Data, Informatics and Technology: An Inspiration for Improved Healthcare 269

A. Hasman et al. (Eds.)

IOS Press, 2018
© 2018 The authors and IOS Press. All rights reserved.
doi:10.3233/978-1-61499-880-8-269

Barriers for Implementation and Use of

Health Information Systems from the
Physicians' Perspectives
Somayeh MALEKZADEHa, Nasim HASHEMIa, Abbas SHEIKHTAHERIb,1 and
Niyoosha-sadat HASHEMIc
a
Iranian Social Security Organization, Tehran, Iran
b
Department of Health Information Management, School of Health Management and
Information Sciences, Iran University of Medical Sciences, Tehran, Iran
c
Islamic Azad University, North Tehran Branch, Tehran, Iran

Abstract. This study aimed to investigate barriers to the implementation and use
of health information systems (HIS) in Iran by physician's view. This cross-
sectional study was conducted in 2016 on 163 physicians employed in 10 teaching
hospitals. Data collection was carried out through a questionnaire with questions
about the technical, organizational, ethical and personal barrier categories. Data
analysis demonstrated that technical (e.g. inadequate planning for implementation
and use of HIS) (3.56±1.32), organizational (e.g. inadequate facilities for fast and
easy access to the Internet) (3.67±1.91), personal (e.g. inadequate awareness of
healthcare providers about the benefits of HIS) (3.33±1.28), as well as legal and
ethical (e.g. concern about the security and confidentially of HIS) (3.15±1.31)
were the most important barriers to the implementation and use of HIS. Reducing
barriers, especially technical and personal ones will increase the implementation
and use of HIS based on the physicians’ perspectives.

Keywords. Health Information System, Implementation, Barriers, Physicians

1. Introduction

Healthcare organizations need timely and quality information to improve quality of

services [1,2]. For this aim, the use of health information systems (HIS) is a must [2].
Despite the importance of these systems, implementation and use of these systems has
many barriers. Based on a study, lack of national information standards, concerns about
physicians’ acceptance and use, lack of national information networks, and concerns
about maintaining confidentiality of information were identified as the most important
barriers [3]. In studies in other countries, human, technical, organizational, personal,
attitude, legal, ethical, and financial barriers have been identified as the challenges of
the implementation and use of HIS [4,5]. A physician, as one of the most important
users, often resist the implementation and use of these systems, which results in
problems in implementation of these systems and also affects the quality of
information. In the studies from the physicians’ viewpoint, personal and organizational

1
Corresponding author, Abbas SHEIKHTAHERI, School of Health Management and Information Sciences,
Iran University of Medical Sciences, Tehran, Iran; E-mail: sheikhtaheri.a@iums.ac.ir
270 S. Malekzadeh et al. / Barriers for Implementation and Use of Health Information Systems

barriers were identified as the most important obstacles [6]. Different countries need to
identify such barriers first to address these challenges. Iran is one of the countries that
are in the process of implementing these systems, but there are no many studies on
these barriers. Therefore, this study aimed at to identify such barriers from the
viewpoint of Iranian physicians.

2. Method

The study was conducted in 2016. The research population consisted of physicians
(general, resident, specialist and sub-specialist) working in teaching hospitals affiliated
to two main universities of Iran (Tehran and Iran Medical Sciences universities)
including 10 hospitals. By using the Krejcie and Morgan table, 260 physicians were
randomly selected. Finally, 163 participated in the study. To collect data, a
questionnaire consisting of 29 questions was prepared based on literature review [1,6-
10]. The questionnaire contained demographic questions (4), organizational barriers (9
questions), technical barriers (9 questions), personal barriers (4 questions) as well as
legal and ethical barriers (3 questions). The questions were designed based on a 5-point
Likert scale (very little to very much) from 1 to 5, respectively. Content validity of the
questionnaire was verified by 10 experts in the field of health informatics and health
information technology and its reliability was determined by calculating internal
correlation (=0.8). In order to collect data, the researchers referred to the hospitals in
person and handed the paper-based questionnaire to physicians. They provided the
necessary explanations to answer the questions and gave them enough time to complete
it. For data analysis, SPSS16 was used for descriptive (mean and percent) and
inferential statistics. ANOVA and T-test were used to compare the means.

