Content

Aykut Hamit Turan, ELECTRONIC MEDICAL RECORDS IMPLEMENTATION SUCCESS: PROPOSAL OF A SUCCESS MODEL in:

Alptekin Erkollar (Ed.)

Enterprise & Business Management, page 141 - 170

A Handbook for Educators, Consultants, and Practitioners

1. Edition 2017, ISBN print: 978-3-8288-3814-7, ISBN online: 978-3-8288-6842-7, https://doi.org/10.5771/9783828868427-141

Series: Enterprise & Business Management, vol. 3

Tectum, Baden-Baden
Bibliographic information
141 Aykut Hamit Turan ELECTRONIC MEDICAL RECORDS IMPLEMENTATION SUCCESS: PROPOSAL OF A SUCCESS MODEL LEARNING OBJECTIVES The objectives of this chapter are to provide detailed information on Electronic Medical Records (EMRs), to propose an implementation success model of EMRs and to give some summary information of Healthcare Industry in a developing country context. Once you have mastered the materials in this chapter, you will be able to: • Understand the key technology, managerial and social concepts behind the Electronic Medical Records • Explain key benefits and advantages of EMRs • Identify Critical Success Factors in EMR implementation • Understand and realize the key constructs of successful EMR implementation process • Observe major unique characteristics of Information and Communication Technology (ICT) implementation in a developing country context CHAPTER OUTLINE This chapter aims to provide detailed information on Electronic Medical Records (EMRs), their implementation process and major success factors behind the implementation process. In addition, you will learn the major advantages and benefits of EMRs, besides their limitations and disadvantages. You will also learn the main underlying information systems platform of Turkish Healthcare, called saglik.net as an example of Electronic Health Care Management System from a developing 142 Aykut Hamit Turan country perspective. The chapter also proposes an EMR implementation success model and the chapter also will discuss in detail the constructs made up of EMR success model. So you will learn which critical factors play an important role in achieving successful implementation outputs for an EMR system. KEYWORDS Electronic medical Records (EMRs), EMR Success Model, Critical Success Factors of healthcare ICTs implementations, Saglik.Net 1 INTRODUCTION Since 20th century, small and large organizations all have felt the need to enhance their productivity and efficiency. Not surprisingly, much of the efficiency and productivity increases have come from new Information and Communication technology (ICT) investments. Today, ICTs are clearly necessary for firm’s survival and success. Although ICTs have usually enhanced the organizational performance, factors actually lead to success in implementation process of ICTs and these factors are not very well understood and outlined by the researchers (Larsen, 2001). Healthcare industry is not different. Healthcare providing organizations are furiously trying to reduce continuously increasing healthcare costs and enhance customer service. Healthcare expenditures in all over the world are continuously increasing. Healthcare spending is expected to exceed 4 trillion USD by 2017 in USA by comprising 20 per cent of US GDP (Wurster et al, 2009). Therefore, healthcare executives are trying to limit these ever increasing costs. ICTs are the major tool and help for healthcare providers’ management team to reduce costs and enhance customer service. Worldwide hospital administrators perceive ICTs as a strategic force needs to be utilized (Caccia-Bava et al, 2006). Hospital managers also seem to understand the important impact of ICTs on organizational performance. Healthcare service delivery is one of the most significant challenges that healthcare organizations face today. Healthcare organizations must continuously find ways to improve efficiency while drawing down costs and remaining financially viable (Thambusamy and Palvia, 2011). In addition, hospital managers should see ICT as a strategic weapon. Although healthcare managers understand the positive impacts of ICTs on hospitals performance, successful implementation of ICTs still 143 Electronic Medical Records Implementation Success depends on user acceptance and actual usage of the systems (DeLone and McLean, 2003). Healthcare managers mostly perceive ICTs as a necessary evil, rather than a strategic necessity (Caccia-Bava et al, 2006). Electronic medical Records (EMRs) are newly emerging ICTs that have become widely implemented, adopted and used in healthcare settings. Health Information technologies (HITs) are one of the most expensive capital investments of any health organization (Cohn et al, 2009). Implementation and adoption of HITs are complex process and requires especially physician’s and other health personnel’s support. HITs are composed of Electronic Medical Records (EMRs), computerized physician order entry and decision support systems all of which integrating and improving access to health related patient data (Cohn et al, 2009). HITs can improve patient and physician relationships, decision making abilities for clinicians, provide efficient access to medical and patient information and can reduced healthcare providing costs and errors. Scholars’ and practitioners have long argued that ICTs are fundamental to firm’s performance, growth and survival, yet they still failed to present the linkages between ICTs and financial performance. Effective and efficient use of ICTs is key factor to differentiate successful firms from unsuccessful ones. ICTs can be seen as an organizational capability. Organizations need to do much more than investing in ICTs and try to create organization wide ICT capabilities. Organizations also need to know or predict the outcomes of Information Systems (IS) to reduce failure rates of their IS investments (Szajna and Scamell, 1993). So early on evaluation of IS development stages can provide extraordinary benefits to IS implementation efforts. Services sector now account more than third of developed economies GDP.  