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Key Success Factors Behind Electronic Medical Record Adoption in Thailand - 25
Key Success Factors Behind Electronic Medical Record Adoption in Thailand - 25
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Salmiya, Kuwait
Charles Newton
International College, Dhurakij Pundit University,
Bangkok, Thailand, and
Damrongsak Bulyalert
Faculty of Medicine, Chiang Mai University,
Chiang Mai, Thailand
Abstract
Purpose – The purpose of this paper is to investigate the elements that health care personnel in
Thailand believe are necessary for successful adoption of electronic medical record (EMR) systems.
Design/methodology/approach – Initial qualitative in-depth interviews with physicians to adapt
key elements from the literature to the Thai context. The 12 elements identified included things related
to managing the implementation and to IT expertise. The nationwide survey was supported by the
Ministry of Public Health and returned 1,069 usable questionnaires (response rate 42 percent) from a
range of medical personnel.
Findings – The key elements clearly separated into a managerial dimension and an IT dimension.
All were considered fairly important, but managerial expertise was more critical. In particular, there
should be clear EMR project goals and scope, adequate budget allocation, clinical staff must be
involved in implementation, and the IT should facilitate good electronic communication.
Research limitations/implications – Thailand is representative of middle-income developing
countries, but there is no guarantee findings can be generalized. National policies differ, as do economic
structures of health care industries. The focus is on management at the organizational level, but future
research must also examine macro-level issues, as well as gain more depth into thinking of individual
health care personnel.
Practical implications – Technical issues of EMR implementation are certainly important. However,
it is clear actual adoption and use of the system also depends very heavily on managerial issues.
Originality/value – Most research on EMR implementation has been in developed countries,
and has often focussed more on technical issues rather than examining managerial issues closely.
Health IT is also critical in developing economies, and management of health IT implementation must
be well understood.
Keywords Thailand, Medical information systems, Electronic health records,
Electronic medical records, EMR implementation, Physician views
Paper type Research paper
Journal of Health Organization and
Management
Vol. 30 No. 6, 2016
An early version of this paper was presented at the 2011 SIBR Conference on Interdisciplinary pp. 985-1008
Business & Economics Research (Society of Interdisciplinary Business Research). Bangkok, © Emerald Group Publishing Limited
1477-7266
Thailand, June 16-18, 2011. DOI 10.1108/JHOM-10-2014-0180
JHOM Introduction
30,6 This study examines factors that personnel in Thailand’s health care industry believe
are necessary for the successful adoption of electronic medical record (EMR) systems
(also often electronic health record, EHR) in Thailand. The concept of EMR started in
the 1970s, and usage of such systems has spread rapidly, although even in most
developed countries, still only a minority of hospitals have fully implemented systems.
986 EMR implementation does not always work well, and there may be resistance to
adoption among key stakeholders. We examine management issues here which can
help improve adoption and implementation success rates.
Such systems go by many names, including EHR, health information technology
(HIT) and many other terms. Technically, different terms sometimes are considered to
cover slightly different content. Occasionally authors argue that the terms must be
carefully distinguished; e.g. Garets and Davis (2006) say EMR and EHR are different in
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The USA, which may have the most extensive data about EMR issues, can serve as a
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community health centers for basic care and routine reporting. However, there is
somewhat less use in management and administration, and weak use in communication
and collaboration (Kijsanayotin et al., 2007, 2009), issues that would require more
coordination and standardization.
( Jaspers et al., 2011). This is a steep price for busy physicians to pay, given that at
the current stage of CDSS development, “clinicians, based on their clinical experience,
are better able to rule out alternative diagnoses than diagnostic CDSS” ( Jaspers et al.,
2011, p. 332).
Many observers think getting usage of the EMR systems is one of the key issues,
often more important than specific technical details of the IT itself. A survey of 302 IT
professionals in the US health care industry showed that more than one-third said the
top priority was achieving “meaningful use” of their EHR systems (Healthcare
Information and Management Systems Society (HIMSS), 2012). (“Meaningful use” is a
technical term used in the American Recovery and Reinvestment Act, which mandates
progressively greater use of Health IT, and defines a number of specific functions and
targets for usage of those functions (Blumenthal and Tavenner, 2010; HealthIT.gov,
2014). This does represent progress compared to the survey results in the previous
year, when half said achieving meaningful use was a top priority (HIMSS, 2012).
