International Journal of Engineering & Technology, 7 (1) (2018) 1-18

International Journal of Engineering & Technology

Website: www.sciencepubco.com/index.php/IJET
doi: 10.14419/ijet.v7i1.8404
Research paper

An evaluation model for the implementation of hospital

information system in public hospitals using
multi-criteria-decision-making (MCDM)
approaches
Ali Aliakbar Esfahani 1, Hossein Ahmadi 2,*, Mehrbakhsh Nilashi 3,7,*, Mojtaba Alizadeh 4,*, Azadeh Bashiri 5,
Mohsen Abbasi Farajzadeh 1, Leila Shahmoradi 5, Mohammad Nobakht 1, Hamid Reza Rasouli 6
1 Marine Medicine Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
2
Department of Health Information Management, School of Health Management and Information Sciences,
Iran University of Medical Sciences, Tehran, Iran
3 Faculty of Computing, Universiti Teknologi Malaysia, 81310 Skudai, Johor, Malaysia
4 APA Research Center of Lorestan University (LU-CERT), Lorestan University, Khorramabad, Iran
5 Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
6 Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
7 Department of Computer Engineering, Lahijan Branch, Islamic Azad University, Lahijan, Iran

*Corresponding author E-mail: ahmadi.h@iums.ac.ir, hosseinis3007@gmail.com, malizadeh@ieee.org, nilashidotnet@hotmail.com

Abstract

Background: Hospital Information System (HIS) is implemented to provide high-quality patient care. The aim of this study is to identify
significant dimensional factors that influence the hospital decision in adopting the HIS.
Methods: This study designs the initial integrated model by taking the three main dimensions in adopting HIS technology. Accordingly,
DEMATEL was utilized to test the strength of interdependencies among the dimensions and variables. Then ANP approach is adapted to
determining how the factors are weighted and prioritized by professionals and main users working in the Iranian public hospitals, in-
volved with the HIS system.
Results: The results indicated that “Perceived Technical Competence” is a key factor in the Human dimension. The respondents also
believed that “Relative Advantage," “Compatibility” and “Security Concern” of Technology dimension should be further assessed in
relation to other factors. With respect to Organization dimension, “Top Management Support” and “Vendor Support” are considered
more important than others.
Conclusion: Applying the TOE and HOT-fit models as the pillar of our developed model with significant findings add to the growing
literature on the factors associated with the adoption of HIS and also shed some light for managers of public hospitals in Iran to success-
fully adopt the HIS.

Keywords: Adoption Model; Iranian Public Hospitals; TOE Framework; HOT-Fit Model; ANP; DEMATEL.

HIS in providing high-quality patient care has been developed [4,

1. Introduction 9, 11-14]. Therefore, implementation of HIS becomes funda-
mentally crucial in making the right diagnostic, treatment and
Rapid changes in the healthcare delivery system throughout the administration requirements, and thereby delivers better patient
world have been possible by the advancement of Information care and support to clinical decision making [15-17]. Even
System (IS). The increasing attention has been given to imple- though the HIS has brought the immense change to process of
menting a Hospital Information System (HIS) in hospitals, par- care delivery, it has attempted to increase the quality and safety
ticularly on the need to consider the acceptance and usage of of care [1], [9], [18-20]. However, compared to other technolo-
HIS among healthcare professionals[1, 2]. Hospitals by adopting gies in the healthcare domain, the acceptance level of HIS is low
Information Technology (IT) applications such as HIS would [5], [17], [21-24]. HIS can support patient care planning and
gain the great benefit, ranging from medical systems to admin- enhance decision making of clinical or administrative functions.
istration systems. HIS is broadly employed in the hospitals Besides, there are some limitations in the clinical practice that
around the world [3-8]. HIS was introduced in the 1960s to sup- are being addressed via the HIS implementation [5], [25-31]. As
port hospital’s financial services [9]. Subsequently, in the 1980s, an example, HIS systems used by nurses are able to control and
it was used in clinical services where a large amount of laborato- track carefully the patient’s care in an electronic manner. Addi-
ry examination data was stored electronically [10]. Since the tionally, nursing documentation as a chief clinical activity, stand
HIS assists healthcare providers to streamline the flow of pa- to obtain a benefit from HIS [5], [24], [32-36]. Thus, it is imper-
tients’ information and its accessibility, the significance of the ative that HIS is designed to address the needs of main users in
Copyright © 2018 Ali Aliakbar Esfahani et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 International Journal of Engineering & Technology

optimally coordinating user activities. At this time, IT priorities 2.3. Innovation adoption in organizations
serve to alleviate medical errors, upgrade in-patient clinical
systems and implementing HIS in the hospitals [33], [37-39]. Organizational innovation has been generally defined as an idea,
Although the potential benefits of HIS in public hospitals are system, practice, product or technology that is perceived as new
highlighted, no comprehensive theoretical assessment of HIS by an adopting organization [49], [53], [54], [57], [58]. A type
implementation in Iranian public hospitals has been done. Iran is of innovation may be novel for an individual adopter, the major-
a developing country that introduces national plans, including ity of individuals at that unit of adoption, for the entire organiza-
SEPAS and TAKFAB as well as organizational e-Health pro- tion, and for the majority of organizations in the population of
jects, for instance, HISs in hospitals that are under development. an organization or for all the world [59], [60]. Consequently,
According to several authors in Iran [22], [35], [40-44], the chal- innovation has been studied at various levels [60], [61]. The
lenges of HIS implementation in Iran related to some fundamen- present study focuses on innovation through HIS at the organi-
tal issues of Human, Technology and Organization. Hence, this zational level. Thus, following the above, HIS can be considered
study is aimed to propose a strategic integrated theoretical mod- as innovation for hospital’s organization, if the hospital organi-
el to serve in guiding a proper and successful HIS implementa- zation perceives HIS as new. Hence, the organizational innova-
tion within public hospitals. Considering that there are no com- tion theories can be potentially useful to this research develop-
prehensive studies on the HIS adoption maturity model and ment of a new model of HIS adoption. Generally, studies on
professional knowledge in this area with regard to Iranian public technology adoption and diffusion in the area on IS are conduct-
hospitals, this study was designed based on two mature theories ed in two levels, user level and organizational level [22], [62],
to identify the significant dimensional factors of HIS adoption [63]. Furthermore, the stage of adoption and the context of study
and their important interrelationship in two different public hos- should be carefully paid attention to, especially in the technolo-
pitals and also to provide some suggestions to enhance their HIS gy and innovation adoption studies [62], [64]. This study is
implementation. Hence, the questions that guide us to achieve based on the organizational innovation, which is intended to
the main study goal, are: (a) what significant factors can affect seek potential dimensional factors that can influence the HIS
the decision to adopt the HIS based on TOE and HOT-fit model? adoption by Iranian public hospitals. Hence, the organizational
(b) What is the appropriate theoretical model that can be used to innovation theories and models along with the existing HIS
ease the HIS adoption? And (c) what Multi Criteria Decision- literature might help to achieve identifying these significant
Making (MCDM) model is appropriate to weigh and prioritize factors that affect the HIS adoption in the context of public hos-
the factors for HIS adoption in Iranian public hospitals? pitals.

