An Exploratory Study of the Readiness of Public Healthcare Facilities in Developing Countries to Adopt Health Information Technology (HIT)/e-Health: the Case of Ghana

Abstract

There are myriad of factors used in assessing health information technology (HIT)/e-Health of healthcare institutions in developing countries and beyond. In this paper, we intended to identify and gain a deeper understanding of factors used in assessing HIT/e-Health readiness in developing countries through the identification of contextual attributes using Ghana as an exemplary developing country. Through in-depth interviews using aide memoire as interview guide, we explored Core readiness, Engagement readiness, Technological readiness, HIT funding readiness, Regulatory and policy readiness, Workforce readiness and Change Management readiness. We adapted the systematic thematic analysis of qualitative data guide suggested by Braun and Clarke (2013) and O’Connor and Gibson (Pimatisiwin 1: 63–90, 2003) in order to generate codes and build over-arching themes. While Organizational cultural readiness was found to be a more applicable theme/factor in place of Engagement readiness and Change management readiness, Resource readiness wasalso deemed a more appropriate theme for HIT funding readiness and Workforce readiness respectively. A total of 23 factors likely to promote HIT adoption in Ghana and 29 factors capable of impeding HIT adoption in Ghana and potentially in other developing countries were identified. For effective assessment of HIT readiness factors, there is a critical need for a deeper understanding of their applicability in differing settings. The outcome of this study offers a valuable insight into improving circumstances under which HIT/e-Health is adopted. When effectually carried out, assessment of this nature could be help side-step losses on large money, effort, time, delay and importantly, dissatisfaction among stakeholders while enabling change processes healthcare institutions and communities involved. This study also contributes to the limited literature on HIT/e-Health implementation scenarios while offering basis for theory-building.

Introduction

Many countries especially in developing countries are still trailing behind in achieving better health outcomes although life expectancy has been improving especially in developed countries. The use of ICT has significantly and positively impacted health outcomes in low and lower middle-income countries (LLMC) [1–4]. e-Health/HIT1 is the use of information and communication technologies (ICT) for health care services and delivery [5]. “HIT functionalities are categorized into coordination levels: information capture, the lowest level, which coordinates through standardization; information provision, which supports unidirectional activities; and information exchange, which reflects the highest level of coordination allowing for bidirectional exchange” [6]. e-Health and HIT are used interchangeably. For the purpose of this study, e-Health/HIT is the delivery and management of health information for and by healthcare providers, receivers and policy makers through the Internet and telecommunications using computers, PDAs, mobile phones and other digital devices. e-Health initiatives in Ghana such as millennium village program (MVP), Mobile Dermatology and Sene PDA have used ICT/Internet and Mobile phones have been used to provide healthcare services to people in deprived/remote communities. Given the recognition of the important role healthcare play for development, improving the quality of healthcare has seen many governments of developing countries showing interest in e-Health/HIT [7–11] but they are recognized as costly investments [12]. The experience to date has been disappointing when initial high hopes confront the chaotic and sometimes corrupt health systems in many countries [13]. As with many developing countries, there is a lack of technology infrastructure in Ghana [14]. There cannot be any meaningful development without effective and efficient telecommunications. In Ghana, the need for efficient and reliable telecommunication services has been recognized, and making their services available is vital to Ghana’s economic advancement [15].