Now a “service world” is emerging in which organizations, people, technology and regulations form new mode of service delivery (Brynson et al, 2004). Changing customer requirements and advancements in ICTs have moved industries from product base to service based economy (Thambusamy and Palvia, 2011). This can create new opportunities for organization to enable service based industries. Successful implementation of ICTs in healthcare industry can create new business models and service innovation for healthcare organizations. 144 Aykut Hamit Turan Healthcare service delivery can be enhanced by increased transparency and process driven methods. There is too much opportunity to innovate in services and provide customized services with lower costs and in a fast manner with the help of ICTs. ICT adoption can enhance competitive advantage of organizations and provides a lot of opportunities especially in services industry (Spohrer and Riecken, 2006). Yet, healthcare industry is the one industry that lags the implementation of health information systems behind. Healthcare organizations have to decrease soaring costs and enhance customer healthcare delivery satisfaction. New and successful implementations of ICTs in healthcare can create new and innovative business models and facilitate new healthcare service delivery methods. Increased data availability and transparency can enable to use data driven methods in healthcare delivery and managerial decision making processes (Thambusamy and Palvia, 2011). Implementation of EMRs has been getting widespread in developing countries, yet there are limited studies on implementation success of EMR in developing country context (Tilahun and Fritz, 2015). Knowing important antecedents of EMR success factors in the implementation process can have significant effects on reducing already high costs of EMR implementations. Hence this study could be among the first studies proposing EMR success factors in the implementation process of EMR in Turkish settings. This study is aimed to examine EMRs, ICT implementations in healthcare settings, an example of a major Turkish healthcare ICT infrastructure and after an extensive literature review offer a process model of EMR Implementation success. At this point, this research is not focused on validating or testing the proposed EMR success model, yet it can offer a valuable framework for further empirical studies. 2 ELECTRONIC MEDICAL RECORDS Electronic Medical records (EMRs), Electronic patient Records (EPRs), Computer Based Patient Records (CPRs) and Electronic Health Records (EHRs) are all used interchangeably to refer to a collection of electronically maintained information related with individuals’ health status and healthcare (Zhang and Zhang, 2016). While EMR, EPR and CPR refer to records implemented at a single or several healthcare 145 Electronic Medical Records Implementation Success institutions, EHR contains records of all personal health information of an individual during his or her lifetime, entered or accepted and accessible by healthcare organizations on multiple sites. EHR is integrated health record system that ultimately all healthcare system is trying to achieve. Implementing modern health information technologies in developing countries can create many advantages such as modernizing healthcare in those low resource areas, saving lives of largely poor population and eliminating burden of poor handling medical records by considering severe lack of health professionals and basic facilities (Tilahun and Fritz, 2015). Getting timely and proper patient information can facilitate speedy and proper human and financial resources allocation that could help hospital management utilize already scarce resources more properly. Governments all around the world have started to allocate significant resources to promote EMRs acceptance and adoption by hospitals and healthcare professionals. Successful adoption of EMRs is important not only increasing service quality and patient safety, but also reducing continuously increasing healthcare costs. All ICT investments in healthcare settings shall be organized around critical business and patient care processes of hospitals. Previous ICT research could not found a robust and consistent relationship between ICT investments and organizational paradox that is called Information technology Paradox (Khatri, 2015). Existing ICT capabilities play an important role in achieving significant benefits from ICT investments. Since ICT investments are quite complex in nature, organizations with greater ICT capabilities can reap more benefits from their ICT investments than organizations without ICT capabilities (Khatri, 2015). Duplication of laboratory tests and prescriptions are not a rare occurrence even in developed countries. For example in Taiwan, number of doctors consulting a patient is about 15 in every year in average (Li et al., 2015). Creation of medical Health Records and exchange systems of health records could be a solution to this problem. Electronic Medical Records (EMRs) are largely expected to reduce medical errors and enhance service quality in Healthcare Industry. EMRs also expected to increase personnel productivity in healthcare settings. Yet, these technologies are widely resisted by same professionals 146 Aykut Hamit Turan expected to benefit from the widespread usage of these systems (Bhattacherjee and Hikmet, 2007). Healthcare personnel usually perceive new healthcare information systems as a great distraction from their regular duties. This resistance from healthcare professionals not only complicates our understanding of information technology adoption, but also undermines potential benefits of Health Information Systems (HIS). One of the significant ways to enhance success of HITs in healthcare settings is to better understand the HIT implementation process and this study is aimed to propose an implementation success model of a HIT as a process model. If managers address adequately the change in power and change in organizational balance, the resistance of new technology will prevail. EMR can be seen as a strategic resource, increasing organizational competitive advantage by reducing operational costs and enhancing organizational efficiency. A sample EMR screen is provided below in Figure 1. Figure 1 Sample EMR Screen Source: Wager et al., 2009 147 Electronic Medical Records Implementation Success What needs to be placed in EMR screen is not a simple question (Wagner et al., 2009). In addition measuring EMR adoption is difficult since it does not occur at the same time at different organizations and measuring adoption levels is quite difficult. 