This discussion suggests that it is necessary to have a good understanding of user
thinking about the key factors needed to make EMR systems work. Even good
technology will fail if the intended users do not use it. Discussing their review, Buntin
et al. (2011) say that:
In fact, the stronger finding may be that the “human element” is critical to health IT
implementation. The association between the assessment of provider satisfaction and
negative findings is a strong one. This highlights the importance of strong leadership and
staff “buy-in” if systems are to successfully manage and see benefit from health information
technology (Buntin et al., 2011, p. 470).
Current discussion has called for more focus on how to make implementation
work better, rather than simply showing that well implemented EMR does provide
benefits. “With the increasing adoption of EHRs and other forms of health IT, it is no
longer sufficient to ask whether health IT creates value; going forward, the most
useful studies will help us understand how to realize value from health IT” ( Jones
et al., 2014, p. 52).
This is particularly important in developing countries, which mostly still need to
catch up to the developed world in terms of availability and quality of health care.
We examine this in Thailand and note that:
[…] the current body of literature comes from developed nations. As access to technology
expands, and the associated costs decline, the potential role and impact of the EMR/EHR
within developing countries need to be explored” (Holroyd-Leduc et al., 2011, p. 736).
It is hard enough to fully implement systems and get users to adopt them where there Electronic
is, relatively, an abundance of resources. The difficulties noted above in getting medical record
effective EMR adoption are compounded in developing countries.
adoption
EMR in Thailand
Thailand can represent conditions in middle-income developing countries fairly well;
the World Bank classifies it as an “upper middle income” country (World Bank, 2014). 991
Within this category of developing countries, Thailand compares similarly to how the
USA compares to developed countries. Thailand ranks 32nd overall in global
competitiveness, above most middle-income countries. However, it ranks somewhat
lower on infrastructure (44th) than many countries at similar development levels, and
much lower on health and primary education (67th) (World Economic Forum (WEF),
2015a). Thailand’s rank on “Impact of ICTs on access to basic services” (including
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number of difficulties in being able to use systems even when they are implemented.
Workload is a key issue (e.g. Parket al., 2015). With a very heavy patient load, doctors in
particular find it difficult to devote time to learning new systems, or to taking on
additional reporting duties to feed data into the systems; this has also sometimes been a
problem even for nurses. In addition, organizational support in terms of such things as
adequate budget and project coordination are important, as well as some lack of depth
in IT knowledge for the systems (Theera-Ampornpunt, 2011; Kijsanayotin et al., 2007,
2009, 2010; Srakoopunet al., 2010). Such problems are not much different from those
noted above in research on developed country EMR implementation.
Method
A major survey was used to assess views broadly in Thailand’s health care industry
about critical success factors in EMR implementation. The questionnaire was adapted
for the situation in Thailand, based on the general literature and the literature
specifically about EMR in Thailand, as discussed above. A very small scale qualitative
pilot was conducted to confirm that the issues on the questionnaire reflected the things
health care personnel are actually currently concerned with. The sample returned 1,066
valid responses.
critical for meaningful research in large organizations in any context (Eriksson and
Kovalainen, 2008, p. 52), and is invariably a key consideration for getting quality data
in Asia’s relationship-oriented cultures (e.g. Srijumpa et al., 2004). This connections
network is important for access to health professionals, to whom outsiders often
havelimited access (Liu and Ma, 2006).
The in-depth interviews were conducted with ten physicians scattered across a
range of departments in the hospital. The procedures generally followed
recommendations from a discussion that specifically addressed using in-depth
qualitative methods to assess concepts relating to customer acceptance of internet
technology in financial services in Thailand (Srijumpa et al., 2004). Interviews were
semi-structured, following a topics list of the success factors, but discussing them
only as respondents brought them up, without imposing the researchers’
conceptualization onto respondents. We used probing questions to get additional
depth when necessary for understanding any of the success factors (Eriksson and
Kovalainen, 2008, Chapter 7).
