As one of the few studies on the evaluation of implemented large scale information infrastructures (EHR) in the Ghanaian context; if not the first of its kind, this study is expected to reveal the challenges, benefits and impact of an implemented electronic health record in a healthcare institution in Ghana, and how such findings correlate to findings of other studies conducted in other developed and developing countries. This study also serves enormous contributions as it explores records keeping in the Ghanaian healthcare sector from another dimension (electronic health records), which paves the way for further studies in the area of large-scale information infrastructure implementation (EHR) in Ghana. It also contributes to knowledge on the deployment and implementation of electronic health records in developing countries, which is noted to be limited (Sood, Nwabueze, Mbarika, et al., 2008).
The study is expected to guide hospital managers, health professionals and information system developers who are interested and involved in the implementation of EHR in the assessment, design, and implementation of EHR systems in their health facilities. The findings of the study may also be valuable for the purpose of policy formulation, implementation and implication for electronic health records and other electronic health applications in the Ghanaian health sector.
7 1.7 CHAPTER DISPOSITION
The study is presented under six chapters. Chapter one introduces the study by giving a brief background to the study, which elaborates on the need for the study. It also presents the statement of research problem, the objectives of the study, the research questions, the motivation for the study and the expected contributions of the study. Chapter two elaborates on the theories underpinning the study and some relevant literature in the field of study. Chapter three presents the methodology used in the conduct of the study as well as the detailed description of the study country and study site. Chapter four provides the presentation and interpretation of the research findings. This consists of data recorded from the interviews, observations, informal discussions and open-ended questions posed to research respondents.
Chapter five discusses the findings of the study in relation to theories and literature on the topic.
Chapter six summarises the study, presents the overall study findings, recommendations for further research, and the study’s conclusions.
8
CHAPTER TWO
THEORETICAL FRAMEWORK AND LITERATURE REVIEW
2.0 INTRODUCTION
The proper management of data storage and retrieval of records are imperative in any organization. In this vein, the system used in keeping records in any healthcare organisation should possess the ability to provide smart search functions, instantaneous and multi-location access, and ability to virtually integrate data elements stored in geographically disperse databases (Berg & Toussaint, 2003), as this is the only sure way to ensure better healthcare delivery. The introduction of EHR in healthcare delivery in recent time is therefore aimed to achieve these functional aims highlighted above. In spite of these functionalities, EHR in the healthcare sector is also aimed to trounce the inherent problems associated with paper-based record management systems that have been used in the healthcare industry for over a century.
In this section, a review of other relevant studies relating specifically to the objectivities of this study is presented. This section firstly brings to bear the theories that underpin the study, as it reviews EHR as an Information Infrastructure and as also an actor-network within the lenses of Actor-Network Theory. It then proceeds to a review of record keeping (paper and electronic record keeping) in various health facilities. With the understanding of EHR as an Information Infrastructure and an Actor-Network, a review of EHR is presented in this section. Other studies relating to the readiness assessment of EHR implementation in other hospitals are also reviewed. This section also highlights the benefits and challenges associated with the implementation of EHR as accounted for by other studies. It then concludes with a summary and the rationale for the present study.
2.1 THEORETICAL FRAMEWORK
This study is underpinned by the concept of Information Infrastructure (II) and the Actor-Network theory (ANT). The researcher chose the concept of II and ANT because they complement each other well and provide a good theoretical basis for the study (Gammon, Johannsen, Sørensen, Wynn & Whitten, 2008). Some previous studies have adopted these theories in order to determine the relationship between information systems and organisational issues (Hanseth & Monteiro, 1998). ANT thus provides an enlightening expression, which
9 describes information infrastructure. Thus, it depicts how, where and to which extent technology influences human behaviour (Ibid). Furthermore, in his work titled “Actor Network Theory and Information Infrastructure” Monteiro justified why it is suitable to compliment the ANT with an information infrastructure perspective in an organisational study of a complex organization (such as Effia Nkwanta Regional Hospital, ENRH) (Monteiro, 2000). According to Monteiro (2000:147), “ANT provides an effective platform from which to critically assess and unravel a set of problematic set of explicit and implicit assumptions made from the management perspective on information infrastructures”. This implies that ANT does not only provide a language with respect to elucidating Information Infrastructure, it also provides an understanding of the relationships between information technology and its various usages (Akrich, 1992; Akrich & Latour, 1992; Hanseth & Monteiro, 1998). Again, Lee (2001) fiercely recommends that research work relating to the field of information systems should endeavour to examine more than just the technological system, or just the social system, or even the two systems side by side; but rather the researcher ought to strive to investigate the phenomena that emerge when the two interact. Hence, the present work takes strong inspiration from Lee and thus strives to understand not only the implementation of the EHR in Effia Nkwanta but also how the EHR is shaped and reshaped by the staff and within the hospital’s environment in general. In accomplishing this aim, the concept of II and ANT is considered the most apt as ANT provides the interpretative framework of analysis, while the concept of Information Infrastructure may be applied to focus on the actual EHR being implemented in the Effia Nkwanta Regional Hospital.
