expectation from the
appointment’s
While
scheduling
patients
system,
records [1]. Therefore, there are more demanding on
people and so forth, the status quo has been distorted [1]. Besides, there is an increasing rate of Malaysian
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electronic services from patients to be given by
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[1].
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control
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decision
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1. Background
healthcare expense, which has been occurring every
slowly in responding to these demands [3]. Even in
year [118,17]. Hence, to enhance the quality of
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hospitals. But, the healthcare community is moving
healthcare and decrease the cost, there is a big pressure
equipment of Computerized Physician Order Entry
on Malaysian government.
(CPOE) by 2009 [3].
To overcome these issues, there are several projects
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United States hospitals, only 17% percent have the
The proper and correct adoption of Information
that have been developed by the Malaysian government
Technology (IT) can significantly affect the quality and
with the aim of promoting and maintaining the
performance of the medical services provided by a
wellness of Malaysians and to provide more and easy
hospital [1,19,128,135]. Hospital Information System
access
(HIS) is a comprehensive, integrated Information
information systems [1,5,8,127]. Such projects include
System (IS) designed to manage the administrative,
the National Telehealth Policy (NTP) that comprises of
financial and clinical aspects of a hospital. HIS
four exciting initiatives for IS such as Telemedicine,
influences in decreasing medical errors, growing the
Mass Customised/Personalised Health Information and
efficiency, cost effectiveness, timely decision making,
Education (MCPHIE), Lifetime Health Plan (LHP),
and improves the quality of healthcare services
and Continuing Medical Education (CME) [8,9]. One
[5,11,33]. In addition, the main aim is to eliminate
of the areas that is focused for intensive development is
manual processes that are now seen as a major
telemedicine [1]. Telemedicine flagship has been
for
every
citizen
regarding
healthcare
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5 intended to provide the healthcare services to
organizations due to the lack of generic theory of
individuals [10]. Furthermore, HIS was introduced
technology innovation [14]. This is more emphasized
under
by Grover [98] on advocating the need to study more
LHP
project
to launch
the
process of
than one innovation characteristic which will lead to
Despite all of these, according to [1,5,12,13,127], only
increase the relative predictive power of characteristics
15.2% of the Malaysian public hospitals are referral
in evaluating the organizational adoption process.
hospitals equipped with either fully integrated or
Hence, the current study makes an effort to incorporate
partially integrated HIS since the Telehealth project
these statements as was suggested.
was launched more than a decade ago and almost 85%
Second, this paper presents study which evaluates the
of public hospitals are delaying in adopting the HIS
important level of interdependeny among critical
technology. Hence, this shows a very slow progress
factors for adoption decision of HIS. In addition, this
among Malaysian public hospitals on the trend of HIS
study proposes MCDM model, which consists of the
This paper describes an empirical study that we
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conducted investigating possible factors influencing
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organizational decision to adopt HIS in public hospitals of Malaysia. The questions that have been raised for
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this study are: (a) What are the current practices of IS in healthcare industry? (b) What are the significant factors that affect the decision to adopt HIS based on Technology
Organization
Environment
(HTOE) framework? (c) What theoretical model is suitable to be applied to facilitate the adoption of HIS? (d)
What
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(DEMATEL) and Analytic Network Processes (ANP)
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2. The problem statement and our contributions
And
an
Decision Making Trial and Evaluation Laboratory
innovation adoption.
Human
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digitalization of the healthcare sector [1,8,9].
Multi-Criteria
Decision-Making
(MCDM) model is suitable to weight and prioritize the
to evaluate and find the importance level of the determined factors for HIS adoption in Malaysia. In this regard, DEMATEL is applied to construct interrelations among adoption factors in the integrated model. By using this approach the interdependencies strength among the adoption factors are tested. The ANP method is then adopted in order to determine the relative importance of the adoption factors, and used to identify how the critical factors are weighted and prioritized by the public hospital professionals, who have plenty of experience and wholly familiar with HIS innovation in different areas of hospital.
factors for HIS adoption in a public hospital?
3. Literature review
The contributions of the study at hand are two-folded.
3.1. The current state of IS in healthcare
First, according to [14,95], there is a lack of theories being developed for a specific type of innovation and for a particular adoption context such as healthcare
Continuous efforts have been carried out in order to improve the current technological scenario in the healthcare industry [16]. Many countries produce
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6 public hospitals, general practices, clinical specialties,
which aimed at providing benefits to their citizens [17].
and allied health facilities, information is not integrated
E-health, Electronic Health Record (EHR), HIS and
and mostly stored on paper”. The lack of integrated
telemedicine are kinds of initiatives that will generally
information storage may cause big challenges in
bring about the usage of IS as a mean to give better
providing reports for the nation’s health surveillance
health services to the population and overcome
and policy and clinical operational decision making.
challenges that perceived as cumbersome by people
On the other hand, compared to other knowledge rich
searching medical treatment. The main purpose is to
industries such as the financial and telecommunication
eliminate manual processes, which are nowadays seen
industries, the use of IS in the healthcare sector is very
as a main obstacle towards providing fast efficient
slow [21]. In addition, the healthcare sector has been
services [18].
reported far behind in adopting of the IS [7,129,130].
There exists another challenge whilst having IS
Table 1 summarizes the initiatives taken by some of the
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countries throughout the world in developing and implementing efficient IS for the context of healthcare
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shared and distributed. The main problem in this
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implemented, in the way that information is stored,
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strategic IS plans for their large scale health systems
[17]. In spite of advancement of technology that are
where it still revolved around pen, paper and human
being implemented in the healthcare sector either in
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context lies with the way information is being handled
developed or developing countries throughout the
technological environment, the manual method may
world, there are still issues with their adoption and
not be suitable [19]. Moreover, according to Omachonu
diffusion.
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memory. Hence, in meeting the demands of the current
and Einspruch [20], “with large numbers of private and Table 1 Healthcare technology initiatives around the world. Continents
Countries
Technology Initiatives
Europe
United Kingdom
Sweden
Electronic patient booking systems, prescription messaging, Picture Archiving and Communication System (PACS), e-Referral systems, clinical repositories, test results storage and send capability [22] Hospital EHR, GP computing, development of integrated communication capacity with home based care and making treatment information available through a portal, national registries and databases, standards development for data interchange purposes [23] EHR [24]
Germany
Smart-card technology [24]
United States
EHR, telehealth, health information network, Personal Health Record (PHR) [145]
Canada
Diagnostic imaging, medication management, registries, laboratory and public health surveillance, telehealth [25] A good level of IS/IT penetration in clinical, administrative and logistics activity in seven main hospitals, OphthWeb, Teleophthalmology [26] HIS which covers all aspects of the hospital’s operation such as clinical, administrative and financial systems [17] Telemedicine, National Health Insurance Smart Card to update patient’s record [27]
Denmark
North America
Asia
Singapore Malaysia Taiwan
Australia
Japan
HIS, telemedicine, telehealth, Decision Support System (DSS) [28]
Australia
EHRs, E-Health initiatives [29]
New Zealand
E-Health, secure online transfer of health information and national register [18]
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7
public hospitals in which they require to serve the
systems which HIS is a good example that has been applied in hospital care environment [30]. HIS is imperative to the healthcare sector specifically in
public with high quality healthcare treatments. Table 2 describes some research findings pertaining to HIS
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There are a wide range of areas in health information
innovation adoption and also highlighting key issues, success stories and recommendations.
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3.2. Hospital Information System (HIS)
Table 2 Summary of reviewed studies of HIS innovation adoption. Findings
Clinical Information System (CIS)
Physicians do not really resist to technology change but the way the technology is implemented by the management is crucial.
[31]
Electronic Medical Record (EMR)
Challenges may include security and privacy issues, reliability of the documentation, legal and ethical issues, implementation issues; solutions include applying technological security and behavioural approaches.
[32]
Hospital Information System (HIS)
Further research required in measuring the performance of HIS specifically looking into the cost-effectiveness and cultural effect of its implementation to patients and hospital employees.
[33]
Drug prescription and distribution system
It functions as, decrease in medication exchanges due to usage of barcode and indicators of mismatch between medication picked and medication prescribed, storage and statistics of number of failures in filling orders. End users were also satisfied with the ongoing training policies.
[19]
Mobile Nursing Technology (MNT)
Adoption of MNT is highly associated with business competition, capability of external suppliers and organisation’s internal needs.
[34]
Clinical Decision Support System (CDSS)
It is recommended that to avoid the user resistence of the system, CDSS should be used incorporating workflows which are consistent with the physicians’ work processes.
[35]
Picture Archiving and Communication System (PACS)
The use of PACS is seen as a tool in gaining competitive advantage.
[15]
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The key factors in determining the successful adoption of RFID are: the presence of a champion, technology push and need pull. Surgeons welcomed the EPR system as long as it provides direct clinical benefits to their work and eased their work practices.
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Electronic Patient Record (EPR)
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Radio Frequency Identification (RFID)
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HIS Innovation
Author
[36] [37]
Computerized Physician Order Entry (CPOE)
Pathology laboratory had to go through various changes and adjustments in their work practices, responsibilities and procedures which causes frustration.
[38]
Electronic Medical Record (EMR)
In assimilating EMR technology, several factors are associated with the physician’s practices, overcome learning barriers, related knowledge and diversity.
[39]
Electronic Signature (e-signature)
These are some of the significant factors which contribute to the adoption of e-signature: hospital size, adequate resources, vendor support, and government policy.
[40]
Electronic Medical Record (EMR)
The EMR failed to be introduced at hospitals in Japan due to the initial exceeded costs.
[41]
Mobile Nursing Information System (MNIS)
There are some of the significant factors contribute to the adoption of MNIS: championship, business competition, and external supplier’s support.
[42]
Electronic Medical Record (EMR)
Several barriers exist during the initial decision to invest in an EMR system within family physician practices in Canada which include: behavioral, cognitive or knowledgebased, economic, and technological.
[143]
have focused on the individual level, by explaining
3.3. Organizational IT adoption theories have
what influences their behavioral intention to use a
extensively been studied with respect to the IT
particular technology. In this regard, Theory of
adoption. However, many of the IT adoption researches
Reasoned Action (TRA), Technology Acceptance
The
individual
and
organizational
level
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8 theory [48], institutional theory [49], Technology
and Unified Theory of Acceptance and Use of
Organization Environment (TOE) framework [43] and
Technology (UTAUT) are the most common theories
recently developed Human Organization Technology
that are used to predict and explain behaviour of
(HOT) fit model [44,72]. Table 3 presents these four
individuals toward adoption and use of technology
aforementioned theories to understand their concepts
across many areas.
and their contribution to predict the various technology
decision
in
adopting
of
specific
innovative
technologies. In this direction, the important theoretical
healthcare environment. It should be noted that in the
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identify what factors are crucial on organizational
adoption into diverse industries with respect to the
following table, asterisks denote the technology that
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For the latter, fewer studies have been conducted to
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Model (TAM), Theory of Planned Behaviour (TPB),
relates to the healthcare industry.
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perspectives include the Diffusion of Innovation (DOI)
Table 3 Studies related to organizational–level theories in various adoption domains
Institutional [49]
Dimensions -Innovation -Organization -Environment
Bussiness to Bussiness (B2B) market place adoption Enterprise Resource Plannig (ERP) system adoption and implementation Wireless application protocol adoption Internet as a teaching tool Mobile internet adoption EDI adoption E-business adoption E-business adoption E-business adoption
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DOI [48]
Domain
Electronic Data Interchange (EDI) adoption Inter and Intra organizational system
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Context Institutional pressures -Coercive -Normative -Mimetic
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Theory/Model/Author
TOE [43]
HOT-fit [44,72]
Dimensions -Technology -Organization -Environment
Dimensions -Human -Organization -Technology
Internet adoption in procurement
Reference [57] [50,51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61]
RFID adoption* PACS adoption* E-Signature adoption* MNIS adoption* EMR adoption*
[36] [15] [40] [42] [63]
Cloud computing adoption*
[79]
Medical records system* E-health*
[45] [64]
Although, DOI focuses on innovation, organizational, and environmental characteristics, and the institutional theory concentrates on the environmental pressures, the TOE framework is perceived as a more comprehensive lens in the context of IS innovation adoption at the firm level by covering all of these characteristics as well [58,98]. In the other words, the TOE framework offers
a combination of the influential factors compared to the DOI and institutional theory, that can effectively lead to IT adoption decision making [65]. Also, it is worth of mentioning that researchers have disputed, it is not possible to have a single theory that applies to all types of innovations due to different innovation types. Hence, an integrated approach of theories are needed
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9 as a lens to be applied in determining the adoption
framework applied and tested in both developed as
process of specific type of innovation [66].
well as developing countries [58, 59,60,124]. From the TOE perspective, the process by which a firm
3.3.1. Technology-Organization-Environment (TOE) framework
adopts and implements technological innovations is influenced
by
the
technological
context,
the
organizational context, and the environmental context
facilitators that influence the adoption stage should be
[43]. The framework provides detailed that firm should
considered. Tornatzky and Fleischer [43] introduced
consider when studying components that influence
the TOE framework in 1990. It is the organizational
organizational adoption of technological innovations.
level theory that predicts the technology adoption
The original TOE framework is shown in Fig. 1.
decision, explained by three different contexts. They
The technology context comprises of the internal and
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external technologies pertaining to the firm involves
technological
context,
the
organizational context, and the environmental context.
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and includes both equipment and process [46]. The organizational context involves the characteristics and
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TOE framework is a generic theory that in previous
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described
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In the discussion of technology innovation, the
resources of the firms such as firm size, managerial
and ability of explanation and prediction over variety
structure, human resources, the amount of slack
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studies have been demonstrated its broad applicability
resources and linkages among employees [17]. The
national/cultural contexts. In a host of industries, TOE
environmental context includes the structure of the
has been focused to explain the innovation adoption.
industry, the firm's competitors, the macroeconomic
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of contexts including technological, industrial, and
This includes financial services [60], manufacturing
concept and the regulatory environment [43].
[61], healthcare [41] and so forth. In addition, the TOE
Technology
Organization
Adoption Decision of Technological Innovation
External Task Environment Fig. 1. The original TOE framework [43].
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10 These elements have been found out as both limitations
point to the lack of fit between the context of
and the likelihood for technological adoption. Hence,
technology,
these are incorporated as a strategy of organization to
Recently, [44,72] conducted a rigorous evaluation of
understand the requirement of, and ways to adopt an
health information system to identify the important
innovation [43].
dimensions which can intensively affect the system
and
organization
[45,69,71].
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human
adoption. Their assessment was performed based 3.3.2. Human-Organization-Technology (HOT) fit
findings of the extant health information system and IS
model
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evaluation studies to finally develop a new framework incorporating the human, organization and technology
Health Information Technology (HIT) adoption that
dimensions (see Fig. 2).
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There are numbers of studies about the evaluation of
Human
Organization
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Adoption of Innovation
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Fig. 2. HOT fit model [44,72].
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Technology
This proposed framework associated with a set of
organizational context, each of the dimenstions and
comprehensive dimensions and measurement of the
appropriate
health information system. They suggest that the more
organization
fit between technology, human, and organization, the
evaluated. In this table, factors that have strong effect
more potential of the health information system can be
on HIS innovation adoption is presented, in which
realized [44,72].
asterisks indicate the most influential factors, plain text
variables, and
including
environment
the
technology,
empirically
was
indicates a factor for which partial support was found, 3.3.3. Justification of the selected TOE framework After investigating and reviewing the significant
and italics mention the factors that were not statistically important.
studies of HIS innovation adoption based on TOE framework, Table 4 was tabulated. In these studies, based
on
circumstances
and
various
needs of
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Table 4 Summary of prior studies in the context of HIS innovation adoption based on TOE framework. Technological context factors
Organizational context factors
Environmental context Reference factors Government involvement* [67] Vendor partnership* Business competition pressure Country wealth
Vital signs monitoring system
Technology readiness/receptivity Relative advantage* Complexity* Compatibility*
Hospital type Hospital ownership Hospital size Internal needs* Resource availability* Technological knowledge* Knowledge management capabilities Project team capability* Top management support*
MNIS
Mobile devices suitability Wireless communication suitability The extent of integration with HIS Cost benefit
Project team’s capability Business competition* [42] Top management support Government policy support User involvement and cooperation External supplier’s support* Championship Internal needs*
Health Level 7 (HL7)
Security System integrity*
Staff’s technological capability* Hospital’s scale* Top Management Attitude toward HL7*
Push of the environment Environmental pressure* Pull of the environment
[73]
E-signature
Security protection System complexity
User involvement Adequate resources* Hospital size* Internet need
Vendor support* Government policy*
[40]
PACS
Cost of PACS Compatibility Benefits of PACS*
Centralization Formalization High-level manager support*
Business competition Governmental policies*
[15]
RFID
Perceived benefits* Vendor pressure
Presence of champions*
Performance gap* Market uncertainty*
[36]
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Innovation
investment. In other words, human and organizational
that used TOE framework in the case of hospital setting
aspects are essential as much as technical issues in
related to the specific components of HIS technology
connection to the system effectiveness [74]. Besides,
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Table 4 attempts to show the significant prior studies
with focusing on adoption stage. These factors play an
there are several studies in the domain of medical
important role in facilitating or inhibiting the decision
informatics that pointed out into the concept of ‘fit’ in
to adopt an innovation in organizations. However, it
explaining the interdependent relationship between
was found that dimensions are differently measured in
human, organization and technology [70,75,76]. Most
accordance
of the existing evaluation studies of health information
with
various
needs,
and
specific
components of HIS innovation in each of these studies.
system focused on the technical issues, which do lack of explaining in why HIS works well or poorly with a
3.3.4. Justification of the selected HOT-fit model specific user in a specific setting [77,78]. Hence, Yusof According to Yusof and his colleagues [44,72], being
and his colleagues [44,72] provided a comprehensive,
parallel within organization, technology and human is
specific evaluation view integrating the dimensions
the crucial ideology in starting to the IT diffusion as it
into the developed HOT-fit model, which posited in the
accounts important strategies influencing the IT
health information system.