2. Literature review 2.4. Adoption theories in IS domain

Studies on technology adoption of innovation have been a long

2.1. HIS definition source of research across various IS domains. Historically,
adoption/diffusion theories have a similarity in content and ob-
Several definitions have been provided pertaining to the HIS. jectives, but some differences exist in practice [65-67]. The
According to the National Library of Medicine [45], HIS is “the purpose of theories of adoption in IS discipline is to understand,
integrated, computer-assisted system designed to keep, manipu- explain, or predict how, why and to what extend individuals or
late, and retrieve information concerned with the administrative organizations will adopt and decide to deploy a new technology
and clinical aspects of providing medical services within the [16]. In the broadest sense, adoption theories describe the signif-
hospital.” In addition, according to Ismail et al. [21], HIS is icant factors influencing technology adoption by individuals or
defined as a computer system by which the whole administrative organizations. Thus, adoption theories are aimed at recognizing
and medical data of a hospital is managed to make the career of and examining all these determinants [68]. In contrast, diffusion
health experts well-organized and operational. In another defini- innovation theories illustrate how an innovation can spread
tion by Kim [46, 47], HIS has been defined as “a designer com- throughout a population over time [65]. According to Wolfe
puter system devised to enhance the clinical and administrative [69], in previous studies related to IS, several theories and mod-
functions of a hospital.” He further added that “HIS is required els on innovation have been determined and used in various
by the nature of its function to be integrated, and hence is re- situations. Major differences can be observed with respect to the
ferred to an integrated hospital information processing system.” level of analysis such as individual level versus organizational
Referring to several definitions of HIS, the present research level, unit of analysis such as individual versus the innovation
defines HIS as a comprehensive, integrated information system versus the organization, and the outcome variable such as use
designed to enhance clinical, financial and administrative func- versus adoption. Given the aim of this study, several theoretical
tions of a hospital. models have been assessed on their applicability in investigating
factors that have effects on HIS adoption in the context of hospi-
2.2. Adoption of HIS tal organization. Several adoption/diffusion theories in IS re-
search have been proposed to make the understanding of factors
The term, adoption is about the decision of any individual or affecting adoption and acceptance of particular technologies
organization to make use of innovation [48-54]. In the organiza- easier. In general, the researchers have investigated two levels of
tional context, adoption is associated to admit a innovation for innovation adoption: the individual and the organization. At the
implementation [55]. In addition, in terms of technology adop- individual level, Technology Acceptance Model (TAM)[70],
tion in the organizational context, Gallivan [56] and Lin et al. Theories of Planned Behavior (TPB) [71], Unified Theory of
[56] defined adoption as employing a new technology in organi- Acceptance and Use of Technology (UTAUT) [69] and Rogers’
zational work and encouraging employees to oblige in applying early diffusion of Innovation (DOI) theory [49] are the most
the technology. As such, in terms of the research topic, adoption commonly-used adoption/diffusion theories in IS research [65],
refers to the decision of employing HIS in the public hospital [72], [73]. Although such models are very useful and important,
work practices and encouraging healthcare professionals to ap- their main focus is on users (individual-level) as well as techno-
ply HIS. logical attributes, while they fail to consider the attributes relat-
ed to organization [69]. In particular, the first three theoretical
models can only be used at individual-level [69], whereas DOI
theory can be used at an individual level as well as at the organi-
zational level [74], [75]. At the organizational level, the most
International Journal of Engineering & Technology 3

frequently used adoption theoretical models, Diffusion of Inno- health information systems, this framework has not been scruti-
vation (DOI) theory [81] as well as a Technology-Organization- nized within the domain of HIS adoption by Iranian public hos-
Environment (TOE) framework [76] are most widely used [72]. pitals, particularly in two cities of Bandar Abbas and Qeshm.
DOI theory has been frequently employed to investigate drivers According to the above discussion, DOI and TOE are the most
of innovation adoption, since it can be used at an individual commonly-used adoption theories in the IS discipline with re-
level as well as at the organizational level [60], [74]. More atten- spect to the organizational innovation adoption. As such, the
tion has been given to TOE framework and it is accepted from researcher in this study examines their ability to explain the HIS
diverse fields of study as it creates Rogers’ DOI theory more adoption.
capable of explaining organizational innovation adoption by
including an important novel component of environmental di- 2.4.1. Technology-organization-environment framework
mension [72], [77]. A lot of research works which have empiri-
cally examined the TOE framework, revealed that the TOE The TOE framework as presented by Tornatzky and Fleischer
framework importantly helped to understand the adoption of [22], gives a proper analytical framework that is applied for
technological innovations [12], [54], [72], [73], [78], [79]. In examining the organizational adoption of diverse types of inno-
many noticeable researches conducted based on TOE framework, vations [72], [81]. This framework has focused on analysis of
factors, which are crucial in information system’s adoption were organizational level that is as a lens to predict an adoption deci-
carefully investigated. This is also the case for different health sion of technology. It covers three different dimensions. They
information systems [48], [72], [73], [78], [80]. However, re- are described as technology, organization and environment. As
garding the context of sensitiveness and complexity of technol- illustrated in Fig. 1, the three dimensions interact with each oth-
ogy adoption, different factors in TOE framework may vary er, and influence decision-making about technological innova-
across different innovation and adoption contexts [73], [76]. tion adoption.
Consequently, even though there are various studies adopted
TOE framework for investigating organizational adoption of a

External task envi- Organization

ronment
Formal and informal
Industry characteris- linking structures
tics and market Communication
structure processes
Technology support
infrastructure Size

Government regula- Technological Slack

tion
Innovation Deci-
sion Making

Technology
Availability
Characteristics

Fig. 1. The TOE Framework [117]

Technological Dimensions describe new/current and exter- work that is applicable and has the explanatory power through-
nal/internal technologies, which are related to organizations (e.g., out various contexts. It has been applied to understand the adop-
compatibility, complexity, and relative advantage). Technologi- tion of many IS applications or technologies such as inter-
cal Dimensions consist of both technologies to be adopted and organizational systems, e-business, electronic data interchange,
existing technologies, and primarily emphasizes on the way that open systems, and enterprise systems. However, each study used
adoption process is affected by the technological characteristics slightly different factors as measures for each of the frame-
[70]. The organizational dimension provides a description of work’s dimensions [5], [73], [83]. In addition, according to Ta-
characteristics of an organization that facilitates or constrains ble 1, it can be demonstrated that in order to explain the adop-
the adoption of technological innovations. The amount of slack tion of several diverse IS innovations; TOE framework can suc-
resources available internally, the qualities of human resources, cessfully be utilized. Likewise, the TOE model was applied and
top management support, organization structure, and firm size tested in Asian, European, and American, in addition to both
are the instances of organizational characteristics. The external developed and developing countries [73], [83-85]. To all intents
environmental dimension concentrates on firm environment that and purposes, the experts generally agree on the three TOE di-
belongs to different stakeholders with which it interacts. TOE mensions suggested by Tornatzky and Fleischer [76], including
framework has been employed by many empirical studies to the effect of environment, organization and technology adoption.
better understand the organizational decision of IS adoption (see However, they asserted that a set of measures or factors for eve-
Table 1). Those studies identify different significant adoption ry certain dimension or technology under research are irreplace-
factors pertaining to the three dimensions of the TOE framework able.
that are summarized in Table 1. DOI theory and TOE frame-
work are largely compatible. TOE framework does not only
consist of technological dimension that is parallel to the one
category in Rogers’ model. It also has two significant and inno-
vative components: an organizational and environmental dimen-
sions. Rogers’ DOI theory provides a more inclusive description
of organizational innovation adoption through TOE framework
[48], [72], [77], [82]. There is much evidence of TOE frame-
4 International Journal of Engineering & Technology

Table 1: Research Using TOE Framework in IS Domains 2.4.1.1. Critical analysis of TOE framework in the domain of
Dimensional Fac- Frequency & Rela-
Author(s) health information systems
tors within TOE tionship direction
Technology By using the TOE framework [96], succeeding the IS adoption
[23, 32, 73, 54, 15, 93, in the context of healthcare industry on many circumstances
Relative Advantage 10 (+)
45, 64, 133, 143]
becomes easier [17], [25], [87-93]. In this regard, within the
Compatibility 6 (+) [23, 73, 93, 35, 64]
[93, 35, 78, 60, 10, 44, healthcare context, Chong and Chan [94] believe TOE frame-
Complexity 6 (+) work is powerful enough to clarify the notion of Radio Frequen-
143]
Trialability 1 (+) [23] cy Identification (RFID) adoption. Additionally, Liu et al. [95]
Perceived Barriers 1 (-) [12, 13] in Taiwanese care institutions applied the TOE framework to
Perceived Risks 2 (-) [42, 91] have been understanding and accelerating the process of telecare
Organization adoption. Furthermore, TOE framework was found as meaning-
[90, 7, 52, 38, 103, 83, ful and effective to identify the factors affecting the e-signature
IS Infrastructure 8 (+)
13]
adoption within a hospital setting [88]. Lian et al. [91] and Ah-
Size 6 (+) [93, 78, 106, 53, 89, 72]
Top Management madi et al. [5], [12] also strongly believed that TOE framework
6 (+) [9, 77, 49, 89, 78, 133] is a potential lens that can appropriately analyze the context of
Support
Satisfaction with hospital technology adoption. Authors applied this framework to
1 (-) [12, 13]
existing Systems explore the significant dimensional factors influencing the HIS
Financial Resources 3 (+) [32, 23, 54, 143] adoption in the context of Taiwan and Malaysia, respectively.
Environment Considering technology adoption that is sensitive to setting and
Business Competi- very complicated several factors in TOE framework may vary
4 (+) [78, 54, 108, 35, 133]
tion
across different innovation and adoption contexts [73], [76]. In
Government
Policy
3 (+) [10, 54, 108] our study, health information system’s works were reviewed
Market Uncertainty 1 (+) [12, 13] with respect to the hospital setting and hospital innovation adop-
Customer Readiness 1 (+) [106] tion based on TOE framework, hence. Table 2 was presented.
Vendor Support 1 (+) [78] Based on particular circumstances and various requirements of
healthcare context, the potential variables for those dimensions
According to Table 1, certain factors which are suggested to be of TOE, including the technology, organization and environment
associated to three dimensions are dissimilar as discovered in were assessed. In this table, factors that empirically influenced
various researches. However, there is a reliable empirical sup- on the healthcare IS innovation adoption is shown, in which
port for the TOE framework. Fichman [86] reviewed available asterisk indicates the most influential factors, plain text men-
research on IS adoption, and found out that organizational adop- tions the factors for which partial supports were found, and italic
tion of IS innovation is affected by those three characteristics. shows the factors that were not statistically important.
Therefore, TOE framework can be considered a suitable inclu-
sive theoretical guide that can help organizations to explore the
factors having impacts on implementation of IS innovation.