The successes of a few initial small-scale or pilot-based HIT/e-Health projects does not guarantee sustainable large-scale adoption and realization of benefits [16], necessitating the need for an e-Health readiness assessment among public healthcare institutions intending to adopt similar systems. Technology innovations in developing countries of which Ghana is no exception face the challenge of life beyond project phase [17]. For example, there were about 20 initial small-scaled pilot-based e-Health initiatives in Ghana [18], most of which in one way or the other are externally funded/supported. At the time of conducting this study, only two (2) were found to be in operation. Important questions to ask are what led to the demise of the 18-initial small-scaled HIT/e-Health initiatives? What lessons could be learned? Assessing the effect e-Health projects continue to remain a difficult task for key stakeholders particularly policymakers and project initiators. Given that a wide range of processes could be supported by IS it is difficult to analyze in a comparative way the benefits and results of e-Health practices in order to define strategies and to assign priorities to potential investments [19]. e-Health readiness refers to the preparedness of healthcare institutions or communities for the anticipated change brought by programs related to ICT [20]. In this study, readiness will imply the preparedness of health care institutions in Ghana to adopt e-Health. Long-term outcomes typically depend on factors such as reliability of sophisticated equipment and availability of technical staff to operate and maintain equipment. There is also the need for adequate funding to finance usual operating expenses, maintenance costs and frequent upgrades that seem to be an intrinsic feature of ICT systems.

Healthcare Institutions and Healthcare Situation in Ghana

The World Health Organization defined Hospitals as health care institutions that have an organized medical and other professional staff, inpatient facilities, deliver medical, nursing and related services 24 h per day, 7 days per week [21]. Healthcare institutions in Ghana refer to public and private clinics, primary healthcare, secondary and tertiary/referral hospitals. In Ghana, as with many other developing countries, there are three healthcare systems: the public which is operated through the national health insurance scheme (NHIS); the private health care organizations and NGOs; and traditional healthcare and self-medication [22]. Access to quality health care is said to be a fundamental human right but the numerous challenges faced by modern health care system make this a reality for only a section of the Ghanaian populace [23].

For a population of about 25,758,108 people [24], there are only 2615 medical doctors on the Ministry of Health’s (MoH) payroll, practicing in 1818 hospitals [25]. Consequently, the doctor to population ratio was 1:10,170 in 2013 nationally, which falls far below the WHO revised standard of 1:600 with far worse ratios recorded in some other parts of the country previously [26].

Generally, there are fewer health facilities in the northern part of Ghana [27], making accessibility of healthcare services difficult while risking increase in self-medication [28] prior to the introduction of NHIS.

In Ghana, there are several health problems such as malaria, HIV/AIDS, maternal and infant mortality and the shortage of health professionals. Unavailability of affordable healthcare and interventions has worsened and as in other developing countries, and people living in hard to reach or travel rural areas find it difficult to get to the nearest healthcare facility, a situation an e-Health system could solve.

Objectives of the Study

There is a general lack of reliable attributes of factors used in assessing HIT readiness assessment factors. As such, the objectives of this study were to (1) obtain a deeper understanding of the contextual attributes of the factors identified in literature used in assessing HIT readiness in the context of public healthcare facilities in Ghana; and (2) identify factors which promote HIT adoption and those impeding HIT adoptions and rank them in order of their importance/seriousness by respondents.

Methods

Study Design

We collected qualitative data during in-depth interviews using an interview guide between February and March 2017 based on an initial identified readiness assessment factors in order to explore their contextual attributes, which were the following: Core readiness, Engagement readiness, Technological readiness, HIT funding readiness, Regulatory and policy readiness [29–50], Change management readiness [51–54] and Workforce readiness [29, 55, 56] with qualified2 respondents. HIT/e-Health is still in its nascent ages in developing countries as qualified research population was relatively small. A total of 13 qualified participants who had a minimum of 4 years and an average of 10 years working experience in healthcare environment and e-Health-related projects were fully interviewed. The minimum education of these participants was undergraduate degree. Three were pursuing their master’s degree and five had master’s degree. One working in public health sector was pursuing a PhD degree. Another one held PhD and was a lecturer in the domain of information systems/technology (IS/T). The rest (three) held a bachelor bachelor’s degree and had been managing various HIT-related projects for at least 4 years and a maximum of 10 years. All these participants had experience in e-Health, telehealth or telemedicine experience (Ref to Appendix 1 for summary).