The list of factors from the literature did not change much, but was slightly refined
to reflect the Thai context, and condensed because the respondents did not see much
distinction between some sets of factors. For example, while Cresswell and Sheikh
(2013) do talk about both fitting organizational/administrative needs and processes,
and specifically fitting physicians’ needs, they do not distinguish these very strongly.
Our respondents felt that administrative processes and medical decisions were entirely
separate issues, and the EMR system needed to support both. On the other hand,
Cresswell and Sheikh (2013) talked about several aspects of “communication”
separately, but our respondents tended to consider various modes (such as
interpersonal, documentation, etc.) all as “communication.” The need for IT staff
support, implicit in Cresswell and Sheikh (2013), was explicit in our interviews.
Ultimately, we ended up with 12 key factors, noted in the bullet points above, and
the respondents tended to see only two key dimensions, one related to managerial
competence (roughly organizational vision and support), and one oriented toward
management of the technical side. Respondents in the large-scale survey were asked
whether they agreed that each of these 12 factors was important in implementing the
EMR system. A ten-point Likert scale from strongly agree (10) to strongly disagree (1)
was used. They are listed in Table I, according to whether the factors seemed to be
mainly more broadly managerial (q1-q6) or mainly about managing the IT support
competently (q7-q12). The tables show representative quotes from the small qualitative
pilot to illustrate the nature of thinking about the factors.
Managerial issues
Electronic
q1. The organization has adequate budget allocation medical record
Top management has to allocate a reasonable budget and view this implementation is for adoption
improving patient care. I think top management is the most (cost-) factor person on EMR
initiation
q2. The organization has clear EMR project goals and scope
Top management has to decide about health care IT, and plan for long-term operation, e.g., home 995
monitoring. The reference should have a common health IT system to enable the patient
information to be shared, and hospitals can generate some statistics by type of patients
q3. The EMR functions support administrative processes for patient management
The functionality of the decision support systems for general administrative processes such as
resource scheduling. Data from EMR should also be used for managing our hospital, forecasting
and planning for better patient services
q4. The EMR functions support medical decisions
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I will use if it allows me to access patient data quickly and correctly, that data needs to be
integrated among departments. I think the awareness of how EMR supports with nurse’s routine
(is important), e.g., for medication administration
q5. The organization has effective EMR project communications
EMR data should be in the same data standard and can be used by hospital referrals as a
communication means. Some data in hospital still being mostly isolated, e.g., X-ray tests, cannot share
with other departments. If it is shared, it will reduce health care cost, human resources, and budget
q6. Development of the system has substantial clinical staff involvement
Development of a system like EMR is not a big deal, but it is needed in modern hospitals. But
changing new user’s attitudes who have never used any system is quite difficult. I think
(management has to consult doctors about) workload and time to pay attention to health IT, (which)
affects so much on using. EMR has to facilitate the changes from paper record to electronic
IT support issues
q7. The system has good electronic communications and connectivity
The system need to be stable, easy to use, and physicians can access it whenever they want. All
points of care should be included in EMR network, and make it accessible, and physicians can
track patient’s condition
q8. The EMR suits department user needs
Easy to modify some functions to fit with hospitals operation. This also serves us to collect a
variety of data types in the future. EMR should allow physicians to add patient details after
patient goes home, e.g., adding pictures of fracture area
q9. The organization has training to improve computer skills
Computer training to increase computer skills
q10. The organization has training in the EMR system
Staff should be eager to learn and improve their jobs using health IT
q11. The EMR vendors provide strong support
About EMR adoption, we want the vendor or IT department quickly response to our requirement,
fix problems quickly
q12. Knowledge and experience of internal IT staff is high Table I.
Modern hospital should have a chief information officer with clear role and responsibly and scope Representative
of work. They should have a good income and a considerable fringe benefit. Position of CIO quotes about the
should be filled by a clinician rather than a technology-based person measures
Sampling
There is potential concern that observing or questioning of the physicians using the
EMR system while they are working might negatively affect patient confidentiality.
