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NigerianHospitalInformationSystems/Benson1

www.jghcs.info[ISSN 2159-6743 (Online)] JOURNALOFGLOBALHEALTHCARESYSTEMS/VOLUME1,NUMBER3,2011

ISSN2159-6743(Online)

HospitalInformationSystems

inNigeria:AReviewofLiterature

AyodeleColeBenson,MBBCH,PhD,DHA*

Abstract

This literature review was developed to examine empirically the factors hinderingadoption of hospital information systems in Nigeria. The study was focused on theperceived paucity of health information technology policy in Nigeria and thecauses of poor implementation of hospital information systems in the country. Thefindings of the literature review highlighted hindrances to the adoption of hospitalinformation systems to include; the high cost of full implementation of a hospitalinformation system, inadequate human capital, corruption, and problemsassociated with poor infrastructure in Nigeria. The recommendations were that theNigerian government needs to provide stable electricity, basic communicationinfrastructures, and Internet access to boost private initiatives in the adoption ofhealth information technology across the country.

Keywords: Global health, health information systems, hospital information systems,

reviewofliterature,Nigeria

*Principal,Echo-ScanServices,Ltd.

Correspondence:AyodeleColeBenson,MBBCH,PhD,DHA,Email:benson_ayodeleatyahoo.com

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HospitalInformationSystems

inNigeria:ReviewofLiterature

The application of information technology in health care is unceasinglyevolving as the quality of patientcare in contemporary times seems to depend on the timely acquisition and processing of clinicalinformation related to the patient (Brailer, 2005). Cholewka (2006) asserted that a significant paradigmshift has occurred in health care service delivery from an era of physician centeredness to emphasis onquality of patient care, from isolationist practices by caregivers to networking in a global world, and from

competition to collaboration among practitioners. In tandem with this trend, improvement in technologyand advancement in information systems has been adopted in the health care industry as a businessstrategy to improve the quality of care (Wilcke, 2008).

A clear understanding of the usefulness of hospital information systems is lacking among health carepolicy makers in Nigeria. The Year 2000 World Health report ranked Nigeria 187 out of 191 countries inhealth care infrastructure and health services provision. A gap in knowledge exists regarding the exactnumber of hospital information systems functionally available in Nigeria, but subjective data project lessthan 5% implementation of any form of hospital information technology in a country of more than 150million people (Idowu, Adagunodo, & Adedoyin, 2006). This review was designed to explore the reasonsfor lack of robust availability of hospital information systems in Nigeria.

Background

Nigeria for a long time has suffered political instability, thus creating the opportunity for corruption tothrive and enhancing poor macroeconomic management (Okafor-Dike, 2008). Following years of militarydictatorship and lack of government accountability, infrastructural decay did not attract the desiredattention (Okogbule, 2007). The petroleum-supported economy faced years of blatant economicmismanagement and the squandering of resources through institutionalized corruption (Pierce, 2006).After a few attempts at democracy in the 20th century, Nigeria reestablished a democratically electedgovernment in 1999, but one still recycling much of the political elements of the military era. A change inthe body polity of the nation has been painfully slow and in some cases retrogressive (Okafor-Dike, 2008).A major task facing the current civilian regime is to rebuild the social institutions and health care sectorby introduction of new national policies. As a result of decades of neglect, there is a serious shortage ofmodern health care facilities. The government has taken steps to promote the development of a basicnational primary care program in the villages, but concerns abound about serious lack of specializedhealth care facilities (Ouma & Herselman, 2008).

The most recent population census held in Nigeria in 2006 estimated a population of 140 millioninhabitants, whereas current projections puts the population at more than 150 million people makingNigeria the most populous country in Africa (World health report, 2008). According to the NationalPopulation Commission (2007), the population is young with 42% in the age group 0-14, 55% in the agegroup 15-64, and only 3% age 65 and above. The National Population Commission (NPC) published awide range of information including the fact that the population is growing rapidly by 2.4% every year.The birth rate is 40 per 1000 and the death rate is 17 per 1000. The fertility rate is 5.5 children per woman.The population, which is ethnically very diverse, representing more than 250 different tribes and

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population groups, is also diverse in religious beliefs. About 50% are Muslims, 40% Christians, and 10%of different indigenous beliefs (National Population Commission, 2007).

Nigeria practices both orthodox medical care and traditional healing. Traditional medicalpractitioners are native doctors who practice in rural areas but occasionally find patronage in urban cities.The health care services by native doctors do not follow formal protocols or depend on scientific tests toarrive at diagnosis. Sometimes their treatments endanger the lives of their patients from overdose of

herbal extracts. These traditional healers do not have orthodox training, but depend on generationalbeliefs handed down by ancestors (Okeke, 2008). Even though the practice of Western medicine is rapidlyexpanding in Nigeria, the non-availability of modern medical technologies in the health care arenaremains a threat to the success of orthodox medicine (Pierce, 2008).

Health care service delivery in Nigeria falls short of international standards resulting from poor stateof health care infrastructure, shortage of medical professionals, threat of re-emerging infectious diseases,and poor sanitation. Over the last five decades post-independence, growth, and development in healthcare has been dismal. HIV/AIDS has been a very serious health challenge. About 3.6 million of thepopulation are HIV positive or have developed AIDS (equivalent to a prevalence of 5.4% of the adultpopulation). More than 300.000 individuals die from AIDS every year (Arikpo, Etor, & Usang, 2007).Another major problem is that of infant mortality. The World Health Organization Report (2008)indicated an infant mortality of 110 per 1000 live births. As a comparison, the infant mortality in Swedenis 2.7 per 1000 live births. Poverty has compounded these problems to give low life-expectancy of 52

years for women and 49 years for men .Recognizable demographic diversity exists in Nigeria with consequent disparity in availability of

health care facilities across the country (Okeke, 2008; Ouma & Herselman, 2008). Electronic medicalrecord systems help to improve access to health care in remote suburban areas and ensure improvedmaintenance of long-term care (Keenan, Nguyen, & Srinivasan, 2006). Onwujekwe (2005) and Ofovweand Ofili (2005), in separate studies conducted to assess patient and community satisfaction, founddiscontent with community members who decried the poorly staffed and inadequately equipped PrimaryHealth Centers (PHCs) in their rural settlements compared to hospitals in urban centers. Suchdemographic disparity in health care accessibility benefits from hospital information technologies andtelemedicine to foster collaboration between clinicians in urban areas and those in rural settlements(Ouma & Herselman, 2008).

Hospital information systems include strategic decision support systems and clinical documentationsystems. Some of the clinical support systems include Laboratory Information Systems (LIS), RadiologyInformation Systems (RIS), and Computerized Order Entry (COE). Others are pharmacy informationsystems and personal data analysis systems with important added feature for messaging betweenproviders and staff, and the ability to share data with other medical facilities (Keenan et al., 2006).Telemedicine is a unique application of hospital information technologies. In its simplest form,telemedicine uses audiovisual information and communications apparatus to deliver health careservicesin a bid to modify socio-economic circumstances of the beneficiaries and improve accessibility to medicalcare (Yun & Chun, 2008).

A paucity of government policy regarding the implementation of hospital information systems existsin Nigeria. The lack of strategic government programs has culminated in the poor adoption of hospitalinformation technologies in health care facilities across the country. Okeke (2008) asserted that the lack ofaccess to modern medical health care facilities has compelled many Nigerian patients to seek treatmentwith traditional healers and patent medicine dealers. The more affluent echelon of the society resorts to

medical tourism overseas to obtain health care services, resulting in a loss of foreign exchange to Nigeria.Accordingto Okafor-Dike (2008), poor leadership in Nigeria has led to years of economic downturn

affecting every aspect of social life. Rather than develop medical services in Nigeria, government officialsand wealthy individuals frequently seek medical treatment abroad even for the most basic health careneeds. Former Vice President Atiku goes to Germany for treatment of his arthritis. Political analysts inboth national and foreign media have often questioned the rationale behind former President Yaraduasfrequent trips for medical treatment in Saudi Arabia even for renal dialysis rather than developingmedical facilities in the country. In an apparent endorsement of the existing malady in the Nigerianhealth care system, Judge Abutu of an Abuja High court, in a case brought before him in 2010, ruled that

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Yaradua violated no laws by remaining on hospital admission in Saudi Arabia for more than two months(Nigeria Judge Rules, 2010). The judgment appears illogical; the decision from a respected legal authorityseems to legitimize the quest for overseas medical treatment by top government officials in Nigeria as aresult of the poor health care infrastructure in the country.