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12 the healthcare industry. The study at hand, develops the
colleagues [44,72], HOT-fit model would be applied in
mature HTOE framework in IS discipline for adopting
a flexible way, taking into account different contexts
an innovation technology in healthcare environment
and purposes, stakeholders’ point of views, wide
and determines the possible influential factors that
phases in
and
importantly affect the adoption decision. Table 5 shows
evaluation methods. According to Lian et al. [79], the
previous studies that identified the four contexts and
HOT-fit model is intensively concentrated on the
their measurement based on the HTOE framework that
adoption of innovation towards healthcare information
statistically influenced the adoption decision of the
systems.
technological innovations with regard to the HIS and
life
cycle,
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development
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system
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Following the work conducted by Yusof and his
healthcare industry. 3.3.5. Factors influencing IT adoption based on HTOE
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framework Healthcare is a large and growing industry that is
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experiencing major transformation in its IT base [80].
The IT change has been more rapid outside than within
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Table 5 Proposed factors influencing the decision to adopt IT innovation based HTOE contexts.
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Dimensions/Factors 1
2
√
3
4
5
6
√
Technology Organization
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Human
Champion innovativeness Perceived technical competence
√
Relative advantage
√
√
Compatibility
√
√
√
Complexity
√
√
√
√
Centralization
√
√
7
Reference 8
9
√
Infrastructure
Environment
Top management support Business competition Vendor support
√
Government Policy
√
√ √ √
18 19
√
√ √
√
√
√
√ √
√ √
√
17
√
√
√
16
√
√
√
15
√
√
√
11 12 13 14
√
Formalization Size
10
√
√
√
√
√
√ √
√
√
√
√ √
√
√
√
√
√
√
√ √
√
Table 6 shows innovations in terms of different types
the particular applicability of TOE framework and
that is the continuity of Table 5. They altogether show
HOT-fit model in determining the adoption decision of
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13 technological innovations in various industries with
respect to the healthcare industry and HIS innovation.
Table 6 Types of innovation. [86]
Innovation
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Author
1
IS
2
[96]
3
[98]
ICT
4
[57]
EDI
5
[79]
Cloud computing
6
[73]
HL7
7
[62]
CRM system
8
[13]
HIS
9
[40]
E-signature
10
[47]
Interorganizational system
11
[109]
12
[60]
13
[15]
14
[34]
15
[42]
16
[36]
17
[63]
18
[62]
19
[82]
Customer-based Interorganizational Systems (CIOS)
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Reference number
EMR
E-business PACS
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Mobile nursing Mobile nursing RFID EMR
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E-learning RFID
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*Note: The innovation studied in bold are related to healthcare context.
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4. Development of the conceptual model (HTOE)
Healthcare is a large and growing industry that is experiencing major transformation in its IT base [80], where IS confronted similar technology adoption in other industries and developed various theories and methods. After carefully reviewing the literature, the study found that TOE framework developed by [43], and HOT-fit model developed by [44,72], are suitable frameworks for the study at hand, incorporating factors that affect the process of adoption decision of HIS innovation. The TOE framework is an organization-level theory that explains three different aspects of a firm’s context
including technological context, organizational context and environmental context which can affect the adoption decisions of an innovation. Additionally, Tornatzky and Fleischer [43] affirmed that technology adoption is taken place through a variety of factors pertaining to those contexts. In this regard, Yusof and his colleagues [44,72], conducted appraisal research to investigate the system adoption in the healthcare industry.
They
found
that
the
alignment
of
organization, technology and human is an important starting point in IT adoption as it is one of the strategies that affects IT investment. Hence, the significance of human capital identified in the
Page 13 of 47
14 organization, and therefore, it plays a critical role in the
attempts to provide an informative guidance model
adoption of HIS.
with
Some studies conducted in the healthcare industry
practitioners in improving and promoting a better
specifically within hospital setting that found the
decision in adopting of HIS technology in the
suitability of applying the TOE framework in
Malaysian
understanding of the technology innovation in the
developed HIS adoption decision model, including
adoption phase [15,36,40,42,67,73,79]. Therefore, it
both dimensions and related latent variables has been
proves the suitability of applying TOE framework in
presented in Table 7.
to
[44,72]
integrated
human,
context.
The
hospital
whole
4.1. Human dimension
us
industry,
hospitals
and
cr
public
our study. In addition, with a focus directly on the healthcare
decision-makers
ip t
respect
Human capital is one of the most key assets in an
that evaluates the healthcare information system [79].
organization [83]. It is important that professionals
In
this
model,
three
significant
elements
are
adapt themselves to utilize the innovative technology. In organizations, there are members of the business that
M
concentrated which need to be applied when adopting
an
organization and technology is a dimensional model
have unique qualities in IT expertise that determine the
healthcare industry. Furthermore, health information
overall management style of the business and also
d
any technology innovations within the context of the
system evaluation is defined as the act of measuring or
expedite the adoption of IT [60,85].
te
exploring attributes of the system, thereby result which
Ac ce p
informs a decision to be made concerning the specific
4.1.1. Champion’s innovativeness
context [44,72,81].
Actions or behaviour by the members of the
Based on the above statements and aforementioned
organization can directly or indirectly influence
discussion, both TOE framework and HOT-fit model
organizational
are deemed suitable in the study at hand that is to apply
researchers
the integrated developed HTOE dimensional model to
characteristic in IT adoption in small businesses
understand the adoption decision of HIS [1,17,44,45,
[85,86]. Furthermore, some people in organization,
68,79]. Based on the literature review, theoretical
such as an entrepreneur figure for instance, Chief
background and previous empirical research findings,
Executive Officer (CEO) or Chief Information Officer
this study develops the conceptual research model (see
(CIO) possess a crucial role in determining the
Fig. 3). This model contains the factors pertaining to
innovative attitude of the organizations [84]. It can be
each contxts which is to realizing of the adoption
argued that in a public hospital context, the person who
process of HIS in the healthcare industry. This study
has more power is able to have control over the
effectiveness investigated
the
[79,144]. role
of
Several human
Page 14 of 47
15 diffusion of IS [17]. Hence, they are attributed as
attitude toward the adoption of that new IT application
champions in firms that play an important role in
[85,86].
adoption of an innovation. This has been caused
aforementioned viewpoint to the field of applying IT
controversy in which if champions certainly harmonize
and further extended it as the willingness to try new IT.
Agarwal
and
Prasad
[91]
apply
this
ip t
to an innovative technology, there will be a positive 4.1.2. Perceived technical competence
information intensity in the hospitals can be seen as the
hospital setting, the satff’s technological capabilities
IS capabilities. Therefore, if the IS staff have sufficient
should be considered as well [73,92]. Ettlie and Yap
knowledge and the adequate skills to adopt IT
[93,94] found that in order to utilize more innovative
innovation technology, hospitals will undoubtedly posit
IT, staff must hold some knowledge of IT innovation.
more confidence all over the process of adoption [79].
us
M
Human
an
According to [62,86], the IS knowledge of staff and the
cr
In the process of adopting an innovative IT in the
d
Champion’s Innovativeness
Ac ce p
te
Perceived Technical Competence
Technology Relative Advantage
Compatibility
Complexity
Organization Centralization
Formalization
Decision to Adopt HIS
Environment Business Competition
Size
Vendor Support
Infrastructure
Top Management Support
Government Policy
Fig. 3. Conceptual Research Model.
Page 15 of 47
16
Table 7 Explanation of variables. Dimensions/Variables
Description
Reference
It is described as the speed that champions adopt and accept new creativity, leads to drive innovation to other staff in a positive manner. The degree that staff must have some knowledge of IT innovation in order to use more innovative IT.
[91]
Relative advantage is the degree to which an innovation is perceived as better than its precursor. It is defined as the extent to which the innovation is consistent with the values, experiences, needs and existing practices of potential adopters. Complexity refers to the degree to which an innovation is perceived as difficult to use.
[48]
The extent of participation in decision making. The extent of rule observance and job codification. Large firms typically have the resources necessary to experiment, pilot, and decide what technology and standards they require. IS infrastructure refers to the existence of sophisticated telecommunication and database facilities within the firm. Top management support refers to whether or not the executives understand the nature and function of IT innovation and therefore fully support the development of it.
[66] [98] [82]
Competition intensity is defined as the degree that the organization is affected by competitiors in the market. The degree to which vendors provide services and it may range from product installation and training to a full-blown business intelligence consultancy engagement. It is defined as the degree to which government establishes policy for range of support and allocating various resources in adoption of HIS.
[59]
Human (D1) Champion’s innovativeness (V1)
[57]
ip t
Perceievd technical competence (V2) Technology (D2) Relative advantage (V3)
cr
Compatibility (V4) Complexity (V5) Organization (D3)
us
Centralization (V6) Formalization (V7) Hospital size (V8) IS infrastructure (V9)
an
Top management support (V10) Environment (D4) Business competition (V11)
M
Vendor support (V12)
d
Government policy (V13)
te
4.2. Technology dimension
[48] [86]
[98] [98,111]
[42,34] [42]
4.2.1. Relative advantage According to Rogers [48], relative advantage is the
external influences of adopting specific IT in the
degree to which an innovation is perceived as better
organization [79]. Following the study conducted by
than its precursor. Relative advantage refers to
Thong [86], the author investigated the influence of IS
carefully considering the adoption of HIS technology
characteristics on innovation adoption in the context of
whether diminish hospital operating costs and acquire
E-business. According to the innovation theory [90],
the relative operational benefits for a given hospital.
individual forms an attitude towards the innovation,
Study conducted by Premkumar [96] implied that
leading to a decision whether to adopt or reject the
relative advantages will influence business and force
innovation.
the
them to adopt new information technologies. Hence,
concerning
being optimistic about the advantages of IS would
characteristics of innovation, Tornatzky and Klein [95]
create as an incentive as a useful business strategy to
identified
adopt the innovation [86].
Ac ce p
The technology dimension entails the internal and
Based
technological
on
innovation
relative
a
meta-analysis literature
advantage,
of
compatibility
and
complexity possess innovation characteristics that are salient to the attitude formation [86].
4.2.2. Compatibility
Page 16 of 47
17 With the new technology available today, more
4.3. Organization dimension
complex systems can be designed. Powerful software tools and hardware at lower prices, reliable networking and standards add new prospects in this field [97].
In the IS literature regarding the adoption and diffusion of innovation, organizational factors have been found as the key determinants [4,98,101,125]. Grover [98]
PACS, Radiology Information System (RIS), Clinical
sub-systems of HIS that are incorporated into fully integrated systems [13,97]. If the sub-systems of HIS
ip t
Pharmacy Information System (PIS) are examples of
categorized organizational factors into centralization, formalization, size, infrastructure, and top management support.
Further,
cr
System (LIS), Nursing Information System (NIS) and
conducted a significant study in adoption of CIOS. He
Davidson
and
Chismar
[99]
concluded that organizational factors, including the
us
Information System (CIS), Laboratory Information
degree of centralization, degree of formalization, are more compatible with the existing systems and/or
hopeful and more feasible to adopt them. Hence, it
hospitals. Lin et al. [73] and Ross et al. [108], emphasized on the influence of top management
M
seems that compatibility is another crucial factor in the
integration and size influence the development of IS in
an
the applications of the hospital, then it will be more
support and infrastructure on the innovation adoption
context of technology.
process.
d
4.2.3. Complexity
te
Complexity of IS has been identified as the critical
[59,73,124,125]
came
to
the
similar
conclusion. 4.3.1. Centralization and formalization
Ac ce p
factors influencing organizations decision about the Centralization or the concentration of decision making
innovative technology adoption [40,73,98,86]. In the public hospitals, there are enormous numbers of patients from the various classes of society that getting medical treatments, dissimilar to private hospitals. Therefore,
this
causes
a
complex
system
activity, frequently has been referred to have a negative relationship on adoption of organizational innovation [98]. Decreased autonomy and a bounded perspective are often given as the reasons for the negative
and
complicated environment [13].
associations
with
this
variable.
Similarly,
formalization, or clear work and procedure definition
Complexity refers to the degree to which an innovation is perceived as difficult to use [86]. It is also suggested that the perceived complexity of an innovation leads to resistance due to lack of skills and knowledge [48].
have been found as a negative associations with initiation/adoption [66,98,100]. Rogers [48] found that over
centralization
and
formalization
inhibit
organizational innovation adoption. [66,101] came to Therefore, it is asserted that in the technical dimension, system complexity needs to be looked, cautiously.
the similar conclusion.
Page 17 of 47
18 infrastructure includes the tangible resource which
the director of general health from the federal
includes infrastructure components such as hardware
government to the state health institute directors. This
and software [107]. According to Ross et al., [108],
indicates that the federal government still provides a
with IS infrastructure the importance of a sharable
centralized control over health policy by using its
platform and technology is essential for integrating
constitutional powers to take over the health functions
systems in the organization in order to make IS
exercised by the states [102]. Hence, the regulatory
application more cost effective, especially in the area
changes and implementation has to be complied from
of operations and support [108]. Hence, increasing use
the healthcare organizations. Also, decisions have to be
of sophisticated IS infrastructure can lead to enormous
made formalizing the roles and responsibilities that
advantage within clinical workflow [109].
must be carried out by different people in various
Public hospitals in developing countries faced some
departments across the hospital pertaining to clinical IS
issues regarding infrastructure. According to Zhu et al.
an
us
cr
ip t
In Malaysia, there is an indirect monitoring between
[60], within the technological context, firm in
initiation, adoption and implementation [17].
countries
has
less
developed
IS
M
developing
4.3.2. Hospital size
infrastructure. In Pakistan, they face barrier of IT
d
The hospital size effect has been asserted in the prior
infrastructure which find difficulty in obtaining a suitable software and hardware [110]. Further, Ismail et
According to Chang [40], larger hospitals have more
al. [13] and Sulaiman & Wickramasinghe [5] surveyed
propensity to adopt e-signature more than smaller
some public hospitals through all Malaysia to identify
Ac ce p
te
studies of organizational innovation adoption [60,103].
hospitals do. They indicated that large hospital has
the critical issues and challenges in the implementation
more resources for changing business strategy. Hence,
of HIS. Most of the respondents referred to the
hospital size contributed a significant influence on
infrastructure issue in their hospitals. The results
decision to adopt innovative technology [40,86].
indicated that increasing the cost of software, external issues of course broadband and network, wireless and
4.3.3. IS infrastructure
also upgrading issue related to hardware are major
According to Grover [98], “IS infrastructure refers to the existence of sophisticated telecommunication and
hindrances in adopting of HIS [17]. 4.3.4. Top management support
database facilities within the firm”. The innovation literature strongly proposes that any technological
The importance of support from top management for a
innovation adoption should be based on a firm’s
proposed innovation is accepted as conventional
technological
wisdom [98]. In this regard, McGinnis and Ackelsberg
strength
[98,104,105,106].
IS
Page 18 of 47
19 world are undergoing healthcare reforms to promote
environment for innovation. Furthermore, the study of
better services and healthcare well-being [18,23,11].
Chang et al. [40] conducted in the context of healthcare
Hence, to cope with this unstable change of the
determined out, top manager’s support will affect new
healthcare environment and increasing competition
IS adoption in hospitals. Moreover, [112,86,144]
among hospitals, the managers are highly tending to
indicated that an organization’s decision to adopt
adopt IT as one of the most feasible strategies to
innovative technology is under the influence of the
enhance
characteristics of the top managers, organizational
advantage [34].
concerns and environmental conditions [86,112].
In the significant study of developing country in
and
competitive
cr
performance
us
hospital
ip t
[111] stated that top management provides a positive
Taiwan, [34,42] found that decision of MNT adoption
[87,88,89,113,114], clearly emphasized that lack of top
was significantly associated with business competition.
management support renders an innovation less likely
It is generally believed that competition increases the
addition,
empirical
work
performed
to be adopted. With regards to the healthcare context
likelihood of innovation adoption [117]. In this regard, according to Mohan and Razali [118], the focus of the
management support was found to be crucial for the
future healthcare system will be on people and
introduction
technology
services, where the use of technology will act as the
d
M
and investigating the adoption of new technology, top
an
by
In
key enabler to provide an accessible, integrated, high
a
new
[15,40,67,73,79,142].
Ac ce p
4.4. Environment dimension
or different
te
of
quality and affordable healthcare system that is recognised as one of the world’s best.
The environmental context includes the business
In Malaysia, the healthcare reform initiative known as
competition, vendor support and government policy
the Telemedicine Blueprint under the Multimedia
[43]. This dimension refers to the higher-level issues
Super Corridor (MSC) has been launched since 1997 to
that surround the hospital administration [17]. It
reform the Malaysian healthcare system [10]. The Total
represents the external factors of the healthcare
Hospital Information System (THIS) project was first
industry. This will no doubt impact hospitals as they
launched in Malaysia in late 1999 as a direct result of
adopt a new IS [34,40,42].
the Prime minister's vision for Malaysia becoming a developed country by the year 2020 [8]. It was the aim
4.4.1. Business competition Prior studies [115,116] show that the degree of business competition is directly associated with the adoption of new IT. Moreover, previous researches
of Malaysia to be the first in the world to have a single HIS which covers all aspects of hospital’s operation, both clinical and non-clinical. These competitive pressure seems to force hospitals to adopt new ISs
have highlighted that various countries around the
Page 19 of 47
20 quickly to provide better services and gain strategic
In Malaysia, HIS has been designed to provide
advantages.
numerous values to the healthcare community and indirectly provide benefits to the patients. Hospitals
4.4.2 Vendor support
implementing the HIS are having integration issues with multiple vendors implementing different versions
world of computing in the healthcare industry. It was in
of HIS in different hospitals, which also causes for
this era that the personal computers influenced
concern in lack of expertise [9,121,122]. Incompetency
distributed data processing as well as the expansion of
of vendors in doing maintenance and support cause the
CIS [119]. This advancement also allows health
technical problem in HIS systems. Moreover, Sulaiman
information system vendors to develop a range of
[17] surveyed potential adopters of HIS in public
administrative and clinical applications for various
hospitals and found that vendors have minimal
healthcare settings. This resulted in the purchasing of
experience in IS troubleshooting and virtually no
cr
us
clinical knowledge.