JHOM Thus, interviews did not ask about and did not have access to information about
30,6 patients, either in aggregate or at the individual patient level. The names of the doctors
interviewed are also kept confidential and no information is disclosed which could
possibly link to individual respondents or individual hospitals. The survey procedure
was discussed with the Thai Ministry of Public Health (MoPH).We received written
approval from MoPH to sample from MoPH hospitals, and this approval letter was
996 included with the cover letter and questionnaire.
The Thai MoPH classifies hospitals into three levels. In practice, they can be
distinguished by size, but key characteristics, such as the depth of specialist care
available, is closely correlated with this. Lists we used included 820 hospitals throughout
Thailand. At this stage, endorsement from MoPH was considered sufficient to overcome
lack of connections, and random sampling was used to choose approximately 20 percent
of the hospitals from the list, roughly in proportion to the number in the three levels. This
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resulted in 169 hospitals that received questionnaires. In each hospital, 15 people received
questionnaires, the breakdown of which was (as much as it was possible to identify the
appropriate positions): one policy maker, two information systems managers, four
physicians, two dentists, two pharmacists, two professional nurses, and two technical
nurses. A total of 2,535 questionnaires were distributed:
• primary care hospitals (90-120 beds): 79 hospitals 1,185 questionnaires;
• secondary care hospitals (121-500 beds): 65 hospitals 975 questionnaires; and
• tertiary care hospitals ( W 500 beds): 25 hospitals 375 questionnaires.
A total of 1,066 usable questionnaires were returned, and the data were analyzed using
SPSS, using basic descriptive statistics, factor analysis, and regression. The overall
response rate of 42 percent. However, the response rate differed somewhat by
professional category, with higher return rates from professional nurses, followed by
pharmacists, and the lowest rates by information systems managers (Table II). Some of
these response rates would be somewhat higher, as professional category could not be
determined with certainty on about 14 percent of the questionnaires. A few respondents
did not answer this question (about 2.2 percent), but most of the inability to be sure about
professional category was because respondents answered more than one. Often, this was
either doctors or nurses who also held some administrative responsibilities.
About 56 percent of respondents were female, and 80 percent were more than
30 years old. As might be expected in this target population, 96 percent of respondents
had at least a bachelor degree; physicians, of course, also held a graduate medical
degree. In total, 95 percent reported experience in using computers, and nearly
accounted for 69 percent of variance (Table III). These two factors had nearly equal
weight in the factor solution, as indicated by the proportion of variance accounted for.
The third factor in the initial solution had an eigenvalue substantially below 1.0,
indicating that only two factors are required to capture the main dimensional structure
of the data. We call factor 1 “managerial expertise,” and factor 2 “technical expertise.”
All questionnaire items had communalities above 0.5, indicating that the majority of
variance in each of the 12 items was captured in these two factors. There was negligible
cross-loading on most items, although Q8 “EMR suits department user needs” loaded
only slightly more strongly on “technical expertise” than on “managerial expertise.”
This issue seems to be perceived as both a managerial and a technical issue. Similarly,
Q7 “good electronic communications & connectivity,” while stronger on the “technical
expertise” dimension, did seem to be perceived as also somewhat representing
“managerial expertise.”
Table IV shows the means of each of the 12 questionnaire items representing key
success factors, organized to indicate the two factors in Table III. It is clear that, in
general, respondents felt that managerial expertise was slightly more important than
technical expertise in implementing the EMR system. Respondents considered all of the
questionnaire items important; all were rated, on average, well above the scale midpoint
of 5.5. However, generally they felt “clear EMR project goals and scope,” “adequate
budget allocation,” “good electric communications & connectivity,” and “clinical staff
involvement” rated highest. Most of these seem to be about managing the
implementation process, rather than about technical expertise.
It is interesting to note that Q11 “the EMR vendors provide strong support” rates
substantially (and significantly) lower in importance than any other questionnaire item.
This suggests a relatively weak relationship with suppliers, which has been noted in
other industries in Thailand (e.g. Suwannaporn and Speece, 2003; Kritchanchai and
Wasusri, 2007). In the US health care industry, poor communications between health IT
suppliers and health care providers is not uncommon, sometimes because health care
administrators often stand between the supplier and the health care professionals.