Analysts acknowledge that the dearth of a modern medical infrastructure in Nigeria has promotedmedical tourism among the rich subset of the Nigerian population. Amaghionyeodiwe (2009), in a study

that examined the impact of government health care funding in Nigeria, observed that the poor healthcare infrastructure continues to widen the differences between the rich and the poor in Nigeria. The majorreason for the widening of differences, according to Amaghionyeodiwe, is that the poor are morestrongly affected by public spending on health care relative to the non-poor. Whereas the rich can affordoversea treatments, the poor continue to suffer from lack of good quality treatment, increased morbidity,and poor medical outcomes, thereby worsening their originally compromised health status emanatingfrom poverty.

Available literature provides common standpoint among various authors that disparities exist in theimplementation of hospital information system in developing and developed countries (Grimm & Shaw,2007; Williams & Boren, 2008). Speculated reasons include (a) Poor technological and funding support indeveloping nations, (b) Poor management capacity at all levels that hinders seamless workflow, and (c)complex milieu of health care service delivery. Other posited factors include (d) continual evolution oftechnology, (e) Confidentiality problems with the use of hospital information systems, and (f) poor

technological background of the Nigerian society (Grimm & Shaw, 2007; Krishna, Kelleher, & Stahlberg,2007). The consequences of non-adoption of hospital information technologies include possible mix-upwith laboratory results, misdiagnosis, medication order errors, and mismanagement of patients (Keenanet al., 2006; Okeke, 2008).

Prior to the introduction of the health care insurance scheme in Nigeria, health care purchases weremade by individual out-of-pocket payments and few employer-based private health insurance withdifferent reimbursement mechanisms (Pierce, 2008). In June 2005, a National Health Insurance Scheme(NHIS) commenced as a trial system. Policy makers planned a regular review of the program, but nochanges thus far have been made in the 5 years of its implementation. The Nigerian House ofRepresentatives and Senate endorsed the scheme, including a moratorium on deductions ofcontributions. The intention was to extend the program to the organized private sector within 1 year of itscommencement in the public sector, but it remains to be seen if this system will provide enough healthcare coverage, particularly to the poor. The lack of well-established information infrastructures within thehospital systems in Nigeria presents a challenge to the health care delivery in the country.

Theoretical Framework

Currently, a gap in knowledge exists about the exact number of hospital information systemsfunctionally available in Nigeria, but the subjective data project less than 5% implementation of any formof hospital information technology in a country of more than 150 million people (Idowu et al., 2006). Theavailable literature provides a common position among various authors that disparities exist in theimplementation of hospital information systems in developing and developed countries (Grimm & Shaw,2007; Williams & Boren, 2008). Speculated reasons include poor technological and funding support indeveloping nations, poor management capacity at all levels that ensures seamless workflow, and acomplex milieu of health care service delivery. Other possible factors for low implementation include the

continual evolution of technology, confidentiality problems with use of hospital information systems, andthe poor technological background of the Nigerian society (Herbst et al., 1999; Grimm & Shaw 2007;Krishna et al., 2007).

Holden (2009) posited that much research related to adoption of health care information technologyhas been atheoretical. In this study, a useful theoretical model is the maturity model to processimprovement originally described in software engineering and used in the novice-to-expert approach tocompetency. The maturity theoretical model describes a modernization framework aimed at thecommitted use of relevant information technology in a change process (Gillies & Howard, 2005).Beneficial uses of information and associated technology as it relates to health care improvement in this

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model includes monitoring individual and organizational performance, facilitating information sharingamong different health care organizations through a multi-agency approach, and empoweringindividuals by providing relevant information to consumers, thereby helping them to make informedchoices (Gillies & Howard, 2005).

An additional theoretical standpoint in this study is that in a heterogeneous society as Nigeria withsignificant disparity in accessibility of health care facilities between urban and rural communities,

hospital information systems will help to bridge the gap in availability of patient care (Ouma &Herselman, 2008). Sammon, OConnor, and Leo (2009) associated patient data analysis systems (PDAs)with enhanced storage and analysis of patient data, enabling physicians to reach improved clinicaldecisions on patient care. Similarly, clinical information systems capture clinical data to enhance promptand efficient decision making (Ward, Joana, Bahensky, Vartak, & Wakefield, 2006; William & Boren,2008). Hospital information systems improve workflow and increase patient throughput (Ouma &Herselman, 2008; Shekelle et al., 2006; Wallis 2007). Sisniega (2009) asserted that the applications ofinformation and communication technologies (ICT) facilitate ubiquitous and instantaneouscommunication between organizations and their stakeholders. Information communication technologyenables people and organizations to achieve a seamless workflow and effective processes throughimproved interactions.

Literature Review

The literature search brought to the fore contextual issues and brief historical overview of hospitalinformation systems. The discussion focused on the infrastructural requirements for implementation ofhospital information systems alongside the cost implications and the role of government infunding thecost. A significant portion of the literature review centered on the Nigerian situation as it relates to thepoor implementation of hospital information systems. Issues highlighted about Nigeria includedemographic diversity and cultural effects on health care, lack of support infrastructure, corruption, lackof technical support services, problems with human capital, an import-dependent economy, and the highthe cost of capital in the Nigerian capital market. The concluding aspects of the literature search containdiscussions on the limitations of hospital information systems and future trends.

Brief Historical Overview

The processes used to collect, process, and store patient information to aid clinical treatment areprobably as old as medicine. The formats for collection of patients records and the ways in which thisinformation is used and subsequently stored for future references has continued to evolve from regularpaper note takings to electronic taped records and present-day hospital information technologies. Wilcke(2008) defined information literacy that affects medical practice as the ability to identify the need forinformation and seek, evaluate, and use information in any presented format. Information technologyinfusion that aids globalization refers to the degree to which various information technology toolsintegrate into organizational activities (Idowu et al., 2006).

The growth of computer technology in the 1980s with consequent improvement in informationliteracy saw the advent of the first breed of hospital information systems (Keenan et al., 2006). Earlierresearchers in hospital information systems categorized them into three types: Consumer informatics,medical and clinical informatics, and bio informatics based on areas of application (Detmer, 2001).Consumer informatics focuses on communications between patients and the public. According to

Svensson (2002), consumer informatics helps to create virtual communities for sharing of health careinformation.

Medical and clinical informatics applications relate directly to health care organizational processes,structure, and clinical outcomes. Electronic medical records system is a major medical and clinicalinformation system aimed at the lowering cost of health care therapies (Svensson, 2002), In its earliestapplications, hospital information systems were mostly used for patients electronic record keeping, buthas advanced into almost all areas of medical discipline. Common applications of hospital informationtechnologies include Computerized Physician Order Entry, Pharmacy Information Systems, Laboratory

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Information Systems, Radiology Information System and Picture Archival and Communication Systems,telemedicine, and many others as these technologies are constantly evolving.

William and Boren (2008) acknowledged that most European countries and the United States areincreasingly adopting electronic medical record (EMR) technology to enhance health care outcome andquality. William and Boren posited that Nigeria lacks robust health care infrastructures and policies forimplementation of information and communications technology (ICT). Complicated by challenges of

epidemics and civil wars, African countries lack ICT in their health care systems. The authors assertedthat historically, lack of human expertise and inadequate financial resources is a bane to robust toadoption of ICT in Sub-Saharan Africa.

Benefits of Hospital Information SystemsHospital Information Systems improve workflow and increase patients access to health care (Ouma

& Herselman, 2008; Shekelle et al., 2006; Wallis 2007). Sisniega (2009) asserted that the applications ofinformation and communication technologies facilitate ubiquitous and instantaneous communicationbetween organizations and their stakeholders. ICT enable people and organizations to achieve seamlessworkflow and effective processes through improved interactions. Electronic health technologies enableeffective networking by physicians, allow online review of patients treatment, and provide for accurateprescription of drugs. Radiology information systems enable the transmission of radiological images for

evaluation in remote sites (Weimar, 2009).Electronic data interchange is part of the applications of a robust and integrated electronic health

record system. The type of integrated system envisioned by President Bushs administration is aimed atwarehousing the health care information of all Americans in a national database by 2014 (Thielst, 2007).Electronic data interchange primarily is aimed at achieving seamless continuity of care, irrespective ofpatient migration from one clinician to another or from one city to another.

