Hospital Information Systems in Nigeria: A Review of Literature

Nigerian  Hospital  Information  Systems/Benson            1  

  ISSN  2159-­‐6743  (Online)    

 

Hospital  Information  Systems   in  Nigeria:  A  Review  of   Literature   Ayodele  Cole  Benson,  MB  BCH,  PhD,  DHA  *       Abstract     This literature review was developed to examine empirically the factors hindering adoption of hospital information systems in Nigeria. The study was focused on the perceived paucity of health information technology policy in Nigeria and the causes of poor implementation of hospital information systems in the country. The findings of the literature review highlighted hindrances to the adoption of hospital information systems to include; the high cost of full implementation of a hospital information system, inadequate human capital, corruption, and problems associated with poor infrastructure in Nigeria. The recommendations were that the Nigerian government needs to provide stable electricity, basic communication infrastructures, and Internet access to boost private initiatives in the adoption of health information technology across the country.   Keywords:   Global   health,   health   information   systems,   hospital   information   systems,   review  of  literature,  Nigeria  

    *Principal,  Echo-­‐Scan  Services,  Ltd.   Correspondence:  Ayodele  Cole  Benson,  MB  BCH,  PhD,  DHA,  Email:  benson_ayodele  at  yahoo.com     www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Hospital  Information  Systems   in  Nigeria:  Review  of   Literature     The application of information technology in health care is unceasingly evolving as the quality of patient care in contemporary times seems to depend on the timely acquisition and processing of clinical information related to the patient (Brailer, 2005). Cholewka (2006) asserted that a significant paradigm shift has occurred in health care service delivery from an era of physician centeredness to emphasis on quality 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 technology and advancement in information systems has been adopted in the health care industry as a business strategy to improve the quality of care (Wilcke, 2008). A clear understanding of the usefulness of hospital information systems is lacking among health care policy makers in Nigeria. The Year 2000 World Health report ranked Nigeria 187 out of 191 countries in health care infrastructure and health services provision. A gap in knowledge exists regarding the exact number of hospital information systems functionally available in Nigeria, but subjective data project less than 5% implementation of any form of hospital information technology in a country of more than 150 million people (Idowu, Adagunodo, & Adedoyin, 2006). This review was designed to explore the reasons for 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 to thrive and enhancing poor macroeconomic management (Okafor-Dike, 2008). Following years of military dictatorship and lack of government accountability, infrastructural decay did not attract the desired attention (Okogbule, 2007). The petroleum-supported economy faced years of blatant economic mismanagement and the squandering of resources through institutionalized corruption (Pierce, 2006). After a few attempts at democracy in the 20th century, Nigeria reestablished a democratically elected government in 1999, but one still recycling much of the political elements of the military era. A change in the 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 sector by introduction of new national policies. As a result of decades of neglect, there is a serious shortage of modern health care facilities. The government has taken steps to promote the development of a basic national primary care program in the villages, but concerns abound about serious lack of specialized health care facilities (Ouma & Herselman, 2008). The most recent population census held in Nigeria in 2006 estimated a population of 140 million inhabitants, whereas current projections puts the population at more than 150 million people making Nigeria the most populous country in Africa (World health report, 2008). According to the National Population Commission (2007), the population is young with 42% in the age group 0-14, 55% in the age group 15-64, and only 3% age 65 and above. The National Population Commission (NPC) published a wide 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   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            3   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 medical practitioners 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 to arrive 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 generational beliefs handed down by ancestors (Okeke, 2008). Even though the practice of Western medicine is rapidly expanding in Nigeria, the non-availability of modern medical technologies in the health care arena remains a threat to the success of orthodox medicine (Pierce, 2008). Health care service delivery in Nigeria falls short of international standards resulting from poor state of 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 health care has been dismal. HIV/AIDS has been a very serious health challenge. About 3.6 million of the population are HIV positive or have developed AIDS (equivalent to a prevalence of 5.4% of the adult population). 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 Sweden is 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 medical record systems help to improve access to health care in remote suburban areas and ensure improved maintenance of long-term care (Keenan, Nguyen, & Srinivasan, 2006). Onwujekwe (2005) and Ofovwe and Ofili (2005), in separate studies conducted to assess patient and community satisfaction, found discontent with community members who decried the poorly staffed and inadequately equipped Primary Health Centers (PHCs) in their rural settlements compared to hospitals in urban centers. Such demographic disparity in health care accessibility benefits from hospital information technologies and telemedicine 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 documentation systems. Some of the clinical support systems include Laboratory Information Systems (LIS), Radiology Information Systems (RIS), and Computerized Order Entry (COE). Others are pharmacy information systems and personal data analysis systems with important added feature for messaging between providers 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 care services in a bid to modify socio-economic circumstances of the beneficiaries and improve accessibility to medical care (Yun & Chun, 2008). A paucity of government policy regarding the implementation of hospital information systems exists in Nigeria. The lack of strategic government programs has culminated in the poor adoption of hospital information technologies in health care facilities across the country. Okeke (2008) asserted that the lack of access to modern medical health care facilities has compelled many Nigerian patients to seek treatment with 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. According to 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 officials and wealthy individuals frequently seek medical treatment abroad even for the most basic health care needs. Former Vice President Atiku goes to Germany for treatment of his arthritis. Political analysts in both national and foreign media have often questioned the rationale behind former President Yaradua’s frequent trips for medical treatment in Saudi Arabia even for renal dialysis rather than developing medical facilities in the country. In an apparent endorsement of the existing malady in the Nigerian health care system, Judge Abutu of an Abuja High court, in a case brought before him in 2010, ruled that   