Table 2: The Utilization of TOE Framework in a Hospital Information System Domain

Author(s) Hospital Technology Technological Dimension Organizational Dimension Environmental Dimension
Business competition*,
Cost benefit, mobile devices
Mobile Nursing Top management support, project team ’s government policy sup-
Hsiao et suitability, wireless communica-
Information Systems capability, user involvement and coopera- port, external supplier‘s
al. [39] tion suitability, the extent of
(MNIS) tion, championship, internal needs* support*
integration with HIS,
Chang et System complexity, security User involvement, adequate resources*, Vendor support*, gov-
Electronic signature
al. [10] protection hospital size*, internet need ernment policy*
Picture Archiving
Chang et Cost of PACS, compatibility, Centralization, formalization, high-level Business competition,
and Communication
al. [11] benefits of PACS* manager support* governmental policies*
System (PACS)
Lee and Vendor pressure, perceived bene- Performance gap*, market
RFID Presence of champions*
Shim [57] fits* uncertainty*
Hospital type, hospital ownership, hospital
Government involve-
size, internal needs*, resource availabil-
Technology readiness/receptivity, ment*, vendor partner-
Yang et al. Healthcare infor- ity*, technological knowledge*,
relative advantage*, complexity*, ship*, business competi-
[102] mation systems knowledge management capabilities,
compatibility* tion pressure, country
project team capability*, top management
wealth
support*
Push of the environment,
Staff‘s technological capability*, hospi- environmental pressure*,
Lin et al.
HL7 System integrity*, security tal‘s scale*, top management, attitude pull of the environment
[61]
toward HL7*

Business competition,
Ahmadi et Relative advantage*, complexity, Centralization, formalization, size*, infra-
HIS vendor support, govern-
al. [110] compatibility structure, top management support
ment policy*
Nilashi et Relative advantage, complexity*, Infrastructure, top management support, intensity of competition,
HIS
al. [123] compatibility*, security concern hospital size, financial resources vendor support*
Ahmadi et Relative advantage*, complexity, Infrastructure, top management support,
HIS Vendor support*
al. [122] compatibility*, security concern* hospital size*, financial resources

Considering the studies shown in Table 2, applying TOE within the context of HIS adoption. These studies are based on
framework in several researches on health information systems circumstances and various needs of the hospital’s organization
adoption, demonstrates the possibility of fitting TOE framework according to the technology, organization, and environment
International Journal of Engineering & Technology 5

dimensions. In addition, Table 2 attempts to show noteworthy information systems. This research examines the effect of hu-
prior studies that used TOE framework related to the context of man resources in the adoption of HIS. According to the afore-
HIS with focusing on the adoption decision process of mentioned discussions, HOT-fit model may be entirely a suita-
healthcare organizations. Furthermore, factors related to those ble model in this study applied to assess and determine the rele-
dimensions have an important role in facilitating or inhibiting vant factors affecting the decision process of HIS adoption with-
the decision to adopt an innovation in hospital organizations. in public hospitals regarding a developing country, Iran.
Nonetheless, dimensional factors are measured in their own way
based on different needs and definite components of HIS in each 2.5. Main drivers and barriers of the HIS adoption
of those studies.
The research model developed in this study requires being com-
2.4.2. Human-organization-technology fit model prehensive for examining drivers and barriers of HIS adoption in
the hospital context; thereby covering dimensional variables that
Research conducted on adoption of health information technolo- are crucial. Regarding the technology adoption context, some
gy stressed on a large number of adoption complications that previous studies approached to identify major dimensions and
emanated from lack of fit between technological, human and variables that have a significant role in ensuring the successful
organizational contexts [5], [96-99]. Recently, Yusof et al. [100] adoption behavior [15], [17], [25], [80], [91], [96], [105]. Hence,
and Yusof et al. [101] identified the important dimensions assuming this study and the results achieved from a review of
through conducting a rigorous evaluation of health information relevant research, the comprehensive dimensions and variables
system adoption. Through evaluating the results of IS assess- are included to investigate the adoption of IS in the healthcare
ment research and health information system, the authors de- domain, particularly hospitals. Table 3 lists dimensions and
fined and designed a new general model based on human, organ- variables extracted from the TOE framework and HOT-fit mod-
ization and technology dimensions. Fig. 2 shows the HOT-fit el based on the prior innovation and HIS empirical studies re-
model. The dimensions addressed technological, human and garding the adoption context.
organizational issues. Table 3 shows the prior empirical studies pertaining to the HIS
context that used the TOE and HOT-fit theoretical model to
Human assess the effects of respective variables on HIS adoption.
Hence, possible articles related to HIS have been retrieved and
read. Variables which can have a strong effect on the process of
adoption of HIS pertaining to each dimension of technology,
Organization organization, and human were sought and depicted. Thus, it can
be said that HIS adoption has been mostly affected by those
dimensional factors. However, the measures were different for
Adoption of Innovation each study using the generic theories of organizational innova-
tion adoption. Therefore, by investigating and looking at empiri-
cal studies of HIS adoption that used different theories, we carry
out theoretical dimensional factors in the process of developing
the conceptual model for HIS adoption in Iranian context. Au-
thors in this study believe that the three dimensions, including
Technology technology, organization, and human are well suited in this re-
search for studying the HIS adoption by public hospitals in Iran.

Fig. 2: HOT-Fit Model [126].

3. Materials and methods
Yusof et al. [101] suggest that HOT-fit model is flexible that can
be employed to analyze and assess different phases of the sys- To perform this study, two public hospitals of Iran in Bandar
tem development life cycle in developed and developing coun- Abbas and Qeshm cities were selected. These hospitals imple-
tries. Theirproposed framework contains comprehensive dimen- mented minor components of HIS. This research was performed
sions and measures. Yusof et al. indicate that HOT-fit model in two rounds. During the first round, different reliable data-
can be deployed both by practitioners and researchers to effec- bases with the thesaurus terms "hospital information system,"
tively assess the IS applications adoption in the healthcare cen- "adoption," "implementation," “TOE framework," and “HOT-fit
ters. Most of the previous HIS researches have emphasized models" were searched. These databases include MEDLINE,
technical issues that direct success or failure of HIS in certain IEEE, Emerald, Elsevier, and PubMed. We limited the search
context and with certain user [5], [12], [91], [96], [102], [103]. year from 2000 to 2017. In the second round and after identify-
Kilsdonk et al. [104] noted that adopting healthcare information ing the potential dimensional factors that affect hospital's adop-
systems in hospital setting is the most important emphasis of tion decision of HIS in public hospitals, we evaluated the identi-
HOT-fit model. Ahmadi et al. [5] provided evidences about the fied dimensional factors using Dematel and ANP techniques to
importance of HOT-fit to lead the successful adoption of HIS in find the significant result. We used convenient sampling, and the
the context of Malaysia. In line with this, Yusof et al. [100] main selection criteria were based on the feasibility of data
classified human into user involvement, clarity of system pur- gathering from hospital's staffs and their potential to share the
pose, user skills, user roles, user perception and user training. required information. The data were collected from the 19 of
These factors pertain to the human context, which their effects February till 15 of March.
have been measured on the organizational adoption of health
6 International Journal of Engineering & Technology

Table 3: Summary of Variable's Results by Theories/Models with Respect to HIS Adoption

Dimensions/Variables

Technology Organization Human

Relative Advantage

Compatibility

Complexity**

Security Concern**

IS Infrastructure

Vendor Support

Top Management Support

Financial Resources
Staff
Perceived Technical Competence of IS
Employees’ IS Knowledge
Hospital Innovation/
Author(s) Theories/Models Used
Technology Studied

Vital signs monitoring

Yang et al. [102] TOE √ √* √*
System √* √* √*
Hsiao et al. [39] MNIS TOE √ √* √ √*
Lin et al. [61] HL7 TOE √* √* √ √ √* √*
Chang et al. [10] E-signature TOE √ √ √* √* √*
Chang et al. [11] PACS TOE √* √ √*
Lee and Shim TOE (need pull & technology
Hospital RFID √*
[57] push)
Health cloud compu-
Lian et al. [60] TOE+HOT-fit √ √* √ √* √* √*
ting
* Empirical significant factors
** Barriers to HIS adoption