A study on electronic medical records by Keenan et al. (2006) found improvement in daily work andenhanced patient care: (a) medication turn-around times fell from 5:28 hours to 1:51 hours; (b) radiologyprocedure completion times fell from 7:37 hours to 4:21 hours; and (c) lab results reporting times fell from31:3 minutes to 23:4 minutes. In the same study, transcribing errors for orders declined, and length ofhospital stay decreased. Other benefits of electronic medical records systems are possibility for onlinemonitoring of vital signs, capability for multi-site review of patients records, and improved physicianscollaboration in patient care. EMR facilitates easy access to medication administration records, sharing ofconsultation reports, and decreased transmit time of test results by reducing the time taken to deliverpaper versions (Keenan et al., 2006).

In a heterogeneous society like Nigeria with significant disparity in accessibility of health carefacilities between urban and rural communities, hospital information systems may help to bridge the gapin availability of patient care (Ouma & Herselman, 2008). Sammon, et al. (2009) associated patient dataanalysis systems (PDAs) with enhanced storage and analysis of patient data enabling physicians to reachimproved clinical decisions on patient care. Similarly, clinical information systems capture clinical data toenhance prompt and efficient decision making (Ward et al., 2006; William & Boren 2008). Health carepolicy makers seeking ways of improving quality of patient care at a reduced cost are leveraging hospitalinformation systems to achieve these objectives (Sammon et al., 2009; Simon et al., 2008).

A major challenge that exists for health care systems is the integration of software systems that canservice the various needs of the organization. Stone, Patrick, and Brown (2005) opined that effective

organization creates specific and strategic objectives, including objectives related to the clinical andoperational strategies (p. 33). Failing to address the interrelationships that exist between the strategies canresult in unforeseen negative consequences (p. 34). In the implementation of an electronic medical record,an organization that fails to identify the need for the EMR system to communicate or integrate with thebilling software may likely encounter increase process failures requiring additional resources forcorrection. Successful organizations develop strategies capable of identifying organizational needs. Suchorganizations anticipate challenges and launch remediation efforts by installation of computer networksand systems (Stone et al., 2005)

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A positive correlation is found between adoption of health care information technology and positiveorganizational financial performance in general, and operationally (Weimar, 2009). This observation isthought to emanate from superior organizational performance by health care providers using novelinformation systems (Menachemi, Burkhardt, Shewchuk, Burke, & Brooks, 2006). In the general industry,electronic commerce transactions have enabled banking and the retail industry to lower cost of servicesand improved ease of access to products for their customers by using the Internet (Sisniega, 2009).

Attributes of superior organizational performance in health care include improved quality of care andpatient safety.

Morath and Turnbull (2005) recommended creating a culture of safety in health care organizations byrecognizing and accommodating the multiple complexities of those organizations. A laudable approachwould be to take advantage of the ability of large-scale data systems to amass information as means ofidentifying significant trends, and enable creation of blame-free sanctuaries in which care errors andobservations of incompetence receive prompt solutions. Data production and collection requiresknowledge to facilitate this undertaking. Various forms of knowledge are essential business asset usedfor development of new products and services, thereby useful in developing a competitive advantage inthe marketplace (Rennolls & AL-Shawabkeh, 2008).

Cohan (2005) expressed a contrary view that investment in information technology does notnecessarily transcend to improvement in productivity. Cohan stressed that shortfall in productivityexpectations have made industrial leaders more cautious in adopting information technology in their

organizational processes. Presenting a balanced view, Farquharson (2009) asserted that adoption ofinformation technology increases productivity but falls short of expectation in improvement ofproductivity considering the high capital investment required for implementation. Farquharson surmisedthat industry productivity paradox exists to some extent with implementation of ICT. Furukawa, Raghu,Spaulding, and Vinze (2006) argue that hospital information systems enhance quality of health caredelivery and safety.

Medical errors in diagnosis and drug administration decline with applications of electronic healthsystems. Electronic physician order entry and medication reconciliation helps patients to understandbetter, the beneficial effect of drugs and deleterious effects of drug misuse (Kramer et al., 2007). Fuji andGalt (2008) opined that more than 1.5 million United States residents suffer injuries from prescriptionerrors and other medical errors annually. Citing the 2008 Institute of Medicine report, To Err is Human,the authors suggested that the above figure might represent only a fraction of patients exposed to adversemedical errors when patients own mix-up is taken into account. Fuji and Galt surmised that someelements of hospital information systems increase patient participation in care process, thereby reducingunwanted outcome of treatment.

Laboratory information systems (LIS) have evolved within the last decade (Harrison & McDowell,2008). Harrison and McDowell (2008) linked the evolution of the LIS technology to advancements ininformation technology solutions, stressing that LIS has led to an increased awareness in thedevelopment of technological solutions designed to minimize medical errors. Following the publicationof the Institute of Medicines reports in the early 2000s and the Institute for Healthcare ImprovementsSaving 100K Lives Campaign, industry awareness has increased on the need for solutions to minimizemedical errors (Harrison & McDowell, 2008).

The LIS industry has accepted the challenge and developed innovative software solutions thatinclude patient result verification, the recognition of critical values in addition to the immediate transferof critical values to physicians for evaluation, and enhanced turnaround time (Harrison & McDowell,

2008). Interfacing software is available to merge the laboratory information operating systems withelectronic health record (EHR) systems, enhancing the continuum of communication among providers.Stone, et al. (2005) and Harrison and McDowell anticipated the future of LIS and EHR will provide forincreased patient safety, enhanced quality of care, and a leaner operating system resulting in efficient andproductive processes.

Woodside (2007) concur that health care organizations use electronic data interchange to sharepatient histories, treatment plans, lab results, and insurance information. Sharing the patient's history inan exchange facilitates initiation of care and decreases the chances of errors. Data interchanges thatinvolve physician's orders and pharmacies can protect the patient by detecting prescriptions of

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incompatible drug combinations, and highlighting potential allergens to patients. Another vital functionof the electronic interchange is the verification of insurance benefits. Many providers do not run tests,ship supplies, or provide care without assurance that the patient has insurance coverage and that theinsurance company has authorized the expenditures. Electronic interchange between entities helps avoiddelays in the approval process and decrease the possibility of poor outcome because of a delay intreatment.

Information technology in general enables intra organizational networking that facilitates effectiveinformation flow within the various units of a firm. In the world of an organizations complex network,workforce diversity, and departmentalization, information can become lost in a milieu of activities; hence,decision-making, schedule of responsibilities, and an information flow chart are necessary for effectiveorganizational operations (Hargie & Dickson, 2007). In addition to prompt delivery of investigationreports to patients and clinicians, some aspects of information technology enable decisions made onorganizational processes to be timely and effectively disseminated to the workforce.

Analytical software systems provide means for both dissemination of information and relevantquantitative data to support management decisions. Analytical information systems help organizations tomaintain a competitive edge in the marketplace by increasing operational speed and maintaining fluidityof information flow (Azevado, Ferraira, & Leitao, 2008). Crane and Crane (2006) reported that numeroussolutions for the medication error problem in hospital settings might be averted with the use of anintegrated systems approach. However, execution of an organizations integrated electronic medical

record without use of communication billing software may escalate process breakdowns. Phillips (2009)stated that the use of an integrated system offers considerable conceptual flexibility and data integrationcapabilities instead of using one module for electronic records. An integrated records system promotes auser-interface with e-records repository to facilitate storage and eventual retrieval of records.

Other benefits of electronic health systems include optimization of clinical time because of effectivecommunication and increased compliance with regulatory guidelines (Georgiu, Westbrook, Braithwaite,& Iedema, 2005). Keenan et al. (2006) opined that electronic medical records system provide an effectiveeducational tool for training of resident doctors and medical students. Health care informationtechnology and e-health offer strong potential in research and development of clinical protocols. Futurestudies in this area may provide broader implications of health care information technologiesapplications (Keenan et al., 2006).

Barriers to Adoption of HIS in the United StatesPolicy implementations in the general industry and health care over a decade ago focused on

constant improvement in quality of goods and services by using innovative technology. Containment ofrising health care cost added to the drive for adoption of information technology in health care (Sobol,Averson, & Lei, 1999; Weimar, 2009). Simon, et al. (2008) asserted that Australia and England are nearuniversal adoption of electronic health systems but significant barriers exist causing a slow pace ofimplementation of hospital information systems across hospitals and health care organizations in theUnited States.