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            4   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 authority seems to legitimize the quest for overseas medical treatment by top government officials in Nigeria as a result of the poor health care infrastructure in the country. Analysts acknowledge that the dearth of a modern medical infrastructure in Nigeria has promoted medical 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 health care infrastructure continues to widen the differences between the rich and the poor in Nigeria. The major reason for the widening of differences, according to Amaghionyeodiwe, is that the poor are more strongly affected by public spending on health care relative to the non-poor. Whereas the rich can afford oversea 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 emanating from poverty. Available literature provides common standpoint among various authors that disparities exist in the implementation of hospital information system in developing and developed countries (Grimm & Shaw, 2007; Williams & Boren, 2008). Speculated reasons include (a) Poor technological and funding support in developing 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 of technology, (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-up with laboratory results, misdiagnosis, medication order errors, and mismanagement of patients (Keenan et al., 2006; Okeke, 2008). Prior to the introduction of the health care insurance scheme in Nigeria, health care purchases were made by individual out-of-pocket payments and few employer-based private health insurance with different 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 no changes thus far have been made in the 5 years of its implementation. The Nigerian House of Representatives and Senate endorsed the scheme, including a moratorium on deductions of contributions. The intention was to extend the program to the organized private sector within 1 year of its commencement in the public sector, but it remains to be seen if this system will provide enough health care coverage, particularly to the poor. The lack of well-established information infrastructures within the hospital 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 systems functionally available in Nigeria, but the subjective data project less than 5% implementation of any form of hospital information technology in a country of more than 150 million people (Idowu et al., 2006). The available literature provides a common position among various authors that disparities exist in the implementation of hospital information systems in developing and developed countries (Grimm & Shaw, 2007; Williams & Boren, 2008). Speculated reasons include poor technological and funding support in developing nations, poor management capacity at all levels that ensures seamless workflow, and a complex 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, and the 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 technology has been atheoretical. In this study, a useful theoretical model is the maturity model to process improvement originally described in software engineering and used in the novice-to-expert approach to competency. The maturity theoretical model describes a modernization framework aimed at the committed 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   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            5   model includes monitoring individual and organizational performance, facilitating information sharing among different health care organizations through a multi-agency approach, and empowering individuals by providing relevant information to consumers, thereby helping them to make informed choices (Gillies & Howard, 2005). An additional theoretical standpoint in this study is that in a heterogeneous society as Nigeria with significant 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, O’Connor, and Leo (2009) associated patient data analysis systems (PDAs) with enhanced storage and analysis of patient data, enabling physicians to reach improved clinical decisions on patient care. Similarly, clinical information systems capture clinical data to enhance prompt and 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 of information and communication technologies (ICT) facilitate ubiquitous and instantaneous communication between organizations and their stakeholders. Information communication technology enables people and organizations to achieve a seamless workflow and effective processes through improved interactions. Literature Review The literature search brought to the fore contextual issues and brief historical overview of hospital information systems. The discussion focused on the infrastructural requirements for implementation of hospital information systems alongside the cost implications and the role of government in funding the cost. A significant portion of the literature review centered on the Nigerian situation as it relates to the poor implementation of hospital information systems. Issues highlighted about Nigeria include demographic diversity and cultural effects on health care, lack of support infrastructure, corruption, lack of technical support services, problems with human capital, an import-dependent economy, and the high the cost of capital in the Nigerian capital market. The concluding aspects of the literature search contain discussions 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 are probably as old as medicine. The formats for collection of patients’ records and the ways in which this information is used and subsequently stored for future references has continued to evolve from regular paper 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 for information and seek, evaluate, and use information in any presented format. Information technology infusion that aids globalization refers to the degree to which various information technology tools integrate into organizational activities (Idowu et al., 2006). The growth of computer technology in the 1980s with consequent improvement in information literacy saw the advent of the first breed of hospital information systems (Keenan et al., 2006). Earlier researchers 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 care information. 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 clinical information system aimed at the lowering cost of health care therapies (Svensson, 2002), In its earliest applications, hospital information systems were mostly used for patient’s electronic record keeping, but has advanced into almost all areas of medical discipline. Common applications of hospital information technologies include Computerized Physician Order Entry, Pharmacy Information Systems, Laboratory   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            6   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 are increasingly adopting electronic medical record (EMR) technology to enhance health care outcome and quality. William and Boren posited that Nigeria lacks robust health care infrastructures and policies for implementation 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 asserted that historically, lack of human expertise and inadequate financial resources is a bane to robust to adoption of ICT in Sub-Saharan Africa. Benefits of Hospital Information Systems Hospital 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 of information and communication technologies facilitate ubiquitous and instantaneous communication between organizations and their stakeholders. ICT enable people and organizations to achieve seamless workflow and effective processes through improved interactions. Electronic health technologies enable effective networking by physicians, allow online review of patients’ treatment, and provide for accurate prescription 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 Bush’s administration