M
Based on these practices of purchasing the best from
an
individual applications for specific clinical usage [7].
ip t
The mid-1980s brought about immense changes to the
4.4.3 Government policy
the multiple vendors for individual departments,
d
challenges began to develop when hospitals tried to
Government policy is an imperative factor in the aspect
and
of environment. There are several studies conducted in
communication among these different systems [7]. The
hospitals setting with regard to developing country
1990s brought about an increasing number of
Taiwan which pointed out the significant influence of
data
to
allow
interoperability
Ac ce p
te
integrate
participants in the vendor community that developed
government policy on adoption decision of HIS
various clinical applications, which made healthcare
innovation. Chang et al. [15] conducted a study to
products more widely available and affordable.
investigate the enabler factors affecting adoption of
According to Castro [120], vendors have a tendency to
PACS as a new technology in hospital setting. They
invest in larger healthcare organizations due to issues
found that perceived government policy is an important
concerning recovery of costs. Vendor support has been
trend to adopt PACS. Additionally, there are other
identified statistically as a significant factor which
empirically-based
contributes to the adoption of IS innovation [17,19].
countries that found government policy influences the
According to Hsiao et al. [42], sufficient support from
decision
the vendors will facilitate the smooth and efficient
[40,42,79,123].
adoption of HIS in the Taiwan’s hospital setting.
The Malaysian healthcare system comprises of the
to
studies
adopt
HIS
related
in
a
to
developing
positive
manner
Ministry of Health (MOH) as the main healthcare
Page 20 of 47
21 study developed the conceptual research model (see
government
is
Fig. 3). Accordingly, in this section, we develop a
currently being used in selected hospitals and is heavily
hybrid MCDM model for the process of HIS adoption
criticised to be just a technology [17,121].
decision. The proposed MCDM model is comprised of
According to Abdullah [8], the implementation of
two main stages. An overview of the process of hybrid
Malaysian HIS in healthcare requires a realistic
proposed model using DEMATEL and ANP is shown
assessment, especially in producing very clear policy.
in Fig. 4. As can be seen in Fig. 4, in the first step, the
Also, Sulaiman [17] emphasized that in Malaysia in
DEMATEL method is used to uncover the relationship
order to have clinical and IS/IT skilled people, there is
among the dimensions (main factors) and variables
a need for training and exposure to both areas and for
(sub-factors) and to find interdependency and feedback
people to remain in the environment in order to
among them. It should be noted that uncovering the
increase
relationships using this approach is very important to
understanding
through
hands
on
experience. On the other hand, there is a lack of
find the weights of main factors and sub-factors appropriately.
M
financial support in the Malaysian healthcare system
cr
telemedicine
us
their
involving
an
initiative
ip t
provider with public hospitals [8]. In this regard,
Hence,
to
this
step,
DEMATEL
approach is more suitable to be applied in decision
[17], financial issues can be seen as one of the main
making as
d
with regard to public hospitals. According to Sulaiman
it is more suitable for real-world
applications compared to the traditional methods in
ways unsuccessful.
analysing the interdependency among the components
te
causes of why the adoption of HIS is slow and in many
of a network [128,130].
Ac ce p
5. A hybrid MCDM model for HIS adoption
As we discussed in the previous section, based on the existing literature review, theoretical background and previous noteworthy empirical research findings, this
Page 21 of 47
22 Start
Dimensions and Variables
ip t
Determine the Dimensions and Variables
cr
Technology
Environment
us
Organization
an
Human
M
Use DEMATEL to analyze the interdependent relationship among the dimensions and variables
d
Use ANP to calculate the weights of the dimensions and variables
Ac ce p
te
Determine the most important factors for HIS adoption
End
Fig. 4. Research flow for MCDM model.
and involve many stakeholders. The main purpose of
5.1. The DEMATEL approach
the DEMATEL method is to analyse different factors
The Decision Making Trial and Evaluation Laboratory (DEMATEL) method was developed in the beginning
affecting a system, and to use expert knowledge to better understand the correlation between these factors,
of the 1970’s at the Battelle Memorial Institute at the for example in terms of relationships and influence Geneva Research Center by Duval and Fontela [129]. It
between the different factors.
was initially created to study the world problem The preparation for the method is to collect the structure
(“world
problematique”)
by
analyzing
scientific, political and economic problems that are
different factors (also called variables in DEMATEL) affecting the system. This can be done using literature
influenced by a complex system of different factors
Page 22 of 47
23 This matrix A is also called the initial direct relation
scale has to be defined, which can be used to express
matrix. It shows the initial direct effects that a factor
the relationship or strength of influence between the
exerts on and receives from other factors. This direct
factors or variables [131]. A typical range for this
relation matrix can also be depicted in an influence
influence scale is 0-no influence; 1-low influence; 2-
map. The second step calculates the normalized direct
medium influence; 3- high influence and 4- very high
relation matrix D from the average matrix A. This is
influence.
done by dividing each element by the largest row sum
In the first step of DEMATEL a number of experts is
of the average matrix, as in the original DEMATEL
asked to indicate the level to which they believe that
method. Some recent applications of the method also
any of the factors influences each other, by applying
used the largest row or column sum as the standard for
the aforementioned influence scale. In mathematical
normalization, but this is not followed in the context of
and n factors that are being studied, we get from every
cr
us
n
this paper. The normalization factor max1 i n aij j 1
represents the total direct influence in our influence
M
expert a n×n answer matrix Xk = [ xijk ] with 1 k H .
an
notation this means if we have H experts in the study
ip t
research or expert opinion. In addition a measuring
scale of the factor with the most direct influence on
te
Ac ce p
x12 ... x1n 0 x2 n xn 2 0
d
other factors. This normalization step is the preparation
0 x X 21 xn1
So we have X1,X2 ... XH answer matrices for each of
for the following steps of DEMATEL where indirect influences are calculated, and provides an aligned scale for all factors for these calculations. So the scalar s is computed with n
the experts, and each element of Xk is an integer in the range of the influence scale, representing the degree of
s max1i n aij
(2)
j 1
and then is used to compute the normalized direct
ij
factor i influencing factor j, and denoted by x . The
relation matrix D with
main diagonal elements of each answer matrix are set to zero, because self-influence of the factors is not
D=
A s
(3)
evaluated in DEMATEL. To incorporate the opinions
Based on that in the next step the direct/indirect or total
of all experts, in the next step an average matrix A =
relation matrix is calculated. The experts have
[aij ] is constructed by calculating the average influence
estimated the direct effects only. It is assumed that the
quantification as follows:
indirect effects of the influence factors (factor a
aij
1 H
H
x k 1
k ij
(1)
influences factor b and factor b influences factor c, so factor a indirectly also influences factor c) is lower
Page 23 of 47
24 than the direct effects, so with increasing indirections
+ ci) shows the total effects given and received by
the indirect influence matrix converges to the null
factor i. Thus
matrix:
imi (ri ci ) ti j tki
lim D 0 k
(4)
k
n
n
j 1
k 1
(8)
represents the degree of importance of the factor i in the entire system. The difference
identity matrix the following holds true: k
1
(5)
k
n
n
j 1
k 1
ef i (ri ci ) tij tki
(9)
cr
1
lim (I + D + D ... D ) (I - D) , T D(1 I) 2
ip t
where 0 is the null matrix, and so with I being the
indicates the net effect that factor i contributes to the
sum of rows and the sum of columns in the total
system. Specifically if efi is positive, the influence
relation matrix T. Now if ri is the sum of the ith row in
factor i is a net cause, while if efi is negative, factor i is
the matrix T:
a net receiver.
(i 1, 2,..., n)
(6)
te
sum of the jth column in the matrix T:
d
factor i exerts on the other factors. Similarly if cj is the
cn with c j ti j where ( j 1, 2,..., n) i 1
Ac ce p
c1 ...
depicted in a directed graph to show the structural relationship between the different influence factors. For
it summarizes both the direct and indirect effects that
n
an
The results achieved by these calculations can be
M
r1 n with r ti j where i j 1 r n
us
Let r and c be n×1 and 1×n vectors representing the
(7)
it summarizes the direct and indirect effects that factor j receives from the other factors. When i = j, the sum (ri
doing that it is advisable to define a threshold value for the influence effects to filter out negligible effects. Only the effects greater than the given threshold value would be shown in the graph. It should be noted that for the evaluation from experts review, the rate of influence measured using the scale represented in Table 8.
Table 8 Influence scale. Value 0 1 2 3 4
Meaning No influence Low influence Medium influence High influence Very high influence
Page 24 of 47
25 It should be noted that for MCDM techniques such
5.2. Analytic Network Process (ANP)
as AHP, there is no general rule for selecting the Recently, MCDM methods have been an active research for solving real-world decision problems
number of respondents. AHP is not a statistically based methodology and a small sample size is
[133,134]. Analytic Network Process (ANP) is a
level. The ANP does not assume independence between elements of the model. Therefore, whilst the
Ar and Kurtaran [140], AHP is technically valid and does not require a large sample size. ANP as a
cr
unidirectional hierarchical relationship among decision
addition, according to Lam and Zhau [139] cited by
special case of AHP is not an exception. Hence, in
us
was developed by Saaty [132]. AHP maintains a
ip t
enough to implement a decision [138,141]. In special case of Analytical Hierarchy Process (AHP)
this study, a small size of 12 experts have been
AHP structures the problem as a hierarchy, the ANP
selected for data collection phase. where applicable sub-criteria) and alternatives are
Step 2: This step involves arranging the results of the
pairwise
M
nodes on the network. In this manner, the ANP allows
an
structures it as a network where the goal, criteria (and
comparisons
in
the
pairwise
comparison matrix ( ). This matrix is then
nodes to illustrate interdependence. The ANP builds
normalised
upon the pairwise comparisons of the AHP where
corresponding column sum to get the normalised
criteria are pairwise compared with respect to each
matrix. The rows of the normalised matrix are then
te
d
for feedback connections and loops within and between
by
dividing
each
entry
by
its
averaged to get the priority vector for each element
where alternatives are compared with respect to each
under consideration.
Ac ce p
alternative, and includes a further set of comparisons
criterion.
Step 3: This step is for the consistency test to
According to Saaty [132], the steps in the quantitative
certify that the original preference ratings made by
component of the ANP are:
the expert were consistent. The consistency ratio is
Step 1: Design a questionnaire for collecting
a measure of the consistency of the individual judgements.
responses from experts. The questionnaire used in this study involved pairwise comparisons of elements on a nine-point scale with nine points awarded if one element was extremely more important than the other and one point awarded if the two elements were equally important.
Step 4: In this step, forming the “unweighted Supermatrix” is included in the ANP model which contains local priorities derived from the pairwise comparisons throughout the model’s network and using this to construct the “weighted Supermatrix”.
Page 25 of 47
26 In the current study, the data collected from 12 experts
more than two clusters in a node of the network and
who are as decision makers that are wholly familiar
involves performing cluster comparisons to get the
with the HIS. Thus, as the objects of the questionnaires
cluster matrix. This cluster matrix is then multiplied
used in our study are the experts and not the users,
by the unweighted Supermatrix to give the weighted
therefore, the sample size of 12 experts would be
Supermatrix. The final priority weights are derived
sufficient for data collection purpose and the hybrid
by multiplying the super-matrix by itself until the
MCDM model implementation. In addition, many
columns stabilize with
researchers have applied MCDM techniques such as
cr
ip t
Step 5: This step is only required when there are
AHP and ANP combined with DEMATEL in their Empirical study
us
6.
researches and provided such small sample size for the hybrid MCDM model implementation [136,137]. Table
an
9 provides the sample characteristics of the type of
6.1 Data collection
te
Table 9 Sample characteristics.
d
M
respondents for this study.
Respondent characteristic 26-31 31-39 39-45 45-58 Gender Female Male Level of education Bachelor’s Master’s Higher Roles of respondents Chief Executive Officers Chief Information Officers IT directors Responding executives’ Above 26 years seniority in the healthcare 21-25 years industry 16-20 years 11-15 years 6-10 years Less than 5 years
Ac ce p
Age
Frequency 2 3 3 4 3 9 2 6 4 3 6 3 1 1 3 3 2 2
Percentage 16.% 25% 25% 33.3% 25% 75% 16.6% 50% 33.3% 25% 50% 25% 8.3% 8.3% 25% 25% 16.6% 16.6%
As can be seen in the Table 9, most of the experts have
positions in an IS department. The responses from the
experience more than ten years seniority in the
respective experts were collected via questionnaire
healthcare industry and furthermore, hold top-level
survey.
Page 26 of 47
27 of all the experts was calculated. To incorporate the
6.2 DEMATEL
indirect influences in the examination, the total relation In the first part of the survey, 12 experts in the context
matrix T is created as presented in Table 10. This is
of HIS were asked to indicate the level to which they
based on the normalized direct relation matrix and is
believe that any of the factors (dimensions and calculated according to Eq. (5). Based on this table, a
ip t
variables) influences each other, by applying the scales
graphical representation of these direct and indirect
between 0 and 4 (see Table 8). In an attempt to
influences is created. It should be noted that in this map
investigate the structural relations among the four
cr
only the most influential relations of the total relation
dimensions, DEMATEL is employed to measure the
matrix are depicted. This total influence map is shown
us
causal impact of each dimension in HIS. As these
in Fig. 5. Based on this total influence map we can see
experts were asked to indicate the degree of influence
that Environment has high influence on other factors, dimension, firstly the direct relation/influence matrix D
is very strongly influenced by factors Human and Environment.
M
was calculated. The individual expert’s opinions on the
especially Technology. Also, factor Technology itself
an
that they believe each dimension has on every other
influence factors were put into answer matrices, and
d
the initial direct relation matrix for the combined rating
te
Table 10 The total-relation matrix T for dimensions. Human
Technology
Organization
Human
1.271
2.073
1.559
1.741
Technology
1.164
1.597
1.262
1.537
Organization
1.052
1.653
1.145
1.364
Environment
1.409
2.141
1.639
1.652
Ac ce p
Dimensions
D1
Environment
D1: Human
D3
D2: Technology D3: Organization D4
D4: Environment
D2
Fig. 5. Total influence map. From Eqs. 6 and 7, with given dimensions and
in Table 11, with (ri-ci) indicating the net effect that
variables, the influences and received values can be
dimension i has on the system and (ri+ci) indicating the
calculated. For four dimensions these values are shown
effect that dimension i contributes to the system.
Page 27 of 47
28 r-c is positive, the variable is causal and if it is
in the system. In other words, the more the value of
negative, it is effect. In addition, row and column
r+c indicates the more interaction of the factor with
difference vector (r - c) represents the net impact
other factors of the system. Thus, Technology and
relationship of the total impact matrix. The row and
Environment factors have the major interaction with
column difference vector of Human (1.748) is greater
other factors. And the Organization has the lowest
than zero, suggesting that the impact of Human on
interaction with other variables. As can be seen in
other dimensions is greater than the impact of other
Table 11, the addition of the row and column vector of
dimensions
Environment (r + c = 13.135) is the highest, indicating
dispatcher. Furthermore, in this model, it can be said
that the mutual effects of Environment and other
that Human and Environment of the system are casual
dimensions are the greatest. Horizontal vector (r-c)
and Technology and Organization are effect.
Hence,
Human
cr
Human.
is
the
shows the power of effect of each factor. Generally, if
an
us
on
ip t
Vertical vector (r+c) is the effect of the required model
Table 11Total effects and net effects for each dimension. Dimensions Technology Human Environment Organization
r 5.559 6.644 6.841 5.214
M
Code D1 D2 D3 D4
d
Similar above procedure is applied for the variables in
te
each dimension. The results of applying DEMATEL
c 7.463 4.896 6.294 5.605
ri+ci 13.022 11.539 13.135 10.818
ri-ci -1.904 1.748 0.547 -0.391
"V2“ with the highest value of r-c (0.112) is prior to
others, and it is called the master dispatcher. The results indicated that this variable has a major influence
Again, combining two total impact factors given (ri)
on other variables in achieving a success in HIS
Ac ce p
for those variables are presented in Tables 12-15.
and received (ci) gives resulted in two additional
adoption. This means that the effects of the other
metrics. When adding the total effects given and
variables will achieve the goal through considering this
received by an influence factor, the degree of
factor. In addition, it can be seen that in the
importance of the different influence factors are
Technology, "V4" with the highest value of r-c (-
identified. By applying total relation matrix, the
1.878) is prior to others, and is called the master
ranking are established and represented (see Table 16),
dispatcher. The results indicated that this variable has a
which shows the overall importance factors in the
major influence on other variables in achieving a
system.
success in HIS adoption. This means that the effects of
According to DEMATEL analysis presented in Table
the other variable will achieve the goal through
16, the factors in the proposed analytical model were
considering these factor. For the Organization, "V7"
found which mostly influenced others or can be
and "V9" can be master dispatcher with r-c (0.825) and
influenced by others. It can be seen that in the Human,
Page 28 of 47
29 r-c (0.998), respectively. Also, in the Environment,
"V11" is master dispatcher.
Table 12 The total-relation matrix T for D1. V1 0.609
V2 0.935
V2
1.047
0.609
ip t
Variable V1
V3 0.15 0.25 0.09
V4 0.25 0.06 0.17
V6 0.908 1.033
V7 0.937 0.829
V8 1.034 0.977
V8
0.988
0.933
0.951
V9
1.169
1.022
1.028
V 10
0.692
0.621
0.756
Table 15 The total-relation matrix T for D4. V 11 5.362
V 12
5.171
V 13
5.198
V5 0.84 0.72 0.50
V9 1.002 1.043
V 10 1.297 1.286
1.007
1.094
1.202
1.497
0.667
0.927
V 12 6.294
V 13 7.106
5.741
6.659
5.969
6.431
d
Dimensions V 11
M
Dimensions V6 V7
an
Table 14 The total-relation matrix T for D3.
us
Variable V3 V4 V5
cr
Table 13 The total-relation matrix T for D2.
