THE USE OF ICT IN HEALTHCARE ORGANIZATION Mohamad Norzamani bin Sahroni, Siti Asma bte Mohammed Universiti Teknologi

MARA Malaysia [email protected] Universiti Perguruan Sultan Idris [email protected] Abstract Healthcare organization received the biggest benefit through information systems innovation in its business process. This study was carried out to determine the extent of the use of ICT in healthcare organization and to collect as much issues related to it. The study conducted in mixed method through questionnaire survey and observation on healthcare organization. The evaluation is based on Donabedians model. Findings of the study are; most clinics were using information systems but not to the extent maximizing the potential benefit of the information system itself, and most clinics were using Internet applications but limited to use email and third party Extranet such as insurance company and patients employer systems for claim purposes. Some issues and further research also highlighted in the discussion. Keywords: Information Systems, Health, Computer Use, Evaluation, Mix Method

1. Introduction ICT in healthcare is able to increase quality and safety of patient care. It is part of healthcare structure in any organizations to support the processes and consequently to deliver better outcome to organization and particularly to the patient (Donabedian 2003). The mean of ICT are primarily own of computers, use of clinic information systems, and Internet and its application such as email and website. Meanwhile, healthcare provider includes both individuals and their organizations, such as a hospital or physician practice (2009). In this study, types of healthcare organization that are taken into account were private hospitals, health centre and clinics. Thus the objectives of this study are to determine the extent of the use of ICT in healthcare organization and to collect as much issues related to it.

2. Method A questionnaire survey was conducted to all health care providers that already identified randomly in the district of Shah Alam. The questionnaire was adapted from dental practices survey (John, Thomas et al. 2003). Out of 41 organizations, 37 are clinics, 2 private hospitals and 2 center of health. A self-administered questionnaire was used to collect data in October 2009. Respondents were also given opportunity to write any related answer to certain questions for further clarifications or additional information. Once again respondent can give comments on any issue related to this area at the end of the questionnaire.

Because of number of sample is small, the analysis is carried out using spreadsheet. The study also carried out an observation to several healthcare organization; 4 clinics and 2 hospitals for further investigation. It is a good method to understand better about processes in
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health (Friedman and Wyatt 2006). For the ease of discussion, the word clinic will represent all respondents except any specified discussion related to center of health or hospital.

3. Results 3.1 Profile and Number of Computer There was no doubt that all clinics are using computer for daily use. Table 1 shows the profile of the clinics in terms of number of computer, amount of IT investment, number of doctors and number of supporting staff. 3.2 The Use of Information Systems Out of 41 healthcare organizations, only 29 organizations (70.7%) claimed that they are using information systems. The distribution of year use of systems is as in Figure 1. The figure shows that the trend of implementation is increasing from the year 2000 to the year 2008. There were various kind of systems used from the name given by the respondents. However there were two clinics claimed that they were also used a system by giving the name of the database management software. It is also counted in the figure.

Table 1: Profile of Respondents N = 41* Number of Computer 1-3 4-6 >6 Amount of Investment < RM 15000 RM 15000 RM 30000 > RM 30000 Number of Doctor 1-3 4-6 >6 Number of Supporting Staff 1-3 4-6 >6 * Some respondents are not answering this part. 27 6 8 17 7 12 23 12 5 19 11 9 % 65.9 14.6 19.5 41.5 17.1 29.3 56.1 29.3 12.2 46.3 26.8 21.9

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Figure 1 Number of healthcare organizations implementing information systems

There were various functions used in the systems by the clinics. Figure 2 show that, the majority (68.3%) of organizations claimed that they used the system for patient registration. It is followed by storing patients prescription (63.4%), medication inventory (56.1%), storing diagnosis information (41.5%), scheduling patient appointment (39.0%) and managing account (34.1%). While the other functions are used for storing digital x-ray (9.8%) and enabling patient viewing own medical history online (2.4%).

Figure 2 Percentage of clinics use various functions of information systems * Respondents could select more than one option

While majority of the respondents were using information systems, there were also clinics opted not to use it. These represent 29 percent or twelve out of forty-one clinics. However
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two of them claimed that they are using system but limited the system by using office application such as spreadsheets and word processing. It is considered as no proper systems used by that particular clinics. Table 2 describes the details on reasons why were they opted not to use systems. 66.7 percents claimed that it is much easier for them to work with manual systems while 50 percents said it is too expensive to have systems and 41.7 percents believed that it was not necessary to computerize at present.

