Study One: Assessing PHCs readiness for the implementation of the EHRS from the project team perspective EHRS from the project team perspective

To explore the large-scale implementation of EHRS in PHCs in SA

3.3 Study One: Assessing PHCs readiness for the implementation of the EHRS from the project team perspective EHRS from the project team perspective

This study aimed to assess Saudi PHCs readiness for the implementation of a new EHRS.

The Saudi MoH is planning to implement an EHRS in all PHCs supervised by the MoH (n=2259). As illustrated in Chapter two, healthcare organisations have to be ready for change prior to EHRS implementation (Doebbeling et al., 2006; Lorenzi et al., 2004;

Yusof & Aziz, 2015; Yusof et al., 2008). An organisation’s readiness for change was found to be an important factor in overcoming the potential challenges and for assuring smooth implementation of EHRS (Amatayakul, 2005; Jennett et al., 2003; O'Connor &

Fiol, 2006) (see Chapter Two). Readiness assessments are crucial to any EHRS implementation, because failure to consider readiness assessment has contributed to the failure of up to half of large organisational change attempts (Weiner, 2009). Furthermore, the purpose of conducting readiness measurement is to assess the preparedness of the healthcare organisations to introduce a new EHRS. Consequently, doing so will assist the project team in identifying any issues or requirements that need to be addressed during implementation (Biruk et al., 2014).

For improved, broader readiness assessments, factors from different perspectives, such as organisational, technological and human factors, should be included (see Chapter Two).

According to Snyder-Halpern (2002), eight different themes need to be considered when assessing a healthcare organisation’s readiness for EHRS implementation. These are:

resources, end-users, technology, knowledge, processes, values and goals, management and structures, and administration support. These eight themes represent the factors identified in the literature review.

On the other hand, this study endeavoured to address some of the detected gaps in the literature, such as the role of CM on EHRS implementation and the provision of FR (see Chapter Two). As illustrated in the literature review (see Chapter Two), leadership and management were identified as influential factors in EHRS implementation. In addition, the cost of the implementation project was found to be an influential factor. Therefore, this study explored the impact of CM and FR on EHRS implementation in Saudi PHCs.

This quantitative research used a self-administered, paper-based, close-ended

questionnaire. The questionnaire was developed for people engaged in EHRS implementation in PHCs, and subsequently merged in one study and data collection instrument. This can assist in improving the response rate and avoiding time consuming procedures when conducting them separately. The objectives of this study are therefore:

• To assess PHCs readiness for EHRS implementation from the project team perspective.

• To evaluate the impact of Financial Resources (FR) and Centralisation Management (CM) on the implementation of the EHRS in PHCs in SA.

3.3.1 Site

This study was carried out at the Saudi Ministry of Health (MoH), which is based in the Ministry headquarters in Riyadh, the capital city of the Kingdom of Saudi Arabia. The Saudi MoH manages and oversees healthcare organisations in Saudi Arabia (see Chapter One). Based on the last statistical yearbook that was published by the Saudi MoH, in 2013, the total number of employees was 430,096 (MoH, 2012).

3.3.2 Population

The study population comprises all project team members directly or indirectly involved in implementing a large-scale EHRS project in Saudi PHCs. These consisted, for example, of heads of relevant departments (IT and PHC departments), senior managers, IT engineers, and technicians. This population of participants within the Saudi MoH has varying backgrounds and experience, departments, occupations and genders. The target population was all project team members (n=53).

3.3.3 Sampling technique

To reach the most appropriate subjects for this study (taking into consideration their involvement in the project implementation and knowledge they held about EHRS implementation in PHCs in SA), non-probability, purposive, snowball sampling was used (Bryman, 2012; Thompson, 2012). Purposive sampling is a strategy that is often used in qualitative research (Bowling, 2009), and is also beneficial for opinion and attitude based

surveys (Thompson, 2012). The selected sampling technique is useful when the data needs to be collected from specific individuals and for a specific purpose. In this study, the selected individuals were people at the Saudi MoH who could provide accurate information about the EHRS implementation project.

Identification of the study sample was conducted over two phases. Initially, I visited the relevant departments at the Saudi MoH (IT department and PHC department). I provided these departments with a copy of the ethical approval and facilitator letters obtained from the Saudi MoH (see Appendix A) to allow access to details of the potential study population. I requested a list of names and contact details of project team members who were involved in the EHRS implementation. The lists contained only twenty-seven names. I spent time at the MoH familiarise myself with the EHRS implementation project.