Table 3: Summary of Variables Results by Theories/Models with Respect to HIS Adoption (Continued)

Dimensions/Variables

Technology Organization Human

Relative Advantage

Compatibility

Complexity**

Security Concern**

IS Infrastructure

Vendor Support

Top Management Support

Financial Resources
Staff
Perceived Technical Competence of IS
Employees’ IS Knowledge
Hospital Innovation/ Theories/Models
Author(s)
Technology Studied Used

Li et al. [59] Mobile nursing technology TOE √ √

Hung et al. [44] Hospital CRM system TOE √* √ √* √* √*
Liu [62] Telecare TOE √ √ √* √
Marques et al.
Medical Records System TOE+HOT-fit √ √*
[69]
Ahmadi et al.
THIS TOE √ √ √ √ √ √* √* √
[109]
Ahmadi et al.
HIS TOE+HOT-fit √* √ √ √ √ √ √ √
[110]
Ahmadi et al.
HIS TOE+HOT-fit √* √* √ √* √ √* √ √ √ √
[122]
Human Resource Information System
Alam et al. [142] TOE+HOT-fit √ √ √ √* √* √*
(HRIS)
Alharbi et al. Cloud based hospital information sys-
TOE+HOT-fit √ √ √ √ √ √ √ √
[144] tem
* Empirical significant factors
** Barriers to HIS adoption
sight into the HIS adoption and served as an important function
3.1. Proposing an integrated hospital information sys- by informing the development of an integrated HIS adoption
tem adoption model model. The literature about health and innovation adoption was
explored further to investigate the roles of these findings in de-
The findings of the existing-related literature based on TOE and termining the behavior of innovation adoption. In addition, those
HOT-fit theoretical model with an attempt on reflection to the dimensional factors were found based on the existing literature
prior hospital innovation adoption studies, provided a great in- review of hospital innovation adoption in the hospital context of
International Journal of Engineering & Technology 7

Iran and other countries. Therefore, this would help a researcher 3.2.1.1. Relative advantage of HIS
to develop an initial model for HIS adoption. The next section
presents the initial integrate theoretical model for HIS adoption. Hung et al. [92] conducted a study within the context of HIS to
Fig. 3 illustrates an initial integrated theoretical model for adop- determine the role of factor relative advantage on its adoption.
tion of HIS. The authors found out the more enthusiasm the hospital would
have in HIS adoption, if advantages realized from adopting HIS.
3.2. An initial integrated theoretical model for his Furthermore, Lin et al. [106] investigate the adoption of Health
adoption Level Seven (HL7) and found out that using HL7 simplifies
communication interfaces and permits the interoperability
Fig. 3 illustrates an initial integrated theoretical model for adop- among heterogeneous healthcare application. According to
tion of HIS. The initial model is proposed through enfolding Chang et al. [88] and Ahmadi et al. [5], within hospital's envi-
literature within a hospital’s context. Moreover, the model is ronment, operating costs have become a big concern as competi-
founded by two theories, including TOE framework and HOT- tion among hospitals are being increased. IDT offers that rela-
fit model. In this model, the factors of and the barriers to HIS tive advantage of an innovation positively affects an organiza-
adoption are categorized into three dimensions, which are Tech- tion’s propensity to adopt an innovation.
nology, Organization, and Human. As shown in Fig. 3, Relative
Advantage, Compatibility, Complexity and Security Concern 3.2.1.2. Compatibility of HIS
are categorized as the Technological Dimension. IS Infrastruc-
According to Rogers [49], compatibility refers to “the degree to
ture, Top Management Support, Financial Resources and Ven-
which an innovation is perceived as consistent with the values,
dor Support are categorized as the Organizational Dimension.
experience and needs of potential units of adoption.” Innovation
Finally, Perceived Technical Competence of IS Staff and Em-
Diffusion Theory (IDT) explains that the adoption of an innova-
ployees’ IS Knowledge are grouped as the Human Dimension to
tion is highly depended on higher compatibility of an innovation
accelerate the adoption of HIS. However, the researcher found
with values, experiences, and needs of an organization. Nilashi
that the barriers to HIS adoption are mainly related to technolog-
et al. [25] believed that compatibility is a crucial factor affecting
ical dimension, which are the complexity and security concern.
the decision of an organization to adopt HIS adoption of Malay-
3.2.1. Technological dimension sian public hospitals. In a study conducted by Ahmadian et al.
[40] regarding the implementation of HIS innovation in two
Technological Dimensions are about the innovation characteris- academic and non-academic hospital’s context of Iran, most
tics intensively influencing the adoption which various studies respondents expressed the compatibility of HIS was low, which
of IS innovation have used it [49]. Most of the innovation char- related to system characteristics of the system task. The authors
acteristics that highlighted and emphasized in the prior HIS described this as a major barrier in HIS system implementation.
studies, include relative advantage, compatibility, complexity To being consistent with results of former IS innovation re-
and security concern [5], [26], [87], [106-109]. searchers and more emphasized by prior HIS adoption studies,
perceived high level of compatibility positively has a significant
effect on the innovation adoption process [40], [42], [110].

Technological context Organizational context

Relative advantage IS infrastructure

Compatibility Top management support

Financial resources
Complexity HIS Adoption

Vendor support
Security concern

Human context

Employees’ IS knowledge

Perceived technical compe-

tence

Fig. 3: The Initial Integrated Theoretical Model and Hypotheses.

8 International Journal of Engineering & Technology

3.2.1.3. Complexity of HIS Zhu et al. [126], regarding the technical context, there is less
developed IS infrastructure within organizations in developing
According to Rogers [49] complexity refers to “the degree to countries. As an example, in Pakistan, hospital sector faces a
which an innovation is perceived as relatively difficult to under- barrier of IS infrastructure, which finds difficulty in obtaining a
stand and use.” Jahanbakhsh et al. [22], [78] emphasized that suitable software and hardware [126]. Additionally, Ismail et al.
HIS importance becomes clear when the great complexity of [21] surveyed several tertiary public hospitals in Malaysia to
health system and the huge number of interventions that each identify the issues and challenges in the development of HIS.
patient faces, the high errors in healthcare organizations. Today, They found that infrastructure issue should be considered as
technological complexity and managing more patients with less- well within the country. Accordingly, it is imperative that IS
er resources are come from recent environment of medical in- infrastructure be investigated in the context of Iranian public
volving with its IT base, and hence, causing medical staffs and hospitals to see its effect on the adoption of HIS technology.
professionals with higher demands [111]. Due to the lack of
skills and knowledge of IS innovations within organizations, the 3.2.2.2. Top management support
perceived complexity of an innovation easily causes resistance,
and therefore, has been a critical concern in adopting the deci- On an attempt to review the prior empirical studies of health
sion process [112-115]. Based on studies that applied TOE to innovation adoption of Ahmadi et al. [12], it was indicated that
examine the adoption process of an innovation, complexity is the frequent role of top manager’s support has a positive effect
negatively associated with the adoption of IS innovation [42]. to change the attitude of the organization towards adopting the
HIS innovation. In addition to that, Thong and Yap [127] assert-
3.2.1.4. HIS security concern ed that the attitude of top managers influences the innovative
technology adoption, particularly when they understood ad-
Data security, in the healthcare environment, is one of the con- vantages and disadvantages of IT and knowledge or experiences
cerns regarding adoption of a health information systems [116], in IT.
[117]. According to Lin et al. [106], information security and Top management support realized to be vital for the introduction
accuracy should be taken into consideration by the healthcare of PACS innovation in Taiwanese hospital's context [88]. In this
provider, attempting to punish any possible errors. This is be- regard, Chang et al. [88] believe top manager’s support im-
cause medical behavior is closely linked to a patient’s personal portantly influences the PACS adoption decision. Yang and Lim
life or privacy and safety. Sulaiman [118] in Malaysia conduct- [80] and Ahmadi et al. [12], stressed the importance of top man-
ed a case study in equipped HIS public hospital. She found that agement in allocating the sufficient resources (financial and
due to the fear of the breach of patient’s privacy during data other sources) for the purpose of adopting vital sign monitoring
transaction, the level of HIS security concern has been high. system and HIS technologies, respectively. Accordingly, it is
Additionally, Luxton et al. [107] believe that security problem is crucial to understand the relationship between sufficient
the most important barrier in the context of a distribute envi- knowledge or experience of top managers and HIS technology
ronment of healthcare affecting technology adoption. Hospitals adoption. Hence, it is concluded that hospitals with high support
are more exposed to this problem where the data requires more of top management regarding HIS, have more willingness in
secured environment for storage and retrieval [91], [119]. Ja- adopting it.
hanbakhsh et al. [22] investigated the factors affecting the suc-
cessful utilization of e-health technology with regard to HIS, in 3.2.2.3. Financial resources
several Iranian public hospitals. They found that mechanisms of
IT security protection are lacked and also there are familiarities One of the popular antecedents to IS diffusion is financial re-
of staffs with standards of IT security such as ISO/IEC 27001. sources [83], [128]. In the same line, one of the strongest predic-
In addition, in other studies of technological innovation in the tors for successful adoption and implementation is sustainable
healthcare, security concern has been one of the critical factors funding available for implementing and continuing an innova-
that inhibit the process of adoption decision in the healthcare tion [129]. Previous studies strengthen that calculating return on
context [22], [109], [120-122]. Thus, in our research, this com- investment, high costs, and sufficient financial resources are a
ponent is taken to be assessed. critical element of HIS technology adoption [87], [130]. Sulaim-
an [118] indicates that financial resources have been reported to
3.2.2. Organizational dimension be the main reason of why the assimilation of HIS is slow and
unsuccessful, within public hospitals in Malaysia. In addition,
Characteristics of an organization can affect the technological the importance of financial resources in the context of various IS
innovation adoption of an organization [76], [91]. According to adoption context, has been highlighted. For example, MacKay et
TOE [76], three dimensions that affect the adoption of techno- al. [131] determined that financial resources can positively in-
logical innovation with regard to organizational dimension are fluence the organizational decision in establishing a website.
IS infrastructure, top management support, vendor support, and Another example is Chang et al. [10] emphasizing that financial
financial resources. resources available in the hospital’s organizations highly affect
e-signature adoption. Thus, hospitals require a long-term plan
3.2.2.1. IS infrastructure for obtaining financial resources in terms of IT budget to facili-
tate HIS implementation.
IS innovation literature strongly suggesting that technological
strength has a crucial role in adopting any kinds of technological 3.2.2.4. Vendor support
innovation [123], [124]. IS infrastructure, including tangible
resources, namely infrastructure components such as hardware Sulaiman and Wickramasinghe [118] and Ismail et al. [21]
and software. Infrastructure in many of the developing countries pointed out the apparent issue of vendor support in the Malaysi-
faced the limitation of sufficient and necessary infrastructure an public hospitals. Jahanbakhsh et al. [22] conduct a study to
such as skilled human resources, hardware, and software to im- identify the major barriers regarding the HIS utilization. The
plement healthcare systems [40]. Ahmadian et al. [40] believed authors found that when the new HIS system is ordered by a
that in Iran, a proper planning should be applied, which can help hospital. A vendor is assigned to do the network-based applica-
growing the available resources' productivity. tion to integrate in different hospital areas such as wards, phar-
Moreover, in developing countries, public hospitals encountered macy, reception, financial and departments. In addition, they
some issues regarding the IS infrastructure [125]. According to
International Journal of Engineering & Technology 9

