implementation of an integrated crm system in hospitals in
TRANSCRIPT
Implementation of an Integrated CRM System in Hospitals
in Pakistan
Naveed Shahid
Bachelor’s Thesis
Degree Programme in Busi-
ness Information Technology
2019
Abstract
27 November 2019
Author(s) Naveed Shahid
Degree programme Business Information Technology
Report/thesis title Implementation of an Integrated CRM System in Hospitals in Paki-
stan
Number of pages and appendix pages 30
The aim of this research is to assess the current health information system prevailing in
hospitals in Pakistan and to explore the possibilities of implementation of an integrated
CRM system. The study also examines the challenges faced by the management, the
potential benefits of system integration as well as the readiness of adapting an inte-
grated system in hospitals in Pakistan. The findings will facilitate to improve the overall
health information system infrastructure.
Qualitative research methodology is used for the empirical findings of the thesis. Inter-
views are conducted to collect primary data for the research. However, data is gathered
for literature review through document review like reports, books, articles and online
sources.
The finding reveals that the current national Health Management Information System
(HMIS) of Pakistan is somehow an integrated system with partially linked with other
systems. However, the current system is still manual paper-based, and no data centrali-
zation is done. The study indicates several challenges preventing system integration in-
cluding a lack of coordination and cooperation of inter-organizational information shar-
ing, commitment and motivation of higher authorities and lack of resources. The re-
search concludes that there is a potential of health information system integration once
functional and structural barrier are overcome.
The study suggests few recommendations to facilitate system integration. These in-
clude promoting a system and culture of inter-organizational cooperation and coordina-
tion, sensitizing decision-makers about the benefits of integrated systems and increase
awareness and promote health education.
Keywords Customer Relationship Management, Integrated CRM in hospitals, Integration of Health Management Information System, HMIS in Pakistan
Table of contents
LIST OF ABBREVIATIONS .................................................................................................
1 Introduction ................................................................................................................... 1
1.1 Research Objective ............................................................................................... 2
1.2 Research Questions ............................................................................................. 3
1.3 Scope of the Research .......................................................................................... 3
1.4 Structure of the Thesis .......................................................................................... 4
2 Literature Review .......................................................................................................... 5
2.1 Customer Relationship Management (CRM) ......................................................... 5
2.2 Role of CRM in Healthcare ................................................................................... 6
2.3 Different Health Information Systems (HIS) in Pakistan ........................................ 7
2.4 Health Management Information System (HMIS) of Pakistan .............................. 10
3 Research Implementation ........................................................................................... 13
3.1 Research Methodology ....................................................................................... 13
3.2 Qualitative Research ........................................................................................... 13
3.3 Interview ............................................................................................................. 14
3.4 Data Collection.................................................................................................... 14
3.5 Research Target Group ...................................................................................... 15
4 Empirical Findings ....................................................................................................... 17
4.1 Implementation of an Integrated CRM system in Hospitals ................................. 17
4.2 Challenges faced while Implementing an Integrated System............................... 19
4.3 Potential Benefits of Implementing an Integrated System ................................... 21
5 Discussion ................................................................................................................... 23
6 Conclusion .................................................................................................................. 25
6.1 Recommendations & Future Work ...................................................................... 26
6.2 Self-Evaluation .................................................................................................... 26
6.3 Validity and Reliability of Research ..................................................................... 27
References ...................................................................................................................... 28
LIST OF ABBREVIATIONS
ACO : Accountable Care Organization
CLMIS : Contraceptive Logistic Management Information System
CRM : Customer Relationship Management
DAO : District Account Officer
DEWS : Disease Early Warning System
DHIS : District Health Information System
EDOH : Executive District Officer of Health
EPI : Expended Program on Immunization
FLCF : First Level Care Facilities
FMIS : Financial Management Information System
FP : Family Planning
FPIU : Federal Program Implementation Unit
HIS : Health Information System
HMIS : Health Management Information System
IT : Information Technology
LHW : Lady Health Worker
MCH : Maternal and Child Health
MIS : Management Information System
NHMIS : National Health Management Information System
OPD : Out-Patient Department
PRM : Patient Relationship Management
RHC : Rural Health Center
RHIS : Routine Health Information System
1
1 Introduction
It has been witnessed in the recent past that the healthcare providers showing their inten-
tions towards Customer Relationship Management (CRM). It is because they have identi-
fied that the solution is CRM which provides improved capabilities in managing healthcare
services. In order to offer better and specialized healthcare services, healthcare providers
are realizing their need to access more information regarding patients. CRM makes it pos-
sible by consolidating key information sources like patient history, medical records, pre-
scriptions and tests (Maurja, 2017). Petit, et al. (1997) stated that accurate and clear infor-
mation is directly connected with productivity and satisfaction. Hence, the importance of
health information system cannot be ignored especially in hospitals. According to Benz &
Paddison (2004), CRM is a way of learning about patients, building good relationships, rel-
evant communication, providing real-time data and tracking results of patients for
healthcare providers. Therefore, the key of CRM in healthcare service is to fulfill the needs
as well as the interests of patients and customers in order to increase patient loyalty.
However, Pakistan is struggling to gain high-quality healthcare standards like developed
countries. Pakistan is lacking behind in advanced technology concerning healthcare that
health service providers such as hospitals who does not have an integrated health infor-
mation system. The significance of an integrated information system has been neglected.
The present CRM system in hospitals in Pakistan commonly known as Health Manage-
ment Information System (HMIS) is not integrated with other systems, is undeveloped, has
weak infrastructure, lacking coherence and collection of data is poorly organized, that is
why health information is not recorded accurately or get delayed.
This research is about implementation of an integrated health information management
system of hospitals in Pakistan. The study will investigate the possibilities of implementing
an integrated system. Health information in Pakistan is recorded through several vertical
health information systems such as the main HMIS, Vertical Health Programs, Service
Statistics, Logistics, Financial & Human Resource MIS and several manual databases. All
these information systems are basically the CRM systems which are fragmented with min-
imal linkage to each other. While CRM and HMIS involve similar approaches as well as
the functionalities and features, the word Health Management Information System (HMIS)
or Health Information System (HIS) will mostly be used instead of using the word CRM in
this report to avoid any confusion. The present information system is focused mainly on
public sector but failed to include large private sector and lacking an integrated information
2
system. Private health sector includes small clinics or individual office-based practices of
general practitioners, laboratories, medium and large hospitals and pharmacies.
The reason for researching on this specific subject is that the author has worked in a hos-
pital in Pakistan as a Database Administrator in the past and has gone through with the
challenges faced by the management considering the recording, managing and analyzing
of the information. The author’s main responsibilities were taking care of patient’s data,
managing and transferring the information into the health information system of the hospi-
tal. The author faced problems in daily routine work related to information management.