2.1 Advantages of EMRs Implementation of EMRs is believed to improve efficiency, access and quality of healthcare services (Zhang and Zhang, 2016). EMRs are one of the central elements that play significant role in transformation healthcare services and they form the central piece in forming the healthcare information systems architecture. EMR systems can significantly increase accuracy of healthcare and patient information recorded in health records, can support clinical decision making and improve accessibility of patients’ healthcare information (Zhang and Zhang, 2016). Other benefits of EMRs can include reduced waiting times for patients, reduced medication order errors and simplified reports generation process. Because of limited healthcare budgets in developing countries, open source or free EMR software are largely used in healthcare facilities (Zhang and Zhang, 2016). EMRs can facilitate healthcare professionals’ access to patient data and can significantly improve quality of the data available at healthcare organizations. EMRs can also improve drastically efficiency of healthcare processes through following standard procedures and reduced medical errors. Ultimately EMRs is expected to enhance healthcare and wellbeing of patients. 2.2 Saglik.Net This section of the chapter an important transformation project of Turkish Healthcare, Saglik.Net is discussed. The WHO defines e-health as using information and communication technologies for health providing (Li et al., 2015). E-health can include treating patients, conducting research, educating health professionals, tracking diseases and monitoring public health. Saglik.Net is one of the fundamental elements of transformation process of Turkish healthcare and it is one of the significant elements of Turkish healthcare reforms. It is one of the backbones and fundamental elements of Turkish e-health initiatives. Electronic medical records 148 Aykut Hamit Turan are consisting of a critical component of e-health initiatives of Turkish healthcare. This project includes all citizens and with broadband access in whole Turkey, health professionals can access all historical and current health information and records of each patient and the system is also supporting e-medicine applications that is the foundations of electronic medical records. The system also keeps track of work force, chattels and real estates as well administrative and financial information of all healthcare providers in the country. The main targets of Saglik.net is listed below1, • To achieve standardization in health information • To form data analysis and decision support systems • To increase data sharing speed among e-health participants • To create electronic personal medical records • To create resource savings and enhance productivity • To coordinate variety of e-health endeavors • To provide support scientific research • To get e-health concept adopted throughout the country Saglik.Net is an information system platform that is integrated, secure, fast and extendable to collect all health institutions electronically created healthcare data, to produce valuable information to all stakeholders of Turkish Healthcare and ultimately to achieve performance and quality increase in service delivery in first, second and third stage of healthcare providers. Saglik.Net can help to define problems before hand in healthcare industry, to offer solutions to the possible problems and to form work lists and investment plans in healthcare industry and to collect data to help variety of research studies in the healthcare. The basic characteristics of Saglik.Net framework is listed below, • Based on Internet technology and can transfer data from first, second and third stage healthcare providers’ independently acquired health information systems • Decision support system that could effectively participate in decision making process, assess sickness type and its severeness and healthcare expenses with the access to demographic 1 http://www.e-saglik.gov.tr/belge/1 – 33811/sagliknet-hakkinda.html 149 Electronic Medical Records Implementation Success information and seemingly transfer of the data to Ministry of Health • Reporting system that can help to satisfy International Organizations different demands on Turkish Healthcare statistics • Infrastructure that could provide international information data exchange according laws and regulations • Providing abilities and capacities to Turkish citizens to access their health information and manage them • Providing early warning systems in healthcare to access to healthcare information The layout of administrative login interface and web site of Saglik.Net is provided below in Figure 2. Figure 2 The Administrative Login Interface of Saglik.Net Source: https://yonetim.sagliknet.saglik.gov.tr Saglik.Net is administered by Turkish Ministry of health and their logo and link can be seen on the right hand side of the page. User name and password are also located in the middle of the webpage. 150 Aykut Hamit Turan 3 CRITICAL SUCCESS FACTORS IN EMR IMPLEMENTATIONS The critical success factors of EMR implementations are not clear in the literature (Standing and Cripps, 2015). Although many studies have considered successful factors in adoption process, they do not consider generally context of adoption. Implementation and adoption e-health technologies vary among countries. The barriers in front of the adoption are documented, but for many countries and healthcare systems, addressing these barriers is still a major problem (Cripps and Standing, 2011). Some of the major barriers are the wide range of stakeholders with different objectives, the risk environment due to the critical nature of patient healthcare and healthcare professionals’ feeling of being overwhelmed due to enormity of the information and communication (ICT) transformation task. Since healthcare industry has its own unique and characteristic challenges and barriers, critical success