They included IT managers at public hospitals in Ghana, health information technology (HIT) project leaders and lecturers in biostatistics/health informatics (See Appendix 1 for details) involved in HIT-/e-Health-related projects.

A primary requirement for participation was knowledge and experience in HIT/e-Health. As a result, an initial search on the Internet for HIT/e-Health initiatives revealed which organizations in Ghana were in one way or the other were involved in e-Health-related projects from which qualified participants were invited. We also used the snowball sampling method given the unique requirements for participation. Interviews, which lasted between 55 min and 1 h, 20 min where all audio-recorded and later transcribed and thematically analyzed. Data collection/interviews took place in the natural setting of the study (hospitals) because qualitative methods seek to describe, explore and understand phenomena from the perspective of the individual participants [57]. Participants who had their own office opted to be interviewed in their offices, whereas those that shared office used other unoccupied office space within their working premises. The lead researcher and participants made advance appointments as per the availability of the respondents in most cases. The lead researcher began the interview with a clear understanding of the participants in terms of backgrounds and the number of years working in their current institutions.

In developing the interview guide, basic characteristics of both participants and of health information technology/e-Health were considered. This was followed by open-ended questions with topic guide and more specifically, the identified e-Health readiness assessment factors. Popular among approaches used for qualitative studies are interviews, participant and non-participant observation [58]. Deegan and Blomquist [59] contend that the best way to gather information in situations where little was known was to ask the relevant people directly, rather than to use other forms of secondary data. In asking the relevant people, however, as Pontin [60] cautioned, the interview guide/guide memoire be piloted first. As a result, the interview guide/guide memoire was first e-mailed to all prospective participants a week prior to the actual data collection/interviews sessions. This allowed the principal researcher to establish if the guide was clear, understandable and capable of answering the research questions, and whether any changes to the interview schedule were required. Follow-up e-mails and telephone calls were made to participants to seek any necessary discussion/clarifications on the interview guide/guide memoire sent earlier to them (Table 1).

Table 1.

Definition of key variables

Readiness assessment factor	Definition
Core readiness	Core readiness in this research study is defined as the identification of the need for HIT and establishing the necessary structures to successfully implement the relevant HIT technology.
Engagement readiness	The process of involving stakeholders in various planning/decision process in order to gain buy-ins
Technological readiness	Available affordable and sustainable physical information, communication & technology infrastructure
Regulatory and policy readiness	Availability of workable HIT/e-Health policies regulating the implementation and use of ICT tools for healthcare delivery
Change management readiness	The ability of organizations to successfully prepare and support individuals when introducing changes.

The University of Southern Queensland (USQ) requires ethical clearance granted for all researches involving humans and animals prior to the commencement of any data collection. Furthermore, participants would only agree to participate in research after the grant of ethics clearance from the university. For this research, ethical approvals were obtained from USQ Human and Ethics application committee granted approval for the project (H13REA149) as well as the Committee on Human Research, Publication and Ethics Komfo Anokye Teaching Hospital (CHRPE/AP/119/17), Ghana.

The study, together with a copies of the ethics [61] approvals, was submitted to and approved by top management/leadership such as Ministers, Chief Executive Officers, Directors and Founders of participating organizations where applicable/in the absence of any internal review boards (IRB) before interviewees could participate.

After data was analyzed, member checking was undertaken as a way of validating lessons learned from Ghana HIT/e-Health projects—factors impeding HIT adoption and factors promoting HIT adoption in public healthcare facilities (See Appendix 2 for identified factors).

Data Analysis

We adapted the guide suggested by Braun and Clarke [62] and O’Connor and Gibson [63] for qualitative data analysis. To analyze the data, the researchers developed categories out of the identified ideas and concepts at the beginning of the data analysis process to enter the abstraction process. For finding and organizing concepts, the researchers firstly focused on the primary message content from the various responses. Thematic analysis is a form of pattern recognition within the data, where emerging themes become the categories for analysis. Initially, the data were read and reread by all three authors to identify and index themes and categories: these mostly centred on phrases, incidents or types of behaviour. This phase, which re-focuses the analysis at the broader level of themes rather than codes, involved sorting the different codes into potential themes and collating all the relevant coded data extracts within the identified themes. To search the themes, the researchers essentially started by analyzing the codes and paid attention to how different codes may combine to form an over-arching theme.