is aimed at warehousing 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 of patient 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 and enhanced patient care: (a) medication turn-around times fell from 5:28 hours to 1:51 hours; (b) radiology procedure completion times fell from 7:37 hours to 4:21 hours; and (c) lab results reporting times fell from 31:3 minutes to 23:4 minutes. In the same study, transcribing errors for orders declined, and length of hospital stay decreased. Other benefits of electronic medical records systems are possibility for online monitoring of vital signs, capability for multi-site review of patients’ records, and improved physicians’ collaboration in patient care. EMR facilitates easy access to medication administration records, sharing of consultation reports, and decreased transmit time of test results by reducing the time taken to deliver paper versions (Keenan et al., 2006). In a heterogeneous society like Nigeria with significant disparity in accessibility of health care facilities between urban and rural communities, hospital information systems may help to bridge the gap in availability of patient care (Ouma & Herselman, 2008). Sammon, et al. (2009) associated patient data analysis systems (PDAs) with enhanced storage and analysis of patient data enabling physicians to reach improved clinical decisions on patient care. Similarly, clinical information systems capture clinical data to enhance prompt and efficient decision making (Ward et al., 2006; William & Boren 2008). Health care policy makers seeking ways of improving quality of patient care at a reduced cost are leveraging hospital information 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 can service 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 and operational strategies (p. 33). Failing to address the interrelationships that exist between the strategies can result 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 the billing software may likely encounter increase process failures requiring additional resources for correction. Successful organizations develop strategies capable of identifying organizational needs. Such organizations anticipate challenges and launch remediation efforts by installation of computer networks and systems (Stone et al., 2005)   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            7   A positive correlation is found between adoption of health care information technology and positive organizational financial performance in general, and operationally (Weimar, 2009). This observation is thought to emanate from superior organizational performance by health care providers using novel information 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 services and 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 and patient safety. Morath and Turnbull (2005) recommended creating a culture of safety in health care organizations by recognizing and accommodating the multiple complexities of those organizations. A laudable approach would be to take advantage of the ability of large-scale data systems to amass information as means of identifying significant trends, and enable creation of blame-free sanctuaries in which care errors and observations of incompetence receive prompt solutions. Data production and collection requires knowledge to facilitate this undertaking. Various forms of knowledge are essential business asset used for development of new products and services, thereby useful in developing a competitive advantage in the marketplace (Rennolls & AL-Shawabkeh, 2008). Cohan (2005) expressed a contrary view that investment in information technology does not necessarily transcend to improvement in productivity. Cohan stressed that shortfall in productivity expectations have made industrial leaders more cautious in adopting information technology in their organizational processes. Presenting a balanced view, Farquharson (2009) asserted that adoption of information technology increases productivity but falls short of expectation in improvement of productivity considering the high capital investment required for implementation. Farquharson surmised that 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 care delivery and safety. Medical errors in diagnosis and drug administration decline with applications of electronic health systems. Electronic physician order entry and medication reconciliation helps patients to understand better, the beneficial effect of drugs and deleterious effects of drug misuse (Kramer et al., 2007). Fuji and Galt (2008) opined that more than 1.5 million United States residents suffer injuries from prescription errors 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 adverse medical errors when patient’s own mix-up is taken into account. Fuji and Galt surmised that some elements of hospital information systems increase patient participation in care process, thereby reducing unwanted 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 in information technology solutions, stressing that LIS has led to an increased awareness in the development of technological solutions designed to minimize medical errors. Following the publication of the Institute of Medicine’s reports in the early 2000s and the Institute for Healthcare Improvement’s Saving 100K Lives Campaign, industry awareness has increased on the need for solutions to minimize medical errors (Harrison & McDowell, 2008). The LIS industry has accepted the challenge and developed innovative software solutions that include patient result verification, the recognition of critical values in addition to the immediate transfer of critical values to physicians for evaluation, and enhanced turnaround time (Harrison & McDowell, 2008). Interfacing software is available to merge the laboratory information operating systems with electronic 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 for increased patient safety, enhanced quality of care, and a leaner operating system resulting in efficient and productive processes. Woodside (2007) concur that health care organizations use electronic data interchange to share patient histories, treatment plans, lab results, and insurance information. Sharing the patient's history in an exchange facilitates initiation of care and decreases the chances of errors. Data interchanges that involve physician's orders and pharmacies can protect the patient by detecting prescriptions of   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            8   incompatible drug combinations, and highlighting potential allergens to patients. Another vital function of 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 the insurance company has authorized the expenditures. Electronic interchange between entities helps avoid delays in the approval process and decrease the possibility of poor outcome because of a delay in treatment. Information technology in general enables intra organizational networking that facilitates effective information flow within the various units of a firm. In the world of an organization’s 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 effective organizational operations (Hargie & Dickson, 2007). In addition to prompt delivery of investigation reports to patients and clinicians, some aspects of information technology enable decisions made on organizational processes to be timely and effectively disseminated to the workforce. Analytical software systems provide means for both dissemination of information and relevant quantitative data to support management decisions. Analytical information systems help organizations to maintain a competitive edge in the marketplace by increasing operational speed and maintaining fluidity of information flow (Azevado, Ferraira, & Leitao, 2008). Crane and Crane (2006) reported that numerous solutions for the medication error problem