During this time, I held informal meetings with some of the participants to ensure their appropriateness for the study and also ask them if there were other members of the project team that were not identified on the lists, in particular those from outside the selected departments. I collected demographic information from participants to ensure they appropriately represented the population. A total of fifty-three participants were selected due to their involvement, knowledge, expertise and participation in EHRS implementation projects in PHCs in SA.

Although bias in purposive sampling is higher compared with probability sampling techniques, this study failed to determine the participants’ departments. Since the participants came from two main departments, namely IT and PHC departments, the determination of departments may assist in reducing bias. However, I physically collected the questionnaires in person, and I can confirm that individuals from both departments participated and returned the questionnaires.

3.3.4 Data collection instrument

The method used in this study was a structured, self-administered questionnaire composed of pre-defined items and response options (Bowling, 2009; Dawson, 2009;

Offredy & Vickers, 2010). Questionnaires are economical and also require less time when compared to other methods. The structured process implemented here by the questionnaires ensured quicker and cost effective collection of large data (Polit et al.,

2002). Such a questionnaire also offered enhanced privacy (Reja et al., 2003). In addition, questionnaires are frequently used to assess healthcare organisations readiness to implement new EHRS (Gagnon, Attieh, et al., 2014; Yusif et al., 2017).

Upon review, the relevant literature questionnaires were found to be common and more effective than other methods of assessing healthcare organisations’ readiness to implement an EHRS (e.g. Biruk et al., 2014; Pare et al., 2011; Saleh et al., 2016; Simon et al., 2008). According to Ajami et al. (2011); Gagnon, Attieh, et al. (2014), using such a questionnaire can lead to better insight and provide more valid findings. The questionnaire was found to be a useful tool to gain information from a larger sample and help to obtain a different perspective on PHC readiness for an EHRS. Comparing with other data collection methods used to assess healthcare organisation, such as semi-structured interviews (Gagnon, Attieh, et al., 2014; Yusif et al., 2017), the questionnaire is less time consuming and also accessible to the majority of the selected population in this study. As a result, the questionnaire method was deemed to be an appropriate method to gather data from a project team perspective.

A specific questionnaire was developed to achieve the study objectives. Most of the items (n=48) in this questionnaire were identified from an existing questionnaire called

“Organisational Information Technology/Systems Innovation Readiness Scale (OITSIRS)” (see Table 3.3.1) (Snyder-Halpern, 2002), that had previously been used to assess the readiness of six US hospitals in 2002 (Snyder-Halpern, 2002), and then used to assess three US community hospitals in 2006 (Snyder & Fields, 2006). The OITSIRS questionnaire has also been identified as a useful tool to assess healthcare organisations readiness for the implementation of new IT (Anderson & Aydin, 2006; Gagnon, Attieh, et al., 2014; Yusif et al., 2017). Moreover, Gagnon et al. (2014) reviewed the frequently used data collection instruments used to assess healthcare organisation readiness for the introduction of new technology, and suggested using OITSIRS. OITSIRS was found to be comprehensive and highlighted most readiness measurements suggested by the literature review (see Chapter Two).

Table 3.3.1: Organisational Information Technology/Systems Innovation Readiness Scale sub-themes.

1.Funding is adequate for completion of EHRS implementation.

2.The project budget includes training/retraining costs.

3.There is a good ratio of full-time in-house to contract IT staff to support the project.

4.The project budget is consistent with the organisation’s strategic plan.

5.Project teams have included both technical support staff and users.

6.Good quality vendor support for the EHRS is typically available.

End-Users/.83 End-user profile

1.Adequate training is available to support users.

2.A core group of users (champions) is available to support implementation

3.Users are typically involved in EHRS implementation.

4.Most users have an adequate level of computer literacy.

5.Users are typically supportive of EHRS.

6.User competencies are appropriately incorporated into job performance criteria.

Technology/.83 IT/S

1.Research and development activities to learn about new technology are supported.

2. Development of information systems is based on current market trends.

3. There is a good fit between organisational and EHRS implementation strategic plans.

4.There are good quality vendor contracts 5.Current work practices are adequately supported by existing information systems.

6.EHRS project implementation timeframes are usually adequate.

1.There is a lot of knowledge about the on-going development needs of EHRS support staff.