Variable
te
Table 16 Total effects and net effects for each variable. r
c
r+c
r-c
1.544
1.657
3.201
-0.112
1.657
1.544
3.201
0.112
0.701
2.886
3.587
-2.184
V 4 Compatibility
1
2.878
3.878
-1.878
V 5 Complexity V 6 Centralization V 7 Formalization
1.870 5.179 5.167
3.800 4.789 4.342
5.670 9.968 9.510
-1.930 0.390 0.825
V 8 Hospital size
4.972
4.747
9.719
0.225
V 9 IS infrastructure
5.918
4.920
10.838
0.998
V 10 Top management support
3.663
6.100
9.763
-2.438
V 11 Business competition
18.762
15.730
34.491
3.032
V 12 Vendor support
17.571
18.004
35.574
-0.433
V 13 Government policy
17.598
20.196
37.794
-2.599
V 1 Champion’s innovativeness
Ac ce p
V 2 Perceievd technical competence V 3 Relative advantage
6.3 ANP analysis
on the ANP model and relationship structure among
In this study, after discovering the interdependency
dimensions and variable, an ANP based survey with
among the dimensions and variables using DEMATEL,
pairwise questions was conducted and distributed to the
the ANP method was applied to obtain the final
12 experts who had experience with the HIS of
weights of four dimensions and their variables. Based
hospitals in Malaysia. From the 12 surveys conducted
Page 29 of 47
30 Saaty’s 9-point of scale the 9 point indicates extreme
rate as 100%).
importance and 1 as the equal importance of one
In addition, for the ANP model, the 12 respondents
component (dimension and variable) over another. The
which participated in the survey were asked to provide
ANP model as shown in Fig. 6 was solved using the
their answers based on a scale of 1-9 to the pairwise
Super Decisions software. After computing the results
questions, such as ‘For the ‘‘HIS adoption in the
of their assessments, the Consistency Ratio (CR)
Malaysian hospitals”, how much more important is
values are all acceptable and the eigenvectors displayed
‘‘Technology” to ‘‘Human”?’ It should be noted that in
are
cr
to enter into the Supermatrix.
te
d
M
an
us
appropriate
ip t
in this study, all of them were valid (effective response
Ac ce p
Fig. 6. ANP model of decision to adopt HIS.
For pairwise comparisons, in the first step, a pairwise
pairwise comparisons for the all variables in each
comparison matrix is prepared for dimensions (Human,
dimension according to the relationships among them
Technology, Environment, and Organization). Thus,
were performed. In this step, the decision maker is
according to the model and the relationships among
asked to respond to a series of pairwise comparisons
dimensions, different matrices of comparisions would
where two variable would be compared at a time with
be formed. Table 17 presents comparisions of the four
respect to an upper level control criterion. The pairwise
dimensions with respect to the overall goal and Table
comparisons of the elements at each level are
18 presents comparison of the four dimensions with
conducted with respect to their relative influence
respect to the Environment. In the second step,
towards their control criterion.
Table 17 Comparison of the four dimensions with respect to the overall goal. With Respect to the Goal
Environment
Human
Organization
Technology
Weights
Page 30 of 47
31 Environment 1.0 Human 0.25 Organization 0.33 Technology 0.5 CR = 0.0651 (desirable value to be less than 0.100)
1.0 0.25 2.0
1.0 5.0
0.45 0.17 0.07 0.29
1.0
Table 18 Comparison of the four dimensions with respect to the overall goal with respect to the Environment. Environment
Human
Organization
Environment 1.0 Human 0.3 1.0 Organization 0.2 0.33 Technology 0.5 2.0 CR = 0.0132 (desirable value to be less than 0.100)
Technology
Weights
1.0
0.46 0.16 0.06 0.29
cr
1.0 5.0
ip t
With Respect to the Goal
experts agree that the "Relative Advantage" is more
calculating the unweighted Supermatrix and weighted
important in relation to the other factors. In addition, in
Supermatrix, the limit Supermatrix
the
is presented in
variable in the dimensions, and these are the final
Organization
considered
dimension,
more
important
an
Table 19. This matrix presents the weight of each
us
According to the steps described in Section 5.2, after
"Hospital rather
Size"
than
is
others.
Furthermore, in the Environment dimension, according to the experts judgment, "Government Policy " is the
M
weight of variable in each dimension.
most important criterion. The results of ANP survey
we can see that the "Perceived Technical Competence",
from experts reveal that the experts in the HIS field
"Relative Advantage", " Hospital Size " and "
believed these factors should not be overlooked by
Government Policy" are the most important variables
managers of hospitals and the adoption of HIS is more
in
and
related to considering of these factors. In addition,
Environment with influence weights of 0.66, 0.57, 0.32
from the results it was found that the experts are more
and 0.51, respectively. The results thus indicate that
concerned about Environment and Technology, as the
from the experts viewpoint, "Perceived Technical
weight of these dimensions are substantially higher
Competence" is the most important factor in the
than those of other dimensions.
Human,
Organization,
Ac ce p
Technology,
te
d
From the results, according to the experts judgment,
Human dimension. In the Technology dimension, the
Table 19 The limit Supermatrix.
Supermatrix Human
Technology Organization
Human
Technology
Organization
Environment
V1
V2
V3
V4
V5
V6
V7
V8
V9
V 10
V 11
V 12
V 13
V1
0.34
0.34
0
0
0
0
0
0
0
0
0
0
0
V2
0.66
0.66
0
0
0
0
0
0
0
0
0
0
0
V3
0
0
0.57
0.57
0.57
0
0
0
0
0
0
0
0
V4
0
0
0.17
0.17
0.17
0
0
0
0
0
0
0
0
V5
0
0
0.26
0.26
0.26
0
0
0
0
0
0
0
0
V6
0
0
0
0
0
0.24
0.24
0.24
0.24
0.24
0
0
0
V7
0
0
0
0
0
0.11
0.11
0.11
0.11
0.11
0
0
0
V8
0
0
0
0
0
0.32
0.32
0.32
0.32
0.32
0
0
0
Page 31 of 47
32
Environment
V9
0
0
0
0
0
0.07
0.07
0.07
0.07
0.07
0
0
0
V 10
0
0
0
0
0
0.26
0.26
0.26
0.26
0.26
0
0
0
V11
0
0
0
0
0
0
0
0
0
0
0.23
0.23
0.23
V 12
0
0
0
0
0
0
0
0
0
0
0.26
0.26
0.26
V 13
0
0
0
0
0
0
0
0
0
0
0.51
0.51
0.51
Policy” is indicated as a crucial variable that promotes
By developing the conceptual research model and
training and persuading the employees to increase their
analysing the MCDM model using the two evaluation
knowledge in using the HIS. In the perspective of
methods of ANP and DEMATEL and based our data
Malaysian context, adoption of HIS in the healthcare
from 12 experts in the context of healthcare, some
requires a realistic assessment, especially in producing
findings from previous IS studies in determining the
very
important factors influencing the decision to adopt the
implementation program. In addition, an appropriate IT
organizational
governance structure is needed in public healthcare
confirmed.
First,
according to results gained from DEMATEL and ANP,
cr an
efficient
adoption
and
facilities to better organize the acquisition and deployment. Furthermore, government’s health policy
M
Environment and Technology are the most imperative
policy,
us
was
clear
an
innovation
ip t
7. Discussion
has been recognized and identified to affect the
influence weight of 0.46 and 0.29. This means that they
adoption of healthcare technology. In this regard,
should not be overlooked by managers of hospitals for
studies conducted by Chang et al. [40] for e-signature
HIS adoption. In addition, “Hospital Size” is the most
innovation, Chang et al. [15] for the PACS innovation,
imperative variable for evaluating the HIS adoption
and Zhu and Kraemer [124] for the e-business
with an influence weight of 0.32 in the Organization
innovation have supported the “Government Policy”.
dimension. In the previous research, the importance of
Another important variable is “Perceived Technical
“Hospital
the
Competence” for evaluating HIS adoption with an
Organization Size influencing the adoption of an
influence weight of 0.66 in Human dimension. It is
innovation
larger
notable that the support from the IT department is
hospitals have a more tendency in adopting the HIS
necessary particularly in the adoption stage. In addition
more than smaller hospitals. This is due to the
to ensuring that the technical support is well delivered,
capability of more resources in large hospitals for
it is important that the people in the IT department
changing the business strategy. Second, “Government
have the ability of adequate technical competency.
Policy” is the most important variable with an
These characteristics, as studied by Wager et al. [7]
influence
Environment
ensure that the staff are able to do their tasks well,
dimension. This finding also echoes the results
show their power in solving the organisation’s needs,
obtained in previous studies, where “Government
and more importantly performing to keep up to date
Ac ce p
te
d
factors for evaluating the HIS adoption with an
Size”
confirmed
[58,86,98,124].
weight
of
0.51
pertaining
Specifically,
in
the
to
Page 32 of 47
33 supported as the most crucial variables in this study
HIS effectiveness of the organization. Previous studies
which show some insights pertaining to the healthcare
also show the importance of this variable including
industry in the Malaysian context.
study of EDI conducted by Kuan and Chau [57], and
8. Limitation and future work
IS conducted by Thong [86]. Fourth, by using the
In this study, some implications and limitations exist
DEMATEL in our study, we could explore the
which need to be focused and scrutinized in further
interrelationship among dimensions and variables to
studies. First, there were a small number of experts in
help improving each dimensions and variables. The
fulfilling the survey for this study. As sophisticated
Technology
Environment
analysis is drived by the large sample size of the
dimension (D4) resulted as having the highest priority
respondents, there is a call for future study conducting
for the development of adoption. This shows that,
a rigorous study to examine the evaluation of HIS
administrators should first look at these two dimensions
adoption decision from a large number of respondents;
and improve upon since they are the most important
this also lead to generalize findings of the prospective study.
M
relative to the other dimensions. Thus, the Technology
cr
and
us
(D2)
an
dimension
ip t
with new techniques and technology that enhance the
Second, the study at hand obtained the point of view
crucial dimensions for evaluating the HIS adoption in
from adopters which already went through the
d
and the Environment should be considered as the
implementation of HIS. This causes bias to its findings
dimensions and variables should be performed by
due to uncovering the non-adopters’ perspective and
administrators for the decision process of HIS
idea regarding to the adoption process and evaluation
Ac ce p
te
the healthcare industry. Therefore, evaluating these
adoption. In general, this method of evaluation could
procedure of HIS innovation. The future studies can
be applied by many of the healthcare industry in
perform investigating the HIS adoption by conducting
hospital setting, however there will be differences
the interview or survey in the non-adopters of HIS to
according to the various contexts and categories of
explore the factors in different view-points regarding
HIS. In summary, it can be said, the relative
the HIS adoption. Accompanying, it would be
importance of the 13 variables may differ considering
suggested to assess and differentiate the different
the confinement of each healthcare industry. It is
influence of those factors between adopters and non-
believed
adopters. Hence, these will allow more generalization
that
“Compatibility”
Management Support”
[86,98],
“Top
[98,125], “IS Infrastructure”
of the findings.
[98,125], and “Business Competition” [57,124], are
Third, in Malaysia there are three categories with
key considerations for organizations deciding to adopt
respect to the HIS consisting of THIS which has the
an innovation. Nonetheless, these four factors were not
most
complete
system,
Intermediate
Hospital
Page 33 of 47
34 to become a developed country. Hence, the current
and Basic Hospital Information System (BHIS) the
study looks to identify the crucial factors including
least complete and limited system. In this case, the
both dimensions and variables which can have a major
choice of implementation of HIS categories for each
and critical effect in determining the achievement of
hospital is according to their embedded beds; THIS is
HIS innovation adoption. Our study applied and
for hospitals more than 400 beds, IHIS and BHIS are
followed the TOE as the main framework which has
for hospitals that have beds between 200 and 400, and
been found as a generic theory of technology diffusion
lower than 200 beds, respectively. Therefore, future
that can be used for studying the adoption of
study would be appreciated to undertake each category
technological innovations. In addition, by integrating
of HIS in those hospitals of different size to examine,
the HOT-fit model which has a foundation in
specify, and provide the suitable model to improve
healthcare
effectively the decision to adopt HIS.
framework, this study hopes to provide a new and
cr
us
system
into
the
TOE
suitable model by allowing some factors which have been excluded in last studies to facilitate more the HIS
M
hospitals in Malaysia according to its culture and
information
an
Fourth, findings in this study covered the public
ip t
Information System (IHIS) lower complete than THIS,
adoption process to be utilized by government and
means, these findings limited to the context of
decision makers within hospitals to improve the trend
d
external environment, however, this is not necessarily
of adoption decision that will lead to provide plenty of
in other developing countries to extend and more
profit to patient community and hospitals. Particularly,
verifying the results of this study since there are the
the administrators and managers can look at the
Ac ce p
te
Malaysian public hospitals. The findings can be tested
scarcity of adopting and implementing the HIS [126].
developed model to evaluate the factors in enhancing
This can make a novel contribution in the context of
the HIS adoption. Based on the statement that the
healthcare industry to enhance more the diffusion of IS
different factors explained the special concerns needed
in hospital setting which can provide plenty of profits
at the specific stage of technology diffusion, this study
to the patient community and hospitals.
considered to clarify the stage of adoption and we
9. Conclusion
defined it as the process through which decision making unit takes an action to invest resources necessary to accommodate the change effort.
During conducting this study, almost 85% of public
In this regard, a hybrid MCDM model using two
hospitals in Malaysia have delayed in adopting and
approaches including ANP and DEMATEL was
implementing the HIS, which can have a negative
proposed which have a contribution in IS literature.
effect on status quo of Malaysia vision of 2020, that is
The interdependencies among dimensions and their
Page 34 of 47
35 pertinent variables evaluated leading to improve the
healthcare industry and also shed some light for
adoption decision process of HIS innovation. The
prospective researchers by giving the future direction
results, thus, indicated that from the experts’ viewpoint
in examining the trend of HIS innovation adoption.
"Perceived Technical Competence" was the most
Acknowledgments: This work was
important factor in the Human dimension. In the
grant from Universiti Teknologi Malaysia, the GUP
Technology dimension, the experts agreed that the
grant (Vote No.: Q.J130000.2506.09H20), K-economy.
"Relative Advantage" was more important in relation
Appreciation also goes to the anonymous reviewers
to the other factors. In addition, in the Organization
whose comments helped us to improve the manuscript.
ip t
Lee HW, Ramayah T, Zakaria N: External
factors in hospital information system (HIS)
an
judgment, "Government Policy " was the most
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d
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To the best of our knowledge, there is no empirical study to examine the Technology-OrganizationEnvironment (TOE) and HumanOrganization-Technology (HOT) fit frameworks in the context of Hospital Information System (HIS) adoption for Malaysian public hospitals. There is no Multi-Criteria DecisionMaking (MCDM) model to examine the importance level of factors for improving the decision process of Hospital Information System (HIS) adoption. Our contributions in this study This study mainly integrates the mature Technology-OrganizationEnvironment (TOE) and recently developed Human-OrganizationTechnology (HOT) fit frameworks to identify factors that affect the hospital decision in adopting of Hospital Information System (HIS) for Malaysian public hospitals. A hybrid Multi-Criteria DecisionMaking (MCDM) model is used to address the dependence relationships of factors with the aid of Analytic Network Processes (ANP) and Decision Making Trial and Evaluation Laboratory (DEMATEL) approaches.
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Current state
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S1386-5056(14)00249-4 http://dx.doi.org/doi:10.1016/j.ijmedinf.2014.12.004 IJB 3148
To appear in:
International Journal of Medical Informatics
Received date: Revised date: Accepted date:
1-10-2014 11-12-2014 26-12-2014
Please cite this article as: H. Ahmadi, M. Nilashi, O. Ibrahim, Organizational decision to adopt hospital information system: An empirical investigation in the case of Malaysian public hospitals, International Journal of Medical Informatics (2015), http://dx.doi.org/10.1016/j.ijmedinf.2014.12.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 Highlights
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An integrated model is developed to facilitate the adoption decision of HIS. The integrated model is based on TOE framework and HOT-fit model. We test interdependencies among the dimensions and variables using ANP and DEMATEL. The results show that Environment and Technology are the most important factors. Hospital decision makers can refer to the study findings to make a better decision.
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2
Organizational decision to adopt hospital information system: An empirical investigation in the case of Malaysian public hospitals
Hossein Ahmadi a, Mehrbakhsh Nilashi a,*, Othman Ibrahim a a Faculty of Computing, Universiti Technologi Malaysia, Johor, Malaysia
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Corresponding author email address: [email protected]
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3 Organizational decision to adopt hospital information system: An empirical investigation in the case of Malaysian public hospitals Abstract. Objectives: This study mainly integrates the mature Technology-Organization-Environment (TOE) framework
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and recently developed Human-Organization-Technology (HOT) fit model to identify factors that affect the hospital decision in adopting of Hospital Information System (HIS).