found that the vendors are far from them and updating their until required technical expertise can be available. Accordingly,
system assuming their needs takes sometimes, hence HIS im- arming with staffs with more knowledge of IS leads to have
plementation has been unsuccessful [22], [132]. Chang et al. [87] more hope in successfully implementing IS [92], [106], [140],
noted that in Taiwan, healthcare technology assisted by vendors [141]. Sulaiman [118] indicates that staffs are more concerned
usually provides solutions from on-site training to link the inno- about the use of HIS in the Malaysian public hospitals. This
vative technology to the IS buyers. Hence, perceived system includes the lack of IS/IT exposure to healthcare staff and hu-
complexity by all hospitals are low. Barlow et al. [133] found man resources management assigned by government [118]. Fur-
that to achieve a successful project plan, assigning a skilled team thermore, Sobol et al. [142] strongly believed that the medical
to fulfill the plan will undoubtedly be the crucial factors at the computerized system implementation is highly affected by
final stage of telecare adoption. Nilashi et al. [25] and Ahmadi et staff’s IT knowledge and capability. Lin et al. [106] found that
al. [5] strongly suggest that Malaysian public hospitals should staffs’ IS capabilities would help hospitals more likely to accept
not overlook the importance of vendor support if they want to the HL7 which known as an integrated hospital technology.
successfully implement HIS. Therefore, vendor support has been Besides, Ahmadian et al. [40] investigated the HIS adoption
frequently suggested to be a critical factor for the adopting unit through an analytic-descriptive study. They obtained the same
to successfully continue the adoption of Hospital technology in result as Lin et al. [106] that users’ knowledge on the system are
hospitals [4], [21], [25], [87], [95], [134]. crucially needed to accept and utilize the technology of HIS.

3.2.3. Human Dimension 3.3. Dematel

According to the HOT-fit model, human factor is central to the Decision-Making Trial and Evaluation Laboratory (DEMATEL)
evaluation of health information system adoption and develop- have been an effective technique of Multi-Criteria Decision
ment [100], [101]. Literature on HIS shows that the studies ne- Making (MCDM) for decision analysis in recent years [135].
glect this important concept in explaining the role of human This technique is mainly used for discovering the relationships
context in behavior of hospital setting towards HIS adoption, among the factors or complex dependency issues among criteria
with respect to perceived technical competence and employees for a problem under investigation [136]. The effect scale de-
IS knowledge [5], [74]. Hence, taken from HOT-fit model, this scribed earlier is used to register the degree of influence. The
study embarks on the analysis of human components in under- steps of DEMATEL are described as follows:
standing the decision to adopt HIS in the hospital industry. Step 1: Subsequent to the accumulation of statistics from the
experts, design an n×n (factors under investigation) answer
3.2.3.1. Perceived technical competence
matrix Xk = [ x ijk ] with, where H indicates the number of experts.
Perceived technical competence is about the IS employees’ ca- The experts provide their responses on a scale ranging between
pability [91]. Ross et al. [135] believe that IS staffs are the core 0 and 4 (see Table 4).
features of a valuable human asset that frequently leads the solu-
tion to the business problems and addresses business opportuni-  0 x
12
... x
1n 
ties through IT. Employee’s skill has been identified crucial 
x 21 0 x 
influencing the organizational adoption of IS within the context X 2n 
of innovation, particularly within the healthcare industry [46],  
[91], [136-139]. x 0 
 n1 x n 2 
According to prior studies of HIS, staffs’ technological capabili-
ties has a crucial role when a hospital is adopting an innovative
The response matrices for each of the experts are expressed as
IS [95], [106]. To ensure that business problems will be solved
X1, X2. XH. Every element of Xk (xij) is an integer on the effect
and able to attain business opportunities through the usage of IT,
scale denoting the extent to which factor i influences factor j. It
possessing powerful IS skills and competency are vital [135].
should be noted that due to the fact that the DEMATEL proce-
According to Lian et al. [91], if the IS staffs having sufficient
dure does not include an assessment of a factor’s self-influence,
knowledge and the needed skills to adopt the new IT, that hospi-
the major diagonals of each answer matrix are fixed as zero.
tal will undoubtedly have more certainty throughout the process
[91], [128]. In addition, Moghadam and Fayaz-bakhsh [41] con-
Table 4: Effect Scale
ducted a study of the interview in the year 2009 to explore the Value Meaning
most important issue of HIS use among the Iranian public hospi- 0 No effect
tals. They strongly believed that if the hospitals want to receive 1 Low effect
an ultimate goal of successfully implementing HIS, system 2 Medium effect
training and obtaining the feedback from the healthcare staff are 3 High effect
vital. 4 Very high effect
To adopt HIS, the organization of a hospital requires a capable
IS department consists of a group of IS staff who has technical Step 2: Generate an average matrix A = [aij] by computing the
competence; it consists of enough knowledge of IT and experi- average influence level as follows:
ences to work with and maintain the HIS functions and hence
adopting the HIS. Consequently, it is highly likely that hospital 1 H k
a  x
with strong IS staff manpower for HIS are certain to adopt this ij  H k 1 ij
technology. As such, our study looks at the human dimensional (1)
characteristics as very crucial in HIS adoption of Iranian hospi-
tal context. Matrix A, also known as the initial direct relation matrix, reveals
the preliminary direct effects of a factor on other factors. This
3.2.3.2. Employees’ is knowledge matrix can also be represented in an influence map.
Step 3: During this stage, the regularized direct relation matrix
Hung et al. [92] emphasized that most of the organizations are D is computed from the average matrix A. From this computa-
n
unable to successfully adopt innovation adoption due to the lack tion, the normalization factor s  max  a is computed to
1 i  n ij
j 1
of skill and technical knowledge, which are intensively required
in the process of development. Hence, they have to postpone realize the normalized direct relation matrix D.
10 International Journal of Engineering & Technology

n
s  max1 i  n  aij (2) 2. Computation of the limit matrix from the super matrix (a)
j 1
Next the super matrix has to be normalized to obtain a column
stochastic matrix. (b) Raise the matrix by the power of 3. (c)
A Repeat the previous two steps until the difference between the
D= (3)
s matrix from step n-1 and step n are smaller than a predefined
value.
Step 4: With the results derived in the third stage, the di- Although the ranking and weighting can be generated by other
rect/indirect or total relation matrix (T) is computed as: methods, ANP is found to be more appropriate in meeting the
needs of this research. Furthermore, it is important to reiterate
lim
k 
Dk  0 (4) that ANP is a developed form of AHP that has an ability to deal
with a more complex decision making problem. ANP is em-
ployed in this case as it represents the more appropriate method-
Where 0 is the null matrix, and so with I being the identity ma-
ology for the first step of this research.
trix we have:

lim
k 
(I + D + D2  ...  Dk )  (I - D) 1 , T  D ( I  D ) 1 (5) 4. Empirical study