According to Ford, Menachemi, and Phillips (2006), in 1991 the Institute of Medicine (IOM) issued areport calling for paperless health records system within 10 years. This visionary call fell short of mediaattention. Scholarly and governmental support was also deficient compared to other reports by the IOM.The consequence is that integrating electronic health record systems into the workplace health care,critical care, and the ambulatory setting does not equate other areas of medical care. Davis (2006), reports

that America is ranked 66th among 100 countries with top class health care infrastructure and systems.Recent studies indicated that whereas 4% to 6% of the United States hospitals and health careorganizations have achieved full implementation of hospital information systems, 14-16% have partialadoption of some forms of hospital information systems (Moore, 2009; Simon et al., 2008; Ward et al.,2006;).

The high cost of implementation of electronic health systems commonly receives the blame for theirpoor adoption. Ward, et al. (2006), in a study of Iowa hospitals, found an 80% adoption rate for urbanhospitals and 3040% adoption rate for rural hospitals, citing the robust financial capabilities of urbanhospitals as the reason for the disparity. Furukawa, et al. (2006), in their analysis of disparity in adoption

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rate of electronic health record systems, asserted that big hospitals with more than 200 beds, teachinghospitals, not-for-profit hospitals, and multi-hospital systems have higher rates of implementation thanindependent non-teaching hospitals. Private not-for-profit health care organizations have twice theadoption rate than for-profit organizations because of reinvestment of organizational profit into healthcare technologies and hospital information systems as a means of retaining not-for-profit status(Feldstein, 2007; Furukawa et al., 2006).

Hikmet, et al. (2008) concurred that organizational characteristics influence the implementation of e-health information systems, but argue that geographical location does not significantly affect rate ofadoption. In an attempt to provide more insight about HIS adoption pattern, Kazley and Ozcan (2007)found that hospital characteristics affect the rate of adoption of hospital information technology. Theseauthors reported that poor implementation occur among smaller hospitals, more rural hospitals, non-system-affiliated health care organizations, and hospitals in areas of high environmental uncertainty. Thelower rate of implementation among rural hospitals correlates more to their small size and limitedresources rather than geographic location.

Other barriers have constrained adoption of electronic health systems in the last decade. Theseinclude inadequate knowledge of available technology; poor service delivery by some product vendors;fear of workflow disruption causing clinicians resistance; uncertainties about return on investment;difficult approval processes for high-capital spending, especially in for-profit organizations; databaseincompatibility causing poor interoperability of various systems; training difficulties to cover large

staffing requirements; regulatory and legal considerations; and differences in information technologypreferences between clinicians and administrators (Alquraini, Alhashem, Shah, & Chowdhury, 2007;Ouma & Herselmen, 2008; Poon, Biumantiial, Jaggi, Honour et al., 2004; Simon et al., 2008; Sobol et al.,1999; Ward et al., 2006; Weimar, 2009).

In the 2005 health data management meeting, a survey of Chief Information Officers in attendancefound 74% of participants showing willingness to introduce clinical information systems in theirrespective hospital practices as a top priority. The surveyed executives worried about the challenges inimplementing effective change management and difficulties in overcoming end-user resistance(Anderson, 2005). Atkinson (2005) asserted that employees are more averse to changes that directly affecttheir status quo. Countering the tendency of end user-resistance requires organizational leaders to adoptstrategies that encourage employees, and yet be persuasive for the workforce to accept and implementdesired change (Atkinson, 2005).

Greene (2005) recommends that organizations wishing to adopt hospital information technologiesmust plan strategically to avoid unintended consequences of information technology implementation.The information gap between management and staff leads to resistance in the implementation of EMRs.Too often managers, who do not perform the daily tasks of documentation, make decisions on the systemcomponents without staff input only to find that adjustments must be made.

In a pilot study in Cyprus on the implementation of electronic medical record systems, Samoutis, etal. (2007) found that the physician's perceptions of the system's effect on their workflow, legal concerns,transition issues, and lack of familiarity with electronic equipment were among the implementationimpediments. On a positive note, Samoutis, et al. found that the computerized system increasedefficiency and improved the quality of care to the patients served. With reimbursement becomingincreasingly associated with quality of care outcomes, implementing the right system with theappropriate components becomes imperative.

Based on the research by Samoutis, et al. (2007), an important step in the implementation process of

hospital information systems is for the medical director to seek the input of associate physicians andadvanced practice nurses within the organization during the appraisal phase, as recommendations fromthe major players in the care delivery process are vital to success. A challenge that exists for theinstallation of computer networks is the culture of the organization and the makeup of each division thatwould use the system. Nurses and physicians may be averse to computer systems because of theperception that personalization of care would be affected (Thede, 2008). Technology advances frequently,and the projected costs of the system upgrades may deter managers' decisions to go forward with theinstallations. The lack of knowledge, poor understanding, and the negative experiences of managers withinformation technology all represent challenges that could be deterrents to adoption.

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Barriers to Implementation of E-Health in AfricaThe Bulletin of the World Health Organization (2008) stated that Nigeria has been searching for the right

policy formulation in health care more than 30 years since the Alma Ata declaration of health for all in

1978. Successive Nigerian governments have not enacted any policy on the implementation of hospitalinformation systems in the health care delivery apparatus of the nation. This lack of policy partly explainsthe continued poor national health outcomes as revealed by the Nigerian Ministry of Health survey in2003. The report put infant mortality at 110 per 1000 births and maternal mortality of 1100 per 100,000 livebirths. The United Nations report ranked Nigeria as the second highest in maternal mortality in the world(Akinyemi, 2008).

In Africa, the loss of health triggers the near-poor into poverty with consequent dehumanizing effectsof extreme poverty (Pick, Rispel, & Doo, 2008). The Millennium Declaration pledged freedom for men,women, and children from adverse consequences of poverty, but in Sub-Saharan Africa, concerns aboundon the projected outcome of the current millennium development initiatives that do not include anyelements of electronic health system implementation (Pick et al., 2008). Ouma and Herselman (2008)indicated that whereas the developed Western nations are at the forefront of implementation of electronichealth, African countries are still at the rudimentary stages of adoption processes. Some of the reasons

attributed to this disparity include poverty, poor economic diversification, and lack of supportiveinfrastructure and inadequate use of natural resources. Stressing that lack of leadership responsibility insetting the right health care priorities may well have been the bane on accelerated development of theNigerian health care.

The peculiar Nigerian situation. The Nigerian health care system has continued to suffer from yearsof neglect by successive governments, hence the poor infrastructural base of both public and privatehealth establishments (Okogbule, 2007). The trend is the same in almost every subset of the national life.At the 2009 UNESCO conference organized to review and evaluate development efforts by member statesafter a decade, the Nigerian score card showed failure in all ramifications. Other West African countrieslike Senegal and Ghana were proud of their achievements within the last 10 years (Ogunlana, 2009).According to Gyoh (2008), the revised health policy document indicated that government expenditure onhealth was below $8 per capita, against the $34 recommended internationally. Compounding poorgovernment funding of health care in Nigeria is the high rate of corruption in the national polity(Christoff, 2005). Overvalued contracts and failed projects abound in an economic system leading to non-actualization of technological breakthroughs and infrastructural decay.

Poverty seems to be a common excuse for poor investment in infrastructure in Nigeria. Sofowora (inpress) opined that despite the abundant natural resources in Nigeria, the country ranks ninth poorest inthe world because of its failure to harness its natural wealth. World Bank (2007) statistics indicated thatthe poverty rate rose from 27% in 1980 to 70% in 1990, and even at present does not show any economicindex of improvement. The consequence is the dearth of basic social infrastructure (Sofowora, in press).Electric power supply is at its lowest ebb with less than 50% of the country connected with electricity. Inplaces with electric power connectivity, the supply is fewer than 12 hoursdaily. Lack of consistent powerhas caused poor industrialization of the country at large. In a related subject examining the poor adoptionof innovative information technology in the Nigerian banking industry, Ayo, Ayodele, Tolulope, and

Ekong (2008) reported that poor electric power supply is a major hindrance. The erratic power supply is achallenge to infrastructural development in every facet of the Nigerian economy.