2. Knowledge about how EHRS implementation is being used by other organisations is available.

3. There is a lot of knowledge about EHRS operational and capital budget trends.

4. Historically, strategic and EHRS implementation goals have been integrated.

5. Administrators are very knowledgeable about EHRS based on their past experience.

6. In the past, EHRS users have been included in decision-making processes.

Processes/.85 Organisational processes that influences IT innovation.

1.EHRS implementation needs are routinely incorporated into the organisation’s business processes.

2. The most appropriate individuals are involved in the development of the EHRS implementation strategic plan.

3. Adequate communication mechanisms exist to support shared communication across all organisational levels.

4. Effective mechanisms are in place to evaluate EHRS implementation.

5. Process improvement mechanisms are used effectively to identify work process redesign needs.

6. EHRS implementation decision-makers are adequately represented on key organisational committees.

Individuals have a positive attitude toward EHRS implementation.

There is a willingness to engage in the EHRS implementation process.

There is an emphasis on the importance of collaborative interdisciplinary teams to support EHR implementation.

There is satisfaction with the contribution that EHRS has made to the organisation.

There is a willingness to act on work process

1.The IT department effectively manages the organisation’s shared databases.

2. The business structure supports involvement of IS in strategic planning.

3.Formal policies and procedures are available to guide EHRS implementation processes.

4. The IT strategic plan is an effective guide for the organisation’s EHRS implementation processes.

5. Formal communication mechanisms exist to support user and IT support staff

1.Sufficient funds are available to support EHRS implementation planning activities.

2. Executives engage in mutual decision-making with IT leaders regarding proposals and ideas.

67 IT/S

innovation.

3. The top-ranking IT executive is regularly included in senior executive meetings.

4. EHRS implementation initiatives are usually addressed as part of the organisation’s overall strategic planning.

5. Non-IT executives are routinely named as co-sponsors for EHRS implementation projects.

6. Board members are actively engaged in key EHRS implementation strategic plan committees.

This information, provided to participants, was divided into three sections (see Appendix A). Firstly, there was a letter which described the nature of the study, the importance of their participation and their right to withdraw at any time. In addition, the letter explained how their responses would be treated and that their participation would be anonymous (for more details, see Section 3.2).

The second part asked for specific details regarding individual perceptions of PHCs readiness to the EHRS implementation, as well as the impact of CM and FR. This part was made up of sixty-eight items and was divided into three main themes. The respondent was required to answer the questions using a seven-point Likert scale response: Strongly disagree (1), Disagree (2), Somewhat disagree (3), No opinion (4), Somewhat agree (5), Agree (6), Strongly agree (7) (see Appendix A). Seven-point Likert scale response found to be useful when involve experts and other participants with wide knowledge about the studied context (Snyder-Halpern, 2002). Each of these themes were included to address the objectives of this study. The first theme aimed to assess PHC readiness for the implementation of the EHRS from the project team perspective. The second and third themes were related to the impact of CM on EHRS implementation in PHCs, and the impact of FR on the EHRS implementation in PHCs. These themes provided data that directly linked to the second objective of this study: “to evaluate the impact of FR and the CM on the implementation of the EHRS in PHCs in SA”.

In order to determine the influence of CM on EHRS implementation, questions 49 to 57 of the survey asked about the respondent’s perception of the influence of this type of management on EHRS implementation. The cost was identified in the literature review as being a barrier to these projects (see Chapter Two). There has been little research, however, about the influence of an abundance of FR as a facilitator for EHRS

implementation. Therefore, the final part of the survey was comprised of eleven questions, from 58 to 68, which related to the respondent’s perception regarding the influence of FR on EHRS implementation in PHCs. The third and final part of the questionnaire collected information about the participant’s demographic details. This asked about the participant’s gender, position, their role in the EHRS implementation project, and if they had been involved in any similar projects before. The demographic information was used to describe the sample in order for inferences regarding the generalisability of the findings to be made.

3.3.5 Questionnaire development

The majority of the questions included in this data collection instrument were taken from a pre-existing questionnaire (see Section 3.3.4). However, as some modifications were made and additional items added, I conducted several preliminary procedures in order to assess and, if necessary, improve the questionnaire. The development of the questionnaire was carried out over two phases:

Phase One

The preliminary instrument was reviewed by two different expert panels. The first panel consisted of the supervisory team. The second panel consisted of external experts, including:

• two IT specialists from the headquarters of the Saudi MoH;

• the heads of the IT departments of two different hospitals;

• one academic from King Saudi University (who held a PhD in Health Informatics);

• one radiologist;

• one pharmacist (who held a master’s degree in Health Informatics).