Step 5: Calculating ri and ci which are direct and indirect effects In our study, based on the analysis of relevant theories in line
that factor i and factor j exerts and receives on the other factors. with reviewing the previous empirical researches on technology
adoption with a direct attention to HIS adoption. The potential
inter and intra-organizational factors were identified for the
 r1 
  n adoption of HIS. This study provides evidence for the applica-
  with ri   t i j Where (i  1, 2,..., n ) (6) bility of the new theoretical model integrated by HOT-fit and
r 
j 1

 n TOE framework in the IS and health IS domains to specifically

explaining the adoption of HIS by public hospitals in the Iranian
c ... c n  with c j   t i j Where ( j  1, 2,..., n ) context. In other words, this study adopted the TOE as the basis
n

1
(7)
i 1
of this research and integrated the human capability's perspec-
tive to its dimensions. In other words, human dimension as a
Step 6: The degree of importance of the factor i in the entire necessary supplement was integrated into the developed model.
system is calculated as: This research uses this integrated theoretical model to develop
the Hospitals-Integrated Hospital Information System Evalua-
n n
im i  (ri  c i )  t i j  t ki (8) tion Adoption Model (Hospitals-IHISEAM). In comparison to
j 1 k 1
previous models, Hospitals-IHISEAM emphasizes more on
n n
intra-organizational factors rather than inter-organizational fac-
ef i  (ri  ci )  t ij   t ki (10) tors.
j 1 k 1
This study developed the conceptual research model (see Fig. 3)
The net effect that factor i contributes to the system is expressed based on the laboratory search of extensive literature review and
as efi. To be precise, if efi is positive, the factor i is deemed a net theoretical background. Now, we develop a hybrid MCDM
cause. On the other hand, if efi is negative, the factor i is deemed model for the process of HIS adoption decision. Two main stag-
a net receiver. The results attained through these computations es have been included within the proposed MCDM model. Fig.
can be portrayed in a directed graph to demonstrate the structur- 4 presents the hybrid proposed model using DEMATEL and
al linkage existing between the various influence factors. ANP. In this regard, the DEMATEL method has been applied
for revealing the relationship between the dimensions as the
main factors and variables as sub-factors and also to determine
3.4. ANP
interdependency among them. It is important to discover the
relationships by applying this approach to identify the weights
The ANP is a generalization of the Analytical Hierarchy Process
of main factors and sub-factors properly. Therefore, DEMATEL
(AHP) to the case in which there exists dependence and feed-
is a suitable approach to be used in the context of decision-
back among factors in decision making problems. Regarding to
making as it is more appropriate for application of the real-
the independence problem, Saaty has developed an advanced
world in interdependency analysis among the network compo-
method named Analytic Network Process (ANP). ANP differs
nents.
slightly from AHP and offers more flexible methodology for a
As discussed earlier, in the first step, we have applied DE-
decision maker. In AHP, elements in lower level of hierarchy
MATEL to find the interdependencies among the dimensions
are weighted and ranked with respect to the higher level. In
and sub-factors. Table 6 presents the overall importance for each
ANP, however, the model is not restricted by such a hierarchy.
factor. From Table 6, it can be found that technological context
This point is clearly explained by Saaty [11], [143], [144], the
and Human context are the most important influence factors on
founder of AHP as well as ANP. Aiming at solving the decision
HIS adoption. In addition, this table also provides the ranks of
problems which cannot be structured hierarchically on account
sub-factors in each dimension. From the results, Relative ad-
of the interaction and dependence of higher-level elements on
vantage followed by Compatibility and Security's concern, Top
lower-level elements as well as elements in the same level, a
management supports followed by Vendor support, and Per-
feedback network like structure is proposed. In particular, the
ceived technical competence are respectively the most important
super matrix approach is the generalization of the hierarchy
factors in Technological context, Organizational context and
approach. It is difficult for many decision making problems to
Human context. Further, in Table 7 we can find two groups of
be formulated in a hierarchical way [143], [145], [146]. The
factors, which are net cause and net receiver factors. From the
computation of ANP can be divided into two main parts:
results, it can be found that the positive values are Net cause
Construction of the super matrix (a) the decision maker enters
factors, and negative values are Net receiver factors. The results
for each criteria and alternative a pairwise comparison matrix. (b)
reveal that technological context and Human context are Net
The values for the super matrix are obtained by computing the
cause, and Organizational context is Net receiver. Moreover,
eigenvectors of the pairwise comparison matrix and writing
from the results it can be found that relative advantage, Top
them as column vectors in the super matrix.
management support and Perceived technical competence have
International Journal of Engineering & Technology 11

the highest net effect on the decision to adopt HIS in each di- infrastructure have the highest negative effect on the decision to
mension. Furthermore, from the Net receiver group of a factor, it adopt HIS in each dimension.
can be found that Employees IS knowledge, Complexity and IS

Start

Determine the Dimensions and Variables

Dimensions and Variables Technology

Organization Human

Use DEMATEL to analyze the interdependent relationship among the dimensions and variables

Use ANP to calculate the weights of the dimensions and variables

Determine the most important factors for HIS adoption

End

Fig. 4: Research Flow for MCDM Model.

Table 5: Sample Characteristics

Respondent Characteristics Frequency Percentage (%)
30 and lower than 30 27 61.36
31-34 12 27.27
35-40 3 6.81
Age
41-45 2 4.54
46-50 - -
More than 50 - -
Male 14 31.81
Gender
Female 30 68.18
Chief technology officer 2 4.54
Chief executive officer 2 4.54
Chief information officer 1 2.27
Roles of respondents Senior clinician 3 6.81
Nurse 18 40.90
Doctors 2 4.54
Others 16 36.36
Lower than 1 5 11.36
1-3 14 31.81
Experience in assigned roles 4-6 10 22.72
7-9 6 13.63
More than 10 6 13.63
5 and lower than 5 15 34.09
6-10 22 50
Experience in healthcare industry 11-15 7 15.90
16-20 2 15.90
21-25 - 4.54

Table 6: Degree of Importance

Dimensions Sub-Factors imi  (ri  ci )
Technological context - 3.7874
Relative advantage 4.5432
Compatibility 4.2353
Security concern 3.0234
Complexity 1.2343
Organizational context - 1.3423
Top management support 4.2433
Vendor support 3.5432
Financial resources 2.2847
IS infrastructure 1.3242
Human context - 3.3461
Perceived technical competence 2.5323
Employees’ IS knowledge 1.3413
12 International Journal of Engineering & Technology

Table 7: Net Effect

Dimensions Net Receiver Net Cause Sub-Factors ef i  (ri  ci )
Technological context √ - 1.9256
√ Relative advantage 0.7852
√ Compatibility 0.6895
√ Security concern 0.1639
√ Complexity -0.4532
Organizational context √ - -0.5642
√ Top management support 1.3853
√ Vendor support 0.6438
√ Financial resources -0.1245
√ IS infrastructure -0.3464
Human context √ - 0.9321
√ Perceived technical competence 0.5436
√ Employees’ IS knowledge -0.3768

In the current study, after using the DEMATEL with the aim of to “Organizational factor”?’ It is emphasized that in Saaty’s 9-
revealing the interdependency among the dimensions and sub- point scale, extreme importance is attributed to the 9 point and 1
factors, the method of ANP deployed to calculate the final weights as the equal importance of one component (dimension and varia-
of three dimensions and the sub-factors within each dimension. ble) over another. The result obtained from the Consistency Ratio
According to the ANP model and structure of relationship regard- (CR) values show that all of them were acceptable and the eigen-
ing both dimensions and variable, an ANP based survey with vectors were appropriate for entering into the Supermatrix, after
pairwise questions was applied and distributed to the 44 main computing the results of their assessments. Based on the ANP
users and experts who had experience with the HIS of hospitals in steps that were described earlier, after the unweighted Supermatrix
Iran. All of the collected 44 surveys were valid (effective response and weighted Supermatrix calculations, the limit Supermatrix
rate as 100%). As ANP model was used in our study, 44 partici- were figured out that is shown in Table 8. This matrix provides the
pants were asked to give their answers based on a scale of 1–9 to weight of each sub-factor in the dimensions. Accordingly, the
the pairwise questions, such as “For the HIS adoption in the Irani- final weights of dimensions and sub-factors are presented in Table
an hospitals”, how much more important is “Technological factor” 9.