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Methods: Accordingly, a hybrid Multi-Criteria Decision-Making (MCDM) model is used to address the dependence relationships of factors with the aid of Analytic Network Processes (ANP) and Decision Making Trial
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and Evaluation Laboratory (DEMATEL) approaches. The initial model of the study is designed by considering four main dimensions with thirteen variables as organizational innovation adoption factors with respect to HIS. By
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using DEMATEL, the interdependencies strength among the dimensions and variables are tested. The ANP method is then adopted in order to determine the relative importance of the adoption factors, and used to identify
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how these factors are weighted and prioritized by the public hospital professionals, who are wholly familiar with the HIS and have years of experience in decision making in hospitals’ Information System (IS) department. Results: The results of this study indicate that from the experts’ viewpoint "Perceived Technical Competence" is
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the most important factor in the Human dimension. In the Technology dimension, the experts agree that the
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"Relative Advantage" is more important in relation to the other factors. In the Organization dimension, “Hospital
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Size" is considered more important rather than others. And, in the Environment dimension, according to the experts judgment, "Government Policy " is the most important factor. The results of ANP survey from experts also reveale that the experts in the HIS field believed, these factors should not be overlooked by managers of hospitals and the adoption of HIS is more related to more considering of these factors. In addition, from the results, it is found that the experts are more concerned about Environment and Technology for the adoption HIS. Conclusions: The findings of this study make a novel contribution in the context of healthcare industry that is to improve the decision process of innovation in adoption stage and help to enhance more the diffusion of IS in the hospital setting, which by doing so, can provide plenty of profits to the patient community and the hospitals. Keywords. Public hospital, Hospital Information System, Adoption, Organizational decision, HumanTechnology-Organization-Environment, Multi-Criteria Decision Making
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4 hindrance to increasing organizational performance in
Physicians and patients today are encountering great
terms of providing fast and efficient health services
pressures from the healthcare setting. In the perspective
[17]. Nevertheless, these innovations have not escaped
of physicians, their irritation is originating from heavy
from various challenges and issues both from internal
patient’s loads, administrative tasks, and losing patient
and external factors [7,15,40].
care
are
In Malaysia, the healthcare system consists of both a
complaining that during the medical interaction, more
public and a private sector. Also the rural areas are
consideration should be provided on them [2,4].
mostly served by government health clinics and
Obviously, medical service all the days of a week are
hospitals [6,17]. The people are acquiring a broad
required to be given specially from the public hospitals,
range of healthcare services in a low price. But, for
effective
and
some reason such as, population structure, increased
individual electronic access to personal medical health
life expectancy, healthcare service expectation from the
appointment’s
While
scheduling
patients
system,
records [1]. Therefore, there are more demanding on
people and so forth, the status quo has been distorted [1]. Besides, there is an increasing rate of Malaysian
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electronic services from patients to be given by
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[1].
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control
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decision
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1. Background
healthcare expense, which has been occurring every
slowly in responding to these demands [3]. Even in
year [118,17]. Hence, to enhance the quality of
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hospitals. But, the healthcare community is moving
healthcare and decrease the cost, there is a big pressure
equipment of Computerized Physician Order Entry
on Malaysian government.
(CPOE) by 2009 [3].
To overcome these issues, there are several projects
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United States hospitals, only 17% percent have the
The proper and correct adoption of Information
that have been developed by the Malaysian government
Technology (IT) can significantly affect the quality and
with the aim of promoting and maintaining the
performance of the medical services provided by a
wellness of Malaysians and to provide more and easy
hospital [1,19,128,135]. Hospital Information System
access
(HIS) is a comprehensive, integrated Information
information systems [1,5,8,127]. Such projects include
System (IS) designed to manage the administrative,
the National Telehealth Policy (NTP) that comprises of
financial and clinical aspects of a hospital. HIS
four exciting initiatives for IS such as Telemedicine,
influences in decreasing medical errors, growing the
Mass Customised/Personalised Health Information and
efficiency, cost effectiveness, timely decision making,
Education (MCPHIE), Lifetime Health Plan (LHP),
and improves the quality of healthcare services
and Continuing Medical Education (CME) [8,9]. One
[5,11,33]. In addition, the main aim is to eliminate
of the areas that is focused for intensive development is
manual processes that are now seen as a major
telemedicine [1]. Telemedicine flagship has been
for
every
citizen
regarding
healthcare
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5 intended to provide the healthcare services to
organizations due to the lack of generic theory of
individuals [10]. Furthermore, HIS was introduced
technology innovation [14]. This is more emphasized
under
by Grover [98] on advocating the need to study more
LHP
project
to launch
the
process of
than one innovation characteristic which will lead to
Despite all of these, according to [1,5,12,13,127], only
increase the relative predictive power of characteristics
15.2% of the Malaysian public hospitals are referral
in evaluating the organizational adoption process.
hospitals equipped with either fully integrated or
Hence, the current study makes an effort to incorporate
partially integrated HIS since the Telehealth project
these statements as was suggested.
was launched more than a decade ago and almost 85%
Second, this paper presents study which evaluates the
of public hospitals are delaying in adopting the HIS
important level of interdependeny among critical
technology. Hence, this shows a very slow progress
factors for adoption decision of HIS. In addition, this
among Malaysian public hospitals on the trend of HIS
study proposes MCDM model, which consists of the
This paper describes an empirical study that we
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conducted investigating possible factors influencing
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organizational decision to adopt HIS in public hospitals of Malaysia. The questions that have been raised for
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this study are: (a) What are the current practices of IS in healthcare industry? (b) What are the significant factors that affect the decision to adopt HIS based on Technology
Organization
Environment
(HTOE) framework? (c) What theoretical model is suitable to be applied to facilitate the adoption of HIS? (d)
What
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(DEMATEL) and Analytic Network Processes (ANP)
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2. The problem statement and our contributions
And
an
Decision Making Trial and Evaluation Laboratory
innovation adoption.
Human
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digitalization of the healthcare sector [1,8,9].
Multi-Criteria
Decision-Making
(MCDM) model is suitable to weight and prioritize the
to evaluate and find the importance level of the determined factors for HIS adoption in Malaysia. In this regard, DEMATEL is applied to construct interrelations among adoption factors in the integrated model. By using this approach the interdependencies strength among the adoption factors are tested. The ANP method is then adopted in order to determine the relative importance of the adoption factors, and used to identify how the critical factors are weighted and prioritized by the public hospital professionals, who have plenty of experience and wholly familiar with HIS innovation in different areas of hospital.
factors for HIS adoption in a public hospital?
3. Literature review
The contributions of the study at hand are two-folded.
3.1. The current state of IS in healthcare
First, according to [14,95], there is a lack of theories being developed for a specific type of innovation and for a particular adoption context such as healthcare
Continuous efforts have been carried out in order to improve the current technological scenario in the healthcare industry [16]. Many countries produce
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6 public hospitals, general practices, clinical specialties,
which aimed at providing benefits to their citizens [17].
and allied health facilities, information is not integrated
E-health, Electronic Health Record (EHR), HIS and
and mostly stored on paper”. The lack of integrated
telemedicine are kinds of initiatives that will generally
information storage may cause big challenges in
bring about the usage of IS as a mean to give better
providing reports for the nation’s health surveillance
health services to the population and overcome
and policy and clinical operational decision making.
challenges that perceived as cumbersome by people
On the other hand, compared to other knowledge rich
searching medical treatment. The main purpose is to
industries such as the financial and telecommunication
eliminate manual processes, which are nowadays seen
industries, the use of IS in the healthcare sector is very
as a main obstacle towards providing fast efficient
slow [21]. In addition, the healthcare sector has been
services [18].
reported far behind in adopting of the IS [7,129,130].
There exists another challenge whilst having IS
Table 1 summarizes the initiatives taken by some of the
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countries throughout the world in developing and implementing efficient IS for the context of healthcare
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shared and distributed. The main problem in this
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implemented, in the way that information is stored,
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strategic IS plans for their large scale health systems
[17]. In spite of advancement of technology that are
where it still revolved around pen, paper and human
being implemented in the healthcare sector either in
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context lies with the way information is being handled
developed or developing countries throughout the
technological environment, the manual method may
world, there are still issues with their adoption and
not be suitable [19]. Moreover, according to Omachonu
diffusion.
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memory. Hence, in meeting the demands of the current
and Einspruch [20], “with large numbers of private and Table 1 Healthcare technology initiatives around the world. Continents
Countries
Technology Initiatives
Europe
United Kingdom
Sweden
Electronic patient booking systems, prescription messaging, Picture Archiving and Communication System (PACS), e-Referral systems, clinical repositories, test results storage and send capability [22] Hospital EHR, GP computing, development of integrated communication capacity with home based care and making treatment information available through a portal, national registries and databases, standards development for data interchange purposes [23] EHR [24]
Germany
Smart-card technology [24]
United States
EHR, telehealth, health information network, Personal Health Record (PHR) [145]
Canada
Diagnostic imaging, medication management, registries, laboratory and public health surveillance, telehealth [25] A good level of IS/IT penetration in clinical, administrative and logistics activity in seven main hospitals, OphthWeb, Teleophthalmology [26] HIS which covers all aspects of the hospital’s operation such as clinical, administrative and financial systems [17] Telemedicine, National Health Insurance Smart Card to update patient’s record [27]
Denmark
North America
Asia
Singapore Malaysia Taiwan
Australia
Japan
HIS, telemedicine, telehealth, Decision Support System (DSS) [28]
Australia
EHRs, E-Health initiatives [29]
New Zealand
E-Health, secure online transfer of health information and national register [18]
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7
public hospitals in which they require to serve the
systems which HIS is a good example that has been applied in hospital care environment [30]. HIS is imperative to the healthcare sector specifically in
public with high quality healthcare treatments. Table 2 describes some research findings pertaining to HIS
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There are a wide range of areas in health information
innovation adoption and also highlighting key issues, success stories and recommendations.
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3.2. Hospital Information System (HIS)
Table 2 Summary of reviewed studies of HIS innovation adoption. Findings
Clinical Information System (CIS)
Physicians do not really resist to technology change but the way the technology is implemented by the management is crucial.
[31]
Electronic Medical Record (EMR)
Challenges may include security and privacy issues, reliability of the documentation, legal and ethical issues, implementation issues; solutions include applying technological security and behavioural approaches.
[32]
Hospital Information System (HIS)
Further research required in measuring the performance of HIS specifically looking into the cost-effectiveness and cultural effect of its implementation to patients and hospital employees.
[33]
Drug prescription and distribution system
It functions as, decrease in medication exchanges due to usage of barcode and indicators of mismatch between medication picked and medication prescribed, storage and statistics of number of failures in filling orders. End users were also satisfied with the ongoing training policies.
[19]
Mobile Nursing Technology (MNT)
Adoption of MNT is highly associated with business competition, capability of external suppliers and organisation’s internal needs.
[34]
Clinical Decision Support System (CDSS)
It is recommended that to avoid the user resistence of the system, CDSS should be used incorporating workflows which are consistent with the physicians’ work processes.
[35]
Picture Archiving and Communication System (PACS)
The use of PACS is seen as a tool in gaining competitive advantage.
[15]
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The key factors in determining the successful adoption of RFID are: the presence of a champion, technology push and need pull. Surgeons welcomed the EPR system as long as it provides direct clinical benefits to their work and eased their work practices.
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Electronic Patient Record (EPR)
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Radio Frequency Identification (RFID)
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HIS Innovation
Author
[36] [37]
Computerized Physician Order Entry (CPOE)
Pathology laboratory had to go through various changes and adjustments in their work practices, responsibilities and procedures which causes frustration.
[38]
Electronic Medical Record (EMR)
In assimilating EMR technology, several factors are associated with the physician’s practices, overcome learning barriers, related knowledge and diversity.
[39]
Electronic Signature (e-signature)
These are some of the significant factors which contribute to the adoption of e-signature: hospital size, adequate resources, vendor support, and government policy.
[40]
Electronic Medical Record (EMR)
The EMR failed to be introduced at hospitals in Japan due to the initial exceeded costs.
[41]
Mobile Nursing Information System (MNIS)
There are some of the significant factors contribute to the adoption of MNIS: championship, business competition, and external supplier’s support.
[42]
Electronic Medical Record (EMR)
Several barriers exist during the initial decision to invest in an EMR system within family physician practices in Canada which include: behavioral, cognitive or knowledgebased, economic, and technological.
[143]
have focused on the individual level, by explaining
3.3. Organizational IT adoption theories have
what influences their behavioral intention to use a
extensively been studied with respect to the IT
particular technology. In this regard, Theory of
adoption. However, many of the IT adoption researches
Reasoned Action (TRA), Technology Acceptance
The
individual
and
organizational
level
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8 theory [48], institutional theory [49], Technology
and Unified Theory of Acceptance and Use of
Organization Environment (TOE) framework [43] and
Technology (UTAUT) are the most common theories
recently developed Human Organization Technology
that are used to predict and explain behaviour of
(HOT) fit model [44,72]. Table 3 presents these four
individuals toward adoption and use of technology
aforementioned theories to understand their concepts
across many areas.
and their contribution to predict the various technology
decision
in
adopting
of
specific
innovative
technologies. In this direction, the important theoretical
healthcare environment. It should be noted that in the
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identify what factors are crucial on organizational
adoption into diverse industries with respect to the
following table, asterisks denote the technology that
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For the latter, fewer studies have been conducted to
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Model (TAM), Theory of Planned Behaviour (TPB),
relates to the healthcare industry.
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perspectives include the Diffusion of Innovation (DOI)
Table 3 Studies related to organizational–level theories in various adoption domains
Institutional [49]
Dimensions -Innovation -Organization -Environment
Bussiness to Bussiness (B2B) market place adoption Enterprise Resource Plannig (ERP) system adoption and implementation Wireless application protocol adoption Internet as a teaching tool Mobile internet adoption EDI adoption E-business adoption E-business adoption E-business adoption
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DOI [48]
Domain
Electronic Data Interchange (EDI) adoption Inter and Intra organizational system
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Context Institutional pressures -Coercive -Normative -Mimetic
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Theory/Model/Author
TOE [43]
HOT-fit [44,72]
Dimensions -Technology -Organization -Environment
Dimensions -Human -Organization -Technology
Internet adoption in procurement
Reference [57] [50,51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61]
RFID adoption* PACS adoption* E-Signature adoption* MNIS adoption* EMR adoption*
[36] [15] [40] [42] [63]
Cloud computing adoption*
[79]
Medical records system* E-health*
[45] [64]
Although, DOI focuses on innovation, organizational, and environmental characteristics, and the institutional theory concentrates on the environmental pressures, the TOE framework is perceived as a more comprehensive lens in the context of IS innovation adoption at the firm level by covering all of these characteristics as well [58,98]. In the other words, the TOE framework offers
a combination of the influential factors compared to the DOI and institutional theory, that can effectively lead to IT adoption decision making [65]. Also, it is worth of mentioning that researchers have disputed, it is not possible to have a single theory that applies to all types of innovations due to different innovation types. Hence, an integrated approach of theories are needed
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9 as a lens to be applied in determining the adoption
framework applied and tested in both developed as
process of specific type of innovation [66].
well as developing countries [58, 59,60,124]. From the TOE perspective, the process by which a firm
3.3.1. Technology-Organization-Environment (TOE) framework
adopts and implements technological innovations is influenced
by
the
technological
context,
the
organizational context, and the environmental context
facilitators that influence the adoption stage should be
[43]. The framework provides detailed that firm should
considered. Tornatzky and Fleischer [43] introduced
consider when studying components that influence
the TOE framework in 1990. It is the organizational
organizational adoption of technological innovations.
level theory that predicts the technology adoption
The original TOE framework is shown in Fig. 1.
decision, explained by three different contexts. They
The technology context comprises of the internal and
are
external technologies pertaining to the firm involves
technological
context,
the
organizational context, and the environmental context.
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and includes both equipment and process [46]. The organizational context involves the characteristics and
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TOE framework is a generic theory that in previous
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described
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In the discussion of technology innovation, the
resources of the firms such as firm size, managerial
and ability of explanation and prediction over variety
structure, human resources, the amount of slack
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studies have been demonstrated its broad applicability
resources and linkages among employees [17]. The
national/cultural contexts. In a host of industries, TOE
environmental context includes the structure of the
has been focused to explain the innovation adoption.
industry, the firm's competitors, the macroeconomic
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of contexts including technological, industrial, and
This includes financial services [60], manufacturing
concept and the regulatory environment [43].
[61], healthcare [41] and so forth. In addition, the TOE
Technology
Organization
Adoption Decision of Technological Innovation
External Task Environment Fig. 1. The original TOE framework [43].
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10 These elements have been found out as both limitations
point to the lack of fit between the context of
and the likelihood for technological adoption. Hence,
technology,
these are incorporated as a strategy of organization to
Recently, [44,72] conducted a rigorous evaluation of
understand the requirement of, and ways to adopt an
health information system to identify the important
innovation [43].
dimensions which can intensively affect the system
and
organization
[45,69,71].
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human
adoption. Their assessment was performed based 3.3.2. Human-Organization-Technology (HOT) fit
findings of the extant health information system and IS
model
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evaluation studies to finally develop a new framework incorporating the human, organization and technology
Health Information Technology (HIT) adoption that
dimensions (see Fig. 2).