Inadequate Internet bandwidth is also a notable challenge in Africa. Internet connectivity problemsabound in Nigeria with the few Internet service providers in the market offering very poor servicesbecause of bandwidth constraints (Ayo et al., 2008). Other barriers hindering adoption of hospitalinformation technology in Nigeria, and some African countries include the high cost of implementation,poor infrastructural development, and inadequate trained manpower. Ouma and Herselman (2008)conducted multiple case studies of technological assessments in the province of Nyanza in Kenya toascertain how rural hospitals are adapting to technology shift in health care. The issues examined were

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the availability of information and communication technology infrastructure, electronic healthtechnologies in place, knowledge of caregivers on the benefits of ICT use in health care, and challengesconstituting barriers to adoption of ICT in the hospitals investigated. The results revealed inadequate ICTinfrastructure for electronic health implementation, a limited number of health care staff with basicknowledge of ICT operations, and a high cost of adoption of electronic health systems. The authors alsoidentified end-user resistance in the few hospitals that had some applications of hospital information

technology.Several authors were in agreement about the high-capital requirement for implementation of hospital

information technologies as a major barrier to adoption (Jha et al., 2009; Menachemi et al., 2006; Simon etal., 2008; Ward et al., 2006). According to Getzen (2007) and Morris, Devlin, and Parkin (2007), adoptionof health care technology comes at significant cost implications that consequently impact the cost ofhealth care delivery. Nigeria undoubtedly is more than 95% a consumer society with no recognizableproduction of medical hardware taking place in the country; cost of importation and delivery furtherinfluences the eventual cost of adopting niche health care technology (Okeke, 2008).

Multiple forces impacting policy and health care. Nigeria for a long-time suffered politicalinstability that created an opportunity for corruption to thrive and enhanced poor macroeconomicmanagement (Apter, 2007; Okeke, 2008; Pierce, 2006). Following years of military dictatorship and lack ofgovernment accountability, infrastructural decay did not attract desired attention (Okogbule, 2007). The

petroleum supported economy faced years of blatant economic mismanagement, and squandering ofresources through institutionalized corruption (Arikpo et al., 2007; Transparency International, 2006).Nigeria has a democratically elected government, but one still propagating much of the political elementsand ideologies of the military era. Change in the body polity of the nation has been painfully slow, and insome cases, retrogressive (Nullis-Kapp, 2005; Okafor-Dike, 2008). Consequent upon decades of neglect,Nigeria is experiencing a serious shortage of modern health care facilities. The government has takensome steps to promote the development of a basic national primary care program in the rural areas, butwith undesirable outcomes because of a lack of basic drugs, inadequate manpower, and serious lack ofspecialized health care facilities (Okeke, 2008; Ouma & Herselman, 2008).

The major challenge for the current Nigerian government is to provide a policy roadmap andadequate funding to support health care delivery in the nation. Lister and Jabukowski (2008) stated thatgovernance is the exercise of political, economic and administrative authority in the management of acountrys affairs at all levels (p. 156). One of the cardinal functions of leadership is to promote change,and providing the roadmap for change is a fundamental leadership requirement (Hamm, 2006). Wren(2005) asserted that leadership entails an individual or a team inducing collective action to pursue anobjective, setting the pace for others to follow. Analysts have studied the responsibilities of Nigerianleaders as they affect national development in terms of the success or failure of government reformprograms in the coming one to two decades. These analysts opine that the leaders successes will enablethe country to transform itself from present state of poverty and corruption to join progressive, largeeconomies in technological advancement and prosperity (Apter, 2007; Arikpo et al., 2007).

The high cost of startup investment for implementation of hospital information systems demandssome level of government leadership by ensuring strategic involvement in funding. According to Hikmet,et al. (2008), a report presented to Congress by the Medicare Payment Advisory Commission during theBush administration indicated that adoption of hospital information technology was a major requirementfor improvement of quality, safety, and good clinical outcome in United States hospitals. The commission

sought for more government funding to improve the rate of implementation of hospital informationtechnologies across the country (Thielst, 2007).

Within 90 days of enactment of President Bushs policy to implement universal electronic healthrecord systems (EHRs), Larkin (2005) reported that implementation could be achieved in fewer than thetargeted 10 years. Larkins comments were based on the work of Brailer, who had designed a frameworkfor implementation. Larkin expressed concerns that such elaborate adoption of interoperable electronichealth records would cost more than the Apollo mission to the moon spearheaded by President Kennedy.The Obama administration in its 2010 health care reform bill sought expansion of implementation ofhospital information systems (Jha et al., 2009). Because the decision to facilitate implementation of the

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policy on EHRs commenced by Bushs administration within the new health care policy was attractingdebate, the Obama administration released $19 billion in ARRA to move the process forward (Jha et al.,2008).

The need for a robust government policy on health care technologies exists in Nigeria and otherAfrican countries to facilitate the implementation of e-health initiatives (Bulletin of World HealthOrganization, 2008). Furukawa, et al. (2006) opined that variation in health information systems and

demographic differences between rural and urban areas presents a challenge to policy formulation aimedat universal adoption of health care information technologies. This concern is even more prevalent inSub-Saharan Africa in which about 80% of the population domicile in rural communities deprived ofbasic social infrastructure and amenities (Okeke, 2008).

Effect of Policy Gap and Poor Implementation of HISThe absence of robust implementation of hospital information systems has compromised some

critical aspects of patients safety and quality of care both in Nigeria and in the United States. Fuji andGalt (2008) suggested that more than 1.5 million United States residents suffer injuries from prescriptionerrors and other medical errors annually. The Institute of Medicine report titled To Err is Human indicatedthat the number of patients exposed to adverse medical errors might be more than the above-cited figurewhen patients own mix-ups with the use of prescription drugs are taken into account.

The practice of Western medicine is rapidly expanding in Nigeria, but non-availability of modern

medical technologies in the health care arena remains a threat to the success of orthodox medicine (Linz& Fallon, 2008). The consequences of non-adoption of hospital information technologies in Nigerianhospitals include (a) Mix-up with laboratory results, (b) misdiagnosis, (c) medication order errors, and (d)mismanagement of patients (Linz & Fallon, 2008; Okeke, 2008). Worsened by a shortage of medicalprofessionals, the threat of re-emerging infectious diseases, poor sanitation, and the prevalence of waterborne diseases; the growth and development in health care has been dismal in Nigeria (Pond & McPake,2006).

Infrastructural Requirement for Adoption of HISThe ease of adoption of electronic health information systems is dependent on existing infrastructure

in a hospital or health care organization (Ward et al., 2006). In a study of Iowa hospitals in the UnitedStates, Ward, et al. (2006) found a higher adoption rate among hospitals already using computer systemsfor scheduling of outpatients, scanning of medical records, patient indexing, transfer, discharge ofpatients, and waiting list administration. Effective application of hospital information systems requiresbroadband Internet connectivity with high-speed capability for data retrieval and transfer (Ouma &Herselman, 2008).

Ayo, et al. (2008), in a study of the framework for implementation of e-commerce in Nigeria, decriedthe abysmally low Internet-access in the country. Internet connectivity enables effective datamanagement systems, picture archival, and communication systems, and is specifically important forrunning of radiological information systems and teleradiology. Other requirements include well-trainedhealthcareworkers and information system administrators (Alquraini et al., 2007; Ouma & Herselmen,2008; Simon et al., 2008; Ward et al., 2006; Weimar, 2009).

Resulting from diverse organizational backgrounds, hospital information system vendors tailorinstallation of their technologies to the needs of each health care organization (Moore, 2009). Anuninterrupted power supply is a prerequisite for adoption of hospital information systems and ensures

avoidance of unintended shutdowns that could lead to loss of data or permanent system damage. Thepower supply is erratic or nonexistent in many regions of the Sub-Saharan Africa. Duke, et al. (2005)asserted that improvement in quality of health care for children in commonwealth of independent statesmust address infrastructural development and focus on provision of mechanisms for prompt andeffective dissemination of health care information to facilitate compliance with clinical guidelines.