Therefore, the author is aware of the challenges faced by the management of hospital rel-
evant to the information systems and motivated to contribute in improving the health ser-
vices in hospitals in Pakistan.
The information gathered through the study will provide an insight about the current health
information system and focus on the implementation of an integrated CRM system in
healthcare services. The results will help in improving the overall healthcare information
management system and facilitates the management of hospitals in Pakistan.
1.1 Research Objective
Health planning and policies are mostly depending on right and timely information on dif-
ferent health issues that is why the importance of health information management system
cannot be under-estimated. Unfortunately, the situation of HMIS in Pakistan is not very en-
couraging. The major problems prevailing in HMIS mentions a lack of an integrated health
information system, flow of information is fragmented, over-reporting, poor quality of orga-
nized data, reliability issues of collected data, data processing and consolidating is manu-
ally done with few exceptions, limited use of data and importance of HMIS is very low.
Hospitals in Pakistan does not have an integrated CRM system in use yet. They are still
using the old manual health information record system which creates problems. There is a
need of newly integrated health information management system in hospitals with better
coordination between various vertical health information systems so that the information
can be stored and utilized in all healthcare services at the same time.
The main purpose of this research is to assess the current situation of health information
management system in hospitals in Pakistan. This study will explore the information sys-
tem prevalent in Pakistan and help to find out that how an integrated health information
management system can be implemented in health sector such as hospitals in Pakistan. A
3
solid solution can help to improve the overall infrastructure of health information manage-
ment system in hospitals in Pakistan. The results will investigate the challenges faced by
the hospital management during their information recording tasks which will ultimately fa-
cilitates them with good governance, transparency, accountability and evidence-based de-
cision making. It will also help healthcare services in Pakistan to understand the need and
importance for utilizing a centralized health information management system. It is a time to
strengthen the whole CRM system with improved and better coordination among different
health information systems, which will contribute in better decision makings, helps in sav-
ing of money wastage, manpower and machinery.
1.2 Research Questions
The study will help to explore the perspective of using an integrated CRM from the view-
point of hospitals in Pakistan. The study will focus on the possibility of a centralized health
management information system implementation in hospitals in Pakistan and points out
the weaknesses and limitations of the current system. In addition, this research will also
help to assess the readiness of adapting an integrated CRM system in the hospitals in
present situation. Based on the research objective, following are the main research ques-
tions posted in order to address the objective:
- How an integrated CRM system can be implemented in hospitals in Pakistan?
- What are the challenges while implementing an integrated CRM system?
- How hospitals in Pakistan can get benefits from an integrated CRM system?
1.3 Scope of the Research
In order to collect more reliable results and avoiding broad scope, the originally planned
interviews from the management of public hospitals have been limited to one interview
only. Therefore, the target group is focused mainly from private hospitals in Pakistan.
However, to avoid wide scope and keeping in mind the reliability of the research, the inter-
viewees chosen for this research are from only two major cities of Pakistan. The research
will be limited to the hospitals and will not consider any other healthcare sectors. The re-
search will cover hospital management’s point of view only and the viewpoint of patients,
customers and other healthcare sectors will not be covered. The research will be nar-
rowed down to cover the implementation and importance of an integrated CRM system in
hospitals in Pakistan.
4
1.4 Structure of the Thesis
The structure of this research will be carried out in different chapters:
Introduction
•The introduction part explains briefly about the subject. It defines the objective of the research, research questions and explains the scope of the the study.
Literature Review
•A comprehensive literature review from the credible sources such as books, articles and other online sources will be done, the definition of terms and reference of what previous research have covered in this subject that is being studied will be covered in this chapter.
Research Implementation
•This section is dedicated to the research methodolgy. This chapter tells the research methodology used to collect relevant information for the research. Data collection metrics and research target group is also covered in this chapter.
Empirical Finding
•This section is dedicated for Empirical finding. This chapter shows and highlights the main results collected. Moreover, primary data is collected and presented in this chapter.
Discussion
•This section is dedicated for the discussion of the collected findings. Primary data is interpreted and analyzed in this chapter.
Conclusion
•The final chapter drives the conclusion of the research and explains the possilities of further research in this topic. It will also presents suggestions, own learning and self-evaluation during the research process.
5
2 Literature Review
This chapter explains the main literature review on which the study is based on. Earlier
studies relevant to the subject is reviewed in this chapter. The purpose of this chapter is to
provide related literature in the field of CRM. Introduction and definition of Customer Rela-
tionship Management (CRM) and the role of CRM in health care sector are discussed. Dif-
ferent health information systems in Pakistan are explored as well as the main Health
Management Information System (HMIS) in Pakistan are explained in this chapter. This
chapter will give a comprehensive base for whole thesis.
2.1 Customer Relationship Management (CRM)
According to some marketing researchers, CRM origin was found in late 1970 and the re-
lationship between total quality management and CRM in 1980 (Baran, et al., 2008). Many
definitions of CRM have been mentioned in literature. Few authors focus on the IT future
of CRM while others from marketing background focuses on technological side. CRM from
the technological is defined by Pepper & Rogers (2004) as “the market-place of future is
being undergoing a technology driven metamorphosis, while the definition of CRM from
marketing side is defined by Couldwell (1998) as “it is a combination of technology and
business process that looks to understand a customer of a company from the prospective
of who they are, what they do, as well as what they are like”.
Bose & Sugumaran (2003) argued that “CRM is an umbrella term which sets the customer
in the center of a company. CRM is related with managing customer relation across all
business functions, audience and point of interactions while customer service is an im-
portant component”. Croteau & Li (2009) argued that “Basically CRM is a tremendous step
towards creating a system which provide a means for keeping individual loyalty in a world
of different souls. One should understand the customer’s change of nature in order to un-
derstand CRM because customers and consumers are not what they used to be before
(Greenberg, 2001). According to Dyche (2001), CRM is an infrastructure that allows the
correct means through which to encourage valuable customers to stay loyal and increase
in customer value. Brown (2000) stated that CRM is neither a project nor a concept. In-
stead, it is a business strategy that aims to understand, manages and anticipates the
needs of company’s potential and current customer. It’s a journey of process, strategy,
technical and organizational change where organization seeks to manage its own enter-
prise better around customer behaviors. It is a process of acquiring, growing and retaining
valuable customers.