Table 2: Reasons for not using information systems N = 12* % 8 66.7 6 50.0 5 41.7 2 16.7

Easier with manual system (using form) Too expensive Not necessary at the moment Others

* Respondents could select more than one option

3.3 Internet Access Majority of clinics have an Internet access except two clinics, where from the analysis on the questionnaire these two clinics were purely work on paper based and have no systems at all. Figure 3 describes the use of Internet by clinics. The highest use of Internet is purposely to make online claim through Extranet (70.7%) for third party such as insurance company, managed care organization (MCO) or the patients employer. 63.4 percents respond for electronic mail, 53.7 percent for searching medical information and followed by updating website (36.6%). For email purposes, 48.8 percents reported that email was used for communicating with third party such as insurance company and medical provider. It is followed by personal use 39.0 percents and appointment matters (scheduling and reminder) 26.8 percents.

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Figure 3 Type of Internet Use * Respondents could select more than one option Meanwhile for website purposes, 15 respondents claimed that they have website to update; to promote their services (100.0 %), to publish medical information (53.3%) and for advertisement (20.0%). Adversely, there were some reasons for those (26 respondents) who did not have a website. As listed in Figure 4, website is not required currently (51.0%), clinics did not have own expertise to develop website (24.0%), too expensive to set up website (22.0%), and the last factor which is interestingly to further investigate is that any health provider cannot do any promotion related to services offer to public (2.7%) as stated in Malaysia Medical Association (MMA) guideline.

Figure 4 Reason for not establishing website * Respondents could select more than one option 4. Discussion The discussion of this study will be based on Donabedians Model (Kunkel, Rosenqvist et al. 2007). This model consists of three approaches namely structure, process and outcome in order to analyze the quality of care (Donabedian 1987), (Donabedian 1997), (Donabedian 2003). Structure of the health systems means equipment, people, relationship among user (physicians), patients and the technology, and financial resources. Kunkel and Westerling (Kunkel and Westerling 2006) describe it as organization resources and administration. Processes mean any process or procedure that occur during health activities; diagnose, prescription, medication dispensing and other appropriate activities before, after or at the point of care given to the patient. Outcome reflects more on changes in patients health status, and impact on patients and physicians. Klecun and Cornford (Klecun and Cornford 2005) justified that information systems introduced in health care organization is considered an innovation that need to be evaluated. Further, Friedman and Wyatt (2006) emphasized that any innovation in health should be assessed based on this triad factors. In the age of information and knowledge, organizations are becoming dependent on technologies. It is proven that all clinics own computers if not all to have so called clinic information systems to help doctors and support staff doing daily tasks. While majority has an Internet access, however it is limited to access third party extranet and email. The same respondents provide the same perception on the importance of Internet and its application as
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in Figure 5. Meanwhile the use and the importance of website are considered at low level. One surprise reason that was given by one respondent is that they have to adhere on what the Malaysia Medical Association guideline mentions that all clinics are not allowed to publish any services except during the opening of the clinics (The-Malaysian-Medical-Association 2002). Website supposes to be a significant tool in order to develop health information society because patient and physician or public and expert can gain knowledge and share information. Another application used by one respondent is the use of short messaging system (SMS) as an appointment reminder to the patients. This notification system is working well rather than email for both clinic and patient. Further study is needed for the case related to Code of Ethics introduced by Malaysian Medical Association and the use of SMS in clinics. It can be described that health care organization still very far behind especially to develop personal health to the public. In terms of structure, clinics done well to establish internal administration structure for own benefits.

Figure 5 Perceptions on the importance of Internet and its application in business Next factor is processes related to health procedure and information systems. Appendix 1 described an observation of processes involved in general practice in clinics or outpatient in hospital. The observation is to get further clarification on respondents feedbacks on what kind of functions used in the systems and how the functions interact from one process to another. Even though clinics claimed that they have a system, the system is not fully integrated or fully computerized from the registration process towards the dispensing of medicine. The shaded boxes suggested that the processes could be fully computerized and bring more benefits to organization. The process can be summarized in 4 main processes; registration, consultation, pharmacy, and payment as in Table 4.