“A key challenge for the development and deployment of ePHRs is the highly
fragmented nature of the health care industry, which can disrupt information flows
across the many constituents that make up the patient-delivery-care process” (Lewis
et al., 2013, p. 578; ePHR ¼ electronic personal health record). In the initial qualitative
validity check discussed above, several comments suggested that some respondents in
the hospital were skeptical of vendor commitment.
Simple visual observation of the means in Table IV suggests that overall,
professionals in Thailand’s health care industry do not believe that the most critical
issues in EMR system implementation are technical. They do, of course, recognize that
technical expertise is important, but do not feel it is as important as managerial
expertise. The project must have clear goals and scope, an adequate budget, and have
user involvement. The technical item that ranked highest was actually about electronic
communication and connectivity, a technical aspect which facilitates the managerial
elements (and which had a cross-loading on the managerial factor). Table V simply
shows that there is a small but significant difference in the perceived importance of the
overall dimension.
Figure 1 graphically shows percentage divergence of the mean on each questionnaire
item from the overall grand mean across all the items. There is a clear tendency to perceive
most elements of managerial expertise as more important than elements of technical Electronic
expertise. However, the third managerial expertise element, “support administrative medical record
processes for patient management,” is notably below other managerial elements. This
likely reflects the nature of the sample which is mostly medical personnel in some
adoption
capacity. The literature shows that patient management is one of the more common
implementations in Thailand. However, it may simply be that this function generally
works moderately well, so respondents do not notice it very much. In addition, as noted, 999
vendor support scores very low comparatively. As noted, this probably reflects the
7.50 technical
5.00
2.50
0.00
Mean
–2.50
–5.00
–7.50
managerial
–10.00
–12.50
pctQ1diff
pctQ2diff
pctQ3diff
pctQ4diff
pctQ5diff
pctQ6diff
pctQ7diff
pctQ8diff
pctQ9diff
pctQ10diff
pctQ11diff
pctQ12diff
Discussion
1000 It is clear from these results that implementing an EMR system is not purely a technical
issue. Substantial attention must be given to managing the implementation of EMR
systems, and to managing the technical support. These are not two disjoint sets of
isolated actions, i.e., they cannot be approached “question by question” in terms of the
items on the questionnaire. Rather, these issues form coherent packages, as the strong
factor analysis results show. The set of 12 “success factor” items contains only two
underlying dimensions – in other words, these issues are strongly interrelated. Poor
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Managerial implications
This research has been directed towards better understanding the concepts related to
success factors for EMR adoption in the Thai context. The research examined views
from a much broader population than only policy makers in health care facilities, but
focussed mainly on users (physicians and nurses) and IT developers to identify the
issues to be overcome for successful adoption of EMR systems. The research has
confirmed that health care professionals perceive some important issues with EMR Electronic
adoption. Key points from this research include. medical record
First, policy makers and stakeholders need to use information about users’ attitudes.
The EMR system cannot fully deliver benefits if many potential users fail to actually use
adoption
it. These research findings highlight users’ attitudes that HIT may well help improve
work conditions and patient care. But it is clear that this is not easy – a number of issues
must be addressed to implement EMR systems and make them responsive to user needs. 1001
Users conceptualize the issues broadly into two dimensions, relating to managerial
expertise in implementing the system, and IT expertise.User views here indicate that
managing the EMR implementation is an even more critical issue than the IT support.
This is consistent with some of the literature. Although management of implementation
is not a very common topic in discussions of health IT systems, some studies have
indicated the importance of some of the issues included here (e.g. Edwards, 2006;
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Carayon et al., 2009; Kaplan and Harris-Salamone, 2009; Jaana et al., 2011; Cresswell and
Sheikh, 2013). This study is further evidence that careful management of the process
must be a high priority, and furthermore, that the range of management issues should
not be considered individually as isolated issues, but as an interconnected package.
Second, the key managerial issues seem to be about adaptation to the context of the
specific organization. General capabilities, especially supporting the administrative
process, and to some extent, supporting medical decisions, are not the most critical
parts of managing the system well. Presumably, these are perceived as rather generic.