in hospital settings might be averted with the use of an integrated systems approach. However, execution of an organization’s 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 integration capabilities instead of using one module for electronic records. An integrated records system promotes a user-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 effective communication and increased compliance with regulatory guidelines (Georgiu, Westbrook, Braithwaite, & Iedema, 2005). Keenan et al. (2006) opined that electronic medical records system provide an effective educational tool for training of resident doctors and medical students. Health care information technology and e-health offer strong potential in research and development of clinical protocols. Future studies in this area may provide broader implications of health care information technologies applications (Keenan et al., 2006). Barriers to Adoption of HIS in the United States Policy 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 of rising 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 near universal adoption of electronic health systems but significant barriers exist causing a slow pace of implementation of hospital information systems across hospitals and health care organizations in the United States. According to Ford, Menachemi, and Phillips (2006), in 1991 the Institute of Medicine (IOM) issued a report calling for paperless health records system within 10 years. This visionary call fell short of media attention. 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 care organizations have achieved full implementation of hospital information systems, 14-16% have partial adoption 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 their poor adoption. Ward, et al. (2006), in a study of Iowa hospitals, found an 80% adoption rate for urban hospitals and 30–40% adoption rate for rural hospitals, citing the robust financial capabilities of urban hospitals as the reason for the disparity. Furukawa, et al. (2006), in their analysis of disparity in adoption   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            9   rate of electronic health record systems, asserted that big hospitals with more than 200 beds, teaching hospitals, not-for-profit hospitals, and multi-hospital systems have higher rates of implementation than independent non-teaching hospitals. Private not-for-profit health care organizations have twice the adoption rate than for-profit organizations because of reinvestment of organizational profit into health care 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 ehealth information systems, but argue that geographical location does not significantly affect rate of adoption. 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. These authors reported that poor implementation occur among smaller hospitals, more rural hospitals, nonsystem-affiliated health care organizations, and hospitals in areas of high environmental uncertainty. The lower rate of implementation among rural hospitals correlates more to their small size and limited resources rather than geographic location. Other barriers have constrained adoption of electronic health systems in the last decade. These include 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; database incompatibility causing poor interoperability of various systems; training difficulties to cover large staffing requirements; regulatory and legal considerations; and differences in information technology preferences 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 attendance found 74% of participants showing willingness to introduce clinical information systems in their respective hospital practices as a top priority. The surveyed executives worried about the challenges in implementing effective change management and difficulties in overcoming end-user resistance (Anderson, 2005). Atkinson (2005) asserted that employees are more averse to changes that directly affect their status quo. Countering the tendency of end user-resistance requires organizational leaders to adopt strategies that encourage employees, and yet be persuasive for the workforce to accept and implement desired change (Atkinson, 2005). Greene (2005) recommends that organizations wishing to adopt hospital information technologies must 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 system components 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, et al. (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 implementation impediments. On a positive note, Samoutis, et al. found that the computerized system increased efficiency and improved the quality of care to the patients served. With reimbursement becoming increasingly associated with quality of care outcomes, implementing the right system with the appropriate 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 and advanced practice nurses within the organization during the appraisal phase, as recommendations from the major players in the care delivery process are vital to success. A challenge that exists for the installation of computer networks is the culture of the organization and the makeup of each division that would use the system. Nurses and physicians may be averse to computer systems because of the perception 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 the installations. The lack of knowledge, poor understanding, and the negative experiences of managers with information technology all represent challenges that could be deterrents to adoption.   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            10  

Barriers to Implementation of E-Health in Africa The 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 hospital information systems in the health care delivery apparatus of the nation. This lack of policy partly explains the continued poor national health outcomes as revealed by the Nigerian Ministry of Health survey in 2003. The report put infant mortality at 110 per 1000 births and maternal mortality of 1100 per 100,000 live births. 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 effects of 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 abound on the projected outcome of the current millennium development initiatives that do not include any elements 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 electronic health, 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 supportive infrastructure and inadequate use of natural resources. Stressing that lack of leadership responsibility in setting the right health care priorities may well have been the bane on accelerated development of the Nigerian health care. The peculiar Nigerian situation. The Nigerian health care system has continued to suffer from years of neglect by successive governments, hence the poor infrastructural base of both public and private health 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 states after a decade, the Nigerian score card showed failure in all ramifications. Other West African countries like 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 on health was below $8 per capita, against the $34 recommended internationally. Compounding poor government 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 nonactualization of technological breakthroughs and infrastructural decay. Poverty seems to be a common excuse for poor investment in infrastructure in Nigeria. Sofowora (in press) opined that despite the abundant natural resources in Nigeria, the country ranks ninth poorest in the world because of its failure to harness its natural wealth. World Bank (2007) statistics indicated that the poverty rate rose from 27% in 1980 to 70% in 1990, and even at present does not show any economic index 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. In places with electric power connectivity, the supply is fewer than 12 hours daily. Lack