2.1.0 THE CONCEPT OF INFORMATION INFRASTRUCTURE (II)
Information Infrastructure started as a political initiative in Bill Clinton’s administration after the adoption of the Bangemann Commission’s report (Bangemann et al., 1994). It became even more prominent after the commencement of the US plan for National Information Infrastructures (NII), which was followed up by the European Union’s plan for Pan-European II (Hanseth & Monteiro, 1998). As a concept, II has generally acquired substantial attention in studies relating to the use of ICT in organisations, and in spite of the mushrooming amount of research dedicated to it, information infrastructure is yet to be ascribed with a univocal overtone (Iannacci, 2010). Perusal of literature hints at a lack of consistency and uniformity regarding the nature and scope of II as a concept, and this could imply a difficulty in surely answering the
10 question: what is an information infrastructure? For example, in a much more limited nuance, Graham (2000) like Shin, Kim and Lee (2006), imputed II to mean technological networks of advanced telecommunication systems for local communities, which is used to provide them with advanced telecommunication services like multimedia applications (Iannacci, 2010). Yet, other writers have also explained II within a much broader perceptivity. For instance, Bowker and Star (1999); Bowker (2005); Braa, Hanseth, and Heywood (2007); Hanseth and Monteiro, (1998) have all explained II to engulf technological and human elements, networks, systems and processes, users’ communicative behaviours and ‘taken-for-granted practices’ (Iannacci, 2010) that contribute to the functioning of an organisation.
This study conceives the EHR in Effia Nkwanta Regional Hospital as an II, which could then be understood as it was defined by Hanseth and Monteiro, (1998). This definition was, however, extended in Hanseth and Lyytinen (2010). According to Hanseth and Monteiro (1998), II personifies information systems or communication networks together with their associated software that shore up the interaction among individuals and organizations by bringing together different systems such as information processing applications, communication networks, physical and software elements in networks and end systems that are usually integrated through standard interface. Squaring the adopted definition of Information infrastructure by Hanseth and Monteiro, (1998) within the perceptivity of this study, EHR in Effia Nkwanta is seen to involve not only a computer software program but also involves a complex array of information systems including basic support systems like operating systems, file servers, communication protocols, printers, etc. Consequently, this study defines an II as “a shared, open (and unbounded), heterogeneous and evolving socio-technical system (which we call installed base) consisting of a set of IT capabilities and their user, operations and design communities”
(Hanseth & Lyytinen, 2010:4). Structurally, therefore, the EHR in Effia Nkwanta Regional Hospital is an II which recursively consists of other infrastructures, platforms, application and IT capabilities (Ibid).
2.1.1 Essence of Information Infrastructure to EHR
The essence of II to the understanding of EHR rests on its unique functions and, accordingly, these characteristics of II make it functional as a framework for this study. Therefore, the adoption, sustainability and the actual benefits to be derived from EHRs could be easily achieved when EHRs are seen within the characteristics or function of II. According to Hanseth and Monteiro (1998), information infrastructure possesses some inherent functions or
11 characteristics and these make them different from other information systems. These functions are: enabling, shared, open, socio-technical, heterogeneous and installed base. The highlights of these characteristics are presented below.