6
“CRM is a technology enabled strategy that converts data driven into business actions in
anticipation of actual customer behavior. It represents a process from a technology pro-
spective to measure and devote enterprise resources to activity which has the highest re-
turns and impact on valuable customer relationship (Buttle, 2009)
CRM in point of view of Brown (2000) is a company-wide business strategy designed to
maximize revenue, profitability and customer satisfaction by managing the organization
around fostering customer satisfying behavior, customer segment and relating processes
from customers through suppliers. Key technology investment in CRM provides increase
customer access, better customer understanding, effective customer integration through-
out customer channel and interaction. CRM application domain includes customer service
& support and technology enabled selling and marketing.
Gartner (2003) gives rather a comprehensive definition of CRM stating that it is widely rec-
ognized and implemented strategy to manage organizational interactions with customer,
sales prospects and clients. It includes the use of technology to organize, synchronize and
automate business processes, sales activities, customer service, marketing and technical
support. The overall goal is to have long lasting relationships with customers. CRM desig-
nates an enterprise-wide business strategy holding and even beyond all client facing de-
partments. Processes, people and technology work together when implementation is ef-
fective to reduce operational cost and increase profitability and productivity.
2.2 Role of CRM in Healthcare
Rapid rise in the amount of healthcare information has moved hospitals to deal an im-
portant issue that is how to utilize medical information technology in order to improve the
quality of healthcare services. Customer relationship management (CRM) is an innovative
approach for healthcare providers to learn how to facilitates the process more effectively
and efficiently. Different hospitals use CRM systems commonly known as Health Manage-
ment Information System (HMIS), Health Information system (HIS), Management Infor-
mation System (MIS), Patient Relationship Management (PRM) and many more. Thus,
the adoption of CRM has increased in hospitals worldwide. (Alireza, et al., 2011)
CRM solutions within healthcare are now seen as a key IT component for value-based
care, population health and ACO strategies. Even though CRM solutions have been avail-
able since the early 90s, it has taken some time for the healthcare to adopt these plat-
7
forms. However, growth in CRM adoption and implementation will add more payers, pro-
viders and the creation of life science companies. CRM includes the patient in payer
space, hospitals including ambulatory practices, specialized facilities and clinics for pro-
viders. Biotechnological, clinical research organizations and even pharmaceutical are
adopting CRM in life science realm. (Brown, 2017)
The research data shows that about third quarters of all health-related queries starts from
the search engine. In today’s digital world, the responsibility is on the healthcare service
organizations to provide consumers the health information they are looking for. In order to
gain meaningful insights related to customer service, the challenge they are facing is to
integrate, analyze, summarize and apply disparate data. A healthcare CRM system be-
came a centralized and integrated healthcare data hub to organize various data streams
which includes analytics, communications and other patient interactions. This helps
healthcare institutions to involve a partnership with healthcare professionals across the
plateau to create an actively engaged consumer base. The role of CRM in hospitals have
grown many-fold with intensively competitive in the healthcare industry. Regarding the
choice of hospitals, today the patients have more choices than ever before. CRM in
healthcare industry is all about the use of technology in order to provide value added ser-
vices to the consumers, improve customer loyalty and create consumer delight. To ad-
dress the human aspects of implementation, there is a need of pre-planning and executive
support. Special CRM systems and cloud-based CRM software are useful to disseminate
the valuable data and needless information. (Kapture, 2017)
2.3 Different Health Information Systems (HIS) in Pakistan
A health information system (HIS) includes both routine and non-routine health data. A
routine information system creates health data that have been collected at public and pri-
vate health centers, community level healthcare and clinics at regular intervals. (Measure
Evaluation, 2017). In Pakistan, the current information system is fragmented because
there are more than 20 different sub-systems, which uses various vertical channels. Be-
sides this, nongovernmental organizations using their own health information system and
countless private hospitals and clinics have separate systems. Several fragmented Health
Information Systems (HIS) or Management Information System (MIS) are present in
health sector in Pakistan which are operating parallel with each other with minimal con-
nection. The main CRM system currently operating titled as National Health Management
Information System (HMIS) is for first level care facilities which was developed in 1992.
Besides the main system, there are some sub-systems geared to the needs of vertical
8
programs such as Lady Health Workers (LHW) Management Information System, Ex-
pended Program on Immunization (EPI), National Aids prevention and Control Program,
Malaria Control Program, Tuberculosis Control Program which are not fully integrated with
HMIS but minimal linkage with each other. (Ali & Horikoshi, 2002)
Following are the few health information systems (HISs) in Pakistan:
• Health Management Information System (HMIS)
Health Management Information system (HMIS) was developed in 1992 for first level care
facilities (HMIS-FLCF) and completed its implementation in August 2000. The review of
thorough reports and relevant documents stated that HMIS gathers only routine data from
first level care facilities (FLCF), Maternal and Child Health centers (MCH) and Rural
Health Centers (RHC). It does not include private sector, secondary hospitals and other
parastatal institutions. (Ali & Horikoshi, 2002)
• Lady Health Worker MIS (LHW)
Lady Health Worker program is handled by Federal Program Implementation Unit (FPIU)
and the only source of community-based data. The FPIU deals with primary health care
policy advice, internal monitoring and evaluation, training, national reporting, payroll, pro-
curement and distribution, operational planning, financial accounting and budgeting. The
LHW program collects data from community level relevant to logistics and service deliv-
ery. All collected information is compiled in reports with help of software and reported to
FPIU. Therefore, LHW information is not shared with facility level. (Mustafa, 2018)
• Malaria, EPI and TB Program
These programs are operated by FPIU. Provincial program coordinators and district pro-
gram managers have certain level of management functions at district and provincial level.
EDOH has responsibility for managing and implementing of these programs at district
level as in case for LHW program. Through EDOH, information created by HIS of each
program is sent to the federal level. At facility level, only a little information is shared.
(Amjad, 2007)
• AIDS/HIV Program
9
This program was established in each province at federal level with provincial offices. The
program deals with preventive activities and surveillance. Any positive case of HIV is re-
ported immediately so that all necessary actions can be taken related to the case. The re-
ports are compiled quarterly by the provincial offices and then transferred to federal office.
All resources are available to provincial offices as a parallel program. (Amjad, 2007)
• DEWS Implementation System
The main purpose of Disease Early Warning System (DEWS) is to detect epidemics
timely. It has been introduced in few pilot districts but still in a very premature stage. The
charts related to program and other stationary are made available for recording infor-
mation in few DEWS pilot districts. (Amjad, 2007)
• Population and Welfare Department MIS (PWD)
At district level, a Reproductive Health Services Centers (RHS Centers) is run for provi-
sion of interventional contraceptive services. Logistic related data is recorded from cen-
tral store down to the community level and the department maintains their own HIS. The
information is transferred to district level from outlets which is compiled and later send to
federal level. (Mustafa, 2018)
• Service Statistics
The service statistics are gathered and compiled through HMIS-FLCF while own records
are maintained by hospitals and report only on indoor admissions, OPD and deaths.