factors have become important. Critical Success Factors premise that if they are adequately or completely considered, then system as a whole has greatly improved chances of adoption and implementation success. Critical Success Factors is simply defined as techniques for improving chances of systems success. The success could be information systems success, general project success or organizational success. Success factor is defined by Daniel (1961). Critical Success Factors has been extensively used in Management ınformation Systems literature. Without strategic and detailed perspective, main intention based technology acceptance models such as Technology Acceptance Model and Unified Theory of Acceptance and Use of Technology — UTAUT by Venkatesh et al. (2003) has outlined key factors in technology acceptance and the critical success factors in adoption process. Table 1 in the following page presents Critical Success Factors from e-health studies literature. The Table 1 is adopted from the recent paper of Standing and Cripps (2015) and outlines seven scholarly papers in Management Information Systems literature. The Critical Success Factors in e-health implementation success has been classified in seven categories as type of system, stakeholder involvement, vision and strategy alignment, communication and reporting, process implementation, consideration of ICT infrastructure and other factors. 151 Electronic Medical Records Implementation Success Literature suggests three attributes on the level of innovation for the success of EMR systems that are data entry hardware quality, existing flexibility of user interfaces and presence of decision support tools (Struik et al., 2014). If EMR systems are easy to use and compatible with the existing working environment at the organizations, users are more willing to adopt and use these systems. The involvement of users and stakeholders is generally viewed one of the most important factors in EMR implementation success. Since work practices are largely changed when new ICT is introduced, it is required to have major players to involve into development and implementation process (Deutsch et al., 2010). Since healthcare information systems have broad range of interest groups, the collaboration and partnership with clinicians and other stakeholders play a crucial role in implementation success (Kaye et al., 2010). In addition, stakeholder management skills need to be observed as a valuable skill set (Vitacca et al., 2009) and communication protocols can be utmost necessary in building strong and good user / stakeholder communication (Amatayakul, 2000). Top management support is essential in EMR adoption by physicians (Chen and Hsiao, 2012). Existence of mission and vision in the process of EMR adoption are also very important. Leadership and commitment of the top management seem to be essential as well. Since EMR systems have privacy implications, careful planning and management of the migration and transfer to the new healthcare IS present utmost importance (Amatayakul, 2000). Project management skills can create successful and unsuccessful implementation projects of EMRs (Deutsch et al., 2010). Hence the most common Critical Success Factors presented in these seven articles are (Standing and Cripps, 2015); • Stakeholder / user involvement • Having a vision / plan for the role of ICTs • Alignment with organizational mission, goals and objectives • A process for implementation that includes an integration and migration path from the old to new systems • Communication with users including the reporting of benefits Resource Based View (RBV) and IT (Information Technology) Business Value Model can provide valuable underlying framework for EMR implementation success process. This school of thought can also provide how ITs could be associated with competitive advantage in the 152 Aykut Hamit Turan Article Amatayaku (2007) Vitacca et al. (2009) Kaye et al. (2010) Type of system Computer based patient records Core competencies to implement e-health and telemedicine General ICT in health sector User / stakeholder involvement End-user involvement; knowledge requirement assessments Patient-centered care; partnering with patients Multidisciplinary team Vision and strategy, and strategic alignment Systems support organizational vision; do systems enable business goals of organization? Public health perspective Innovative leadership: vision; commitment; practical needs Communication and reporting Communicate value of the systems to users Communicate clear benefits Communication of benefits and funding Process for implementation, migration, integration and training Need for an integration and migration plan for the system Process for implementation; financial incentives for clinicians; collaborative processes; training for clinicians Plan for ICT infrastructure Longer-term systems infrastructure ICT plan Others Evaluate the systems to manage benefits delivery Quality improvement: evaluation and organizational learning Table 1 Critical Success Factors in e-health Acceptance and Adoption Process 153 Electronic Medical Records Implementation Success Leonard (2004) Axelsson et al. (2011) Deutsch et al. (2010) Chen and Hsiao (2012) General ICT in health sector Hospital information systems Electronic health records adoption Hospital information systems by physicians Buy-in from stakeholders Project team competency Health policy-related goals and implementation strategy Top management support Communication and reporting Training Acceptance and change management; project management Ease of systems use Dealing with unpleasant events; amount of resistance Highly committed developers and their understanding of the organization Legal requirements related to data protection Systems quality 154 Aykut Hamit Turan IT context (Melville et al., 2004). Figure 3 below outlines impacts of the major characteristics and resources of an organization on organizational performance as proposed in Business Value model from Melville et al. (2004). Figure 3 IT Business Valu / e Model Source: Melville et al., 2004 Researchers has applied RBV framework in order to theoretically analyze the competitive advantage results of ınformation Technology and to assess the relationships between IT and other firm resources in order to enhance firm performance and ultimately to create competitive advantage. 