Cost ImplicationsThe high investment cost and uncertain return on investment is a notable challenge to

implementation of electronic health strategies (Menachemi et al., 2006). More worrisome is the

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observation by researchers that technology spending does not necessarily transcend to expectedimprovements in productivity and profitability (Roztocki & Weistroffer, 2006). Weimar (2009) estimatedthe cost expectation of full implementation of hospital information systems in a 100-bedded hospital isabout $35 million in five years. Ward, et al. (2006) asserted that with problems of uncertainreimbursement and a focus on technology at the detriment of healthy business consideration, adisconnection exists between the drive for adoption of e-health and the continued survival of healthcare

organizations.The changes to health care reimbursement and reduction in funding pose financial threat to

organizations. Compounded by the need to install computer networks as a requirement forimplementation of hospital information systems, health care organizations find the cost benefit analysisincreasingly challenging. Moore (2009) argued that return on investment is achievable by creatingefficient paperless and filmless systems that leads to staff reduction and decrease or eliminate need forreport transcription. Moore reported a one million dollar cost saving at their cardiac hospital byeliminating services of medical transcriptionists for a year. The hospital equally achieved staff reductionin the front and back offices during the same period.

Menachemi, et al. (2006) asserted that regardless of analysis approach or method of electronic healthsystem employed, information technology adoption consistently correlates with increased financialoutcome operationally and in general organizational processes with consequent improvement inorganizational performance. Brailer (2005) projected a 7.5% cost saving from reduction of drug

prescription error and in general 30% improvement in financial performance by adoption ofcomprehensive electronic health record system and widespread organizational restructuring. Theelectronic health record systems improve the efficiency and reduce cost of data storage and retrieval (Linz& Fallon, 2008). Simon, et al. (2008), in a study conducted to ascertain the estimated use of electronichealth records (EHRs) in ambulatory care practices in the United States, found practice size influencedthe adoption of EHRs with solo and small practices lagging behind larger practices. Most participantsagreed that electronic health records systems have the potential to improve the quality and safety ofhealth care, and may reduce health care costs.

The opportunity costs that an organization may face if it does not invest in these tools include a lackof process performance improvements and a decline in profit margins. Aggregation of data into a datawarehouse facilitates analysis and supports frequent process improvement. This involvement assistsorganizational efforts with assessment of patient outcomes, patient safety, and organizational skills. Profitmargins are constantly dwindling in health care delivery organizations with decreased payment forrendered services. Data warehousing, data mining, and analytics may promote maximal intensity,efficiencies, and effectiveness. A suggestion for the use of hospital information technology is to improvebusiness, clinical processes, health care outcomes, and profit margins (Glandon, Smaltz, & Slovensky,2008, p. 236).

Health care organizations have an opportunity to maximize outcomes when they select to invest inprofitable systems. Wickramasinghe, Bali, Gibbons, and Schaffer (2008) asserted that the health careindustry has the history of using leading edge technologies and embracing new scientific discoveries tofacilitate better cures for diseases. The limitation is that adoption of health care technology often increasesthe cost of health care delivery (Getzen, 2007). In a poor country like Nigeria, further increase in healthcare cost may alienate a sizeable subset of the population from accessing care from orthodox medicalpractitioners (Okeke, 2008).

Human Resources ProblemsHuman resources requirements in the health care industry include a wide range of personnel who

deliver clinical care, supportive services in laboratory, radiology, physiotherapy, and ancillary services.The trend to use digital medical equipment with the possibility for networking demands that medicalstaff possess a good knowledge of information technology applications and uses. In Nigeria, there hasbeen an ongoing depletion of the highly skilled workforce resulting from migration to foreign nations.The health care workforce shortage in the rural areas originally caused by rural-urban migration withinthe country is made worse by large numbers of Nigerian doctors, nurses, radiographers, and laboratory

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scientists departing to developed western countries in search of better pay, better living conditions, andcareer improvement (Glasser, Peters, & MacDowell, 2006).

A shortage of a skilled health care workforce known to affect mostly rural communities all over theworld has currently taken a new dimension in Nigeria with acute shortage of various categories ofmedical staff in urban hospitals leading to a systematic decline in the quality of health care services inNigeria (Glasser et al., 2006; Okeke, 2008). Meetings held by senior government officials on December 2

and 3, 2004, decried the growing shortage of health care professionals in the country. The participantsstressed the need for urgent actions to curtail the trend as it could jeopardize the governments efforts toreduce poverty and disease. Another major concern was that the depletion of a skilled workforce iscapable of hindering developmental goals (Nullis-Kapp, 2005). Okeke (2008) opined that underfunding ofhealth care services by the government because of neglect and claims of over-stretched budgets have leftmany hospitals in Nigeria in a poor physical state, under-staffed, and lacking in modern medicalequipment. Consequently, the limited health care professionals inundated by excessive workload seemoften stressed to the limits (Perry, 2005).

In these circumstances, adoption of hospital information system may be relevant to improveworkflow and bridge the gap created by personnel shortages (Ouma & Herselman, 2008; Shekelle et al.,2006; Wallis, 2007). The challenge remains that time spent training depleted s health care workforce inNigeria will amount to increased waiting time for patients to access care. Uploading patient informationfrom paper-based records into hospital information systems results in an increased workload and

constitutes a significant reason for end-user resistance. With an already over-stretched health care staff,the increased workload on information technology training will constitute a barrier to adoption of HIS.

A study conducted by Kaliyadan, Venkitakrishnan, Manoj, and Dharmaratnam (2009) showed anincrease in time taken to complete patient records for new cases using EMR compared with paperrecords. The study results indicate that average time taken for the completion of the EMR-basedconsultation for new cases was 19.15 minutes (range, 10-30 minutes; standard deviation, 6.47). The paper-based consultation had an average time of 15.70 minutes (range, 5-25 minutes, standard deviation, 6.78).Following the t-test, thep-value was 0.002, which was significant. Chambliss, Rasco, Clark, and Gardner(2001) attributed these timing problems to disruptions in clinical routines and poor typing speed by someclinicians. Samoutis, et al. (2007) in their study of EMR adoption in Cyprus reported that physiciansperceptions of the impact of EMR systems on their workflow and lack of familiarity with electronicequipment were among the barriers to implementation. These challenges may be rifer in Nigeria becauseof already compromised health care workforce population.

Corruption in NigeriaCorruption in Nigeria is a major challenge that has shaped the socio-economic life of the nation and

negatively impacted the health-care development and service delivery. The ugly face of the present-dayNigeria is endemic multidimensional corruption (Okogbule, 2007). According to Amnesty International,Nigeria ranked between the most corrupt and the second most corrupt nation in the world from1996 to2006. Nigeria's Corruption Perception Index (CPI) score has ranged from 0.69 to 2.2 (out of a maximum of10) reaching above the 2 score line for the first time in 2006 (Transparency International, 2006). A nationonce extolled as the giant of Africa because of its massive land area, large population size, andassertiveness of its political elite compared to other African nations once again is making another roundof popularity, but in a derogatory manner.

According to Apter (2007), in the committee of nations, Nigeria often denotes fraud and corruption.

The extent of involvement of fraud perpetuators in Nigeria and those operating outside the shores of thecountry is unquantifiable. Apter stated that fraudulent practices range from online identity theft,marketing of nonexistent goods, prosperity churches, false non-governmental organizations solicitingfunds from foreign donors, to outright imposition by persons as government officials awarding boguscontracts. The activities of corrupt elements in society have tarnished the social and corporate image ofthe nation, causing a drought of foreign investment in the country (Arikpo et al., 2007). Corruption existsin every facet of life in Nigeria, and has negatively affected the willingness of international investors todo business in Nigeria. The engagement of the larger society in corruption occurs by ambivalentcomplicity (Apter, 2007). Sustained aiding and abetting of corruption in the Nigerian society makes it

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impossible for the nation to rise above mediocrity in almost every area of socioeconomic endeavorincluding health care (Apter, 2007; Arikpo et al., 2007).

Nigeria as an Importing EconomySustainable economic growth has been far from attainment in Nigeria because the nation is over 95%

a consuming economy (Okeke, 2008). Technological advancement produces positive change in socialstructure and innovations, and acts as vehicle for modernization (Arikpo et al., 2007). Nigeria is lacking intechnological depth; hence, it depends on foreign technology to drive the countrys developmentalefforts. The consequence has been slow economic growth and over dependence on importation for mostconsumer products. Nigeria seems to have become a dumping ground for substandard products fromAsia and other parts of the world (Arikpo et al., 2007).