Rather, the EMR implementation project must be carefully defined with clear goals and
scope and needs sufficient budgetary support. Clinical users must have substantial
involvement in defining system features and functions and communications must work
effectively. These things make sure that the system will fit user needs well.
Note that this implies two-way communications, both keeping everyone informed and
bringing in user views. The importance of user involvement has been an occasional
theme in studies for quite some time (e.g. Anderson, 1997; Edwards, 2006; Carayon et al.,
2009), as has the importance of good communications to achieve this (e.g. Kaplan and
Harris-Salamone, 2009; Cresswell and Sheikh, 2013). However, the fact that this issue
still needs to be pointed out in studies suggests that users are not always involved
in meaningful ways. In general, involving users in the development and implementation
of IT systems is just a specific case of customer involvement in the new product
development process. It has been demonstrated in many industries that such
involvement greatly improves success rates in new product/new service introduction
(e.g. in Thailand, Rajatanavin and Speece, 2006; Suwannaporn and Speece, 2010).
Third, among IT issues, the electronic communications are considered the most
important. The literature on IT implementations does not often examine the
communications infrastructure; however, the health IT manager should be aware of the
importance of the communications network. This, of course, supports the managerial
factors just discussed above. Knowledge and experience of internal IT staff is also
relatively important, again an issue related to the ability to adapt the EMR system to
the specific context of the organization. Jaana et al. (2011) noted that hospital IT
directors in Canada cited the importance of a skilled IT support staff; the research here
among (mostly) doctors and nurses confirms this. A few prior studies have also cited
the need for training in general computer skills and specifically on the EMR system
(e.g. Edwards, 2006; Kaplan and Harris-Salamone, 2009; Cresswell and Sheikh, 2013).
While respondents here do not discount these needs, these are not relatively among the
most critical issues.
JHOM Finally, and quite notably, vendor support was relatively by far the least important
30,6 individual element. Since vendors are the developers of the system, or represent the
developers, and have a big role in implementing EMR in the organization, this is
noteworthy and deserves additional research in the future. It could possibly suggest
that vendors are generally doing so well that users in Thailand do not bother worrying
about this issue as much. More likely, it reflects the somewhat poor linkage between
1002 suppliers and customers which is characteristic of other industries in Thailand
(e.g. Suwannaporn and Speece, 2003; Kritchanchai and Wasusri, 2007), and sometimes
characteristic in the EMR industry in the west (e.g. Lewis et al., 2013).
This would indicate a need for EMR vendors to learn to communicate more
effectively with the customers for their systems. This, of course, would include
recognition that the cooperation needs to be much broader than just the technical
aspects of the system. Claybaugh and Srite (2009) show that good communication on a
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broad set of issues is important for customer perceptions of a good relationship with IT
vendors. This study further demonstrates that vendors need strong customer
relationships, beyond simply setting up the system.
Conclusion
Much research about implementation of EMR systems examines how characteristics of
users and their attitudes toward the system affect usage of such IT systems. This work
often uses some version of the Technology Acceptance Model (e.g. Edwards 2006;
Ketikidis et al., 2012; Kijsanayotin et al., 2009). Other work focusses on characteristics of
organizations or technology. In their extensive review of recent research, Cresswell and
Sheikh (2013) found that a range of technical, social, and organizational issues have
important impacts on successful implementation. Many of their issues are about the
nature of the context, such as government HIT policy, characteristics of the adopting
organization, or characteristics of available technology. Certainly managerial decisions
must account for such issues, so it is important to understand them, but they are not
themselves things which managers control.
Even when some managerial issues are included, few discussions carefully
distinguish the managerial issues from various characteristics of users or systems. For
example, some factors in Cresswell and Sheikh (2013) are clearly managerial, but they
are not specifically distinguished from other issues, and managerial issues are not
examined as a package. There is not very much focus specifically on how management
of the EMR implementation process influences adoption. This research shows that a
range of main users in Thai hospitals feel that management of the implementation
process is even more important than technical issues. Clearly, we need to know more
about this, and especially need to demonstrate that these sorts of management
expertise issues, along with technical expertise, do actually improve perceptions
toward using the EMR systems.