2.1.1.1 The Enabling Function of II
IIs possess an ‘enabling’ function, which allows them to support a wide range of activities in an organisation. IIs do not therefore subsist merely as technologies used for just recuperating or automating an already existing activity, rather IIs exist to open up fields of new activities in an organisation. Hence, the EHR in Effia Nkwanta as an II has an ‘enabling’ function which transcends the single function of the automation of health records in the Hospital. The EHRs in the Hospital should also be able to support new fields of activities like alerts systems or reminders, easy and concurrent record retrieval by health professionals, single access points for patient records, and rapid access to patient records both within the organization and across organizations as well as other new activities like the continuing education of practitioners.
2.1.1.2 The Shared function of II
II allow for the sharing of information by members of a community or collection of users as they serve as a communication channel or resource base for the purposes of its users. That is, it becomes an object used by all to achieve an overall goal, although it might appear differently to each user (Hanseth & Monteiro, 1998). Owing to this shared function, II are irreducible and the irreducibility of II, according Hanseth and Monteiro (1998), implies that all the various users use the same infrastructure as the system cannot be split or divided into separate parts that are independent of different groups. The authors, however, were quick to add that even if infrastructures are disintegrated into separate units for investigative or design purposes, each fragmented unit must be integrated through a standardized interface. EHR as a shared Nkwanta should be able to be used by various workers in the facility to achieve a desired goal.
The pharmacist and the medical doctor must all be able to access the health information of the patient at any time to make health decisions. Thus, the EHR in Effia Nkwanta will facilitate data sharing among health professionals and various departments and institutions.
12 2.1.1.3 The Open Function of II
IIs do not limit the number of users, vendors and stakeholders who are involved in the development, implementation and the use of the system. Hence, openness as a function of II refers to its lack of boundaries. This arrangement does not, however, mean that everything is included in IIs but rather it emphasizes the fact that, drawing a stringent boundary between what is on one side of an II and what is at the other side of it could be undesirable (Hanseth &
Monteiro, 1998). Again, IIs are open in the sense that they are dynamic and always shifting, thus there is the need for every II to be flexible to some extent in order to enjoy stability over a period of time (Ibid). In what seems to be a more technical argument, Hanseth, (2002) intimated that the openness of an II indicates a characteristic, where there is no beginning and ending in the development of an II and where there is no perceptible limit to the number of individuals involved in the design and implementation of the system. Hence, EHRs in this study could be construed as an II that is open or unlimited to many users, who are mostly health care professionals in various departments in the Effia Nkwanta Regional Hospital. The EHR could also be construed as open as it also involves different stakeholders as well as human and non-human actors in its design and implementation. The openness of EHR in Effia Nkwanta Regional Hospital in this study can again be understood in the light of the flexibility of the EHR to adapt to changes, as there is no beginning and ending its implementation.
2.1.1.4 The Socio-Technical Network Function of II
IIs consist of more than just the various individual components (Hanseth & Monteiro, 1998).
IIs cover a broad spectrum of both technological and social components like human and organizational elements. According to Hughes (1994), technology defines every organisation and they are also in turn redefined by it. Thus IIs, as socio-technical networks, pose an emphasis on both the technological aspect of the infrastructure and the social dynamics that are brought to bear on the infrastructure from the organisation, its members and even the community at large (Hanseth & Monteiro, 1998). In this study, therefore, the EHR in Effia Nkwanta Regional Hospital is understood as an II that cannot work properly without the support of the staff and other social elements. This leads the researcher to make the point that, the users and other social elements should be seen as key factors in the implementation of the EHR in the hospital, thus, it is not just a matter of ‘pure technology’ which determines the success or otherwise of the EHR. As Coeira, (2003) observes, the triumph of any system (and in this regards the EHR) in
13 healthcare delivery, is partly determined by how well the users are able to interact with the system.
2.1.1.5 The heterogeneous function of II
In view of the fact that IIs have a broad socio-technical network and are also open to different activities, relationships and alliances, together with changeable conditions for development, IIs are heterogeneous (Hanseth & Monteiro, 1998). As heterogeneous, IIs also connect various components and assimilate them into interdependent networks – an ecology of networks. This implies that within Effia Nkwanta Regional Hospital, when the EHR malfunctions, all the rest of the infrastructure could also run into huge problems.