of consistent power has caused poor industrialization of the country at large. In a related subject examining the poor adoption of 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 a challenge to infrastructural development in every facet of the Nigerian economy. Inadequate Internet bandwidth is also a notable challenge in Africa. Internet connectivity problems abound in Nigeria with the few Internet service providers in the market offering very poor services because of bandwidth constraints (Ayo et al., 2008). Other barriers hindering adoption of hospital information 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 to ascertain how rural hospitals are adapting to technology shift in health care. The issues examined were   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            11   the availability of information and communication technology infrastructure, electronic health technologies in place, knowledge of caregivers on the benefits of ICT use in health care, and challenges constituting barriers to adoption of ICT in the hospitals investigated. The results revealed inadequate ICT infrastructure for electronic health implementation, a limited number of health care staff with basic knowledge of ICT operations, and a high cost of adoption of electronic health systems. The authors also identified 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 et al., 2008; Ward et al., 2006). According to Getzen (2007) and Morris, Devlin, and Parkin (2007), adoption of health care technology comes at significant cost implications that consequently impact the cost of health care delivery. Nigeria undoubtedly is more than 95% a consumer society with no recognizable production of medical hardware taking place in the country; cost of importation and delivery further influences the eventual cost of adopting niche health care technology (Okeke, 2008). Multiple forces impacting policy and health care. Nigeria for a long-time suffered political instability that created an opportunity for corruption to thrive and enhanced poor macroeconomic management (Apter, 2007; Okeke, 2008; Pierce, 2006). Following years of military dictatorship and lack of government accountability, infrastructural decay did not attract desired attention (Okogbule, 2007). The petroleum supported economy faced years of blatant economic mismanagement, and squandering of resources through institutionalized corruption (Arikpo et al., 2007; Transparency International, 2006). Nigeria has a democratically elected government, but one still propagating much of the political elements and ideologies of the military era. Change in the body polity of the nation has been painfully slow, and in some 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 taken some steps to promote the development of a basic national primary care program in the rural areas, but with undesirable outcomes because of a lack of basic drugs, inadequate manpower, and serious lack of specialized health care facilities (Okeke, 2008; Ouma & Herselman, 2008). The major challenge for the current Nigerian government is to provide a policy roadmap and adequate funding to support health care delivery in the nation. Lister and Jabukowski (2008) stated that “governance is the exercise of political, economic and administrative authority in the management of a country’s 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 an objective, setting the pace for others to follow. Analysts have studied the responsibilities of Nigerian leaders as they affect national development in terms of the success or failure of government reform programs in the coming one to two decades. These analysts opine that the leaders’ successes will enable the country to transform itself from present state of poverty and corruption to join progressive, large economies in technological advancement and prosperity (Apter, 2007; Arikpo et al., 2007). The high cost of startup investment for implementation of hospital information systems demands some 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 the Bush administration indicated that adoption of hospital information technology was a major requirement for 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 information technologies across the country (Thielst, 2007). Within 90 days of enactment of President Bush’s policy to implement universal electronic health record systems (EHRs), Larkin (2005) reported that implementation could be achieved in fewer than the targeted 10 years. Larkin’s comments were based on the work of Brailer, who had designed a framework for implementation. Larkin expressed concerns that such elaborate adoption of interoperable electronic health 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 of hospital information systems (Jha et al., 2009). Because the decision to facilitate implementation of the   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            12   policy on EHRs commenced by Bush’s administration within the new health care policy was attracting debate, 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 other African countries to facilitate the implementation of e-health initiatives (Bulletin of World Health Organization, 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 aimed at universal adoption of health care information technologies. This concern is even more prevalent in Sub-Saharan Africa in which about 80% of the population domicile in rural communities deprived of basic social infrastructure and amenities (Okeke, 2008). Effect of Policy Gap and Poor Implementation of HIS The 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 and Galt (2008) suggested that more than 1.5 million United States residents suffer injuries from prescription errors and other medical errors annually. The Institute of Medicine report titled To Err is Human indicated that the number of patients exposed to adverse medical errors might be more than the above-cited figure when 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 Nigerian hospitals 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 medical professionals, the threat of re-emerging infectious diseases, poor sanitation, and the prevalence of water borne diseases; the growth and development in health care has been dismal in Nigeria (Pond & McPake, 2006). Infrastructural Requirement for Adoption of HIS The 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 United States, Ward, et al. (2006) found a higher adoption rate among hospitals already using computer systems for scheduling of outpatients, scanning of medical records, patient indexing, transfer, discharge of patients, and waiting list administration. Effective application of hospital information systems requires broadband 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, decried the abysmally low Internet-access in the country. Internet connectivity enables effective data management systems, picture archival, and communication systems, and is specifically important for running of radiological information systems and teleradiology. Other requirements include well-trained health care workers 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 tailor installation of their technologies to the needs of each health care organization (Moore, 2009). An uninterrupted 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. The power 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 states must address infrastructural development and focus on provision of mechanisms for prompt and effective dissemination of health care information to facilitate compliance with clinical guidelines. Cost Implications The 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   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            13   observation by researchers that technology spending does not necessarily transcend to expected improvements in productivity