3. Results

The mean age was 30.2±7.3 years. 52.1% of participants were female and most of them
were general practitioner (73.1%) and had less than 5 years working experience
(80.4%). Most of them have experiences in using hospital information systems and
electronic medical records. The average work experience was 6.2±3.64. The overall
mean score for barriers was as follows: technical (3.4±0.89), personal (3.1±0.98),
organizational (3.06±0.88), and legal (3.04±1.2) (Table 1). Among the technical
barriers, the most important ones were the lack of national networks and appropriate
information systems and Internet access. Inappropriate planning and inadequate
support services were the most important organizational barriers. Inadequate awareness
of providers and their participation in system implementation as well as information
security were the most important personal and legal barriers. Physicians' opinions about
any of these barriers were not significant within age groups. Women (p=0.022) and less
experienced physicians (p=0.022) considered their legal barriers more important. Less
experienced physicians (p=0.022) considered technical barriers more important in
comparison with experienced physicians (p=0.04). General physicians considered
organizational barriers more important than residents and specialists (p=0.003).
 S. Malekzadeh et al. / Barriers for Implementation and Use of Health Information Systems 271

Table 1.Physicians’ perspectives on barriers of implementation and use of HIS

Barrier Barriers Very much Moderate Very little Mean±SD

category and much and little
Organizational Changing clinical workflows (33.7)55 (32.5)53 (33.7)79 2.87±1.19
following the use of HIS
Complexity of delivery of health (19.7)32 (25.2)41 (55.3)90 2.51±1.05
care due to use of computers
Getting new skills and (35.0)57 (32.5)53 (32.5)53 3.02±1.11
participation in new courses
Inadequate support of senior (46.0)46 (24.5)40 (29.4)48 3.29±1.28
managers
Shortage of human resources (44.2)72 (23.3)38 (36.5)53 3.19±1.27
specialized in health information
technology
Lack of efficient planning for (57.7)94 (17.2)28 (25.2)41 3.56±1.32
HIS
Inadequate maintenance, support (52.1)85 (18.4)30 (29.4)48 3.33±1.28
and updating services systems
Reduction of performance when 38(23.4) 50(30.7) (46.0)75 2.67±1.16
implementing HIS
The intangible benefits of HIS 71(43.6) 37(22.7) (33.8)55 3.10±1.34
Technical Lack of national health (56.4)92 (23.9)39 (19.6)32 3.61±1.20
information networks
Inadequate effective information (58.9)96 (19.6)32 (21.5)35 3.60±1.14
systems
Lack of fast and easy internet (58.3)95 (22.7)37 (19.0)31 3.67±1.91
access
Lack of equipment and hardware (53.3)87 (27.6)45 (19.0)31 3.52±1.17
for access to HIS
Lack of suitable software for (40.5)66 (31.1)54 (26.4)43 3.20±1.18
users’ needs
Inappropriate infrastructure to (57.6)94 (22.1)36 (20.3)33 3.53±1.22
integrate information systems
Lack of national standards for (35.6)58 (31.9)52 (32.5)53 3.04±1.21
medical vocabularies
Lack of national standards for (42.3)69 (33.7)55 (23.9)39 3.27±1.07
data exchange
Incompatibility of existing HISs (48.5)79 (20.2)33 (31.3)51 3.23±1.28
in terms of structure and content
Personal Inadequate awareness of (48.5)79 (24.5)40 (27.0)44 3.33±1.28
healthcare providers about
benefits of HIS
Unwillingness of providers to use (39.3)64 (20.9)34 (39.9)65 3.05±1.29
computers
Increasing providers’ (35.0)57 (32.5)53 (32.5)53 3.06±1.13
workloadsfor documentation
Inadequate participation of (46.0)75 (27.6)45 (26.4)43 3.27±1.20
providers in the process of
designing and implementing HIS
Legal and Concerns about the exchange of (33.1)54 (30.7)50 (36.2)59 2.96±1.28
ethical patient data and information
without informing patients
Concerns about the access of (41.1)67 (17.2)28 (41.7)68 3.02±1.34
unauthorized persons to
information
Concerns about the security and (42.3)69 (23.9)39 (33.8)55 3.15±1.31
confidentiality
272 S. Malekzadeh et al. / Barriers for Implementation and Use of Health Information Systems