Hospitals maintain abstract register annually for priority diseases which simply trans-
ferred to Federal Bio-statistics Cell. (Amjad, 2007)
• Logistic MIS
The storekeepers record for stores, drugs and equipment on prescribed registers or
instruments. Whenever procurement is required, a paper-based bookkeeping is man-
aged, and managers are informed because logistic HIS does not exist in district with
regular reporting. Stock registers are maintained by the district health organizations
like EDOH, DOH and Hospital Managers (MSs) through respective storekeepers.
Managers have the responsibility for verifying stocks on regular basis. (Amjad, 2007)
• Financial MIS
10
One of the most accurate and organized paper-based system in district is Financial
Management Information System. The budget is distributed by EDO (Finance & Plan-
ning) to all institutional offices. The money is transferred officially to District Account
Officer (DAO) who has the responsibility of releasing payments on production of in-
voices and bills. (Amjad, 2007)
• Human Resource MIS
In terms of data quality, Human Resource Management Information System is the sec-
ondary to FMIS. It is a paper-based system which provides information about vacant po-
sitions, disciplinary proceedings & actions, transfer & posting and personal files. Original
appointment records are maintained by EDOH office and personal files are managed at
duty station. Otherwise, to maintain the overall data for human resources, there is no
proper system. (Amjad, 2007)
• Capital Asset MIS
There is no management information system to maintain the capital assets for organiza-
tions. However, every institution maintains a master stock register for capital assets such
as equipment, building, ambulances and vehicles. The records are maintained by the
storekeeper for future reference. (Amjad, 2007).
2.4 Health Management Information System (HMIS) of Pakistan
In modern age, a well-designed and fully functioning management information system is
an essential tool. The old method of collecting data and analyzing in Pakistan was
viewed to be revolutionized if the information repository was to be suitably utilized in the
health data. It was taken as a national strategy during that time. In response to this, the
health ministry of Pakistan collaborated with international health agencies and provincial
health departments established a CRM system named as a national health management
information system (HMIS) in early 1990s as a mainstream routine HIS in public
healthcare. HMIS and CRM involve similar approaches as HMIS introduces the princi-
ples of Customer Relationship Management (CRM) to the healthcare world. The system
covered the information only from first level health facilities such as basic health units
and rural health centers. An assessment of existing system was carried out and a thor-
ough report was published which stated that the current information system was weak,
poorly organized, did not provide information timely and not proper linked with other sub-
systems and vertical programs. Most of the health information programs had separate
11
reporting systems. It also pointed out that the data processing and consolidating was
performed manually that resulted in time consuming and increased the chances of hu-
man error. As suggested by the national health organization, the main strategy for re-
structuring the process was to use a consensus building approach that was agreed to
transfigure the existing reporting system into a centralized and comprehensive health
management information system (Ali & Horikoshi, 2002)
Subsequently, Government of Pakistan also developed a parallel community-based sys-
tem for primary healthcare in 1994. In addition, several other information systems related
to AIDS, Malaria and TB programs are operational at district levels but only minimally inte-
grated with national HMIS. (Arshad, et al., 2017)
The HMIS as opposed to a centralized information system, is understood initially to carry
out information-based decision making to enable field level managers. This function of
system is plausible under a delegated system. Pakistan launched healthcare reforms in
2001 to address the needs of economic, political, social and epidemiologic. After the de-
volution, a discussion started in 2001 regarding revamping the HMIS and developing a
secondary level healthcare facility into the system. Consequently, District Health Infor-
mation System (DHIS) was developed in 2006 which provides information for implement-
ing and monitoring major indicators of disease pattern, physical resources, preventive ser-
vices and district planning. HMIS is fragmented to more than 20 different HMISs collecting
information from healthcare facilities. (Qazi, et al., 2008)
An initiative to upgrade DHIS by introducing DHIS 2 had been taken in 2018 for collection,
validation, analysis and presentation of health information. Meetings are underway for this
reason for designing and planning DHIS 2 in Pakistan. The draft of the terms of refer-
ences have been done. Integration of information from all healthcare departments will be
the role of DHIS 2. The new DHIS 2 will be able to record data daily rather than monthly
and having facility level in-charges will enter the data instead of computer operator at dis-
trict level. Regular entered data will encourage officials to be more active to provide health
services. (Mustafa, 2018)
A study has been conducted to evaluate the Routine Health Information system (RHIS) in
Punjab province of Pakistan and assess the potential for integration of community-based
data into national Health Management Information System (HMIS) which is gathered from
public and private organizations. Both primary and secondary data were used in that re-
port. Primary data was collected through Key informant interviews (KIIs) whereas second-
12
ary data was collected through document review which includes articles, reports and sta-
tistical data. The study revealed that the community-based FP data was not integrated
fully with HMIS. Pakistan Bureau of Statistics and the cLMIS attempted to integrated FP
data via Contraceptive Performance Report which is an integrated system. But it could not
be materialized because of rigid structures of different departments so the efforts for inte-
gration were stopped. The data from LHW-MIS, DHIS and Population Welfare Department
(PWD) are compiled and presented in this system. The study shows that there is a possi-
bility to integrated LHW-MIS with DHIS because they come under provincial Department
of Health (DoH). But it is hard for integration between Department of health (DoH) and
Population Welfare Department (PWD) because of a separate ministry and administration,
which makes it difficult to maintain and share information. The report stated that there are
few data quality problems in HMIS which must be solved before integrating systems.
These problems must be taken care of along with the integration of CHIS into HMIS.
(Mustafa, 2018)
13
3 Research Implementation
This chapter discusses the description of research process and research methodology. It
describes information about the methods used in undertaking this research as well as the
justification of using this research method. This chapter also explains different phases of
research including the selection of participants, data collection method and introduction of
the participants.
3.1 Research Methodology
According to Denzin & Lincoln (2000) research methodology is ascertained by the com-
plexion of research questions and the aim being investigated. In order to answer the re-
search questions, the research methodology acquired in a study must be used as a tool.
Babbie & Mouton (2010) refer research methodology as a researcher’s approach to ac-
complish the research project. Carter & Little (2008) stated that methodologies justify the
methods that generates data and methods produce knowledge. Therefore, methodologies
include epistemic content. In a nutshell, methodology in this study refers to the approach
chosen for collecting and analyzing data.