Results of Thematic Analysis

Nine themes emerged from respondents’ remarks and they are presented below.

Core Readiness

e-Health Plan

Like any other initiative, participants unanimously agreed that before attempting to develop any HIT program, be it EMR, EHR and e-Prescription, it is inevitable for a healthcare organization to have a concise plan, which should be motivated by the vision of the hospital. However, implementing plans have been difficult.

“Somewhere in 2011 we saw the need to have an e-Health strategy and so it was done” R4.

“yes there are some plans … I’m sure most hospitals do have their own plans. Those plans must come from the national eHealth strategy”.

“Therefore, we for example, had three desired outcomes. 1. Data timeliness, that all operations are available in real time. 2. Data integrity, that the data available is accurate and reliable. 3. Data usage, if the data is accurate and reliable then you can use it for decision-making.” R3.

“…well, the implementations of these plans have been a bit of challenge”

It has been a slow progress; however, some healthcare institutions are executing their plans.

“Going forward, management then put in something we called health informatics unit as the beginning of the implementation of the strategic plans for the introduction of HIT. So, the informatics unit brought the biostatistics department, the IT, and Telecommunication together to form the health informatics. The idea was that telecommunication will create commination among departments; IT will deliver applications, which are needed, then the biostatics will now use it to collect data and analyse it for usage” R3.

The Implementation of HIT plans remained a challenge in Ghana due to limited funding and skilled health informaticians.

“The only difference is that it’s been extremely difficult to implement it because it comes with some commitment, some cost, and people are able to move around it and do one or two implementations especially when it favours some people” R4.

Needs Assessment

In planning for e-Health implementation, a needs assessment/identification of needs is the first critical step towards building an effective and sustainable HIT program. On this note, R13 asserts.

“…that plan must take care of the assessment of what we need. We have to make sure that out of the plan we are able to identify what services we want to deliver using the telemedicine or whatever technology it will be” R13.

A need assessment, while not a guarantee, can improve the success rate by helping in identifying and developing a value driven HIT program.

“…we have to make sure we get it right because we do not usually have enough funds” R7.

It appears from the data analyzed that the biggest challenge in the case of public hospitals in Ghana was the inability to conduct needs assessments effectively.

“…sometimes, my teams find it difficult to do proper elicitation. I mean gathering requirements information from end-users I think asking the right questions remains a challenge. Because of that in most cases, we end up with a lot of problems meeting their needs” R9.

“…you actually end up assuming especially when they do not speak much for you” R4.

When probed into what sort of “problems” they encounter, the respondent further elaborated “problems” as:

“because end-users end up not being clear about their requirements and eventually, conflicting requirements are gathered, and we have to change them in most cases”.

It be induced that there was a lack of skill set in requirement gathering—Asking the right questions remains a challenge for most IT personnel. As information requirement for most organizations complicate, it is yet to be seen how the evolving complexities of expanding systems would be understood without training and continue professional development.

Identification of Relevant Healthcare Services to Be Delivered Through e-Health Systems and Evidence of System Effectiveness Improve Justification and Planning for e-Health Implementation

This concept summarized findings from respondents who argued that in planning for any HIT technology, telemedicine, mHealth and other types of e-Health services, there was the need for the identification and selection of services that could best be improved with appropriate HIT systems.

“…for us to make good use of the little money allocated to IT, we make sure that we initiate programs that are most needed… I mean we have to look at the services that mHealth or telemedicine can best serve” R13.

“some of the projects were good for public health…the SMSs and mobile phone-based healthcare …” R2.