The purpose of the expert panels was to review the preliminary instrument, to check the if the questions being understandable, and to assess the content of the questions to ensure that all included items were relevant to the target population and addressed the study objectives.

Both panels of experts suggested adding some demographic questions such as participant gender, and level of involvement (i.e. whether it was direct or indirect). In addition, they suggested to reduce the Likert scale responses from eight to seven where “no opinion”

had one option instead of two.

Phase Two

Following a review and feedback on the questionnaire by the expert panels, it was sent to a small number (n=5) of the project team as a pilot study to ensure that the questionnaire was clear, understandable and reliable. The data collection questionnaire was piloted at the headquarters of the Saudi MoH with volunteer members from the project team who had agreed to take part. Certain criteria were taken into consideration, such as different position level (e.g., supervisors, directors and senior managers), different departments, and different nationalities.

The aim of the pilot study was to gain feedback from the participants about the quality questionnaire such as readability, comprehensiveness, appropriateness and clarity. The pre-test draft of the questionnaire included questions at the end to assess what participants thought about it:

1. Did you understand the questions?

2. Were there any questions you did not understand and why?

3. Are there any questions you think should have been included?

4. Were there any questions you think should have been excluded?

5. Any comments.

Each participant in the pilot study completed the first draft of the questionnaire and also provided comments and feedback about the process and measures, the questionnaire administration time, and the clarity of the questions. Based on the responses from the pilot, none of the participants suggested including or excluding any questions. Overall, the pre-test pilot showed that the questionnaire was relatively clear and easy to complete.

The pre-test was conducted over a period of two weeks, from 15^th September 2014 to 22^nd September 2014. As a result of the pilot feedback, minor spelling and grammar modifications were made to improve the clarity and readability of the questionnaire. In addition to the grammar and spelling mistakes, one duplication in the included items and

numbering issues was detected by the volunteers. Since the modifications made were relatively minor, responses from volunteers were included in the final results.

3.3.6 Data collection process

Once the data collection instrument had been developed and was ready to be used, I started to think about the most appropriate method to distribute it. The first consideration was how to increase response rate and encourage participants to take part in this study.

Therefore, the initial step in the data collection process for a questionnaire study is to decide whether to use an electronic or paper-based questionnaire. Each method has advantages and disadvantages. I decided to use the paper-based version due to the characteristics of the target participants. The majority of the potential participants in this study were occupying senior positions (e.g., senior managers and heads of departments).

To improve the response rate, I had to encourage participants by visiting them in person and providing them with a copy of the questionnaire with an invitation letter attached. It was felt that using a paper-based questionnaire was better than sending an electronic copy by email and would ensure a greater engagement and completion rate. In addition, during the visit I described the importance of the research and the value of their participation.

Although arranging to meet key people was difficult, I spent a lot of time to ensure that all relevant individuals received a copy of the questionnaire. Some participants did however receive a copy of the questionnaire via their personal assistant. Despite the challenges of distributing a paper-based questionnaire, this did not prove overly onerous, as all the participants were located in one place.

The questionnaire was distributed during the week of October 06, 2014. Fifty-three surveys were distributed to participants. Two “in person” reminder visits to the participants were undertaken after the distribution of the questionnaire. One took place during the week of October 20, 2014, and the other took place during the week of November 03, 2014. Between these visits, phone calls were made to remind the participants to complete the questionnaire, either directly or via their personal assistant.

3.3.7 Data analysis

All data from the questionnaire was coded in numerical categories into SPSS Version 22 (Field, 2013). Firstly, a Cronbach’s alpha test was used to examine the data collection

reliability (see Chapter Four for more details). Thereafter, an initial descriptive analysis of the questionnaire data was undertaken. According to Taylor (2005), descriptive statistics are required to show quantitatively how a specific attribute is distributed within a population. Moreover, the purposes of conducting the descriptive analysis was to obtain a full description of the gathered data that included responses to the demographic questions and the main questionnaire. Descriptive analysis was used to display the data obtained from the participants. Due to the nature of the data obtained from the

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