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There are numbers of studies about the evaluation of
Human
Organization
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Adoption of Innovation
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Fig. 2. HOT fit model [44,72].
d
Technology
This proposed framework associated with a set of
organizational context, each of the dimenstions and
comprehensive dimensions and measurement of the
appropriate
health information system. They suggest that the more
organization
fit between technology, human, and organization, the
evaluated. In this table, factors that have strong effect
more potential of the health information system can be
on HIS innovation adoption is presented, in which
realized [44,72].
asterisks indicate the most influential factors, plain text
variables, and
including
environment
the
technology,
empirically
was
indicates a factor for which partial support was found, 3.3.3. Justification of the selected TOE framework After investigating and reviewing the significant
and italics mention the factors that were not statistically important.
studies of HIS innovation adoption based on TOE framework, Table 4 was tabulated. In these studies, based
on
circumstances
and
various
needs of
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Table 4 Summary of prior studies in the context of HIS innovation adoption based on TOE framework. Technological context factors
Organizational context factors
Environmental context Reference factors Government involvement* [67] Vendor partnership* Business competition pressure Country wealth
Vital signs monitoring system
Technology readiness/receptivity Relative advantage* Complexity* Compatibility*
Hospital type Hospital ownership Hospital size Internal needs* Resource availability* Technological knowledge* Knowledge management capabilities Project team capability* Top management support*
MNIS
Mobile devices suitability Wireless communication suitability The extent of integration with HIS Cost benefit
Project team’s capability Business competition* [42] Top management support Government policy support User involvement and cooperation External supplier’s support* Championship Internal needs*
Health Level 7 (HL7)
Security System integrity*
Staff’s technological capability* Hospital’s scale* Top Management Attitude toward HL7*
Push of the environment Environmental pressure* Pull of the environment
[73]
E-signature
Security protection System complexity
User involvement Adequate resources* Hospital size* Internet need
Vendor support* Government policy*
[40]
PACS
Cost of PACS Compatibility Benefits of PACS*
Centralization Formalization High-level manager support*
Business competition Governmental policies*
[15]
RFID
Perceived benefits* Vendor pressure
Presence of champions*
Performance gap* Market uncertainty*
[36]
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Innovation
investment. In other words, human and organizational
that used TOE framework in the case of hospital setting
aspects are essential as much as technical issues in
related to the specific components of HIS technology
connection to the system effectiveness [74]. Besides,
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Table 4 attempts to show the significant prior studies
with focusing on adoption stage. These factors play an
there are several studies in the domain of medical
important role in facilitating or inhibiting the decision
informatics that pointed out into the concept of ‘fit’ in
to adopt an innovation in organizations. However, it
explaining the interdependent relationship between
was found that dimensions are differently measured in
human, organization and technology [70,75,76]. Most
accordance
of the existing evaluation studies of health information
with
various
needs,
and
specific
components of HIS innovation in each of these studies.
system focused on the technical issues, which do lack of explaining in why HIS works well or poorly with a
3.3.4. Justification of the selected HOT-fit model specific user in a specific setting [77,78]. Hence, Yusof According to Yusof and his colleagues [44,72], being
and his colleagues [44,72] provided a comprehensive,
parallel within organization, technology and human is
specific evaluation view integrating the dimensions
the crucial ideology in starting to the IT diffusion as it
into the developed HOT-fit model, which posited in the
accounts important strategies influencing the IT
health information system.
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12 the healthcare industry. The study at hand, develops the
colleagues [44,72], HOT-fit model would be applied in
mature HTOE framework in IS discipline for adopting
a flexible way, taking into account different contexts
an innovation technology in healthcare environment
and purposes, stakeholders’ point of views, wide
and determines the possible influential factors that
phases in
and
importantly affect the adoption decision. Table 5 shows
evaluation methods. According to Lian et al. [79], the
previous studies that identified the four contexts and
HOT-fit model is intensively concentrated on the
their measurement based on the HTOE framework that
adoption of innovation towards healthcare information
statistically influenced the adoption decision of the
systems.
technological innovations with regard to the HIS and
life
cycle,
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development
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system
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Following the work conducted by Yusof and his
healthcare industry. 3.3.5. Factors influencing IT adoption based on HTOE
an
framework Healthcare is a large and growing industry that is
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experiencing major transformation in its IT base [80].
The IT change has been more rapid outside than within
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Table 5 Proposed factors influencing the decision to adopt IT innovation based HTOE contexts.
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Dimensions/Factors 1
2
√
3
4
5
6
√
Technology Organization
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Human
Champion innovativeness Perceived technical competence
√
Relative advantage
√
√
Compatibility
√
√
√
Complexity
√
√
√
√
Centralization
√
√
7
Reference 8
9
√
Infrastructure
Environment
Top management support Business competition Vendor support
√
Government Policy
√
√ √ √
18 19
√
√ √
√
√
√
√ √
√ √
√
17
√
√
√
16
√
√
√
15
√
√
√
11 12 13 14
√
Formalization Size
10
√
√
√
√
√
√ √
√
√
√
√ √
√
√
√
√
√
√
√ √
√
Table 6 shows innovations in terms of different types
the particular applicability of TOE framework and
that is the continuity of Table 5. They altogether show
HOT-fit model in determining the adoption decision of
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13 technological innovations in various industries with
respect to the healthcare industry and HIS innovation.
Table 6 Types of innovation. [86]
Innovation
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Author
1
IS
2
[96]
3
[98]
ICT
4
[57]
EDI
5
[79]
Cloud computing
6
[73]
HL7
7
[62]
CRM system
8
[13]
HIS
9
[40]
E-signature
10
[47]
Interorganizational system
11
[109]
12
[60]
13
[15]
14
[34]
15
[42]
16
[36]
17
[63]
18
[62]
19
[82]
Customer-based Interorganizational Systems (CIOS)
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Reference number
EMR
E-business PACS
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Mobile nursing Mobile nursing RFID EMR
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E-learning RFID
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*Note: The innovation studied in bold are related to healthcare context.
Ac ce p
4. Development of the conceptual model (HTOE)
Healthcare is a large and growing industry that is experiencing major transformation in its IT base [80], where IS confronted similar technology adoption in other industries and developed various theories and methods. After carefully reviewing the literature, the study found that TOE framework developed by [43], and HOT-fit model developed by [44,72], are suitable frameworks for the study at hand, incorporating factors that affect the process of adoption decision of HIS innovation. The TOE framework is an organization-level theory that explains three different aspects of a firm’s context
including technological context, organizational context and environmental context which can affect the adoption decisions of an innovation. Additionally, Tornatzky and Fleischer [43] affirmed that technology adoption is taken place through a variety of factors pertaining to those contexts. In this regard, Yusof and his colleagues [44,72], conducted appraisal research to investigate the system adoption in the healthcare industry.
They
found
that
the
alignment
of
organization, technology and human is an important starting point in IT adoption as it is one of the strategies that affects IT investment. Hence, the significance of human capital identified in the
Page 13 of 47
14 organization, and therefore, it plays a critical role in the
attempts to provide an informative guidance model
adoption of HIS.
with
Some studies conducted in the healthcare industry
practitioners in improving and promoting a better
specifically within hospital setting that found the
decision in adopting of HIS technology in the
suitability of applying the TOE framework in
Malaysian
understanding of the technology innovation in the
developed HIS adoption decision model, including
adoption phase [15,36,40,42,67,73,79]. Therefore, it
both dimensions and related latent variables has been
proves the suitability of applying TOE framework in
presented in Table 7.
to
[44,72]
integrated
human,
context.
The
hospital
whole
4.1. Human dimension
us
industry,
hospitals
and
cr
public
our study. In addition, with a focus directly on the healthcare
decision-makers
ip t
respect
Human capital is one of the most key assets in an
that evaluates the healthcare information system [79].
organization [83]. It is important that professionals
In
this
model,
three
significant
elements
are
adapt themselves to utilize the innovative technology. In organizations, there are members of the business that
M
concentrated which need to be applied when adopting
an
organization and technology is a dimensional model
have unique qualities in IT expertise that determine the
healthcare industry. Furthermore, health information
overall management style of the business and also
d
any technology innovations within the context of the
system evaluation is defined as the act of measuring or
expedite the adoption of IT [60,85].
te
exploring attributes of the system, thereby result which
Ac ce p
informs a decision to be made concerning the specific
4.1.1. Champion’s innovativeness
context [44,72,81].
Actions or behaviour by the members of the
Based on the above statements and aforementioned
organization can directly or indirectly influence
discussion, both TOE framework and HOT-fit model
organizational
are deemed suitable in the study at hand that is to apply
researchers
the integrated developed HTOE dimensional model to
characteristic in IT adoption in small businesses
understand the adoption decision of HIS [1,17,44,45,
[85,86]. Furthermore, some people in organization,
68,79]. Based on the literature review, theoretical
such as an entrepreneur figure for instance, Chief
background and previous empirical research findings,
Executive Officer (CEO) or Chief Information Officer
this study develops the conceptual research model (see
(CIO) possess a crucial role in determining the
Fig. 3). This model contains the factors pertaining to
innovative attitude of the organizations [84]. It can be
each contxts which is to realizing of the adoption
argued that in a public hospital context, the person who
process of HIS in the healthcare industry. This study
has more power is able to have control over the
effectiveness investigated
the
[79,144]. role
of
Several human
Page 14 of 47
15 diffusion of IS [17]. Hence, they are attributed as
attitude toward the adoption of that new IT application
champions in firms that play an important role in
[85,86].
adoption of an innovation. This has been caused
aforementioned viewpoint to the field of applying IT
controversy in which if champions certainly harmonize
and further extended it as the willingness to try new IT.
Agarwal
and
Prasad
[91]
apply
this
ip t
to an innovative technology, there will be a positive 4.1.2. Perceived technical competence
information intensity in the hospitals can be seen as the
hospital setting, the satff’s technological capabilities
IS capabilities. Therefore, if the IS staff have sufficient
should be considered as well [73,92]. Ettlie and Yap
knowledge and the adequate skills to adopt IT
[93,94] found that in order to utilize more innovative
innovation technology, hospitals will undoubtedly posit
IT, staff must hold some knowledge of IT innovation.
more confidence all over the process of adoption [79].
us
M
Human
an
According to [62,86], the IS knowledge of staff and the
cr
In the process of adopting an innovative IT in the
d
Champion’s Innovativeness
Ac ce p
te
Perceived Technical Competence
Technology Relative Advantage
Compatibility
Complexity
Organization Centralization
Formalization
Decision to Adopt HIS
Environment Business Competition
Size
Vendor Support
Infrastructure
Top Management Support
Government Policy
Fig. 3. Conceptual Research Model.
Page 15 of 47
16
Table 7 Explanation of variables. Dimensions/Variables
Description
Reference
It is described as the speed that champions adopt and accept new creativity, leads to drive innovation to other staff in a positive manner. The degree that staff must have some knowledge of IT innovation in order to use more innovative IT.
[91]
Relative advantage is the degree to which an innovation is perceived as better than its precursor. It is defined as the extent to which the innovation is consistent with the values, experiences, needs and existing practices of potential adopters. Complexity refers to the degree to which an innovation is perceived as difficult to use.
[48]
The extent of participation in decision making. The extent of rule observance and job codification. Large firms typically have the resources necessary to experiment, pilot, and decide what technology and standards they require. IS infrastructure refers to the existence of sophisticated telecommunication and database facilities within the firm. Top management support refers to whether or not the executives understand the nature and function of IT innovation and therefore fully support the development of it.
[66] [98] [82]
Competition intensity is defined as the degree that the organization is affected by competitiors in the market. The degree to which vendors provide services and it may range from product installation and training to a full-blown business intelligence consultancy engagement. It is defined as the degree to which government establishes policy for range of support and allocating various resources in adoption of HIS.
[59]
Human (D1) Champion’s innovativeness (V1)
[57]
ip t
Perceievd technical competence (V2) Technology (D2) Relative advantage (V3)
cr
Compatibility (V4) Complexity (V5) Organization (D3)
us
Centralization (V6) Formalization (V7) Hospital size (V8) IS infrastructure (V9)
an
Top management support (V10) Environment (D4) Business competition (V11)
M
Vendor support (V12)
d
Government policy (V13)
te
4.2. Technology dimension
[48] [86]
[98] [98,111]
[42,34] [42]
4.2.1. Relative advantage According to Rogers [48], relative advantage is the
external influences of adopting specific IT in the
degree to which an innovation is perceived as better
organization [79]. Following the study conducted by
than its precursor. Relative advantage refers to
Thong [86], the author investigated the influence of IS
carefully considering the adoption of HIS technology
characteristics on innovation adoption in the context of
whether diminish hospital operating costs and acquire
E-business. According to the innovation theory [90],
the relative operational benefits for a given hospital.
individual forms an attitude towards the innovation,
Study conducted by Premkumar [96] implied that
leading to a decision whether to adopt or reject the
relative advantages will influence business and force
innovation.
the
them to adopt new information technologies. Hence,
concerning
being optimistic about the advantages of IS would
characteristics of innovation, Tornatzky and Klein [95]
create as an incentive as a useful business strategy to
identified
adopt the innovation [86].
Ac ce p
The technology dimension entails the internal and
Based
technological
on
innovation
relative
a
meta-analysis literature
advantage,
of
compatibility
and
complexity possess innovation characteristics that are salient to the attitude formation [86].
4.2.2. Compatibility
Page 16 of 47
17 With the new technology available today, more
4.3. Organization dimension
complex systems can be designed. Powerful software tools and hardware at lower prices, reliable networking and standards add new prospects in this field [97].
In the IS literature regarding the adoption and diffusion of innovation, organizational factors have been found as the key determinants [4,98,101,125]. Grover [98]
PACS, Radiology Information System (RIS), Clinical
sub-systems of HIS that are incorporated into fully integrated systems [13,97]. If the sub-systems of HIS
ip t
Pharmacy Information System (PIS) are examples of
categorized organizational factors into centralization, formalization, size, infrastructure, and top management support.
Further,
cr
System (LIS), Nursing Information System (NIS) and
conducted a significant study in adoption of CIOS. He
Davidson
and
Chismar
[99]
concluded that organizational factors, including the
us
Information System (CIS), Laboratory Information
degree of centralization, degree of formalization, are more compatible with the existing systems and/or
hopeful and more feasible to adopt them. Hence, it
hospitals. Lin et al. [73] and Ross et al. [108], emphasized on the influence of top management
M
seems that compatibility is another crucial factor in the
integration and size influence the development of IS in
an
the applications of the hospital, then it will be more
support and infrastructure on the innovation adoption
context of technology.
process.
d
4.2.3. Complexity
te
Complexity of IS has been identified as the critical
[59,73,124,125]
came
to
the
similar
conclusion. 4.3.1. Centralization and formalization
Ac ce p
factors influencing organizations decision about the Centralization or the concentration of decision making
innovative technology adoption [40,73,98,86]. In the public hospitals, there are enormous numbers of patients from the various classes of society that getting medical treatments, dissimilar to private hospitals. Therefore,
this
causes
a
complex
system
activity, frequently has been referred to have a negative relationship on adoption of organizational innovation [98]. Decreased autonomy and a bounded perspective are often given as the reasons for the negative
and
complicated environment [13].
associations
with
this
variable.
Similarly,
formalization, or clear work and procedure definition
Complexity refers to the degree to which an innovation is perceived as difficult to use [86]. It is also suggested that the perceived complexity of an innovation leads to resistance due to lack of skills and knowledge [48].
have been found as a negative associations with initiation/adoption [66,98,100]. Rogers [48] found that over
centralization
and
formalization
inhibit
organizational innovation adoption. [66,101] came to Therefore, it is asserted that in the technical dimension, system complexity needs to be looked, cautiously.
the similar conclusion.
Page 17 of 47
18 infrastructure includes the tangible resource which
the director of general health from the federal
includes infrastructure components such as hardware
government to the state health institute directors. This
and software [107]. According to Ross et al., [108],
indicates that the federal government still provides a
with IS infrastructure the importance of a sharable
centralized control over health policy by using its
platform and technology is essential for integrating
constitutional powers to take over the health functions
systems in the organization in order to make IS
exercised by the states [102]. Hence, the regulatory
application more cost effective, especially in the area
changes and implementation has to be complied from
of operations and support [108]. Hence, increasing use
the healthcare organizations. Also, decisions have to be
of sophisticated IS infrastructure can lead to enormous
made formalizing the roles and responsibilities that
advantage within clinical workflow [109].
must be carried out by different people in various
Public hospitals in developing countries faced some
departments across the hospital pertaining to clinical IS
issues regarding infrastructure. According to Zhu et al.
an
us
cr
ip t
In Malaysia, there is an indirect monitoring between
[60], within the technological context, firm in
initiation, adoption and implementation [17].
countries
has
less
developed
IS
M
developing
4.3.2. Hospital size
infrastructure. In Pakistan, they face barrier of IT
d
The hospital size effect has been asserted in the prior
infrastructure which find difficulty in obtaining a suitable software and hardware [110]. Further, Ismail et
According to Chang [40], larger hospitals have more
al. [13] and Sulaiman & Wickramasinghe [5] surveyed
propensity to adopt e-signature more than smaller
some public hospitals through all Malaysia to identify
Ac ce p
te
studies of organizational innovation adoption [60,103].
hospitals do. They indicated that large hospital has
the critical issues and challenges in the implementation
more resources for changing business strategy. Hence,
of HIS. Most of the respondents referred to the
hospital size contributed a significant influence on
infrastructure issue in their hospitals. The results
decision to adopt innovative technology [40,86].
indicated that increasing the cost of software, external issues of course broadband and network, wireless and
4.3.3. IS infrastructure
also upgrading issue related to hardware are major
According to Grover [98], “IS infrastructure refers to the existence of sophisticated telecommunication and
hindrances in adopting of HIS [17]. 4.3.4. Top management support
database facilities within the firm”. The innovation literature strongly proposes that any technological
The importance of support from top management for a
innovation adoption should be based on a firm’s
proposed innovation is accepted as conventional
technological
wisdom [98]. In this regard, McGinnis and Ackelsberg
strength
[98,104,105,106].
IS
Page 18 of 47
19 world are undergoing healthcare reforms to promote
environment for innovation. Furthermore, the study of
better services and healthcare well-being [18,23,11].
Chang et al. [40] conducted in the context of healthcare
Hence, to cope with this unstable change of the
determined out, top manager’s support will affect new
healthcare environment and increasing competition
IS adoption in hospitals. Moreover, [112,86,144]
among hospitals, the managers are highly tending to
indicated that an organization’s decision to adopt
adopt IT as one of the most feasible strategies to
innovative technology is under the influence of the
enhance
characteristics of the top managers, organizational
advantage [34].
concerns and environmental conditions [86,112].