Table 8: The Limit Super matrix

Technology (D1) Human (D2) Organization (D3)
Supermatrix
V1 V2 V3 V4 V5 V6 V7 V8 V9 V 10
V1 0.282 0.282 0.282 0.282 0.282 0.282 0.282 0.282 0.282 0.282
V2 0.198 0.198 0.198 0.198 0.198 0.198 0.198 0.198 0.198 0.198
Technology (D1)
V3 0.141 0.141 0.141 0.141 0.141 0.141 0.141 0.141 0.141 0.141
V4 0.055 0.055 0.055 0.055 0.055 0.055 0.055 0.055 0.055 0.055
V5 0.145 0.145 0.145 0.145 0.145 0.145 0.145 0.145 0.145 0.145
Human (D2)
V6 0.048 0.048 0.048 0.048 0.048 0.048 0.048 0.048 0.048 0.048
V7 0.044 0.044 0.044 0.044 0.044 0.044 0.044 0.044 0.044 0.044
V8 0.033 0.033 0.033 0.033 0.033 0.033 0.033 0.033 0.033 0.033
Organization (D3)
V9 0.028 0.028 0.028 0.028 0.028 0.028 0.028 0.028 0.028 0.028
V 10 0.026 0.026 0.026 0.026 0.026 0.026 0.026 0.026 0.026 0.026

Table 9: Model with Relative Indicator Weights

Dimensions Variable Sub-Factors Final Weights
Technological context D1 - 0.487
V1 Relative advantage 0.282
V2 Compatibility 0.198
V3 Security concern 0.141
V4 Complexity 0.055
Human context D2 - 0.389
V5 Perceived technical competence 0.145
V6 Employees’ IS knowledge 0.048
Organizational context D3 - 0.124
V7 Top management support 0.044
V8 Vendor support 0.033
V9 Financial resources 0.028
V 10 IS infrastructure 0.026
tive advantage of HIS positively affect HIS adoption (with an
5. Discussion influence weight of 0.282). This finding is also consistent with the
study of Ahmadi et al. [5]whom asserted that HIS brings conven-
ience to healthcare organizations regarding the cost reduction,
The conceptual research model in this study was developed and patient care processes which can expedite the decision-making
the two evaluation methods of ANP and DEMATEL were ana- process, time saving and improve patient care. The meta-analysis
lyzed. Additionally, data was collected from 44 professionals and study of Jeyaraj et al. [74] found that relative advantage of innova-
main users in the context of hospital, hence, the significant dimen- tion is one of the best predictors of innovation adoption in the
sions and variables affecting the organizational innovation of HIS organizational context. As a result, this study stresses that hospi-
was identified and confirmed. Technology and Human with an tals require to realize the relative advantage of applying HIS ap-
influence weight of 0.487 and 0.389 are found as the most crucial plications or in other words, some expected benefits of using the
dimensions for assessing the HIS adoption. This result was ob- HIS. Hence, it is important that government develops some strate-
tained using DEMATEL and ANP analysis techniques. This indi- gies to increase the awareness of the average relative advantage
cates that major decision-makers of hospitals involving HIS adop- hospitals regarding the diverse benefits of HIS technology.
tion, should not overlook them. Our study has resulted that rela-
International Journal of Engineering & Technology 13

The result of this study identified that high level of compatibility effectiveness. Additionally, the transparency has to be assured that
has an evident positive effect on HIS adoption (with an influence will assist to ensure positive values of integrity and honesty in
weight of 0.198). The study confirms the findings of other studies procurement and IT vendor selection process.
that high level of HIS compatibility with existing systems is the “Perceived Technical Competence” is another imperative factor
significant factor influencing hospital’s decision of adopting or with respect to Human dimension with an influence weight of
implementing the HIS [5], [80], [91], [147]. Yang et al. [80] up- 0.145, which helps to better evaluate the HIS adoption. IT depart-
dated TOE to be in line with the health information system envi- ment support has become very important, specifically in the adop-
ronment. The results of their studies support the inclusion of inno- tion stage. This is to ensure that the technical support is adequate
vation characteristics and in particular, compatibility as part of the and staffs working in the IT department have the enough ability.
TOE perspective that can influence the decision to adopt wireless Additionally, the investigation of HIS adoption in Malaysian pub-
vital signs monitoring system. Adoption diffusion studies also lic hospitals conducted by Ahmadi et al. [5] stressed the im-
found that an innovation, which is more compatible, attracts faster portance of perceived technical competence. By applying the
adoption by the prospective adopters. This may be because with a DEMATEL technique in the current study, we have explored the
high level of compatibility with HIS or any other innovations, interrelationship between dimensions and variables with the pur-
solely, the minimal adjustments and change is required to be un- pose of enhancing each dimension and variable. Results described
dertaken within hospital organization, which implies less re- that technology dimension (D1) and Human dimension (D2) ob-
sistance to adoption. The government and hospital manager should tained the most priority for adoption development. Therefore,
therefore develop best and more extensive HIS strategies and these two dimensions should be looked carefully by administrators
plans, specifically within the average compatibility hospital's con- in the healthcare industry and also expand upon since they are the
text to ensure the integration of new HIS systems within hospitals, most imperative relative to the other dimensions. Thus, the as-
leading a hospital to a best future. sessment of importance identified dimensions and variables, found
The research findings of this study demonstrate that security con- in our study should be performed by administrators in the HIS
cern is found to have a significant negative relationship with hos- implementation decision process.
pitals to adopt HIS, meaning that higher concern with security will It can be concluded that the relative importance of dimensions,
result in lower adoption of HIS by hospitals (with an influence and their 10 variables can differ depends on the confinement of
weight of 0.141). The present finding is in accordance with the each healthcare industry. Nonetheless, factors such as “Complexi-
findings of Lian et al. [91] who explored hospital’s adoption of the ty," “IS infrastructure," “Financial Resources," and “Employees IS
new technology. Their study concluded that security concern has a knowledge” were not supported as the significant factor in this
greatly negative influence on behavior of hospitals’ adoption of study, which created some insights into the Iranian public hospi-
innovative technology. Due to the significance of patient data in tals.
hospitals, secure environment for storage and retrieval of data is
required that hospitals feel safe to use the HIS system. Thus, 5.1. Contribution
greater concern about security of data is one of the major issues
for every hospital to adopt and migrate to the HIS. Additionally, The goal of this study was to develop a model as an effective lens
study by Ahmadi et al. [5] posits that the concern for the data se- for a concise and comprehensive understanding of HIS adoption
curity is one of the major issues for every organization to adopt decision in the Iranian public hospitals. In other words, this study
and migrate to the innovative technology. In other words, the con- provides an insight into the factors and barriers that affect the
cern of the data security in hospitals is high. Therefore, security adoption of HIS and particularly to practice these issues among
concern needs to be identified as one of the crucial factors in HIS the Iranian public hospitals. Hence, the integrated theoretical
adoption. Thus, it is important to develop the strategies in order to model was developed from the reviewing of relevant extensive
ensure the high level of data security regarding the HIS technolo- literature and empirically tested and validated via a quantitative
gy, therefore to encourage hospitals to use HIS in their work pro- study in two public hospitals of Bandar Abbas and Qeshm. Thus,
cesses. our study has both theoretical and practical contributions.
In this study, top management support (with an influence weight Notwithstanding, there is previous literature about the innovation
of 0.044) and vendor support (with an influence weight of 0.033) process, a little information is available about the innovation adop-
were observed to have a significant influence on HIS adoption in tion process in public hospitals. As of now, many studies applied
the hospitals. Sulaiman [118] and Ismail et al. [21] came to the the generic adoption theories to examine HIS adoption with re-
same conclusion. They investigated the hospital's major issue of spect to DOI [49] and TOE framework [76]. Therefore, due to
HIS adoption in a developing country. Is mail et al. [21] through lack of this, we analyze the adoption-factors and barriers in the
an in-depth interview highlighted that the multiple vendors sup- HIS context by integrating TOE [76] with HOT-fit model [100],
port in the context of Malaysian public hospitals cause a main [101] trying to figure out the successful adopting the HIS by Irani-
challenge for HIS implementation. Furthermore, Jahanbakhsh et al. an public hospitals. Furthermore, the consistency of HOT-fit is
[22] found that selecting the appropriate vendor that provides the assessed as a supplement into the TOE framework to design an
perfect support is essential that lead to succeed the utilization of integrated theoretical model for HIS adoption used by Iranian
HIS. Besides, the result of this study is consistent with some pre- public hospitals.
vious studies in the domain of healthcare [5], [12], [22] where There are several studies in all industries that pointing out the
vendor support found to be significantly affecting the hospital’s importance of the human dimension upon the adoption of IS,
technology adoption. where the TOE framework does not have an explicit category
This study’s result is more supported by the study of Sulaiman “Human”. Regarding the literature in HIS, most studies over-
[118] that was conducted within a Malaysian public hospital. The looked this concept in explaining the role of human as a strong
author found that being dependent on the international vendor motivation in behavior of hospital towards HIS. Hence, the pre-
software causes local hospital staff to have insufficient skills and sent study has an important theoretical implication that the factors,
knowledge, thereby causing to increase the cost of overseas ven- specifically, perceived technical competence of IS staff engaged in
dor support and maintenance. Thus according to the result of this the human dimension, crucially need to be considered in further
study, more in-house development should be established to reduce research when adopting and implementing HIS.
a cost as well as strengthen local IT skills and experience. It is also In the context of Iran, clarifying the e-Health, national project is
vital to the alignment of the selected IT vendor organization goals important and significant where the Iranian 5-year national plan
to the hospital’s HIS strategic goals in order to guarantee better assists to reveal the efforts and achievements of the government,
quality delivery and support such as training. There is also a re- and lessons learned obtained from this experience within each
quirement to perform frequent evaluation of the selected IT Ven- hospital during HIS utilization. Additionally, prior to this study,
dor company regarding the IS services in terms of efficiency and little understanding existed in the main barriers and facilitators of
14 International Journal of Engineering & Technology