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Table 4: Four main process in outpatient setting Process Registration Propose Use identity card or insurance card Consultation Notes on Notes in paper & computer Notes in (Structured computer instead text based (Text based) with sketch) Symptoms Symptoms Prescription Prescription Dos calculation Pharmacy Transcribe Read prescription prescription Payment Manual Auto calculation calculation based on number of medicine Current Fill-up Form Reason Paperless Online claim Easy to review medical history

Clarity on drugs avoid homonym Exact dose calculation Avoid giving wrong medicine Avoid mistakes and faster

This finding shows that, qualitative approach (observations) give a better picture about processes developed in the information systems. The processes that are not sufficiently provided in the systems will lead to some problem to the user and the patients. The last factor is about outcome from the use of the systems. The study only assessed the respondents perceptions towards using the systems and the importance of Internet for business use. Dependent on technology in a positive way where respondents believed with information systems they can reduce the use of papers (65.9 % from 29 respondents), increase time to perform certain tasks such as searching on patient records (68.3%), better on reading prescriptions instead on transcribing (51.2%) and accessibility to patients medical history electronically (58.5%). Negatively, they also face problems when dealing with information systems. Out of 29 respondents, 29.3 percents claimed that there are some reports that cannot be generated from the systems, 26.8 percents claimed that the systems itself cannot communicate with the computers in the clinics, 22.0 percents claimed that inefficient maintenance by vendor, 14.6 percents because of systems error, 13.8 percents agreed that problem with black-out makes them to work manually and need to update the data immediately. However black-out should not be an issue if they apply uninterruptible power supply as part of their disaster recovery planning.

5. Conclusion There is no doubt on the importance of ICT in any organization especially in health. With a very limited financial resource for this study, the findings can only describe the level of ICT usage in health organizations, issues and problems claimed by respondents, and the application of triad factors structure-process-outcome in this study. With ICT, clinics could contribute more on developing information health society rather than applying the ICT for internal use.
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6. References (2009). "HIPAA Definitions." Retrieved 20 September 2009, 2009, from http://security.louisville.edu/Resources/Forms/hipaadefinitions.html#HealthcareProvider. Donabedian, A. (1987). "Commentary on Some Studies of the Quality of Care." Health Care Financing Review Annual Suplement. Donabedian, A. (1997). "The quality of care: How can it be assessed?" Archives of Pathology & Laboratory Medicine. Donabedian, A. (2003). An Introduction to Quality Assurance in Health Care. New York, Oxford University Press. Friedman, C. P. and J. C. Wyatt, Eds. (2006). Evaluation Methods in Biomedical Informatics. Health Informatics Series, Springer. John, J. H., D. Thomas, et al. (2003). "Questionnaire survey on the use of computerisation in dental practices across the Thames Valley region." British Dental Journal 195(10). Klecun, E. and T. Cornford (2005). "A critical approach to evaluation." European Journal of Information Systems 14(3): 229-243. Kunkel, S., U. Rosenqvist, et al. (2007). "The structure of quality systems is important to the process and outcome, an empirical study of 386 hospital departments in Sweden." BMC Health Services Research 7(104). Kunkel, S. T. and R. Westerling (2006). "Different types and aspects of quality systems and their implications: A thematic comparison of seven quality systems at a university hospital." Health Policy 76(2): 125-133. The-Malaysian-Medical-Association. (2002). "Code of Medical Ethics." Retrieved 17 January 2010, 2010, from http://www.mma.org.my/Portals/0/pdf/MMA_ethicscode.pdf.

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Appendix 1 Processes in Outpatient Setting Registration Consultation

Pha

Fill-up Form PH

Q-Number

Diagnosa + Write History Prescription

Manual Automation Manual Manual Automation Automation Automation Automation (IS) Text Based GH (IS) Automation Automation Manual (IS) Text Based C1 Manual Automation Automation Manual (IS) Text Based C2 Manual Automation Automation*Manual (IS) Text Based C3 Manual C4 Manual Manual Manual Manual

Drug/ Dose Send Medicine Calculation Prescription Manual (by Manual Manual Patient) Manual (by Manual Manual Patient) Automation Manual Manual (IS) Automation Manual Manual (IS) Automation Manual Manual (IS) Manual Manual Manual

Rec Pre

Ma

Ma Aut (IS) Aut (IS) Aut (IS)

Ma

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