3.2 Qualitative Research
This research is a mixture of qualitative approach (interviews) and literature study. Denzin
& Lincoln (2000) explain qualitative research as a composite research method which in-
cludes a collection of various materials case study, introspective, personal experience, ob-
servational interviews, visual and interactional texts which explains meanings to people’s
lives. The main objective of qualitative approach is to analyze data to create valuable in-
formation about the phenomenon. In qualitative research, the data is analyzed so that the
information can be presented in a consistent and clear manner because the amount of in-
formation collected through different methods can me massive, which makes the research
in-depth. However, it cannot be applicable on large scale. Generally, results from qualita-
tive research contain a huge amount of information gathered from a limited number of
people. The data is analyzed and summarized by breaking down the content and con-
structing it in a new entity (Tuomi & Sarajärvi, 2009)
14
3.3 Interview
Schostak (2006) defines interview as an extendable communication which aims to have
in-depth information about a specific subject through which comprehensive meaning of
phenomenon can be gained. According to Potter & Hepburn (2005) interview is a tool to
collect valuable information in qualitative research approach. It allows the researcher to
communicate with the participants more efficiently during the process in case of misunder-
standing. Tuomi & Sarajärvi (2009) stated that an interview is a good option to collect val-
uable information when the subject is relatively new or has not been researched thor-
oughly yet. An interview gives the opportunity to the researcher to recall or clarify the re-
search question and to conduct a meaningful conversation with the participants. Selecting
a data collection method mostly depends on the type of information which a study aims to
find and the source of data collection. An interview can be arranged when there is a sur-
vey or questionnaire having specific questions structured in same order while each inter-
view.
3.4 Data Collection
This research encompasses on in-depth interviews held with the hospital administration in
Pakistan and on literature study. Interviews were conducted to collect valuable research
data. Individuals in related field were interviewed for this research. In this thesis, a qualita-
tive exploratory approach was applied in order to come up with the answers of the re-
search questions. For this purpose, semi-structured interviews were conducted, in which
the interviews took place according to specified theme-related questions. Based on the re-
search questions, an interview guide was created to provide an outline of the topic. The
interview questions were not arranged in any order so that themed interviews provided
participants open hands and an opportunity to discuss the topic more freely. Due to long
distance with the interviewees and time management, research questionnaire was sent to
one of the participants through email and rest of the four interviews were conducted online
via Skype. An invitation email pertaining general idea about the topic was sent prior to the
interviews. The participants were informed about the purpose of the interview and pro-
vided the assurance that the information and anonymity will be confidential and will be
used only for this research purpose. Interviews were conducted in October 2019. All the
interviews were recorded and permission from all participants were asked for this purpose.
Later, the interview recordings were transformed into transcript. Specific research ques-
tions were prepared which was used to transform the interview towards the satisfaction of
research purpose. However, additional questions were made encountered while conduct-
ing interviews.
15
Primary data for this research was collected through in-depth interviews. The primary data
collection methods chosen for this research is good in this case because conducting an
interview is the best way to collect quality, reliable and updated information. Only hospital
management can represent their department and know about the topic well enough. An
interview is considered more efficient and effective way also because there are only few
hospitals that are managed to collect data from, so it is important to discuss and explain
the topic in person if needed.
Following were the questions that were asked during the interviews:
- What is your designation/ role in hospital?
- What kind of system is used in your hospital?
- What are the weaknesses/limitations in current system?
- What is the importance of an integrated CRM system in your opinion?
- How an integrated CRM can be implemented in hospitals in Pakistan?
- What improvements a centralized CRM system brings in the hospitals?
- What are the challenges in implementing an integrated CRM system in your opinion?
- Please tell the readiness of adapting an integrated CRM system in present situation?
- What are the recommendations to improve the current system in your opinion?
However, in order to keep interviews go smoothly, more interaction and additional ques-
tions were added while conducting interviews.
3.5 Research Target Group
In order to collect authentic and reliable information, overall nine requests were made in
total to different target individuals from which five executives with working background in
administration of hospitals and deep knowledge of CRM systems responded and agreed
to participate in the research. Since the subject of the research represents hospitals in Pa-
kistan, therefore, all the interviewees chosen were from Pakistan and currently working in
administration in different hospitals. However, one of the participants recently resigned
from the job and moved to other country but still had a very deep knowledge and insights
on the current situation of the systems. A brief introduction about the interviewees is men-
tioned to bring reliability to the research. In order to protect the privacy, the anonymity of
the participants is respected by creating aliases. Brief introduction about the participants is
mentioned in following manner:
16
Participant 1 (P1) is a Development Head at Yahya Welfare Complex Hospital and had
been working as a Finance Manager previously for more than 7 years. His educational
background is related to CRM and he has a good understanding of CRM systems.
Participant 2 (P2) works as Procurement Manager at Yahya Welfare Complex Hospital.
He is responsible for managing the procurement team, supplier assessment, procurement
of hospital equipment and managing the procurement system.
Participant 3 (P3) is the Founder and CEO of Muhammad Ali Jinnah Medical Complex. He
had been working with CRM systems for more than 5 years and has deep knowledge
about health information systems. The questionnaire was sent to him by email.
Participant 4 (P4) is a Medical Officer at Aga Khan Health Services. He has master’s de-
gree in Health Economics and Management, and he has been working presently with es-
tablished organizations like Aga Khan Health Service Region Sindh.
Participant 5 (P5) works as an Operations Manager at Shifa International Hospital who is
responsible of overseeing general functioning of healthcare services in hospital, managing
staff and implement policy.
All interviewees provided detailed information about the topic. In order to find the potential
interview participants and suitable designation for conducting interviews regarding the
topic, help from colleagues was taken prior in choosing the participants. After carefully
choosing the participants, an invitation letter was sent to give the general idea of the sub-
ject.
17
4 Empirical Findings
The purpose of this research was to find the solution to what can be done to make an inte-
grated CRM system implemented in hospitals in Pakistan. In addition to this, potential
benefits and challenges were also discussed. For this purpose, interviews were conducted
to gather valuable information. Representatives from related field expertise and different
hospitals were chosen for the interviews. The information collected from the participants
was quite realistic and applicable. Empirical results based on the transcript from the re-
sponses described in the following manner.