155 Electronic Medical Records Implementation Success 4 The Proposed Electronic medical Record Implementation Success Model Below is the proposed electronic medical Records (EMR) implementation success model. The model is designed as a process model, where two proposed characteristics and capabilities of the organization, Electronic Medical Records Heath Information Systems leads to organizational performance construct. The research model is largely based originally on DeLone and McLean’s (2003) seminal work on ICT implementation success literature review. In addition more recent paper by Thambusamby and Palvia (2011) has been used to some extend to form the constructs and process flow of the offered model in this research. The research model of EMR success factors has been presented in Figure 4 below. Figure 4 The Proposed EMR Implementation Success Model Complexity Compatibility Relative Advantage Top Management Support Training Information Quality Service Quality System Quality Organizational Performance Individual Performance Satisfaction System Use The factors / constructs that made up of the model are discussed below. 4.1 Capabilities Capabilities are related with capacity and capabilities of implemented EMR system, organization and ICTs. 4.1.1 EMR Capabilities Complexity is the degree of difficulty in understanding and using the ICT. Complexity is opposite to ease of use that is systems relative perceived feelings of free of mental and physical effort (Davis, 1989). Technical 156 Aykut Hamit Turan complexity of EMR: technical complexity is the EMRs compatibility with the existing systems namely hardware and software. If ICT related systems are easier to integrate, there is a greater chance of realizing full organizational benefits (Tornatzky and Klein, 1982). Moreover, the more compatible EMR with existing software, the more satisfied users are. Rogers (1983) defined complexity of the systems among one of the five factors influencing end users to adopt new technologies. Complexity is the degree of innovation is difficult to use. Complexity is the degree of difficulty in innovation’s understanding and implementation (Rogers, 1983). Users tend to reject new innovations that are too complex technically, requires advanced user skills, produce inconsistent reports and need extensive expert support (Sharma and Yetton, 2007). Complex technologies can create knowledge barriers reducing possibility of user adoption and acceptance. Complexity is among the key barriers to technology adoption (Lin, 2007). Hence, complexity of ICTs has adverse effects on implementation success. Compatibility is defined as the degree of innovation being consistent with existing organizational values, beliefs, needs and experiences (Rogers, 1983). Compatibility is the degree of innovation’s consistency with existing organizational values, beliefs and experiences. Relative Advantage, complexity and compatibility are mentioned as most significant factors playing important role in ICT based innovations diffusion (Lin, 2007). Lin (2007) argued that greater compatibility of innovation with organizations processes can create familiarity and enhance the acceptance of innovation. In EMR case, compatibility is the degree of new EMR system to be able to exchange data with other existing systems in the healthcare organization. Relative advantage, complexity and compatibility are the most frequently used in the literature factors for ICT based innovation diffusion (Lin, 2007). Relative Advantage is the degree that innovation brings benefits to the organization. Organizations prefer and adopt innovations that bring organizational benefits rather than maintaining status quo. Relative advantage is a multidimensional construct capturing the benefits of a system such as lower costs, savings in time and effort and decrease in comfort (Choudhury and Karahanna, 2008). Relative advantage is the degree of innovation to bring benefits more from its precursor (Lin, 2007). Relative advantage can be in terms of increased efficiency, 157 Electronic Medical Records Implementation Success effectiveness, economic benefits and enhanced status. Relative advantage is related how much EMR brings benefits to the healthcare providers, healthcare personnel and administrative bodies. If healthcare providers, doctors and administrative bodies perceived sufficient benefits from EMR adoption, they would most likely to use it. 4.1.2 Organizational Capabilities Top management Support: Full commitment from senior executives is a must for successful implementation of ICTs. Top management should send a clear signal to various departments in an organization that the project is important (Bradford and Florin, 2003). System orientation requires various organizational departments have clear view of organizational objectives and understand how they can help in development of ICTs (Lin, 2007). Organization having and emphasizing managerial support can achieve better and greater extent of ICT diffusion. Management should ensure firm’s employees understand and become involved in EMS implementation process. Training: Since EMR packages can be quite complex, user training is necessary for successful implementation. Training can enhance organizational performance measures and also make better allocation of organizational resources while increasing user satisfaction (Bradford and Florin, 2003). End user training is a critical for the successful implementation of ICTs (Sharma and Yetton, 2007). Hence many ICT investments would be organized with expensive formal training programs. Training programs can enable users to acquire knowledge in three main domains as application knowledge regarding the knowledge on commands and tools of the new application implemented, business context knowledge regarding learning how to perform business tasks successfully and collaborative task knowledge related with how other colleagues use the application for their tasks (Sharma and Yetton, 2007). 