Many respondents agreed that there are strong evidence suggesting that HIT will be effective when a proper need assessment was conducted leading to a value driven HIT initiative. They referred to known projects including Sene PDA and MVP.

“…the telemedicine project by MVP is another successful project, which is in progress and is about to be scaled up to other districts outside Amansie West. Maternal and infant mortality in the district has seen a tremendous decline in recent years. So, it’s still ongoing” R3.

“All of those small-small projects symbolize the growth eHealth in the country…hopefully, we can expand on them as we are currently doing …they have been good and because they are not very invasive, a lot of the enrolled patients were ok with them” R5.

In the data, respondents were also cautious of not implying that the successful stories should be taken as basis for future implementation of similar or related projects. They were of the view that for every HIT there will also be the need for any needed assessment to be conducted.

Value Proposition

Data analyzed suggests that for HIT initiatives to be valuable, implementing team must ensure that HIT aligns with healthcare organizations’ mission/vision and be able to serve the designated client population, which in this study are healthcare providers and patients alike. Again, in initiating any HIT, the ability of the technology to enable reliable diagnosis to majority of healthcare consumers whiles reducing care cost was paramount. In this context, two respondents asserted:

“If you have a good HIT system in place, every single detail that is dealt with or about the patient in any hospital in this country could easily be requested/known anywhere. You realise that some come here in the morning until late and travelling from far. Maybe they could not find their files at first or sometimes they may not need to come here at all” R8.

“Our main goal is to reduce travelling while increasing access to healthcare for everyone. Imagine people travelling from the northern region to here [Kumasi]. Why not having their information sent to us including photos, X-rays and those stuff.” R12.

While these value propositions seem to be known, it was critical to understand the context in which some of the assertions were being made. Outside the office of the IT manager, a foyer at the ground floor laid patients and relatives. Some have come from far northern Ghana and not sure when they will be attended to. The effect of the “informal economy” R1 was present while exploring the issue of referral systems between tertiary or teaching, secondary and primary/community/polyclinics healthcare facilities. The underdeveloped nature of Ghana has grouped populace according to cultures, making cultural responsiveness an important element to be considered when getting ready for HIT implementation. On this note, respondents believed that the way people live was an important thing to consider as asserts R7:

“Some people have not been to hospital for most part of their lives. They believe in herbs and other traditional medicines. So, if you want to introduce them to these technologies, you have to take your time to educate them” R7.

“Naturally, a lot of patients want to personally see a doctor or healthcare provider and then they will feel they have been looked after” R 9.

Lack of HIT National Coordinating Office and Collaborations Difficulties

There are many disparate HIT projects in Ghana in partnership with the Ghana MOH and GHS. These projects, however, have no shared objectives with those of the MoH and GHS. As a result, many respondents spoke of the need for HIT national coordinating office. In this regard, R1 asserted that:

“People have attempted to introduce small, small systems to see how they work. May be all the lessons learned should be put together. There is pilot here, pilot there, pilot there a lot, a lot has been written. So, what have we learnt in all these? Is there anybody looking to put these together and see, synthesis it and see”? However, if there is a national coordinating office, which knows about all these projects that would have made a big difference, there is little collaboration” R1.

On the Issue of Lack of Collaboration Leading to Interoperability Issues R7 Asserts

“The other challenge is that the National Information Technology Agency (NITA) does not involve us as stakeholders in their projects and does not conduct need assessment with us. For instance, they are having a project whereby they wanted to create a data centre for the whole Ghana to link all government agencies. We were there when someone from NITA came with a letter from NITA to install a network device, so I sent him to the server room; he couldn’t because he did not know our network” R7.

A National HIT Coordinating Office Will Play an Important Role in Making Sure Related Projects Are Managed Well as Programs to Achieve Expected Outcomes

“Maybe we need an office that will actually be coordinating these things within the country and then seeing who is doing what; what are the results, what are the benefits; are they sustainable” R3.