4.1 Implementation of an Integrated CRM system in Hospitals
All the participants acknowledged on the needs and importance of an integrated CRM
system in hospitals in Pakistan. In order to answer to the main research question, the par-
ticipants responded on the implementation of an integrated system as follows:
“I strongly believe that the federal government should take an initiative in the
integration of HMIS with various vertical programs. Government should build
a mechanism that starts implementation of an integrated system from main
public hospitals in capital city and later move on to other cities and expands
its coverage to private hospitals and other healthcare sectors”. (P1)
“Apparently, with the collaboration between National and Provincial HMIS
Cell, workshops should be organized on systems integration design review
and with active participation of all stakeholders, an integrated information
system should be developed.” (P2)
“The present condition of the health information system in Pakistan highly
demands that the decision makers should come forward to take an initiative
to introduce changes in integration between different vertical systems and
centralized them into one major system.” (P4)
“In my opinion, integration and coordination among different vertical health
program information systems and sub-systems is essential and must be en-
couraged through regular meetings. Ministry of Health is responsible for de-
veloping and implementation of a centralized health information system. It is
18
important to encourage information collection efforts and promote one inte-
grated system” (P5)
In response to the implementation process, all participants agreed on this point that the
implementation of an integrated system should be done in phases. Some of the partici-
pants stated in following words:
“Once an integrated system is developed, a pilot test should be conducted in
some selective hospitals first. Once the pilot test turns out to be successful
and effective, the scope of system should be expanded throughout the coun-
try regardless of the size or status of the hospital. A task force team should
be built who provides awareness, education and training to the staff. This
approach will not only save financial resources but also improve the effi-
ciency of overall information system.” (P1)
“At first, priority setting should be done followed by the involving of all stake-
holders and convince them to begin working on National HMIS plan and poli-
cies. There is a high demand to improve and channeled reporting mecha-
nism which must not be dependent on the absence or availability of staff.
Lastly, there is a need to improve surveillance for vital registration mecha-
nism in case of census not possible.” (P4)
“National plan should be agreed, and implementation should be done in
phases from top to the bottom approach. Public hospitals should be covered
first and then private and other health sectors. Usage of integrated system
should be compulsory for any kind of healthcare services. Practicing license
should not be given if any department do not want to register and use inte-
grated system or it should be cancelled if license has already been given to
them. Training and awareness to the staff is very important phase and must
be obliged for everyone.” (P5)
However, one participant claimed that the national Health Management Information Sys-
tem is an integrated system. He said:
“The National Health Management Information System (HMIS) in Pakistan is
basically an integrated health information system with partially intercon-
nected with other vertical channels and HIS sub-systems but it is still limited
19
to paper-based system and there is no online data recording done so far”
(P4)
On the contrary, one participant disagreed and mentioned that private hospitals on smaller
scale does not need an integrated system. Small hospitals cannot afford the burden of
highly integrated systems due to its high implementation requirements.
“I agree that the importance of a centralized information system cannot be
underestimated for hospitals in Pakistan. However, we run a very small pri-
vate hospital and I think integrated CRM systems are not necessary for small
organizations we run now” (P3)
4.2 Challenges faced while Implementing an Integrated System
Implementation of an integrated system in hospitals in Pakistan may not be an easy
task. Scope of current health information is limited to only first level care facilities. Sev-
eral barriers preventing complete integration of systems are perceived. Participants re-
sponded to answer the research question about the challenges faced in implementing an
integrated CRM system as follows:
“I think the lack of interest and commitment from the key stakeholders is
one of the major challenges we are facing now. They have no plans or poli-
cies and do not want to accept the seriousness of current health situation.
Other than that, lack of inter-organizational information sharing, improper
population registration system and exceeding population of the country in
opposite of the medical professionals are some initial challenges in the im-
plementation of integrated system.” (P2)
“For me, the first and foremost challenge comes in front is the lack of cen-
sus which arises because of an insufficient vital registration mechanism.
Secondly, integration of systems need approach from bottom to top in such
a manner that data is compiled, and decisions are made on that database.
However, poor infrastructure, a culture and system of non-coordination
among departments, limited financial and human resources prevent fully
integration of health information systems.” (P4)
20
One interesting finding which most participants accepted that lack of awareness and
health education is a massive issue in this regard. Participants responded about it in
such manner:
“I have seen that people have less awareness about the technology and no
education about health and human rights. Even the higher-level administra-
tion is not motivated, ready to adapt latest technology. They are used to
working with same old regular systems and do not want to change their
way of working. There is a lack of interest in learning new upgraded sys-
tems. On top of that, lack of facilities and technology advancement, high
illiteracy rate, outdated equipment and machinery and overall poor health
information infrastructure are considered to be some major barriers in this
implementation process.” (P1)
“There are several social, structural and technological hurdles preventing
implementation of an integrated CRM system in hospitals in Pakistan. I
have observed that there is a need to highly encourage doctors, nurses
even management staff to utilize technology and provide them training and
facilities. Secondly, mismanagement, corruption and budget are some
common issues faced by majority of the private hospitals in Pakistan. And
finally, low literacy rate, lack of facilities and training to staff are the main
causes.” (P3)
“It seems that higher authorities are not serious about it. They do not come
forward and look into this matter. All stakeholder should involve in plan-
ning, designing and implementation of the system. It’s a matter of fact that
lack of seriousness shows from the authorities which is a biggest challenge
in this country.” (P5)
He further stated:
“There are couple of other things that seems to be the biggest struggle in
implementing an integrated system in hospitals such as lack of awareness
of the importance and benefits of an integrated system, lack of knowledge
of using an integrated system and the problems of convincing profession-
als to accept and utilize new technologies. Also, private hospitals and clin-
ics are not registered so information from them cannot be merged with the
21
main system. There is no cooperation exists among different departments
and ministry.” (P5)
4.3 Potential Benefits of Implementing an Integrated System
All participants agreed on this point that the implementation of an integrated health in-
formation system will be beneficial for hospitals in Pakistan. In response to answer to
the research question about the potential benefits of implementation of an integrated
health information system in hospitals in Pakistan, following were the comments of the
participants:
“I think the use of an integrated health information system will increase the
profitability of hospitals. It helps to centralize patient information at one
place as well as provide long time saved history of patients, fast treatment,
easy to access and manage, less headache for staff.” (P3)
“One of the biggest advantages of integrated information system is the
unification and integration of public and private health sector records
which provides accuracy and reliability and help in better coordination
among different healthcare sectors. It will also provide better human re-
source management, improve patient trust and satisfaction and decision
making. (P5)
Majority of the participants admitted that having an integrated information system im-
proves the performance and quality of health services and help in better decision mak-
ing. They stated that:
“Integrated system will provide automated work-flows which keeps
healthcare professional reminded of task and duties that needs to be done.
Another benefit is that patient data will be secured. Patients perceptions on
confidentiality and privacy of health data will be covered. Integrated system
will perform as a uniform system and provide better coordination among
different health service providers which automatically enhance organiza-
tional performance.” (P1)
“The importance of an integrated system cannot be ignored. There is no
doubt that a well implemented and integrated system brings improvements
in the organization. Implementation of an integrated system will improve
22
and enhance overall performance of the organization. It will provide real-
time data access, improve decision making and provide better human re-
source management.” (P2)
“Implementation of an integrated system will be very beneficial for hospitals
in Pakistan. First, it will improve the quality of healthcare services. It will
also bring improvement in patient trust and satisfaction. When data will be
centralized, it will easily be accessible, provide faster processing and treat-
ment, accuracy, reliability and easily manageable.” (P4)
23
5 Discussion
The main objective of this research was to review the current health information system
prevailing in Pakistani hospitals and investigate that what can be done to implement an
integrated health information system in hospitals in Pakistan. Additionally, to find out the
challenges faced while implementation of an integrated system as well as the possible
benefits of an integrated system. The study also investigated the readiness of adaption
of such system. The results collected from the participants while conducting interviews
were surprising.