4.2 Quality This construct refers to the quality of services provided EMR software and system and also healthcare providers. Information Quality is the output quality of an Information System. Information Quality has five distinct dimensions as completeness, ease of understanding, personalization, relevance and security. In terms of 158 Aykut Hamit Turan EMR, the information quality characteristics can be relevance, accuracy, timeliness, content, format, completeness and understandability. Both system quality and information quality regarded as important indicators in systems implementation success (DeLone and McLean, 2003). EMR systems with high level of information quality shall provide quality information and outputs to healthcare workers. Service Quality is the overall user satisfaction and assessment of an IS. Service quality is related with reliability, assurance and responsiveness of the service provided by the system. Service Quality concept is originated from Parasuraman et al’s (1998) SERVQAUL instrument. DeLone and McLean (2003) suggested five dimensions of service quality that are tangibility, reliability, responsiveness, assurance and empathy. EMR systems service quality could include system’s visual appealing, interactivity, empathy, being trustworthy and responsive to users’ requests. Services are different from physical goods and most intangible. Services are processes and satisfaction depends on confirmation of expectations (Grover et al, 1996). Traditionally the effectiveness of Information Systems has been measured by the products it has produced mostly rather than the service it has served. Hence, if we do not incorporate service quality in the process of measuring ınformation Systems efficiency, the measurement will be inaccurate. System Quality is the desired characteristics of an Information System. System Quality has six dimensions as stated by DeLone and McLean (2003): adaptability, availability, reliability, response time and usability. In terms of EMR system’s quality, the dimensions can be ease of use, ease of navigation, consistency of page layouts and visual appeal. 4.3 Performance Performance is related with organizational, individual performance, satisfaction of end users and final expected real system use. Organizational Performance is overall performance of healthcare provider. The existing research on how ICTs can affect organizational performance is somewhat uncertain and debatable (Melville et al, 2004). Literature seems to show divergence in how to conceptualize key constructs and existing relationships between ICTs and organizational performance. In general literature seems to indicate the positive relationship between ICT investment and firm performance (Melville 159 Electronic Medical Records Implementation Success et al, 2004). The value created by ICTs can be shared with the company, trading partners and customers. Organizational performance is related with how efficiently organizational resources are utilized. It includes usage of ICT resources and management of other organizational resources such as people, capital and equipment. Individual Performance is the performance of individual user while performing their works and duties. It is the degree of EMR system to enhance physicians and other health employees’ performance. Increased performance can result in increased satisfaction of healthcare professionals as well as patients. Satisfaction is related with end users’ satisfaction of the system. End users are people who directly interact with computers. End user computer satisfaction is one of the measures of end user computer success (Doll and Torkzadeh, 1988). End user satisfaction is the degree of satisfaction of end users from their direct interactions with a specific Information System. End user computer satisfaction is the direct attitude of users interacting with a specific computer application (Doll and Torkzadeh, 1988). End user satisfaction has been found to have a direct and positive effect on intention to use, yet it has no causal relationship with direct use (Chen and Cheng, 2009). End User Satisfaction (EUS) : User satisfaction is an important topic for IS researchers (Whitten, 2004 – 2005). End User Satisfaction is a critical factor in success of ICT implementation (Au et al, 2008). Today it is widely acknowledged that ICT implementation failure is most due to psychological and organizational factors rather than technological issues. Many IS projects fail because of lack of commitment from users and top management. People should be willing to use and utilize new ICTs to get the full benefit from these systems. After 1990s new variables such as equity, training method, task uncertainty and task complexity have been added as factors to explain End User Computer Satisfaction construct (Au et al, 2008). In order to better understand the roots of satisfaction, we need to pay close attention to motivation. Landy and Becker (1987) mentioned three theories of motivation that are expectancy theory, needs theory and equity theory. By integrating these three well known organizational theories, we can have better understanding of EUS. Based on the Equity Theory (Pritchard, 1969), individual feel satisfied or dissatisfied if his or her inputs are greater than the benefits received from 160 Aykut Hamit Turan the transaction. In IS context, the inputs and benefits for IS end users are usually too narrowly or too unclearly defined. Need satisfaction has found to be positively correlated with satisfaction (Oliver, 1995). Usually ignored by IS developers and managers, social and self-development needs could potentially cause significance resistance from end users in ICT implementation process. System use is related with the active, real and physical use of the system by end users. The better capabilities of EMR system, Organization and general ICTs can lead to improved system, service and information quality that in turn enhances organizational, individual performance and satisfaction, resulting more and more system usage. Earlier DeLone and McLean (2003) model has laid a good and fundamental characteristics of ınformation System leading satisfaction and usage. The authors also included system quality factor that is fundamentally related to user attitudes and perceptions of the system. 