Nigeria is the fifth largest exporter of crude oil in the world, yet lacks the capacity to producefinished petroleum products. Locally consumed petroleum products are imported from foreign nations.The three Nigerian refineries have since broken down, and because of obsolete technology, haveremained unserviceable over the years. Institutionalized corruption is the bane of infrastructuraldevelopment in Nigeria (Ayo et al., 2008). Most government officials use their offices to facilitate moneylaundering through inflated contracts. The arrest of two Nigerian governors in London in 2004 and 2005under different circumstances of money laundering charges are clear manifestations of the scale of

corruption in Nigeria and how it has robbed the nation of much needed resources for technologicaladvancement (Okogule, 2007).

High Lending Interest Rates in NigeriaFinancial stability of the capital market affects every aspect of national economy (Ayo et al., 2008).

The Nigerian financial market has been unstable for many years. High capital-flight as a result of highrates of money laundering, bad loans, and massive importations often depleted the capital base of thebanks (Ayo et al., 2008; Okogbule 2007; Sanusi, 2009). These shortcomings and corrupt practices by bankexecutives have forced many Nigerian banks and other financial institutions out of business over theyears. The most recent effort to improve the capital base of Nigerian banks took place in 2006. The aimwas to boost the economy, encourage lending and decrease interest rates to single digits as obtainable inother developed economies (Soludo, 2007). This effort did not yield the desired effects as lending interestrates remained between 22-25% in all the Nigerian banks, depending on type, and tenure of credit (Ayo etal., 2008). The high interest rates have not encouraged investment in health care because of long-gestational periods required for return on investment in health care and the economic uncertainties thatsurround technological investment in health (Ward et al., 2006).

Frequent market failures have not encouraged Nigerian medical practitioners to invest significantlyinto health technology. Aside from the high cost of innovative medical technologies, the credit market inthe country is averse to long-tenure loans compelling most practitioners to invest into other areas of theeconomy that have better prospect for quick return on investment, like housing, stocks, oil, and gas (Ayoet al., 2008). Because the recent global economic meltdown and consequent collapse of most lendinginstitutions around the world, further lag in medical investment in Nigeria may be inevitable. A majorshakeup of the Nigerian banks in July 2009 by the Central Bank governor exposed massive fraudulentacts perpetuated by highly placed bank officials in five Nigerian banks. Records revealed that grants ofunsecured personal loans depleted the capital base of the affected banks (Sanusi, 2009), making it

impossible for them to engage in meaningful banking that could facilitate investments into health careinfrastructure.

Cultural Influence on Adoption of HIS in NigeriaCulture by common understanding refers to a peoples way of life. Nigeria has a large demographic

setting represented by more than 250 ethnic groups and presents diversity of cultural practices andnorms in minute detail (Okeke, 2008). Certain peculiarities are becoming a way of life in Nigeria; notablewithin the emergent common culture are materialism and individualism. Whereas the politicalgrandfathers of the nation of Nigeria fought for independence based on the common good of all, the new

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political elite have introduced a culture of materialism and individualism to the detriment of a commongoal. Eckersley (2005) asserted that the impact of societal cultures on health is often underestimated,explaining that culture could influence the levels of inequalities. For instance, materialism andindividualism accentuate the rich-poor divide, thereby breeding social vices because of the perceiveddictum of survival of the fittest.

Materialism leading to social inequality has become a hindrance to development in Nigeria. A recent

minister of health and officials of the ministry embezzled 300 Million Naira, an equivalent of about twomillion United States dollars meant for the pilot study of telemedicine in the country. Although, thegovernment official was fired from office but as of 2010, telemedicine practices are nonexistent in anyform in Nigeria. The culture of corruption in Nigeria and mismanagement of economic resources bygovernment office-holders borne out of the need to satisfy materialistic and individualistic aspirationshas led to the impoverishment of the nation. The prevalence of poverty rose sharply from 28.1% in the1980s to 65.6% in 1996 (Onwujekwe, 2005). The yearning for quick wealth among Nigerians has led tomassive corruption in the national frontier and fraudulent practices internationally.

The new face of Nigeria has become an impediment to the free flow of goods and services in Nigeria.Foreign companies trade cautiously with Nigerian business entities and this will no doubt impact anymajor initiative to implement hospital information technology in Nigeria on a large scale. The culture ofinstitutional corruption by government officialsdoes not encourage the delivery of the best products intothe country because of the kick-backs (bribes) they receive from product vendors who, in turn, supply

substandard products in a bid to achieve desired profit margins. In the view of Aripko, et al. (2007)because Nigerians allow these practices to continue unabated, the citizenry are in ambivalent complicity.Analysts surmise that this culture is here to stay, except the nation seeks the only way out which mayrequire a total re-orientation of value systems (Okogbule, 2007).

The need exists to replace individualism and materialism with aspirations that promote the commongood of all. Ghana, a close West African neighbor of Nigeria, has transformed successfully in the past twodecades from similar circumstances of corruption and poverty to becoming a rallying point in the region.Therefore, there is hope for Nigeria if the leadership will simply provide the new orientation. Wren(2005), described leadership as the process by which an individual or a team induces followership topursue objectives set by the leader not necessarily by persuasion but through examples set by the conductof the leader. The change in Ghana implies that a new culture of accountability, honesty, pursuit of acommon goal, and nation building is possible for Nigeria through cultural reformation spearheaded bythe right type of leadership. As a benefit of socio-cultural reformation, Ghanas industries currentlyattract capital once targeted for Nigeria in areas of education, health care, tourism, and several otherinvestments because of Ghanas stable socio-political climate, stable electrical power supply, and lowcorruption-rate (Somiah, 2006).

Limitations of HISManagement of electronic health record systems is constantly evolving with about 17 different

systems currently available to service various clinical applications, facilitate strategic decision making,and improve administrative workflow (Hikmet et al., 2007). Although aimed at constant qualityimprovement, the rapid evolution of these information technologies is a major limitation. The short shelf-life compels users to upgrade frequently or lose the ability to interface with newer innovations (Brailer,2005). The upgrade and running cost burden is remarkable and outside the reach of small hospitals andhealth care trusts. Physsician health care administrators and boards understand the benefits of hospital

information technologies, but they do not find easy justification for the cost (Thielst, 2007).Compounding the cost issues, the lack of interoperability of information systems marketed by

different vendors is a significant concern (Brailer, 2005). Problems with Interoperability do not allowseamless retrieval of patient information across different operating systems. Patient clinical data may beaccessed only in hospitals with compatible information systems, thereby hampering the key benefit ofeasy and universal access to patient data that the technology is meant to support (Arrow et al., 2009).Other key concerns constituting major limitations of hospital information technologies include wrongidentifications, wrong or incomplete information documented in hospital systems, the possibility of

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making changes to patient information by unauthorized persons; an event that carries considerable safetyimplications (Fuji & Galt, 2008).

Researchers recognized the cost curtailment capabilities, improved quality of care, and promptdelivery of acute care associated with telemedicine. However, telemedicine, as a type of hospitalinformation technology, has some obvious barriers (Hjelm, 2005; Wootton, Jebamani, & Dow, 2005).According to Ashley (2002), notable among the drawbacks are some legal requirements of multiple

licenses and credentials. Because practices in telemedicine sometimes require clinicians to provideconsultation across interstate boundaries, clinicians with limited licensure may have legal problemsdelivering service in certain locations. Whereas credentialing stipulates minimum standards of training,education, and qualifications needed by professionals to provide care, each state may require differentbenchmarks for its practitioners according to state law. These specific statutes may affect the ability of aclinician to offer telemedicine services.

Another drawback with telemedicine is the physical separation between the health professional andthe patient. In the 1990s, Wootton (1996) called this drawback the depersonalization of health care.Wootton further opined that bureaucracy is another drawback of telemedicine. The use of telemedicinemay require a radical change in the way that services are provided and paid for. Concerns about howservices are billed and reimbursement obtained abound. Patient privacy is impinged upon by practices oftelemedicine. According to Ashley (2002), in a survey conducted in 1999, 20% of participants believedthat medical information was not properly used and 16.7% of participants admitted to providing

inaccurate data to conceal what they considered private informationBarjaktarevic (2008) expressed similar concerns of inadequate confidentiality for patient records

because of possibility of data mismanagement electronically. Georgiou, Westbrook, Braithwaite, andIedema (2005) asserted that the extent of organizational impact of adoption of hospital informationsystems is often underestimated; stressing that a major incident of patient risk exposure emanating fromthe system is capable of causing far-reaching organizational consequences. Callens and Cierkens (2008),commenting on legal concerns with the use of EHRs, concur that new e-health applications, includingelectronic health records, e-health platforms, health grids, and further use of genetic data, come withfresh legal challenges and undeniable legal consequences in case of information mismanagement oridentity theft.