To answer for the research question about the implementation of an integrated system in
hospitals in Pakistan, majority of the participants urged that developing and implement-
ing an integrated health information system is the responsibility of government and
higher-level authorities. They stated that Government of Pakistan and Ministry of Health
should come forward and take initiative to develop and implement such kind of system.
Priorities should be set, and national action plan should be built. However, all partici-
pants were agreed that the implementation should be carried out in phases. For this pur-
pose, regular meetings and workshops should be organized, and a team should be built.
A task force team should be responsible to implement and expand the implementation
process all over the country. They should also be responsible to provide awareness and
teaching to the staff. All key stakeholders should be involved in planning, designing and
implementation phase of an integrated system. After the development phase, a pilot test
should be conducted to examine the situation of a new system. An individual or a group
is unable to impact on implementation. On the other hand, one participant disagreed and
commented that an integrated system is not necessary for private and small-scale hospi-
tals. They cannot bear the burden of high implementation requirements.
There are a couple of things on top of others that seemed to be the biggest challenge in
implementation of an integrated CRM system in hospitals in Pakistan. Based on the an-
swers collected from the participants, two participants stated that such kind of systems
can be operational in other countries but not workable in Pakistan. Three participants
said that lack of commitment and seriousness from higher-level officials is the main prob-
lems. They do not show interest in such matters. According to most of the participants,
lack of awareness of the importance and role of integrated systems, high illiteracy rate,
no motivation of adapting new technologies, lack of resources and facilities prevent sys-
tem integration. Additionally, there are some technical issues as well stated by two par-
ticipants which make it prohibitive such as different health departments have separate
ministry and administration, there is a culture of non-cooperation with other departments
24
as they don’t come under each other that make it difficult to share and maintain data.
Moreover, majority of private healthcare facilities are not legally registered which makes
it hard to collect data from them too.
All participants acknowledged that an integrated health information system can bring im-
provements in hospitals in Pakistan. One of the biggest benefits of an integrated health
information system mentioned by most of the participants was the improvement in the
quality of healthcare services and organizational performance. According to them, an in-
tegrated system will provide real-time data access which helps in better coordination
among different healthcare service providers that ultimately results in data accuracy and
reliability and improved better decision making. They also mentioned that implementa-
tion of an integrated system would improve healthcare service infrastructure as well.
Based on the findings, it was clear from the participants answers that the role and im-
portance of an integrated system cannot be ignored. Modifying in the current health in-
formation system and implementing an integrated system is essential. All participants
acknowledged that the condition of current health information system in hospitals in Pa-
kistan is not good enough. Most of the participants agreed that different vertical infor-
mation systems should be centralized into one major integrated HMIS system. They also
mentioned that the scope of integrated HMIS should be increased.
25
6 Conclusion
The main point of this research was to review the health information systems prevailing
in Pakistan and to explore the potential of health information system integration in hospi-
tals in Pakistan. The research found that consensus exists among the participants that
there are several challenges in the implementation process of health information system
integration which should be addressed prior to system integration. The finding revealed
that there are several barriers exist which are preventing system integration. For exam-
ple, there is a lack of inter-organizational coordination and cooperation. It is difficult to
develop a system integration among various sub-systems because they fall under sepa-
rate ministry and administration. In addition to that, lack of commitment and motivation
from the higher officials and lack of resources prevents system integration.
The study shows that that the current health information system is weak, infrastructure is
poor, information is fragmented and is minimal interconnected with other vertical pro-
grams and sub-systems. There is a strong need to upgrade and integrate health infor-
mation system. Thus, the importance and role of an integrated health information system
in hospitals in Pakistan cannot be ignored.
The study revealed that there is a possibility of integrated health information system. The
research shows that the National Health Management Information System (HMIS) of Pa-
kistan is somehow an integrated system, but partially linkage with other systems. There-
fore, HMIS has the capabilities to be a fully integrated health information system, but
there is a need of a uniform mechanism and culture of interorganizational coordination
and cooperation needs to be established and promoted. First, priorities should be incor-
porated for various vertical programs and sub-systems within the present HMIS. It can
be concluded that there is a potential of implementation of an integrated health infor-
mation system in hospitals in Pakistan once technical and structural barriers are ad-
dressed. The readiness of adapting an integrated system in hospitals of Pakistan in pre-
sent situation depends on the national consensus and coordination/collaboration. Hospi-
tals and administration are capable and ready to adapt any upgradation but still needs
motivation, awareness and on top of that commitment and planning from the higher au-
thorities.
26
6.1 Recommendations & Future Work
To facilitate integration of HMIS with other vertical programs and HIS sub-systems, the
study suggests few recommendations. These include a system and culture of interorgan-
izational collaboration and coordination, sensitizing decision makers about the im-
portance and benefits of integrated system by raising awareness among the profession-
als, use of technology must be encouraged to officials, information systems should be
data-driven instead of action driven and strengthening computerized national identity
card (CNIC) based population registration mechanism to make a centralized and family
centered approach to integrate information.
The study still leaves a gap for future work. This research mostly covers the private hos-
pital’s management perspective of an integrated information system. Therefore, a study
from the perspective of public hospitals management should be researched in order to
get a better picture. Also, this study mainly focused on hospitals in Pakistan and leaves a
gap to research about other public and private healthcare sector which is an important
aspect in the exploration of implementation of an integrated health information system.
This aspect will deepen the credibleness and trustworthiness of the research and will
brings better results.
6.2 Self-Evaluation
As for the self-evaluation, the study finished in a quicker timeframe than it was planned
initially. As per the initial project plan, the same amount of time was allocated to each
chapter. One of the most important things that has been learnt during the process is the
importance and role of planning, organizing work as well as making right decisions on
right time. It was difficult to focus on work in the beginning, but the focus and interest
started increasing by the passage of time. The good part in this process was re-
searcher’s previous relevant work experience in hospital and knowledge about the infor-
mation systems and challenges faced by the hospital administration. On the other hand,
the most challenging part of this thesis was to conduct interviews. As the researcher re-
siding in one country and the interviewees and the subject of the thesis belongs to other
country, finding the participants and choosing the suitable participants for this subject
was challenging. Because of that, the interviews were conducting in a bit later phase of
thesis. However, the researcher successfully abled to contact suitable interviewees
through personal references. After successfully conducting the research on this topic,
the researcher’s knowledge about the healthcare services and health information sys-
27
tems in Pakistan increased as well as the skills of conducting interviews, project man-
agement and research strengthened. If the researcher would get a chance to do the
same work again, the researcher would like to conduct interviews in the early phase so
that the research could find its way easily. Also, the participants for this research could
be increased and interviewees from more technical backgrounds of information systems
could be approached. The researcher’s main objective for conducting the study on this
subject is achieved, and a lot of new information is learnt during the research process.