In the significant study of developing country in
and
competitive
cr
performance
us
hospital
ip t
[111] stated that top management provides a positive
Taiwan, [34,42] found that decision of MNT adoption
[87,88,89,113,114], clearly emphasized that lack of top
was significantly associated with business competition.
management support renders an innovation less likely
It is generally believed that competition increases the
addition,
empirical
work
performed
to be adopted. With regards to the healthcare context
likelihood of innovation adoption [117]. In this regard, according to Mohan and Razali [118], the focus of the
management support was found to be crucial for the
future healthcare system will be on people and
introduction
technology
services, where the use of technology will act as the
d
M
and investigating the adoption of new technology, top
an
by
In
key enabler to provide an accessible, integrated, high
a
new
[15,40,67,73,79,142].
Ac ce p
4.4. Environment dimension
or different
te
of
quality and affordable healthcare system that is recognised as one of the world’s best.
The environmental context includes the business
In Malaysia, the healthcare reform initiative known as
competition, vendor support and government policy
the Telemedicine Blueprint under the Multimedia
[43]. This dimension refers to the higher-level issues
Super Corridor (MSC) has been launched since 1997 to
that surround the hospital administration [17]. It
reform the Malaysian healthcare system [10]. The Total
represents the external factors of the healthcare
Hospital Information System (THIS) project was first
industry. This will no doubt impact hospitals as they
launched in Malaysia in late 1999 as a direct result of
adopt a new IS [34,40,42].
the Prime minister's vision for Malaysia becoming a developed country by the year 2020 [8]. It was the aim
4.4.1. Business competition Prior studies [115,116] show that the degree of business competition is directly associated with the adoption of new IT. Moreover, previous researches
of Malaysia to be the first in the world to have a single HIS which covers all aspects of hospital’s operation, both clinical and non-clinical. These competitive pressure seems to force hospitals to adopt new ISs
have highlighted that various countries around the
Page 19 of 47
20 quickly to provide better services and gain strategic
In Malaysia, HIS has been designed to provide
advantages.
numerous values to the healthcare community and indirectly provide benefits to the patients. Hospitals
4.4.2 Vendor support
implementing the HIS are having integration issues with multiple vendors implementing different versions
world of computing in the healthcare industry. It was in
of HIS in different hospitals, which also causes for
this era that the personal computers influenced
concern in lack of expertise [9,121,122]. Incompetency
distributed data processing as well as the expansion of
of vendors in doing maintenance and support cause the
CIS [119]. This advancement also allows health
technical problem in HIS systems. Moreover, Sulaiman
information system vendors to develop a range of
[17] surveyed potential adopters of HIS in public
administrative and clinical applications for various
hospitals and found that vendors have minimal
healthcare settings. This resulted in the purchasing of
experience in IS troubleshooting and virtually no
cr
us
clinical knowledge.
M
Based on these practices of purchasing the best from
an
individual applications for specific clinical usage [7].
ip t
The mid-1980s brought about immense changes to the
4.4.3 Government policy
the multiple vendors for individual departments,
d
challenges began to develop when hospitals tried to
Government policy is an imperative factor in the aspect
and
of environment. There are several studies conducted in
communication among these different systems [7]. The
hospitals setting with regard to developing country
1990s brought about an increasing number of
Taiwan which pointed out the significant influence of
data
to
allow
interoperability
Ac ce p
te
integrate
participants in the vendor community that developed
government policy on adoption decision of HIS
various clinical applications, which made healthcare
innovation. Chang et al. [15] conducted a study to
products more widely available and affordable.
investigate the enabler factors affecting adoption of
According to Castro [120], vendors have a tendency to
PACS as a new technology in hospital setting. They
invest in larger healthcare organizations due to issues
found that perceived government policy is an important
concerning recovery of costs. Vendor support has been
trend to adopt PACS. Additionally, there are other
identified statistically as a significant factor which
empirically-based
contributes to the adoption of IS innovation [17,19].
countries that found government policy influences the
According to Hsiao et al. [42], sufficient support from
decision
the vendors will facilitate the smooth and efficient
[40,42,79,123].
adoption of HIS in the Taiwan’s hospital setting.
The Malaysian healthcare system comprises of the
to
studies
adopt
HIS
related
in
a
to
developing
positive
manner
Ministry of Health (MOH) as the main healthcare
Page 20 of 47
21 study developed the conceptual research model (see
government
is
Fig. 3). Accordingly, in this section, we develop a
currently being used in selected hospitals and is heavily
hybrid MCDM model for the process of HIS adoption
criticised to be just a technology [17,121].
decision. The proposed MCDM model is comprised of
According to Abdullah [8], the implementation of
two main stages. An overview of the process of hybrid
Malaysian HIS in healthcare requires a realistic
proposed model using DEMATEL and ANP is shown
assessment, especially in producing very clear policy.
in Fig. 4. As can be seen in Fig. 4, in the first step, the
Also, Sulaiman [17] emphasized that in Malaysia in
DEMATEL method is used to uncover the relationship
order to have clinical and IS/IT skilled people, there is
among the dimensions (main factors) and variables
a need for training and exposure to both areas and for
(sub-factors) and to find interdependency and feedback
people to remain in the environment in order to
among them. It should be noted that uncovering the
increase
relationships using this approach is very important to
understanding
through
hands
on
experience. On the other hand, there is a lack of
find the weights of main factors and sub-factors appropriately.
M
financial support in the Malaysian healthcare system
cr
telemedicine
us
their
involving
an
initiative
ip t
provider with public hospitals [8]. In this regard,
Hence,
to
this
step,
DEMATEL
approach is more suitable to be applied in decision
[17], financial issues can be seen as one of the main
making as
d
with regard to public hospitals. According to Sulaiman
it is more suitable for real-world
applications compared to the traditional methods in
ways unsuccessful.
analysing the interdependency among the components
te
causes of why the adoption of HIS is slow and in many
of a network [128,130].
Ac ce p
5. A hybrid MCDM model for HIS adoption
As we discussed in the previous section, based on the existing literature review, theoretical background and previous noteworthy empirical research findings, this
Page 21 of 47
22 Start
Dimensions and Variables
ip t
Determine the Dimensions and Variables
cr
Technology
Environment
us
Organization
an
Human
M
Use DEMATEL to analyze the interdependent relationship among the dimensions and variables
d
Use ANP to calculate the weights of the dimensions and variables
Ac ce p
te
Determine the most important factors for HIS adoption
End
Fig. 4. Research flow for MCDM model.
and involve many stakeholders. The main purpose of
5.1. The DEMATEL approach
the DEMATEL method is to analyse different factors
The Decision Making Trial and Evaluation Laboratory (DEMATEL) method was developed in the beginning
affecting a system, and to use expert knowledge to better understand the correlation between these factors,
of the 1970’s at the Battelle Memorial Institute at the for example in terms of relationships and influence Geneva Research Center by Duval and Fontela [129]. It
between the different factors.
was initially created to study the world problem The preparation for the method is to collect the structure
(“world
problematique”)
by
analyzing
scientific, political and economic problems that are
different factors (also called variables in DEMATEL) affecting the system. This can be done using literature
influenced by a complex system of different factors
Page 22 of 47
23 This matrix A is also called the initial direct relation
scale has to be defined, which can be used to express
matrix. It shows the initial direct effects that a factor
the relationship or strength of influence between the
exerts on and receives from other factors. This direct
factors or variables [131]. A typical range for this
relation matrix can also be depicted in an influence
influence scale is 0-no influence; 1-low influence; 2-
map. The second step calculates the normalized direct
medium influence; 3- high influence and 4- very high
relation matrix D from the average matrix A. This is
influence.
done by dividing each element by the largest row sum
In the first step of DEMATEL a number of experts is
of the average matrix, as in the original DEMATEL
asked to indicate the level to which they believe that
method. Some recent applications of the method also
any of the factors influences each other, by applying
used the largest row or column sum as the standard for
the aforementioned influence scale. In mathematical
normalization, but this is not followed in the context of
and n factors that are being studied, we get from every
cr
us
n
this paper. The normalization factor max1 i n aij j 1
represents the total direct influence in our influence
M
expert a n×n answer matrix Xk = [ xijk ] with 1 k H .
an
notation this means if we have H experts in the study
ip t
research or expert opinion. In addition a measuring
scale of the factor with the most direct influence on
te
Ac ce p
x12 ... x1n 0 x2 n xn 2 0
d
other factors. This normalization step is the preparation
0 x X 21 xn1
So we have X1,X2 ... XH answer matrices for each of
for the following steps of DEMATEL where indirect influences are calculated, and provides an aligned scale for all factors for these calculations. So the scalar s is computed with n
the experts, and each element of Xk is an integer in the range of the influence scale, representing the degree of
s max1i n aij
(2)
j 1
and then is used to compute the normalized direct
ij
factor i influencing factor j, and denoted by x . The
relation matrix D with
main diagonal elements of each answer matrix are set to zero, because self-influence of the factors is not
D=
A s
(3)
evaluated in DEMATEL. To incorporate the opinions
Based on that in the next step the direct/indirect or total
of all experts, in the next step an average matrix A =
relation matrix is calculated. The experts have
[aij ] is constructed by calculating the average influence
estimated the direct effects only. It is assumed that the
quantification as follows:
indirect effects of the influence factors (factor a
aij
1 H
H
x k 1
k ij
(1)
influences factor b and factor b influences factor c, so factor a indirectly also influences factor c) is lower
Page 23 of 47
24 than the direct effects, so with increasing indirections
+ ci) shows the total effects given and received by
the indirect influence matrix converges to the null
factor i. Thus
matrix:
imi (ri ci ) ti j tki
lim D 0 k
(4)
k
n
n
j 1
k 1
(8)
represents the degree of importance of the factor i in the entire system. The difference
identity matrix the following holds true: k
1
(5)
k
n
n
j 1
k 1
ef i (ri ci ) tij tki
(9)
cr
1
lim (I + D + D ... D ) (I - D) , T D(1 I) 2
ip t
where 0 is the null matrix, and so with I being the
indicates the net effect that factor i contributes to the
sum of rows and the sum of columns in the total
system. Specifically if efi is positive, the influence
relation matrix T. Now if ri is the sum of the ith row in
factor i is a net cause, while if efi is negative, factor i is
the matrix T:
a net receiver.
(i 1, 2,..., n)
(6)
te
sum of the jth column in the matrix T:
d
factor i exerts on the other factors. Similarly if cj is the
cn with c j ti j where ( j 1, 2,..., n) i 1
Ac ce p
c1 ...
depicted in a directed graph to show the structural relationship between the different influence factors. For
it summarizes both the direct and indirect effects that
n
an
The results achieved by these calculations can be
M
r1 n with r ti j where i j 1 r n
us
Let r and c be n×1 and 1×n vectors representing the
(7)
it summarizes the direct and indirect effects that factor j receives from the other factors. When i = j, the sum (ri
doing that it is advisable to define a threshold value for the influence effects to filter out negligible effects. Only the effects greater than the given threshold value would be shown in the graph. It should be noted that for the evaluation from experts review, the rate of influence measured using the scale represented in Table 8.
Table 8 Influence scale. Value 0 1 2 3 4
Meaning No influence Low influence Medium influence High influence Very high influence
Page 24 of 47
25 It should be noted that for MCDM techniques such
5.2. Analytic Network Process (ANP)
as AHP, there is no general rule for selecting the Recently, MCDM methods have been an active research for solving real-world decision problems
number of respondents. AHP is not a statistically based methodology and a small sample size is
[133,134]. Analytic Network Process (ANP) is a
level. The ANP does not assume independence between elements of the model. Therefore, whilst the
Ar and Kurtaran [140], AHP is technically valid and does not require a large sample size. ANP as a
cr
unidirectional hierarchical relationship among decision
addition, according to Lam and Zhau [139] cited by
special case of AHP is not an exception. Hence, in
us
was developed by Saaty [132]. AHP maintains a
ip t
enough to implement a decision [138,141]. In special case of Analytical Hierarchy Process (AHP)
this study, a small size of 12 experts have been
AHP structures the problem as a hierarchy, the ANP
selected for data collection phase. where applicable sub-criteria) and alternatives are
Step 2: This step involves arranging the results of the
pairwise
M
nodes on the network. In this manner, the ANP allows
an
structures it as a network where the goal, criteria (and
comparisons
in
the
pairwise
comparison matrix ( ). This matrix is then
nodes to illustrate interdependence. The ANP builds
normalised
upon the pairwise comparisons of the AHP where
corresponding column sum to get the normalised
criteria are pairwise compared with respect to each
matrix. The rows of the normalised matrix are then
te
d
for feedback connections and loops within and between
by
dividing
each
entry
by
its
averaged to get the priority vector for each element
where alternatives are compared with respect to each
under consideration.
Ac ce p
alternative, and includes a further set of comparisons
criterion.
Step 3: This step is for the consistency test to
According to Saaty [132], the steps in the quantitative
certify that the original preference ratings made by
component of the ANP are:
the expert were consistent. The consistency ratio is
Step 1: Design a questionnaire for collecting
a measure of the consistency of the individual judgements.
responses from experts. The questionnaire used in this study involved pairwise comparisons of elements on a nine-point scale with nine points awarded if one element was extremely more important than the other and one point awarded if the two elements were equally important.
Step 4: In this step, forming the “unweighted Supermatrix” is included in the ANP model which contains local priorities derived from the pairwise comparisons throughout the model’s network and using this to construct the “weighted Supermatrix”.
Page 25 of 47
26 In the current study, the data collected from 12 experts
more than two clusters in a node of the network and
who are as decision makers that are wholly familiar
involves performing cluster comparisons to get the
with the HIS. Thus, as the objects of the questionnaires
cluster matrix. This cluster matrix is then multiplied
used in our study are the experts and not the users,
by the unweighted Supermatrix to give the weighted
therefore, the sample size of 12 experts would be
Supermatrix. The final priority weights are derived
sufficient for data collection purpose and the hybrid
by multiplying the super-matrix by itself until the
MCDM model implementation. In addition, many
columns stabilize with
researchers have applied MCDM techniques such as
cr
ip t
Step 5: This step is only required when there are
AHP and ANP combined with DEMATEL in their Empirical study
us
6.
researches and provided such small sample size for the hybrid MCDM model implementation [136,137]. Table
an
9 provides the sample characteristics of the type of
6.1 Data collection
te
Table 9 Sample characteristics.
d
M
respondents for this study.
Respondent characteristic 26-31 31-39 39-45 45-58 Gender Female Male Level of education Bachelor’s Master’s Higher Roles of respondents Chief Executive Officers Chief Information Officers IT directors Responding executives’ Above 26 years seniority in the healthcare 21-25 years industry 16-20 years 11-15 years 6-10 years Less than 5 years
Ac ce p
Age
Frequency 2 3 3 4 3 9 2 6 4 3 6 3 1 1 3 3 2 2
Percentage 16.% 25% 25% 33.3% 25% 75% 16.6% 50% 33.3% 25% 50% 25% 8.3% 8.3% 25% 25% 16.6% 16.6%
As can be seen in the Table 9, most of the experts have
positions in an IS department. The responses from the
experience more than ten years seniority in the
respective experts were collected via questionnaire
healthcare industry and furthermore, hold top-level
survey.
Page 26 of 47
27 of all the experts was calculated. To incorporate the
6.2 DEMATEL
indirect influences in the examination, the total relation In the first part of the survey, 12 experts in the context
matrix T is created as presented in Table 10. This is
of HIS were asked to indicate the level to which they
based on the normalized direct relation matrix and is
believe that any of the factors (dimensions and calculated according to Eq. (5). Based on this table, a
ip t
variables) influences each other, by applying the scales
graphical representation of these direct and indirect
between 0 and 4 (see Table 8). In an attempt to
influences is created. It should be noted that in this map
investigate the structural relations among the four
cr
only the most influential relations of the total relation
dimensions, DEMATEL is employed to measure the
matrix are depicted. This total influence map is shown
us
causal impact of each dimension in HIS. As these
in Fig. 5. Based on this total influence map we can see
experts were asked to indicate the degree of influence
that Environment has high influence on other factors, dimension, firstly the direct relation/influence matrix D
is very strongly influenced by factors Human and Environment.
M
was calculated. The individual expert’s opinions on the
especially Technology. Also, factor Technology itself
an
that they believe each dimension has on every other
influence factors were put into answer matrices, and
d
the initial direct relation matrix for the combined rating
te
Table 10 The total-relation matrix T for dimensions. Human
Technology
Organization
Human
1.271
2.073
1.559
1.741
Technology
1.164
1.597
1.262
1.537
Organization
1.052
1.653
1.145
1.364
Environment
1.409
2.141
1.639
1.652
Ac ce p
Dimensions
D1
Environment
D1: Human
D3
D2: Technology D3: Organization D4
D4: Environment
D2
Fig. 5. Total influence map. From Eqs. 6 and 7, with given dimensions and
in Table 11, with (ri-ci) indicating the net effect that
variables, the influences and received values can be
dimension i has on the system and (ri+ci) indicating the
calculated. For four dimensions these values are shown
effect that dimension i contributes to the system.
Page 27 of 47
28 r-c is positive, the variable is causal and if it is
in the system. In other words, the more the value of
negative, it is effect. In addition, row and column
r+c indicates the more interaction of the factor with
difference vector (r - c) represents the net impact
other factors of the system. Thus, Technology and
relationship of the total impact matrix. The row and
Environment factors have the major interaction with
column difference vector of Human (1.748) is greater
other factors. And the Organization has the lowest
than zero, suggesting that the impact of Human on
interaction with other variables. As can be seen in
other dimensions is greater than the impact of other
Table 11, the addition of the row and column vector of
dimensions
Environment (r + c = 13.135) is the highest, indicating
dispatcher. Furthermore, in this model, it can be said
that the mutual effects of Environment and other
that Human and Environment of the system are casual
dimensions are the greatest. Horizontal vector (r-c)
and Technology and Organization are effect.