According to Benham-Hutchins (2009) because of challenges involved in integrating new hospitalinformation systems with old paper documentation and record systems, clinicians, and other health carepractitioners may become encumbered with multiple and conflicting sources of patient information.Multiples of paper and electronic documentation may disrupt a seamless workflow and influence thequality and efficiency of service delivery. These circumstances also have the potential to cause new typesof medical errors resulting from poor harmonization of patient information. Understanding theseconcerns requires examination of human factors in the design of technology that is able to adapt to theway health care providers do their job. The delivery of patient-friendly services demands that health careproviders continue to work toward improvement in the method of care pathways and processes.

Georgiou, et al. (2005) asserted that hospital information technologies eliminate some aspects ofhuman interaction among staffs, thereby hindering workplace collaboration and cohesion. Keenan, et al.(2006) concurred that the human element is still very important in health care delivery and technology isjust a tool in the hands of trained personnel. Other economic limitations of hospital informationtechnologies include (a) the inability to ascertain an accurate return on investment (Menachemi et al.,2006), (b) problems with appropriate reimbursement for technology use, and (c) focus on technological

issues at the expense of health care services and business concerns (Ward et al., 2006). In their pilot studyof the implementation of an electronic medical record, Samoutis, et al. (2007) found that the physician'sperceptions of the system's effect on their workflow, legal concerns, transition issues, and lack offamiliarity with electronic equipment were among the impediments of implementation.

Samoutis, et al. (2007) observed that computerized systems increased work efficiency and improvedthe quality of care to the patients served. Recent health care debates reinforced the demands forreimbursement that are associated with quality of care outcomes. Implementing the right systems toincorporate the appropriate components is a necessity. Benham-Hutchins (2009) suggested adequate

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input of unique and valuable nursing perspectives at all stages of the hospital information technology(HIT) system life cycle.

Remedies Aimed at Improving e-Health CoverageCebul, Rebitzer, Taylor, and Votruba (2008) asserted that modern information technology promotes

the sharing and coordination of patients clinical information, but its adoption has been slow in the health

care arena. Various authors have suggested ways of improving adoption of hospital informationtechnologies in developed and developing countries. Although undeniable demographic differencesexists in different regions of the world, some common themes emerge that can enhance implementationof e-health applications anywhere in the world. Suggested remedies include replacement of fee forservice payment systems with a system that rewards and encourages use of innovative informationsystems, establishment of a funding agency to sponsor adoption of health care information technologies,and identification of revenue sources accruable from the use of hospital information systems.

Other measures to encourage adoption of HIS include the provision of tax incentives for full adoptionand the development of hospital information systems that promote data exchange by interoperability andeasy access to a national database functioning as a repository of patient clinical information (Arrow et al.,2009; Ouma & Herselman, 2008; Moore, 2009). Other recommendations for improved adoption of hospitalinformation systems in Africa include improving staff training on e-health applications; purchasingcheaper options in the form of user-friendly software, especially in rural hospitals with limited economic

resources, and improving rural electrification to power information communication infrastructures insuburban communities. To ensure long-term use of e-health facilities, contract agreements with ICTexperts are necessary for regular maintenance of information system hardware. Government should alsofacilitate the adoption of hospital information systems in both urban and rural hospitals (Ouma &Herselman, 2008).

Future Trends

The new trend among health care organizations in a changing global environment is the adoption ofsophisticated information systems to support clinical operations and strategic management. Majorattributes of current systems include an emphasis on information protection, provision of disease-management software, and programs that reduce medical errors. Future trends will seek to improveinteroperability, expand the use of the Internet, and development of electronic health (e-health)applications. More vendors are likely to focus on smart devices with wireless capabilities to improve dataentry and retrieval and support consumers through development of niche home appliances (Glandon etal., 2008). Electronic Health Records (EHR), smart cards, and vein mapping for identification allow easyaccess to medical information and prevent fraudulent use of information by others.

According to Garets and Horowitz (2008), clinicians should engage in evaluation of hospitalinformation technologies because information systems will become repositories of clinical data. Electronicmedical records systems and other information systems will attain commonplace applications inhospitals and other health care centers in the coming decade. President Bush set a target of developingelectronic health records for all Americans by 2014 (Thielst, 2007). Health care policy makers andorganizational leaders should work to understand the operational intricacies of various hospitalinformation technology options in readiness for universal adoption in the next few years (Garets &Horowitz, 2008).

The future trend in Nigeria is hard to predict. The demand for adoption of innovative technologyabounds, but the economic implications and other infrastructural requirement put a barrier to adoption.The Nigerian government and governments of other African countries will have to invest heavily oninfrastructure to facilitate any attempt aimed at catching up with the developed world in the adoption ofhospital information technologies (Ouma & Herselman, 2008).

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Conclusion

The analysis presented in the literature review provided insight into the enormous health care benefits ofhospital information systems, and their usefulness as educational tools in training clinicians. Theliterature review brought to the fore the disparity in adoption of hospital information systems betweenNigeria, the United States, and some other countries. In Nigeria, poverty, poor government funding, lack

of appropriate government policies on adoption of health care technologies, human capital flight todeveloped countries, the low technological base of the country, inadequate electricity supply, andcorruption are among common assertions that authors believed are responsible for poor adoption ofhospital information system (Apter, 2007; Arikpo et al., 2007).

Contextual issues constituting barriers to adoption of hospital information systems formed a majorpart of the literature review, and there seemed to be more impediments to adoption in Sub-SaharanAfrica than in the developed western world. The high cost of implementation of all the components ofhospital information systems appears to be a global challenge. Apart from a lack of infrastructuralrequirements for adoption of hospital information system in Nigeria, the neo-cultural influence ofmaterialism and individualism have added to an environment of corruption, thereby creating a viciouscycle (Eckersley, 2005; Okeke, 2008). Chapter 2 also provided insight into the effects of the paucity ofhealth care policy on health care delivery in Nigeria with an emphasis on poor e-health applications inthe country.

The high cost of implementation of hospital information systems and other barriers are concerns tomost authors. A positive correlation has been found between the adoption of health care informationtechnology and positive financial performance both in general organizational and operational processes(Furukawa et al., 2006; Weimar, 2009). Some suggestion is that the Nigerian government enacts policiesaimed at widespread implementation of HIS and provides funding support to health care organizationsacross the country to facilitate adoption of HIS in their care processes.

Analysts further clamored for improvement in rural electrification to power informationcommunication infrastructures in suburban communities (Arrow et al., 2009; Ouma & Herselman, 2008;Moore, 2009). Others argue that the Nigerian government needs to invest heavily on infrastructure tofacilitate any attempt at catch up with the developed world in the adoption of hospital informationtechnologies (Ayo et al., 2008; Ouma & Herselman, 2008).

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References

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Akinyemi, K. (2008). Nigeria: Poor primary health care cause of maternal mortality. Retrieved fromhttp://allafrica.com/stories/200809150693.html

Alquraini, H., Alhashem, A. M., Shah, A., & Chowdhury, R. I. (2007). Factors influencing nurses attitudestowards the use of computerized health information systems in Kuwaiti hospitals.Journal ofAdvanced Nursing, 57(4), 375381. doi:10.1111/j.1365-2648.2007.04113.x

Amaghionyeodiwe, L. A. (2009). Government health care spending and the poor: Evidence from Nigeria.International Journal of Social Economics, 36(3), 220- 236. doi:10.1108/03068290910932729

Anderson, H. J. (2005). Tackling the challenge of systems integration. Health Data Management, 13(4), 8.Retrieved from http://www.healthdatamanagement. com/issues/

Angst, C. M., & Agarwal, R. (2009). Adoption of electronic health record in the presence of privacyconcerns: The elaboration likelihood model and individual persuasion.MIS Quarterly, 33(2), 339-370. Retrieved from http://www.misq.org/

Apter, A. (2007). A culture of corruption: Everyday deception and popular discontent in Nigeria.AfricanStudies Review, 50(

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