5 Organizational learning and System Adoption Organizational learning is another important factor to consider in ICT implementation success. Learning is quite related with past experience and past experience with ICTs can enhance greatly future implementations success (Robey et al, 2000). Therefore, experience with technology in earlier days of organization can have positive and profound effects on implementation success of new information technologies. In addition, information technologies can provide remote access to organizational memory of organizational members by fostering communication and discourse. The following critical success factors in EMR are created based on Nah et al (2003)’s study of ERP success factors based on CEOs. 1. Appropriate business settings existence: If the healthcare organization has complex legacy systems in use. Then the implementation would require much more technological and organizational changes. The EMR implementation should reduce the complexity created by organization and existing legacy systems. 2. Appropriate business plans and visions existence: Creating effective business plan and vision, creating and sharing project mission 161 Electronic Medical Records Implementation Success and goals and justifying investment in EMR are necessary for successful EMR implementation. Since EMR implementation can exceed time frame of typical organizational project, clear and concise business plan and vision are required. The project mission should be related to business needs and be clearly stated. 3. Fostering change management culture and program: Recognizing the need for change, enterprise wide culture and structure management and user education and training, user support and organizational involvement, commitment to change are required for successful EMR implementation. If the change required for EMR implementation process, there should be more and clear top management support. At the same time, people, organization and culture of the organizations shall be changed. Formal training programs for users to better explain how EMR systems would affect their job are required. 4. Communication: Targeted and effective communication among stakeholders, project communication and user input are necessary for successful EMR implementation. Every organizational level should know their expectations and responsibilities through implementation process. Communication among stakeholders is critical success factor in EMR implementation success. 5. EMR teamwork and composition: Best people on team, cross functional teams, full time team members, empowered decision makers are needed for successful EMR implementation. EMR requires collaboration and cooperation of administrative and medical employees of a healthcare organization. Especially physicians and nurses support is a must. Organizational, medical and technical knowledge is necessary for successful implementation. ERP team should have experts from all organizational areas and best people need to be employed in the teams. 6. Monitoring and evaluating the performance: Track milestones and targets, performance tied compensation, analysis of user feedback. Feedback from users that is medical staff in addition to feedback from patients also needs to be integrated in project performance evaluation and progress criteria. 162 Aykut Hamit Turan 7. Project champion: Existence of project champion, high level executive support to champion and project sponsor commitment are required. Since EMR implementation requires organizational commitment and determination, project champion is needed in such implementation efforts. This champion needs to be high level manager of the organization and be able to set goals and legitimize the change. 8. Project management: Assigning responsibility, clearly establishing project scope, controlling project scope, evaluating any proposed change, defining project milestones, setting realistic milestones and dates, enforcing project timeliness, and coordinating project activities across all affected parties are necessary for implementation project success. Since most IS project are evaluated based on the extent to meet their time and budget constraints, project management activities are really important. Hence, the EMR implementation project needs to be also managed based on best project management practices. Budget, implementation time, total effort, people’s commitment and project schedules can easily cause project failures, if not predicted and managed properly. 9. Top management support: Approval and support from top management, top management publicly and explicitly identified project as top priority, allocate resources makes the success chances of implementation process better. Top management support is one of the main necessities of ICT projects implementation success. The EMR project has to be approved and supported by top management. For successful EMR implementation, top management should involve and clearly show their support and willingness to allocate valuable resources to the other organizational members. As listed above, the potential factors in successful implementation of ICTs include top management support, extensive user designer interaction, compatibility of task characteristics, innovation characteristics such as relative advantage, complexity and compatibility, commitment to change and implementation efforts and sufficient project planning and definition (Lee and Kim, 2007). Process of innovation adoption can be influenced 163 Electronic Medical Records Implementation Success by three factors that are external environment, technological context and organizational context (Lee and Kim, 2007). Market uncertainty, competitive intensity and government support are among the factors related with external environment. Compatibility and complexity are the main factors as technological context and formalization and centralization of the organization are the major factors of organizational context. Obtaining top management support is major requirement for successful implementation along with having a project champion who would educate parties and promote the project is also a necessity. 