and profitability (Roztocki & Weistroffer, 2006). Weimar (2009) estimated the cost expectation of full implementation of hospital information systems in a 100-bedded hospital is about $35 million in five years. Ward, et al. (2006) asserted that with problems of uncertain reimbursement and a focus on technology at the detriment of healthy business consideration, a disconnection 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 for implementation of hospital information systems, health care organizations find the cost benefit analysis increasingly challenging. Moore (2009) argued that return on investment is achievable by creating efficient paperless and filmless systems that leads to staff reduction and decrease or eliminate need for report transcription. Moore reported a one million dollar cost saving at their cardiac hospital by eliminating services of medical transcriptionists for a year. The hospital equally achieved staff reduction in the front and back offices during the same period. Menachemi, et al. (2006) asserted that regardless of analysis approach or method of electronic health system employed, information technology adoption consistently correlates with increased financial outcome operationally and in general organizational processes with consequent improvement in organizational 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 of comprehensive electronic health record system and widespread organizational restructuring. The electronic 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 electronic health records (EHRs) in ambulatory care practices in the United States, found practice size influenced the adoption of EHRs with solo and small practices lagging behind larger practices. Most participants agreed that electronic health records systems have the potential to improve the quality and safety of health 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 lack of process performance improvements and a decline in profit margins. Aggregation of data into a data warehouse facilitates analysis and supports frequent process improvement. This involvement assists organizational efforts with assessment of patient outcomes, patient safety, and organizational skills. Profit margins are constantly dwindling in health care delivery organizations with decreased payment for rendered 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 “improve business, 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 in profitable systems. Wickramasinghe, Bali, Gibbons, and Schaffer (2008) asserted that the health care industry has the history of using leading edge technologies and embracing new scientific discoveries to facilitate better cures for diseases. The limitation is that adoption of health care technology often increases the cost of health care delivery (Getzen, 2007). In a poor country like Nigeria, further increase in health care cost may alienate a sizeable subset of the population from accessing care from orthodox medical practitioners (Okeke, 2008). Human Resources Problems Human 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 medical staff possess a good knowledge of information technology applications and uses. In Nigeria, there has been 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 within the country is made worse by large numbers of Nigerian doctors, nurses, radiographers, and laboratory   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            14   scientists departing to developed western countries in search of better pay, better living conditions, and career improvement (Glasser, Peters, & MacDowell, 2006). A shortage of a skilled health care workforce known to affect mostly rural communities all over the world has currently taken a new dimension in Nigeria with acute shortage of various categories of medical staff in urban hospitals leading to a systematic decline in the quality of health care services in Nigeria (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 participants stressed the need for urgent actions to curtail the trend as it could jeopardize the government’s efforts to reduce poverty and disease. Another major concern was that the depletion of a skilled workforce is capable of hindering developmental goals (Nullis-Kapp, 2005). Okeke (2008) opined that underfunding of health care services by the government because of neglect and claims of over-stretched budgets have left many hospitals in Nigeria in a poor physical state, under-staffed, and lacking in modern medical equipment. Consequently, the limited health care professionals inundated by excessive workload seem often stressed to the limits (Perry, 2005). In these circumstances, adoption of hospital information system may be relevant to improve workflow 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 in Nigeria will amount to increased waiting time for patients to access care. Uploading patient information from 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 an increase in time taken to complete patient records for new cases using EMR compared with paper records. The study results indicate that average time taken for the completion of the EMR-based consultation for new cases was 19.15 minutes (range, 10-30 minutes; standard deviation, 6.47). The paperbased consultation had an average time of 15.70 minutes (range, 5-25 minutes, standard deviation, 6.78). Following the t-test, the p-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 some clinicians. Samoutis, et al. (2007) in their study of EMR adoption in Cyprus reported that physicians’ perceptions of the impact of EMR systems on their workflow and lack of familiarity with electronic equipment were among the barriers to implementation. These challenges may be rifer in Nigeria because of already compromised health care workforce population. Corruption in Nigeria Corruption 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-day Nigeria 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 to 2006. Nigeria's Corruption Perception Index (CPI) score has ranged from 0.69 to 2.2 (out of a maximum of 10) reaching above the 2 score line for the first time in 2006 (Transparency International, 2006). A nation once extolled as the giant of Africa because of its massive land area, large population size, and assertiveness of its political elite compared to other African nations once again is making another round of 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 the country is unquantifiable. Apter stated that fraudulent practices range from online identity theft, marketing of nonexistent goods, prosperity churches, false non-governmental organizations soliciting funds from foreign donors, to outright imposition by persons as government officials awarding bogus contracts. The activities of corrupt elements in society have tarnished the social and corporate image of the nation, causing a drought of foreign investment in the country (Arikpo et al., 2007). Corruption exists in every facet of life in Nigeria, and has negatively affected the willingness of international investors to do business in Nigeria. The engagement of the larger society in corruption occurs by ambivalent complicity (Apter, 2007). Sustained aiding and abetting of corruption in the Nigerian society makes it   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            15   impossible for the nation to rise above mediocrity in almost every area of socioeconomic endeavor including health care (Apter, 2007; Arikpo et al., 2007). Nigeria as an Importing Economy Sustainable 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 social structure and innovations, and acts as vehicle for modernization (Arikpo et al., 2007). Nigeria is lacking in technological depth; hence, it depends on foreign technology to drive the country’s developmental efforts. The consequence has been slow economic growth and over dependence