The supposed national coordinating body, NITA, is only an implementing agency, but needs to do more to bring all related projects under its control so that lessons learned from various projects could be brought to bare for better development of relevant HIT projects and their implementations.

General lack of required HIT resources such as computers, Internet and enough bandwidth among rural healthcare facilities hindered collaborations among healthcare facilities especially those in rural areas, which limits the potential of e-Health systems–information exchange.

“We also even bear that in spite of even the rural-urban migration large proportion of our populace is still rural and the facilities are not that developed in these settings to really support e-Health.” R1.

“…most of those hospitals never even had computers before. The computers they had were used for secretarial purposes” R8.

“…large proportion of our populace is still rural, and the facilities are not that developed in these settings to really support e-Health. So, we must prepare them for these technologies” R1.

IT Governance

The starting point of governance in IT is the definition of an operational structure, which outlines roles and responsibilities of ongoing projects and those that are yet to start. That would involve taking into consideration interests of all stakeholders including the needs of relevant staff in order to come up with solutions that mirror everyone’s need such as

“To have proper implementation, people need to understand what we have, their role, the governance structure, people should be involved, you can’t bypass any group of people so there are issues with IT governance, because the framework is there” R4.

“Our core service is to serve the public by delivering quality healthcare as a hospital… we cannot do this if we only think of patient, neither can we do it if we only think of our staff… We can do this by looking at the big picture” R12.

In the data, risk of not accepting new systems was apparent. Given the newness of health information/e-Health systems, the challenge implementing an IT governance programs was not induced. This comes down the choice of a suitable IT governance framework such as COBIT and ITIL based on the needs of the hospital.

Promoting Change Management and Stakeholder Engagement

The following concepts were found to be relating to HIT change management and engagement.

Stakeholders Involvement in Selecting e-Health Systems/Technologies Promote Change

From the gathered data, one of the key findings was the need for stakeholders, particularly healthcare providers to be involved when it comes to deciding on which HIT technology will best serve the identified needs. Participants agreed that when stakeholders are involved in the selection process of the technology, it brings a sense of ownership and acceptance and above all support from leadership. Regarding this, R6 and R9 state:

“They took it away and came back with their recommendations/modification and we modified it…before signing for the user acceptance. Management must be convinced on the capabilities of the systems. You realize that during this period there have been a lot of change management because we have engaged them there is a lot of ownership and buy-ins from various leadership” R6.

“We don’t use the systems. Primarily, these systems are meant for them and we are only making sure that the systems are deployed and functioning. And so, we want to listen to them so we can help them” R9.

With the realization that HIT systems should be customer (providers and receivers)-centered, the question of whether consumers would be ready to pay for improved serves also was noticed.

“We do not only have to assess the kind of services that need to be delivered via e-Health, but also the need to find out if consumers will be in the position to pay for any additional fees when the needs arise. Maintaining systems and getting them functioning all the time is expensive…” R13.

The Need for Evidence of Past Successes with Instituting HIT-Related Initiatives

During the analysis of the data, respondents spoke of the influence of past successes as an important “plus” in any attempt in getting clinicians and non-clinicians alike to begin to hope that they can easily support the cause for any future systems. The delicate nature of the healthcare environment does warrant a high success rate with past HIT to assure providers that they will be not interrupted when such systems are deployed.

“…to be able to refer to some of our successes in the past will mean that there will be no fears with future projects” R2; “…the telemedicine project by MVP is another successful project, which is in progress and is about to be scaled up to other districts outside Amansie West” R3.

“…we need to make sure that we do not dwell so much on our past successes. Because, here in the hospital the situation is different and even the patients are also different. Patients in the rural small communities may be different from those in the cities. Also doctors in practicing in rural communities were more likely to accept most electronic health record as that may help them in reaching out to other doctors and preventing patients travelling to cities for referral purposes” R7.