6 CONCLUSION Effective implementation of new technologies is necessary to solve organizations productivity problems. Successful implementation of ICTS depends on our better understanding of user attitudes and behaviors and efficient implementation process of such technologies. Technology alone is not sufficient successful implementation of ICTs and transformation of successful human resources management practices are also necessary (Connor et al, 1990). The process success model of EMR implementation can be valuable guideline for healthcare provider institutions managers for a better grasp of important factors in the success of EMR systems implementation. Other ICT implementation factors including IS expertise, IS security, IS infrastructure, Project champion can also be the independent variables of future research. Another good predictor of EMR implementation success would be the external vendor or consultant support. Significant and important role of vendors and consultants are mentioned as a significant factor in EMR implementation success (Tsai et al, 2011). Yet EMR is coming not without disadvantages. Ineffective communication has been mentioned as the one of the most important reasons to cause preventable medical errors (Taylor et al., 2014). EMRs can help to increase communication and connectivity in healthcare (Institute of Medicine, 2001). EMRs can address the existing problem of communication among nurses and physicians in hospitals. However Taylor et al., 2014) found that EMRS in fact could decrease frequency of face to face communication between physicians and nurses. Moreover, the authors argued that quality of communication even got worsened after EMR implementation. Face to face communication has some 164 Aykut Hamit Turan favorable features such as observing and reacting verbal and nonverbal cues compared with electronically mediated communication. Research in the literature (Beuscart-Zephir et al., 2005; Niazkhani et al., 2009) indicated that specific EMR implementation of Computerized Physician Order Enter (CPOE) can replace face to face (Synchronous) with electronically mediated (Asynchronous) communication. EMRs can also have other disadvantages mainly although access is possible to medical records, EMRs cannot review the information in the records. 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(2009), “Strategic, Political and Cultural Aspects of IT Implementation: Improving the Efficiency of an IT System in a Large Hospital”, Journal of Healthcare Management, (54:3), 191- Zhang, X. Y. and Zhang, P.  (2016), “Recent Perspectives of Electronic Medical Record System”, Experimental and Therapeutic Medicine, (11: ), 2083 — 2085 168 Aykut Hamit Turan KEY TERMS Electronic Medical Records Advantages and disadvantages Critical success factors EMR implementation Model Turkish Healthcare Systems Organizational learning systems Healthcare systems adoption Organizational performance QUESTIONS FOR FURTHER STUDY 1. What is the definition of Electronic medical Records? 2. What are the main advantages of utilizing EMRs? 3. What is Saglik.Net? What are unique features and significance of Saglik.Net? 4. What are the critical success factors in EMR implementation process? 5. How various capabilities of an organization or EMR influence the performance of organization and individual users? 6. What is a learning organization and how being a learning organization influence the adoption process of EMRs EXCERCISES How Information and Communication Technologies have affected our lives and specifically healthcare industry? Please discuss. How Information and Communication Technologies utilization and implementation as well as usage differ in developing countries comparing developed nations? Please discuss. If you are a manager in a healthcare organization, how could you assess the success or failures of your EMR implementation endeavor? Please discuss. 169 Electronic Medical Records Implementation Success Visit a hospital and investigate their patient admission, treatment and prescription system. Prepare a report on how useful this system in improving hospital’s performance? FURTHER READING Hannan, T. J. (1996). Electronic medical records. Health informatics: An overview, 133 – 148. Miller, R. H., & Sim, I. (2004). Physicians’ use of electronic medical records: barriers and solutions. Health affairs, 23(2), 116 – 126. Wang, S. J., Middleton, B., Prosser, L. A., Bardon, C. G., Spurr, C. D., Carchidi, P.  J., ... & Kuperman, G. J. (2003). A cost-benefit analysis of electronic medical records in primary care. The American journal of medicine,114(5), 397 – 403. Bates, D. W., Ebell, M., Gotlieb, E., Zapp, J., & Mullins, H. C. (2003). A proposal for electronic medical records in US primary care. Journal of the American Medical Informatics Association, 10(1), 1 – 10. Ludwick, D. A., & Doucette, J. (2009). Adopting electronic medical records in primary care: lessons learned from health information systems implementation experience in seven countries. International journal of medical informatics,78(1), 22 – 31. Lærum, H., Ellingsen, G., & Faxvaag, A. (2001). Doctors’ use of electronic medical records systems in hospitals: cross sectional survey. Bmj, 323(7325), 1344 – 1348.

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Abstract

The development of information technology has sped up the importance of management information systems, which is an emerging discipline combining various aspects of informatics, information technology and business management. Understanding the impact of information on today’s organisations requires technological and managerial views, which are both offered by management information systems.

This publication takes an interest in the cooperation of business management and management information systems. Its contributions focus on both research areas and practical approaches, in turn showing novelties in the area of enterprise and business management. Main topics covered in this book are technology management, software engineering, knowledge management, innovation management and social media management. This book adopts an international view, combines theory and practice, and is authored for researchers, lecturers, students as well as consultants and practitioners.