on importation for most consumer products. Nigeria seems to have become a dumping ground for substandard products from Asia 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 produce finished petroleum products. Locally consumed petroleum products are imported from foreign nations. The three Nigerian refineries have since broken down, and because of obsolete technology, have remained unserviceable over the years. Institutionalized corruption is the bane of infrastructural development in Nigeria (Ayo et al., 2008). Most government officials use their offices to facilitate money laundering through inflated contracts. The arrest of two Nigerian governors in London in 2004 and 2005 under 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 technological advancement (Okogule, 2007). High Lending Interest Rates in Nigeria Financial 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 high rates of money laundering, bad loans, and massive importations often depleted the capital base of the banks (Ayo et al., 2008; Okogbule 2007; Sanusi, 2009). These shortcomings and corrupt practices by bank executives have forced many Nigerian banks and other financial institutions out of business over the years. The most recent effort to improve the capital base of Nigerian banks took place in 2006. The aim was to boost the economy, encourage lending and decrease interest rates to single digits as obtainable in other developed economies (Soludo, 2007). This effort did not yield the desired effects as lending interest rates remained between 22-25% in all the Nigerian banks, depending on type, and tenure of credit (Ayo et al., 2008). The high interest rates have not encouraged investment in health care because of longgestational periods required for return on investment in health care and the economic uncertainties that surround technological investment in health (Ward et al., 2006). Frequent market failures have not encouraged Nigerian medical practitioners to invest significantly into health technology. Aside from the high cost of innovative medical technologies, the credit market in the country is averse to long-tenure loans compelling most practitioners to invest into other areas of the economy that have better prospect for quick return on investment, like housing, stocks, oil, and gas (Ayo et al., 2008). Because the recent global economic meltdown and consequent collapse of most lending institutions around the world, further lag in medical investment in Nigeria may be inevitable. A major shakeup of the Nigerian banks in July 2009 by the Central Bank governor exposed massive fraudulent acts perpetuated by highly placed bank officials in five Nigerian banks. Records revealed that grants of unsecured 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 care infrastructure. Cultural Influence on Adoption of HIS in Nigeria Culture by common understanding refers to a people’s way of life. Nigeria has a large demographic setting represented by more than 250 ethnic groups and presents diversity of cultural practices and norms in minute detail (Okeke, 2008). Certain peculiarities are becoming a way of life in Nigeria; notable within the emergent common culture are materialism and individualism. Whereas the political grandfathers of the nation of Nigeria fought for independence based on the common good of all, the new   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            16   political elite have introduced a culture of materialism and individualism to the detriment of a common goal. 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 and individualism accentuate the rich-poor divide, thereby breeding social vices because of the perceived dictum 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 two million United States dollars meant for the pilot study of telemedicine in the country. Although, the government official was fired from office but as of 2010, telemedicine practices are nonexistent in any form in Nigeria. The culture of corruption in Nigeria and mismanagement of economic resources by government office-holders borne out of the need to satisfy materialistic and individualistic aspirations has led to the impoverishment of the nation. The prevalence of poverty rose sharply from 28.1% in the 1980s to 65.6% in 1996 (Onwujekwe, 2005). The yearning for quick wealth among Nigerians has led to massive 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 any major initiative to implement hospital information technology in Nigeria on a large scale. The culture of institutional corruption by government officials does not encourage the delivery of the best products into the 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 may require a total re-orientation of value systems (Okogbule, 2007). The need exists to replace individualism and materialism with aspirations that promote the common good of all. Ghana, a close West African neighbor of Nigeria, has transformed successfully in the past two decades 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 to pursue objectives set by the leader not necessarily by persuasion but through examples set by the conduct of the leader. The change in Ghana implies that a new culture of accountability, honesty, pursuit of a common goal, and nation building is possible for Nigeria through cultural reformation spearheaded by the right type of leadership. As a benefit of socio-cultural reformation, Ghana’s industries currently attract capital once targeted for Nigeria in areas of education, health care, tourism, and several other investments because of Ghana’s stable socio-political climate, stable electrical power supply, and low corruption-rate (Somiah, 2006). Limitations of HIS Management 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 quality improvement, the rapid evolution of these information technologies is a major limitation. The short shelflife 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 and health 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 allow seamless retrieval of patient information across different operating systems. Patient clinical data may be accessed only in hospitals with compatible information systems, thereby hampering the key benefit of easy 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 wrong identifications, wrong or incomplete information documented in hospital systems, the possibility of   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            17   making changes to patient information by unauthorized persons; an event that carries considerable safety implications (Fuji & Galt, 2008). Researchers recognized the cost curtailment capabilities, improved quality of care, and prompt delivery of acute care associated with telemedicine. However, telemedicine, as a type of hospital information 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 provide consultation across interstate boundaries, clinicians with limited licensure may have legal problems delivering service in certain locations. Whereas credentialing stipulates minimum standards of training, education, and qualifications needed by professionals to provide care, each state may require different benchmarks for its practitioners according to state law. These specific statutes may affect the ability of a clinician to offer telemedicine services. Another drawback with telemedicine is the physical separation between the health professional and the 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 telemedicine may require a radical change in the way that services are provided and paid for. Concerns about how services are billed and reimbursement obtained abound. Patient privacy is impinged upon by practices of telemedicine. According to Ashley (2002), in a survey conducted in 1999, 20% of participants believed that medical information was not properly used and 16.7% of participants admitted