HIS by Iranian public hospitals. However, our study attempted to Our study uncovers some requirements to make the training pro-
provide lighter on factor's explanation for the HIS adoption based gram to the IS staff in hospital's environment [32], [68], [91]. In
on theories and former health information system empirical results. this case, government agency and in particular, Iranian ministry
Thus, practical guidelines are offered to make strategies geared and hospital administrators should look at this result and prepare
towards maintaining the effectiveness and availability of those their strategy and policy at fostering the uptake of HIS. The devel-
weighty dimensional factors. These results will help drawing bet- oped model of this study is recommended as a guideline for evalu-
ter implications for policy makers at Ministry and Healthcare and ating the factors to better decision-making and improvements in
Medical Education, IT and hospital senior managers as well as the process of HIS systems implementation.
researchers in the field of healthcare.
6. Future work
5.2. Practical implications

Several meaningful implications are proposed, which obtained Our study was performed in the context of non-teaching hospitals.
from the findings of present study. The results gained in our study Hence, it is offered that the scope of the present study be extended
indicate that relative advantage to be an important factor influenc- by future study throughout a combination of teaching and non-
ing the adoption of HIS technology. This was because participants teaching hospitals. This will lead more understandings of whether
were aware of the benefits of HIS technology. Therefore, it im- this study’s findings are constrained to responses in non-teaching
plies the importance of user awareness of the benefits of HIS posi- hospitals.
tively has an impact on the adoption of HIS. On this basis, an Studies of future can do the investigation of the HIS adoption by
intervention plan should be devised by government to enhance the performing survey or interview in HIS adopters and non-adopters
user awareness by better educating and training of the top hospital context to realize the factors in diverse perspectives regarding the
management and medical personnel. HIS adoption. In addition, it is offered to evaluate and distinguish
Furthermore, our study draws an implication for government and the different influence of those factors between adopters and non-
hospital managers to enable the HIS into the hospital work proce- adopters in adopting HIS. By doing so, more generalization of the
dures and needs of it. In the other words, HIS is needed to be findings is obtained.
compatible with the relevant hospital and its tasks. This means Since the healthcare industry is many institutionalized environ-
that serious efforts should be made to increase the HIS compatibil- ments, it is relatively crucial to scrutinize the effects of institution-
ity with existing hospital’s IT architectures in all aspects with al pressures on hospital adoption of IS innovation. Nevertheless,
respect to the average compatibility hospitals. as of now, few studies have sought the influence of institutional
Participants in our study perceived security concern as a major pressures on the process of HIS adoption by using or applying the
barrier in their HIS adoption. Jahanbakhsh et al. [22] wrote that institutional theory, especially in the organizational context.
despite strong physical security within some Iranian public hospi- Hence, this can be a potential area to be focused in future to obtain
tals, there are inadequacies of IT security in the hospital environ- a better understanding of the HIS adoption in Iranian healthcare.
ments. The reason for obtaining this result is that the confidentiali-
ty and security of HIS is imposing the sensitive information to be 7. Conclusion
protected by various stakeholders of hospitals in order to fulfill the
needs of an announced act. Hence, hospitals have concerned about HIS has a growing importance in hospital's management in the
HIS implementation due to the data protection issues. This result Iranian public health system. During the performance of this study,
implies that advanced security features have to be utilized by hos- a few studies have paid attention in a comprehensive manner to
pital managers, top management in IT departments and/or vendors implementation of the HIS, which may put a negative effect on an
to make sure security and data protection are at utmost priority. Iranian strategic plan of IT decisions in hospital's environment.
Authorities of hospitals also require preparing a framework of Therefore, the crucial dimensions and variables in our study have
national IT security, based on the ISO/IEC 27000 family standard, been identified, which can lead to achieve and determine the HIS
for better protecting of all data on medical servers. Thus, a suita- innovation adoption. TOE framework known as a generic theory
ble mechanism helping to protect the healthcare data, are estab- of technology diffusion was mainly applied in our study to achieve
lished. a better understanding the adoption of technological innovation,
With respect to the environmental dimension factors, the present specifically HIS systems. Additionally, through focusing on HOT-
study discovered that top management support and vendor support fit model, which is related to the context of health information
are significant factors that affect the implementation of HIS within system and integrating it with the TOE framework, this study
the public hospital context. Jahanbakhsh et al. [22] conducted an develops a new and suitable model by covering significant factors,
interview study regarding the HIS utilization in several public which were excluded in former studies to facilitate better the HIS
hospitals of Iran. Authors found that when vendor and hospital adoption process that to be fulfilled by decision-makers and gov-
have a weak communicating, users face some limitations and ernment within public hospitals of Iran. This developed model
problems. As an instance, when the vendor installs the new HIS, allows the administrators and managers to assess the identified
some training workshops are performed. Hence, nurses as the important factors in better improving the HIS adoption.
main users get a problem with the new HIS, also some resistance The current study used two approaches of hybrid MCDM model,
occurs. Inside hospitals, the IT department should give support all including ANP and DEMATEL to make a contribution in the
the time and days of a week to alleviate the issues that emerge. health IS literature. Besides, the interdependencies among dimen-
After users satisfied with new HIS, and some effective changes sions and their contributing variables were assessed towards the
were brought with respect to new system, the HIS will be de- success of the adoption decision process of HIS innovation. There-
ployed, accepted and no longer complaints made. Thus, inappro- fore, from the professionals’ and users’ viewpoint, it was found
priate management support, technical administration and also that “Perceived Technical Competence” is the most crucial factor
avoid accepting changes along with improper selection of vendors in the Human dimension. On the other hand, with respect to Tech-
are the major barriers to implement HIS in Iranian hospitals. Thus, nology dimension, the potential respondents believe that the “Rel-
the Iranian ministry should cautiously explain a clear strategy for ative Advantage," “Compatibility” and “Security Concern” was
vendor selection to offer their HIS according to needs of hospital. significant in relation to the other factors. Moreover, in the dimen-
Vendors should fully give support to applications they developed sion of organization, “Vendor Support” and “Top Management
as all hospitals met supplementary challenges and shortcomings Support” was understood more powerful than others. ANP survey
on the vendors’ part. Selecting the same vendor for more than one results explained that the professionals, and HIS users emphasized
hospital may give a better result in solving those issues [32], [68], that managers should carefully adapt these factors in hospitals in
[91], [148-152 ]. which the HIS adoption is connected to more attention to these
International Journal of Engineering & Technology 15

factors. Furthermore, we revealed that the respondents of this tional Journal of Community Medicine and Public Health 4 (2017)
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