2.1.1.6 II as an Installed base
According to Hanseth and Monteiro, (1998), IIs are developed from an already existing or continuously evolving infrastructure, hence it stands to reason that IIs cannot be a novelty but rather they are always inspired by or brought forth on the back of an already existing system.
Like many authors, Hanseth and Monteiro (1998) made the observation that technological advancement and the changing circumstances of the world often trigger the institutionalization of newer technologies or replacement of some parts of the already existing technology. But, they were quick to add that developing completely a new system that is not based on any existing system often becomes difficult, particularly within a healthcare sector that is highly fragmented. So, they agreed that both the old and new systems ought to be connected together, to aid interoperability. Hanseth (2002) made the point that when designing a ‘new’ component of infrastructure, it should be kept in mind that the new component will only be accepted and also work well in the organisation if it can be integrated or substitute a part of an existing infrastructure. This implies that the implementation of the EHR in Effia Nkwanta Regional Hospital ought to be seen as something that is not new but rather it ought to be conceived of as an II, which was installed based on the paper-based record system. Further, for a successful implementation of the EHR in the Hospital, one ought to consider the installed based (paper record) as very relevant as it influenced (and continues to influence) the way the EHR system was planned and designed.
14 2.1.2 The Actor Network Theory (ANT)
ANT seeks to conceptualize the relationship between technology and societies and this has gained prominence in much research involving information systems, since it provides new concepts and ideas for the understanding of the socio-technical nature of information systems (Walsham, 1997). Thus, ANT is seen as an approach taken by social scientists to investigate the social and technical aspects of an organisation that include people, organizations and technology -all enmeshed in a network (Monteiro, 2000; Walsham, 1997). The theory is credited to the writings of Michel Callon, Bruno Latour, and John Law. ANT asserts that the use of technologies in organisations (like Effia Nkwanta Regional Hospital) does not come as a result of any scientific inference. Rather, technologies themselves evolve because of an inherent social momentum that the technologies themselves possess. The theory again contends that, the only way of ensuring order and efficiency in an organisation (Effia Nkwanta Regional Hospital, in this regards) rest on the ability of the organisation to establish networks that will shape social interaction within the organisation (Callon & Law, 1995; Hanseth & Monteiro, 1998; Latour, 1991). ANT views an information infrastructure (EHR) as both an actor in the organisation and also as a tool for establishing a network that links all other actors. Therefore, the actors within a network consist of both human and non-human factors that are heterogeneous to the extent that they are treated in the same way and are even given the collective name of hybrid collectif (Aanestad & Hanseth, 2000; Callon & Law, 1995; Latour, 1991; Walsham, 1997). As an Actor-Network, the EHR in Effia Nkwanta consists of various social and technical actors that play specific roles within a network, which the EHR itself establishes. In this vein, the activities of an actor (both human and non-human) are conceived within a network, but not as acting independently (Aanestad & Hanseth, 2000). Hence, establishing the EHR system and ensuring its effectiveness demands the detection of plausible actors that directly or indirectly affect the continuation of the system. Thus ANT offers a language for explaining the many small, concrete technical and non-technical mechanisms that go into the building and use of EHR in the facility. ANT would aid in recognising key actors who are involved in the implementation of the EHR in the hospital as well as explain the necessary elements required for developing a stable EHR in the facility.
2.1.2.1 Translation and Inscription
Monteiro, (2000) identified 'translation’ and ‘inscription’ as the two major means of conceptualizing what actually occur within the Actor-networks.
15 Translation
Translation involves “creating convergences and homologies by relating things that were previously different” (Callon 1981; 211). Actors within the network might have various requirements, needs, interests, expectations and even their way of perceiving a problem might differ; thus there is the need to build synergies between these various actors within the network
Translation involves “creating convergences and homologies by relating things that were previously different” (Callon 1981; 211). Actors within the network might have various requirements, needs, interests, expectations and even their way of perceiving a problem might differ; thus there is the need to build synergies between these various actors within the network