6.3 Validity and Reliability of Research
The concepts of validity and reliability are widely criticized in qualitative research context
because they are mainly used in testing and evaluation in quantitative research method-
ology (Tuomi & Sarajärvi, 2009). According to Wilson (2010), the reliability issues are
mostly connected with subjectivity. Once a researcher adopts subjective approach, the
level of reliability of the study starting to be compromised. Although, the concept of relia-
bility in qualitative research are considered to re-define as neutrality, consistency, de-
pendability and credibility. However, the concept of validity in qualitative research is de-
fined as the quality and trustworthiness (Golafshani, 2003). According to Oliver (2010),
validity is considered to be a compulsory requirement for all kinds of researches.
Validity and reliability of the research show the quality of study done in order to collect au-
thentic results. For the empirical findings, the validity and reliability of the research are
formed by selecting suitable candidates for interviews, keeping in mind the language bar-
rier and to avoid framing questions. Therefore, it can be stated that even though the par-
ticipants answered all questions according to their best knowledge, some issues can still
be undiscovered due to uncertainty. The literature part of the thesis is written using credi-
ble sources such books, journals and online sources to collect reliable information.
28
References
Ali, M. & Horikoshi, Y., 2002. Situation analysis of health management information system
in Pakistan. 41(2), pp. 5-6.
Alireza, K. et al., 2011. Improving the CRM System in Healthcare Organization. Internal
Journal of Computer Engineering & Sciences (IJCES), 1(12), pp. 28-35.
Amjad, S., 2007. Asia-Pacific Community of Practice on Managing for Development
Results. [Online] Available at: https://wpqr4.adb.org › LotusQuickr › cop-mfdr › HIS-Pak
[Accessed 29 October 2019].
Arshad, A., Noordin, M. F. & Othman, R. B., 2017. A Synthesis on SWOT Analysis of Public
Sector. (IJACSA) International Journal of Advanced Computer Science and Applications,
8(8), pp. 130-136.
Babbie, E. & Mouton, J., 2010. The Practivce of Social Research. 10th ed. Cape Town:
Republic of South Africa, Oxford University Press Southern Africa.
Baran, R., Galka, R. & Strunk, D., 2008. Principles of Customer Relationship Management.
Ohio: Thomson/South-Western.
Benz, G. & Paddison, N., 2004. Developing Patient-Based Marketing Strategies. Healthcare
Executive, Volume 19, pp. 40,42.
Bose, R. & Sugumaran, V., 2003. Application of Knowledge Management Technology in
Customer Relationship Management. Knowledge and Process Management, pp. 42-46.
Brown, J., 2017. The Growing Role of CRM In Healthcare. [Online] Available at:
https://healthsystemcio.com/2017/05/29/the-growing-role-of-crm-in-healthcare/
[Accessed 05 October 2019].
Brown, S., 2000. Customer relationship management. In: Stinley, ed. A strategic imperative
in the world of e-Business. Toronto: Wiley, pp. 29-31.
Buttle, F., 2009. Customer Relation Management: Concepts and Technologies. 2nd ed.
USA: Elsevier Ltd.
29
Carter, S. & Little, M., 2008. Justifying knowledge, justifying method, taking action:
Epistemologies, methodologies, and methods in qualitative research. Qualitative Health
Research, Volume 17, pp. 1316-28.
Couldwell, C., 1998. A Data Day Battle, Computing. NY: Times Books.
Croteau, M. A. & Li, P., 2009. Critical success factors of CRM technology. Canadian Journal
of Administrative Sciences, Volume 20, pp. 21-34.
Denzin, N. & Lincoln, Y., 2000. Handbook of Qualitative Research. 2nd ed. Thousand Oaks:
Sage.
Dyche, J., 2001. The CRM Handbook. 2nd ed. Chicago: Addison- Wesley Professional.
Gartner, 2003. CRM success is in strategy and implementation, not software. Inside, 19(11),
pp. 11-12.
Golafshani, N., 2003. Understanding Reliability and Validity in Qualitative Research. The
Qualitative Report, 8(4), pp. 597-606.
Greenberg, P., 2001. CRM at the speed of light, capturing and keeping in internet real time.
4th ed. Berkeley: Mc Graw Hill.
Kapture, 2017. Role Of CRM In Healthcare Services. [Online] Available at:
https://www.kapturecrm.com/blog/role-crm-healthcare-services/
[Accessed 09 October 2019].
Maurja, N., 2017. Healthcare and the Role of CRM. [Online] Available at:
https://cynoteck.com/blog-post/healthcare-and-the-role-of-crm/ [Accessed 10 October
2019].
Measure Evaluation, 2017. Routine Health Information System Curriculum, North Carolina:
Carolina Population Center.
Mustafa, M., 2018. The routine health information system in Punjab province, Pakistan.
3(12), pp. 50-62.
30
Oliver, V., 2010. 301 Smart Answers to Tough Business Etiquette Questions, New York
USA: Skyhorse Publishing.
Pepper, D. & Rogers, M., 2004. Managing Customer Relationships. 2nd ed. New Jersey:
John Wiley & Sons.
Petit, J., Goris, J. & Vaught, B., 1997. An examination of organizational communication as
a moderator of the relationship between job performance and satfisfaction. Journal of
Business Communication, Volume 34, pp. 81-88.
Potter, J. & Hepburn, A., 2005. Qualitative Interviews in Psychology: Problems and
Possibilities. Qualitative Research in Psychology, 2(01), pp. 281-307.
Qazi, M. S., Ali, M. & Kuroiwa, C., 2008. The Health Management Information System of
Pakistan under devolution: Health Managers' Perceptions. 2(2), pp. 75-80.
Schostak, J., 2006. Interviewing and Representation in Qualitative Research.. 1st ed. NY:
Open University Press.
Tuomi, J. & Sarajärvi, A., 2009. Qualitative research and content analysis. 3rd ed. NY: Sage
Jounals.
Wilson, J., 2010. Essentials of Business Research: A Guide to Doing Your Research
Project, NY: SAGE Publications.