Hence,
Human
cr
Human.
is
the
shows the power of effect of each factor. Generally, if
an
us
on
ip t
Vertical vector (r+c) is the effect of the required model
Table 11Total effects and net effects for each dimension. Dimensions Technology Human Environment Organization
r 5.559 6.644 6.841 5.214
M
Code D1 D2 D3 D4
d
Similar above procedure is applied for the variables in
te
each dimension. The results of applying DEMATEL
c 7.463 4.896 6.294 5.605
ri+ci 13.022 11.539 13.135 10.818
ri-ci -1.904 1.748 0.547 -0.391
"V2“ with the highest value of r-c (0.112) is prior to
others, and it is called the master dispatcher. The results indicated that this variable has a major influence
Again, combining two total impact factors given (ri)
on other variables in achieving a success in HIS
Ac ce p
for those variables are presented in Tables 12-15.
and received (ci) gives resulted in two additional
adoption. This means that the effects of the other
metrics. When adding the total effects given and
variables will achieve the goal through considering this
received by an influence factor, the degree of
factor. In addition, it can be seen that in the
importance of the different influence factors are
Technology, "V4" with the highest value of r-c (-
identified. By applying total relation matrix, the
1.878) is prior to others, and is called the master
ranking are established and represented (see Table 16),
dispatcher. The results indicated that this variable has a
which shows the overall importance factors in the
major influence on other variables in achieving a
system.
success in HIS adoption. This means that the effects of
According to DEMATEL analysis presented in Table
the other variable will achieve the goal through
16, the factors in the proposed analytical model were
considering these factor. For the Organization, "V7"
found which mostly influenced others or can be
and "V9" can be master dispatcher with r-c (0.825) and
influenced by others. It can be seen that in the Human,
Page 28 of 47
29 r-c (0.998), respectively. Also, in the Environment,
"V11" is master dispatcher.
Table 12 The total-relation matrix T for D1. V1 0.609
V2 0.935
V2
1.047
0.609
ip t
Variable V1
V3 0.15 0.25 0.09
V4 0.25 0.06 0.17
V6 0.908 1.033
V7 0.937 0.829
V8 1.034 0.977
V8
0.988
0.933
0.951
V9
1.169
1.022
1.028
V 10
0.692
0.621
0.756
Table 15 The total-relation matrix T for D4. V 11 5.362
V 12
5.171
V 13
5.198
V5 0.84 0.72 0.50
V9 1.002 1.043
V 10 1.297 1.286
1.007
1.094
1.202
1.497
0.667
0.927
V 12 6.294
V 13 7.106
5.741
6.659
5.969
6.431
d
Dimensions V 11
M
Dimensions V6 V7
an
Table 14 The total-relation matrix T for D3.
us
Variable V3 V4 V5
cr
Table 13 The total-relation matrix T for D2.
Variable
te
Table 16 Total effects and net effects for each variable. r
c
r+c
r-c
1.544
1.657
3.201
-0.112
1.657
1.544
3.201
0.112
0.701
2.886
3.587
-2.184
V 4 Compatibility
1
2.878
3.878
-1.878
V 5 Complexity V 6 Centralization V 7 Formalization
1.870 5.179 5.167
3.800 4.789 4.342
5.670 9.968 9.510
-1.930 0.390 0.825
V 8 Hospital size
4.972
4.747
9.719
0.225
V 9 IS infrastructure
5.918
4.920
10.838
0.998
V 10 Top management support
3.663
6.100
9.763
-2.438
V 11 Business competition
18.762
15.730
34.491
3.032
V 12 Vendor support
17.571
18.004
35.574
-0.433
V 13 Government policy
17.598
20.196
37.794
-2.599
V 1 Champion’s innovativeness
Ac ce p
V 2 Perceievd technical competence V 3 Relative advantage
6.3 ANP analysis
on the ANP model and relationship structure among
In this study, after discovering the interdependency
dimensions and variable, an ANP based survey with
among the dimensions and variables using DEMATEL,
pairwise questions was conducted and distributed to the
the ANP method was applied to obtain the final
12 experts who had experience with the HIS of
weights of four dimensions and their variables. Based
hospitals in Malaysia. From the 12 surveys conducted
Page 29 of 47
30 Saaty’s 9-point of scale the 9 point indicates extreme
rate as 100%).
importance and 1 as the equal importance of one
In addition, for the ANP model, the 12 respondents
component (dimension and variable) over another. The
which participated in the survey were asked to provide
ANP model as shown in Fig. 6 was solved using the
their answers based on a scale of 1-9 to the pairwise
Super Decisions software. After computing the results
questions, such as ‘For the ‘‘HIS adoption in the
of their assessments, the Consistency Ratio (CR)
Malaysian hospitals”, how much more important is
values are all acceptable and the eigenvectors displayed
‘‘Technology” to ‘‘Human”?’ It should be noted that in
are
cr
to enter into the Supermatrix.
te
d
M
an
us
appropriate
ip t
in this study, all of them were valid (effective response
Ac ce p
Fig. 6. ANP model of decision to adopt HIS.
For pairwise comparisons, in the first step, a pairwise
pairwise comparisons for the all variables in each
comparison matrix is prepared for dimensions (Human,
dimension according to the relationships among them
Technology, Environment, and Organization). Thus,
were performed. In this step, the decision maker is
according to the model and the relationships among
asked to respond to a series of pairwise comparisons
dimensions, different matrices of comparisions would
where two variable would be compared at a time with
be formed. Table 17 presents comparisions of the four
respect to an upper level control criterion. The pairwise
dimensions with respect to the overall goal and Table
comparisons of the elements at each level are
18 presents comparison of the four dimensions with
conducted with respect to their relative influence
respect to the Environment. In the second step,
towards their control criterion.
Table 17 Comparison of the four dimensions with respect to the overall goal. With Respect to the Goal
Environment
Human
Organization
Technology
Weights
Page 30 of 47
31 Environment 1.0 Human 0.25 Organization 0.33 Technology 0.5 CR = 0.0651 (desirable value to be less than 0.100)
1.0 0.25 2.0
1.0 5.0
0.45 0.17 0.07 0.29
1.0
Table 18 Comparison of the four dimensions with respect to the overall goal with respect to the Environment. Environment
Human
Organization
Environment 1.0 Human 0.3 1.0 Organization 0.2 0.33 Technology 0.5 2.0 CR = 0.0132 (desirable value to be less than 0.100)
Technology
Weights
1.0
0.46 0.16 0.06 0.29
cr
1.0 5.0
ip t
With Respect to the Goal
experts agree that the "Relative Advantage" is more
calculating the unweighted Supermatrix and weighted
important in relation to the other factors. In addition, in
Supermatrix, the limit Supermatrix
the
is presented in
variable in the dimensions, and these are the final
Organization
considered
dimension,
more
important
an
Table 19. This matrix presents the weight of each
us
According to the steps described in Section 5.2, after
"Hospital rather
Size"
than
is
others.
Furthermore, in the Environment dimension, according to the experts judgment, "Government Policy " is the
M
weight of variable in each dimension.
most important criterion. The results of ANP survey
we can see that the "Perceived Technical Competence",
from experts reveal that the experts in the HIS field
"Relative Advantage", " Hospital Size " and "
believed these factors should not be overlooked by
Government Policy" are the most important variables
managers of hospitals and the adoption of HIS is more
in
and
related to considering of these factors. In addition,
Environment with influence weights of 0.66, 0.57, 0.32
from the results it was found that the experts are more
and 0.51, respectively. The results thus indicate that
concerned about Environment and Technology, as the
from the experts viewpoint, "Perceived Technical
weight of these dimensions are substantially higher
Competence" is the most important factor in the
than those of other dimensions.
Human,
Organization,
Ac ce p
Technology,
te
d
From the results, according to the experts judgment,
Human dimension. In the Technology dimension, the
Table 19 The limit Supermatrix.
Supermatrix Human
Technology Organization
Human
Technology
Organization
Environment
V1
V2
V3
V4
V5
V6
V7
V8
V9
V 10
V 11
V 12
V 13
V1
0.34
0.34
0
0
0
0
0
0
0
0
0
0
0
V2
0.66
0.66
0
0
0
0
0
0
0
0
0
0
0
V3
0
0
0.57
0.57
0.57
0
0
0
0
0
0
0
0
V4
0
0
0.17
0.17
0.17
0
0
0
0
0
0
0
0
V5
0
0
0.26
0.26
0.26
0
0
0
0
0
0
0
0
V6
0
0
0
0
0
0.24
0.24
0.24
0.24
0.24
0
0
0
V7
0
0
0
0
0
0.11
0.11
0.11
0.11
0.11
0
0
0
V8
0
0
0
0
0
0.32
0.32
0.32
0.32
0.32
0
0
0
Page 31 of 47
32
Environment
V9
0
0
0
0
0
0.07
0.07
0.07
0.07
0.07
0
0
0
V 10
0
0
0
0
0
0.26
0.26
0.26
0.26
0.26
0
0
0
V11
0
0
0
0
0
0
0
0
0
0
0.23
0.23
0.23
V 12
0
0
0
0
0
0
0
0
0
0
0.26
0.26
0.26
V 13
0
0
0
0
0
0
0
0
0
0
0.51
0.51
0.51
Policy” is indicated as a crucial variable that promotes
By developing the conceptual research model and
training and persuading the employees to increase their
analysing the MCDM model using the two evaluation
knowledge in using the HIS. In the perspective of
methods of ANP and DEMATEL and based our data
Malaysian context, adoption of HIS in the healthcare
from 12 experts in the context of healthcare, some
requires a realistic assessment, especially in producing
findings from previous IS studies in determining the
very
important factors influencing the decision to adopt the
implementation program. In addition, an appropriate IT
organizational
governance structure is needed in public healthcare
confirmed.
First,
according to results gained from DEMATEL and ANP,
cr an
efficient
adoption
and
facilities to better organize the acquisition and deployment. Furthermore, government’s health policy
M
Environment and Technology are the most imperative
policy,
us
was
clear
an
innovation
ip t
7. Discussion
has been recognized and identified to affect the
influence weight of 0.46 and 0.29. This means that they
adoption of healthcare technology. In this regard,
should not be overlooked by managers of hospitals for
studies conducted by Chang et al. [40] for e-signature
HIS adoption. In addition, “Hospital Size” is the most
innovation, Chang et al. [15] for the PACS innovation,
imperative variable for evaluating the HIS adoption
and Zhu and Kraemer [124] for the e-business
with an influence weight of 0.32 in the Organization
innovation have supported the “Government Policy”.
dimension. In the previous research, the importance of
Another important variable is “Perceived Technical
“Hospital
the
Competence” for evaluating HIS adoption with an
Organization Size influencing the adoption of an
influence weight of 0.66 in Human dimension. It is
innovation
larger
notable that the support from the IT department is
hospitals have a more tendency in adopting the HIS
necessary particularly in the adoption stage. In addition
more than smaller hospitals. This is due to the
to ensuring that the technical support is well delivered,
capability of more resources in large hospitals for
it is important that the people in the IT department
changing the business strategy. Second, “Government
have the ability of adequate technical competency.
Policy” is the most important variable with an
These characteristics, as studied by Wager et al. [7]
influence
Environment
ensure that the staff are able to do their tasks well,
dimension. This finding also echoes the results
show their power in solving the organisation’s needs,
obtained in previous studies, where “Government
and more importantly performing to keep up to date
Ac ce p
te
d
factors for evaluating the HIS adoption with an
Size”
confirmed
[58,86,98,124].
weight
of
0.51
pertaining
Specifically,
in
the
to
Page 32 of 47
33 supported as the most crucial variables in this study
HIS effectiveness of the organization. Previous studies
which show some insights pertaining to the healthcare
also show the importance of this variable including
industry in the Malaysian context.
study of EDI conducted by Kuan and Chau [57], and
8. Limitation and future work
IS conducted by Thong [86]. Fourth, by using the
In this study, some implications and limitations exist
DEMATEL in our study, we could explore the
which need to be focused and scrutinized in further
interrelationship among dimensions and variables to
studies. First, there were a small number of experts in
help improving each dimensions and variables. The
fulfilling the survey for this study. As sophisticated
Technology
Environment
analysis is drived by the large sample size of the
dimension (D4) resulted as having the highest priority
respondents, there is a call for future study conducting
for the development of adoption. This shows that,
a rigorous study to examine the evaluation of HIS
administrators should first look at these two dimensions
adoption decision from a large number of respondents;
and improve upon since they are the most important
this also lead to generalize findings of the prospective study.
M
relative to the other dimensions. Thus, the Technology
cr
and
us
(D2)
an
dimension
ip t
with new techniques and technology that enhance the
Second, the study at hand obtained the point of view
crucial dimensions for evaluating the HIS adoption in
from adopters which already went through the
d
and the Environment should be considered as the
implementation of HIS. This causes bias to its findings
dimensions and variables should be performed by
due to uncovering the non-adopters’ perspective and
administrators for the decision process of HIS
idea regarding to the adoption process and evaluation
Ac ce p
te
the healthcare industry. Therefore, evaluating these
adoption. In general, this method of evaluation could
procedure of HIS innovation. The future studies can
be applied by many of the healthcare industry in
perform investigating the HIS adoption by conducting
hospital setting, however there will be differences
the interview or survey in the non-adopters of HIS to
according to the various contexts and categories of
explore the factors in different view-points regarding
HIS. In summary, it can be said, the relative
the HIS adoption. Accompanying, it would be
importance of the 13 variables may differ considering
suggested to assess and differentiate the different
the confinement of each healthcare industry. It is
influence of those factors between adopters and non-
believed
adopters. Hence, these will allow more generalization
that
“Compatibility”
Management Support”
[86,98],
“Top
[98,125], “IS Infrastructure”
of the findings.
[98,125], and “Business Competition” [57,124], are
Third, in Malaysia there are three categories with
key considerations for organizations deciding to adopt
respect to the HIS consisting of THIS which has the
an innovation. Nonetheless, these four factors were not
most
complete
system,
Intermediate
Hospital
Page 33 of 47
34 to become a developed country. Hence, the current
and Basic Hospital Information System (BHIS) the
study looks to identify the crucial factors including
least complete and limited system. In this case, the
both dimensions and variables which can have a major
choice of implementation of HIS categories for each
and critical effect in determining the achievement of
hospital is according to their embedded beds; THIS is
HIS innovation adoption. Our study applied and
for hospitals more than 400 beds, IHIS and BHIS are
followed the TOE as the main framework which has
for hospitals that have beds between 200 and 400, and
been found as a generic theory of technology diffusion
lower than 200 beds, respectively. Therefore, future
that can be used for studying the adoption of
study would be appreciated to undertake each category
technological innovations. In addition, by integrating
of HIS in those hospitals of different size to examine,
the HOT-fit model which has a foundation in
specify, and provide the suitable model to improve
healthcare
effectively the decision to adopt HIS.
framework, this study hopes to provide a new and
cr
us
system
into
the
TOE
suitable model by allowing some factors which have been excluded in last studies to facilitate more the HIS
M
hospitals in Malaysia according to its culture and
information
an
Fourth, findings in this study covered the public
ip t
Information System (IHIS) lower complete than THIS,
adoption process to be utilized by government and
means, these findings limited to the context of
decision makers within hospitals to improve the trend
d
external environment, however, this is not necessarily
of adoption decision that will lead to provide plenty of
in other developing countries to extend and more
profit to patient community and hospitals. Particularly,
verifying the results of this study since there are the
the administrators and managers can look at the
Ac ce p
te
Malaysian public hospitals. The findings can be tested
scarcity of adopting and implementing the HIS [126].
developed model to evaluate the factors in enhancing
This can make a novel contribution in the context of
the HIS adoption. Based on the statement that the
healthcare industry to enhance more the diffusion of IS
different factors explained the special concerns needed
in hospital setting which can provide plenty of profits
at the specific stage of technology diffusion, this study
to the patient community and hospitals.
considered to clarify the stage of adoption and we
9. Conclusion
defined it as the process through which decision making unit takes an action to invest resources necessary to accommodate the change effort.
During conducting this study, almost 85% of public
In this regard, a hybrid MCDM model using two
hospitals in Malaysia have delayed in adopting and
approaches including ANP and DEMATEL was
implementing the HIS, which can have a negative
proposed which have a contribution in IS literature.
effect on status quo of Malaysia vision of 2020, that is
The interdependencies among dimensions and their
Page 34 of 47
35 pertinent variables evaluated leading to improve the
healthcare industry and also shed some light for
adoption decision process of HIS innovation. The
prospective researchers by giving the future direction
results, thus, indicated that from the experts’ viewpoint
in examining the trend of HIS innovation adoption.
"Perceived Technical Competence" was the most
Acknowledgments: This work was
important factor in the Human dimension. In the
grant from Universiti Teknologi Malaysia, the GUP
Technology dimension, the experts agreed that the
grant (Vote No.: Q.J130000.2506.09H20), K-economy.
"Relative Advantage" was more important in relation
Appreciation also goes to the anonymous reviewers
to the other factors. In addition, in the Organization
whose comments helped us to improve the manuscript.
ip t
Lee HW, Ramayah T, Zakaria N: External
factors in hospital information system (HIS)
an
judgment, "Government Policy " was the most
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Conflict of interest statement The authors of this paper declare that there is no conflict of interest. Summary Points
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To the best of our knowledge, there is no empirical study to examine the Technology-OrganizationEnvironment (TOE) and HumanOrganization-Technology (HOT) fit frameworks in the context of Hospital Information System (HIS) adoption for Malaysian public hospitals. There is no Multi-Criteria DecisionMaking (MCDM) model to examine the importance level of factors for improving the decision process of Hospital Information System (HIS) adoption. Our contributions in this study This study mainly integrates the mature Technology-OrganizationEnvironment (TOE) and recently developed Human-OrganizationTechnology (HOT) fit frameworks to identify factors that affect the hospital decision in adopting of Hospital Information System (HIS) for Malaysian public hospitals. A hybrid Multi-Criteria DecisionMaking (MCDM) model is used to address the dependence relationships of factors with the aid of Analytic Network Processes (ANP) and Decision Making Trial and Evaluation Laboratory (DEMATEL) approaches.
cr
Current state
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