4. Discussion

The technical, personal, organizational, and legal barriers are the most important
barriers for HIS, respectively. Other studies in Iran and other countries also indicated
that technical barriers were the most important barrier for electronic health records
[1,4]. The most important technical barriers were the lack of facilities for fast and easy
access to the Internet. Other studies [7,11] also described technical barriers as one of
the most important obstacles. The most important personal barrier was inadequate
awareness of providers about the characteristics and benefits of HIS that matches with
the Jabraeili study. According to him, if the benefits of HIS are shown for users, their
resistance will decrease [8]. Lorenzi mentioned the lack of willingness to learn
computer skills, imposed discipline, time wasting, and increased responsibility for
providers' resistance to use of HIS [12]. Inadequate planning for HIS was recognized as
one of the most important organizational barriers. Also, organizational barriers, after
financial and technical ones, were identified as the most important challenges for HIS
[9], which is consistent with our results. However, changing the workflows and the cost
of support in their study was the most important. Organizational barriers were also, of
great importance after technical and personal barriers [10]. In a study, organizational
barriers had more priority than technical barriers [8]. The need for extensive changes in
organizational structure, service delivery processes and managerial factors should be
considered [8]. Concerns about the security of HIS were one of the main barriers
identified in our study. This study showed that the most important barriers to the
implementation and use of HIS are technical barriers. Therefore, it is suggested that,
while developing appropriate hardware and software infrastructure, use of content and
data exchange standards to integrate HISs should also be considered. In order to
eliminate personal barriers, it is recommended to hold courses for physicians with the
aim of familiarizing them with the benefits of such systems.

References

[1] N. Mirani, H. Ayatollahi, H. Haghani, A Survey on barriers to the development and adoption of electronic
health records in Iran, Journal of Health Administration 15 (2013), 65-75.
[2] M.J. Ball, Hospital information systems: perspectives on problems and prospects, 1979 and 2002,
International Journal of Medical Informatics 69 (2003), 83-89.
[3] J. Haughom, S. Kriz, D.R. McMillan, Overcoming barriers to EHR adoption [Online], 2006. Available
from: URL:http://www.hfma.org/Templates/InteriorMaster.aspx?id=27523/
[4] R. Hasanain, K. Vallmuur, Progress and challenges in the implementation of electronic medical records
in Saudi Arabia: A systematic review, Health Informatics- An International Journal 3 (2014), 1-14.
[5] V. Palabindala, A. Pamarthy, N.R Jonnalagadda, Adoption of electronic health records and barriers,
Journal of Community Hospital Internal Medicine Perspectives 6 (2016), 1-3.
[6] A.S. McAlearney, J.L.Hefner, C.Sieck, M.Rizer, T.R.Huerta, Fundamental issues in implementing an
ambulatory care electronic health record, Journal American Board Family Medicine 28 (2015), 55-64.
[7]M. Thakkar, D.C. Davis, Risks, barriers and benefits of electronic health record systems: a comparative
study based on size of hospital, Perspectives in Health Information Management 3 (2006), 1Ǧ19.
[8] M. Jebraeily, et al., Barriers of electronic health records implementation, H Inf Manag 8 (2012), 807-14.
[9] C.S. Kruse, C. Kristof, B. Jones, E. Mitchell, Barriers to electronic health record adoption: a systematic
literature review, Journal of Medical Systems 40 (2016), 252.
[10] A. Ameri, et al., Barriers to implementing electronic health records from the perspective of
administrators and hospital managers in Kerman, Journal of Health Administration 69 (2017), 19-30.
[11] M. Amatayakul, EHR? Assess readiness first, Healthcare Financial Managers 59 (2005), 112Ǧ113.
[12] N.M. Lorenzi, R.T. Riley, N.A. Dewen, Barriers and resistance to informatics in behavioral health,
Studies in Health Technology and Informatics 84 (2001), 1301-1304.