Top Management Support and Availability of Change Leaders Promote Change Management

The impact of a lack of attention to change management can have devastating consequence on the outcome of HIT. It was evident in the data that change management did not receive attention from HIT implementers in Ghana.

“We don’t see change to be important when we are doing these things, but they do really affect us” R13.

… We did a pilot and at the end of the day we realized that… you see implementations in the advanced countries and here [Ghana] are not the same…so there were some lessons learned and that is one of the reasons why I think the change management is key but the availability of change leaders is even more important” R4.

“…you know they have a way of telling you that they are not interested in it because they will not use it even if it’s good…” R2.

“What we are doing now is to make sure we get representative among all the stakeholders we are working with. Even at the “Organization A” we do have someone we work with, at NITA we also we someone we can always talk to concerning our progress and next lines of actions” R8. Another reiterates, “At “HB”, I have this guy we invite to our meetings. In Takoradi, and all our sites, we have different people. Sometimes we use church leaders to promote our projects” R13.

Identification of Internal/External Champions to Promote the Implementation of HIT Systems

A reasonable portion of respondents underscored the need for champions who can go out there to interact with interest groups and individuals. They related that identification of champions for every HIT project was very crucial as preparatory measures towards successful implementation. Not only do HIT initiative champions seen as important for the successful implementation of the projects, but also play key roles where necessary in funding the projects.

“In most cases, our champions have been healthcare providers who already have relationship with majority of his/her communities” R4.

“NITA was our champion and sponsor for the Korle Bu-Wa-Zebila project. They provided some routers and some computers at some point” R3.

“Our advocates are a very good source of sponsorships especially when they are in decision-making positions”.

Availability of System Implementation Plan with Clear Anticipated Changes

One other important characteristic of change that emerged from the data was the need for HIT implementing leadership to ensure every information concerning systems being implemented were communicated well to all immediate stakeholders. These included clear timetables, anticipated outcomes and potential impact on current workflow/structure.

“What we actually did was to inform the doctors and the nurses when our teams come around, their names, what they will be helping them with and all that…” R5.

“A lot of them attend conferences so they are familiar with HITs but the problem here is whether our current infrastructure will allow the systems to work is what I think make them nervous” R9.

“How can you achieve e-Health when IT position is not in the grading of the staff?” R8.

Technology, System Implementation and Quality Assurance

ICT infrastructure in urban Ghana has improved over the last decades, thanks to reformed telecommunication industry in the early 1990s; but rural communities in Ghana were still lacking proper ICT infrastructure and other HIT fundamental resources.

“In the cities and big hospitals, I think there will not be problems because ICT infrastructure has improved or stabilized… but the outskirts and rural or remote communities still have problems with network or telecoms resources” R3.

Respondents also agreed that HIT implementation requires a blend of technology and management/planning in collaboration with stakeholders. They perceived that to successfully deploy any system, it was necessary to collaborate with stakeholders first.

“Their contribution was crucial for even technology selection and implementation” R5.

“…so they [contributed] how the implementation was going to be done.” R6.

Lessons were necessary if success was to be achieved with HIT system deployments in future. While participants agreed that most healthcare professionals were happy to participate in relevant user training sessions, they believe that there has to a structured training program.

“We train almost everyone who is concern with the system – doctors, nurses, cardiologist surgeon. I think we did a wrong deployment. If we did it in phase installation. If polyclinic, we train only them. But now we trained all of them, if they later forget who will be responsible”? R12.

According data gathered, the difficulty in implementing HIT remained a general challenge. In the data, the need for adept in HIT-related vendor technologies was evident. Majority of the participants agreed that technologies that can have technical modifications made to them to suit the needs of implementing hospitals were more relevant. An important consideration to be given when it comes to selecting technologies, according to participants, was how different systems can interface particularly new ones can be integrated and interfaced with legacy systems for the purpose of exchanging information. On this note, respondents 6, 10 and 12 relate:

“After collecting the data from the users, it was now time to gather information about relevant technologies, hardware and software because we were not developing it from scratch.” R12.