to providing inaccurate data to conceal what they considered private information Barjaktarevic (2008) expressed similar concerns of inadequate confidentiality for patient records because of possibility of data mismanagement electronically. Georgiou, Westbrook, Braithwaite, and Iedema (2005) asserted that the extent of organizational impact of adoption of hospital information systems is often underestimated; stressing that a major incident of patient risk exposure emanating from the 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, including electronic health records, e-health platforms, health grids, and further use of genetic data, come with fresh legal challenges and undeniable legal consequences in case of information mismanagement or identity theft. According to Benham-Hutchins (2009) because of challenges involved in integrating new hospital information systems with old paper documentation and record systems, clinicians, and other health care practitioners may become encumbered with multiple and conflicting sources of patient information. Multiples of paper and electronic documentation may disrupt a seamless workflow and influence the quality and efficiency of service delivery. These circumstances also have the potential to cause new types of medical errors resulting from poor harmonization of patient information. Understanding these concerns requires examination of human factors in the design of technology that is able to adapt to the way health care providers do their job. The delivery of patient-friendly services demands that health care providers 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 of human 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 is just a tool in the hands of trained personnel. Other economic limitations of hospital information technologies 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 study of the implementation of an electronic medical record, Samoutis, et al. (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 impediments of implementation. Samoutis, et al. (2007) observed that computerized systems increased work efficiency and improved the quality of care to the patients served. Recent health care debates reinforced the demands for reimbursement that are associated with quality of care outcomes. Implementing the right systems to incorporate the appropriate components is a necessity. Benham-Hutchins (2009) suggested adequate   www.jghcs.info  [ISSN 2159-6743 (Online)]  

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Nigerian  Hospital  Information  Systems/Benson            18   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 Coverage Cebul, 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 information technologies in developed and developing countries. Although undeniable demographic differences exists in different regions of the world, some common themes emerge that can enhance implementation of e-health applications anywhere in the world. Suggested remedies include replacement of fee for service payment systems with a system that rewards and encourages use of innovative information systems, 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 adoption and the development of hospital information systems that promote data exchange by interoperability and easy 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 hospital information systems in Africa include improving staff training on e-health applications; purchasing cheaper 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 in suburban communities. To ensure long-term use of e-health facilities, contract agreements with ICT experts are necessary for regular maintenance of information system hardware. Government should also facilitate 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 of sophisticated information systems to support clinical operations and strategic management. Major attributes of current systems include an emphasis on information protection, provision of diseasemanagement software, and programs that reduce medical errors. Future trends will seek to improve interoperability, 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 data entry and retrieval and support consumers through development of niche home appliances (Glandon et al., 2008). Electronic Health Records (EHR), smart cards, and vein mapping for identification allow easy access to medical information and prevent fraudulent use of information by others. According to Garets and Horowitz (2008), clinicians should engage in evaluation of hospital information technologies because information systems will become repositories of clinical data. Electronic medical records systems and other information systems will attain commonplace applications in hospitals and other health care centers in the coming decade. President Bush set a target of developing electronic health records for all Americans by 2014 (Thielst, 2007). Health care policy makers and organizational leaders should work to understand the operational intricacies of various hospital information 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 technology abounds, 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 on infrastructure to facilitate any attempt aimed at catching up with the developed world in the adoption of hospital information technologies (Ouma & Herselman, 2008).

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Nigerian  Hospital  Information  Systems/Benson            19   Conclusion The analysis presented in the literature review provided insight into the enormous health care benefits of hospital information systems, and their usefulness as educational tools in training clinicians. The literature review brought to the fore the disparity in adoption of hospital information systems between Nigeria, 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 to developed countries, the low technological base of the country, inadequate electricity supply, and corruption are among common assertions that authors believed are responsible for poor adoption of hospital information system (Apter, 2007; Arikpo et al., 2007). Contextual issues constituting barriers to adoption of hospital information systems formed a major part of the literature review, and there seemed to be more impediments to adoption in Sub-Saharan Africa than in the developed western world. The high cost of implementation of all the components of hospital information systems appears to be a global challenge. Apart from a lack of infrastructural requirements for adoption of hospital information system in Nigeria, the neo-cultural influence of materialism and individualism have added to an environment of corruption, thereby creating a vicious cycle (Eckersley, 2005; Okeke, 2008). Chapter 2 also provided insight into the effects of the paucity of health care policy on health care delivery in Nigeria with an emphasis on poor e-health applications in the country. The high cost of implementation of hospital information systems and other barriers are concerns to most authors. A positive correlation has been found between the adoption of health care information technology 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 policies aimed at widespread implementation of HIS and provides funding support to health care organizations across the country to facilitate adoption of HIS in their care processes. Analysts further clamored for improvement in rural electrification to power information communication 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 to facilitate any attempt at catch up with the developed world in the adoption of hospital information technologies (Ayo et al., 2008; Ouma & Herselman, 2008).

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                                                                             JOURNAL  OF  GLOBAL  HEALTH  CARE  SYSTEMS/VOLUME  1,  NUMBER  3,  2011