This research provides a good beginning at understanding the range of managerial
issues needed for successful adoption of EMR systems. One strength of the research is
that it covers a large random sample of health care workers, including mostly doctors
and nurses who would actually be using the system, i.e., the adopters. Support for the
research by the Thai MoPHensured that the response rate was fairly high, 42 percent.
The research process was careful to pull the main concepts (but not specific questions)
from the literature, and to confirm that the concepts are indeed relevant in Thailand. In
other words, the data used here to begin examining the issues seems to have fairly high
reliability and external validity.
On the other hand, adaptation of the questionnaire to context makes easy direct Electronic
comparison to other countries slightly problematic, although careful proceedure can medical record
reduce this difficulty. In addition, while Thailand is fairly representative of middle-
income developing countries, there is, of course, no guarantee that findings can be
adoption
generalized to other such countries. National policies differ, as do economic structures
of the health care industry. Thailand does show a standing among developing
countries which is similar to how the USA fits with developed countries – generally 1003
highly competitive within their groups overall, but lagging on implementation of HIT,
at least partly because of lack of coherent policy.
Perhaps a middle-income developing country with more coherent policy would show
somewhat different results. Better policy and more expereince in implementation might
lead to better management practice so that the issues here could be considered routine
rather than very important. Our focus has been on management issues at the
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organizational level, but future research certainly must also examine macro-level
factors such as policy, as well as gain more depth into thinking of individual health
care personnel.
As Ketikidis et al. (2012) already noted, research is needed in a wide range of cultural
(and economic development) contexts to confirm generalizability. Some countries are
less advanced than Thailand, while some are advanced developed countries, and
success factors may shift. Notably, the role of budgets and infrastructure may shift in
more advanced economies, or may be even more prominent in countries that are
substantially less developed than Thailand. Less developed countries may lack the
technical expertise which is generally available to Thai public hospitals.
EMR systems, when used well to their full extent, can improve the safety and
effectiveness of the public health care delivery system. However, the rate of
successful implementation worldwide is not very high. This study on the key
success factors for EMR systems should benefit managers, administrators, other
stakeholders in public health care and vendors of health care IT. Managerial
actions do indeed play an important role in EMR implementation. It is hoped
that this study, and others like it, can help improve successful implementation
of EMR systems. The whole range of managerial issues should be further studied
to see how management of the implementation process can affect the uptake and
use of the EMR.
References
Agency for Healthcare Research and Quality (2009), “National healthcare disparities report,
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formerly a health IT Project Director and Co-owner of a major Thai medical informatics vendor
which was sole Thailand distributor of EMR systems for a number of vendors worldwide.
She has implemented EMR systems in over 30 major public and private hospitals throughout
Thailand over the past decade. She sold her share in the company several years ago to pursue her
PhD studies full time. Kanida Narattharaksa is the corresponding author and can be contacted at:
nk1689@icloud.com
Mark Speece is Associate Professor of Marketing at the American University of Kuwait.
Earlier, he spent 16 years in Southeast Asia, much of it at the Asian Institute of Technology in
Bangkok, and he continues as an adjunct in PhD programs at the Dhurakij Pundit University
in Bangkok. His PhD in marketing is from the University of Washington. He also has a PhD in
Middle East economic geography from the University of Arizona. Much of his research is on
customer acceptance of internet technologies and services.
Charles Newton is emeritus Professor, School of Engineering and Information Technology,
University of New South Wales, Canberra. He was the Dean at the Dhurakij Pundit University
International College, Bangkok, for most of the past decade and is now Emeritus Dean and Senior
Advisor to DPUIC. His PhD is in nuclear physics from the Australian National University.
Much of his teaching and research has been in the field of operations research and decision
support systems.
Damrongsak Bulyalert is an Assistant Professor in the Department of Internal Medicine and
Assistant Dean of the Faculty of Medicine, Chiang Mai University. He also practices in Maharaj
Nakorn Chiang Mai Hospital at the Chiang Mai University. His PhD in Physiology is from the
Emory University, Atlanta, Georgia, and his MD is from the Chiang Mai University. He has a
long-standing interest in medical informatics, and has completed a number training programs in
medical informatics, TQM, and information security policy.
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