“…it just didn’t meet their requirement, in terms of information need, the quality of the service to be rendered, the integration into the DHIMS was not done. The workflow processes… meanwhile the whole hospital was built for complete automation…the workflow needs, integration/interoperability with other systems, clinical needs, which may be the workflow, because there is DHIMS and all of those were not considered” R6.

“Interoperability issues and those technical things have to be seriously considered” R10.

“…integrate into the surveillance. There is no real-time surveillance information coming up from the DHIMS previously” R6.

Lacking Skilled Health Informaticians Impede System Implementation Success

According to the data analyzed, perception of the shortage of skills seemed to be mixed. On the one hand, respondents appear to suggest that there are other reasons than the known one of “lack of trained personnel” in Ghana when it comes to IT.

“When it comes to human resource, the doctors and nurses are the preference. It is an element of priority. Ministry of Communication (MoC) came up with scheme of services for IT personnel but could not implement it” R6.

“The Ghana Health Services (GHS) for an example does not even have a structure for supporting IT personnel within their set up. It tells you the recognition that IT is given” R1.

“The GHS for an example doesn’t even have structure for supporting IT personnel within their set up. It tells you the recognition that IT is given. People may pay lip service but, on the ground, we seem to lack the capacity to support” R1.

“Inability to retain trained personnel due to employment quota. Financial clearance from the finance ministry, which only comes once in every 2 years and when it comes it’s just few.” R2.

“The project is such that we are recommending two persons and getting it through GHS isn’t easy.” R9.

HIT Policies and Practicing Regulations

The data gathered underscored the need for proper and reliable e-Health policy availability to serve as a guide for healthcare facilities intending to implement any electronic healthcare system. Participants blamed the lack of any e-Health policy document, which they understood was obstructing the ability of responsible agencies to conduct and coordinate the activities of various existing silos HIT-related projects in the country. Asked whether there was any policy document in any form, R6 dissented as with some other respondents.

“No, we don’t have policy. So, we need to have a national policy for each e-Health technology such mHealth, Telemedicine, etc…even if it not national driven, individual hospitals coming up with their own have to consider the national one”. R6.

“There are no sufficient policies for the various types of e-Health that we have. mHealth for instance that has not specific policy document but there are projects of mHealth going on in the country” R10.

“I also think they need to do this in knowing that policy, infrastructure and human resource (HR) are issues at the national level” R3.

While it was apparent in the data there was not e-Health policy, one respondent disagreed referring to the 2010/11 drafted national e-Health strategy document as the policy but acknowledged difficulty in implementation and operationalization of the said policy. Some aspects of the data seemed to be suggesting that individual healthcare facilities were more likely to have some form of organizational e-Health guiding policy for their use.

“Somewhere in 2011 we saw the need to have an e-Health policy and so it was done” R4.

“A number of them have gone paperless” R3.

Data Availability and Protection

One of the key reasons many public hospitals were going paperless was the need for quality and easily accessible data.

“Data timeliness, that all operations are available in real time. 2. Data integrity that the data is available is accurate and reliable. 3. Data usage, if the data is accurate and reliable then you can use it for decision-making” R2.

Another reason for most hospitals exploring the possibility of successfully implementing HIT was for the protection of patient information from unauthorized persons. A few of the participants spoke passionately about the lack of regard for patient information as many healthcare providers appear not concern about the integrity of patient data.

“If it is electronic, access levels will prevent unauthorised persons from accessing unwarranted patient information – on need to know basis. For instance, you are a laboratory technician. You need to work with samples, which are coded and not patient names. In health facilities, patients are to be referred to by their identity numbers. But what do we see here? Confidentiality is zero.” R8.

“Here in the hospital, there was an instance where a senior public officer’s health information was leaked to the media… I mean how”? R3.

Lack of HIT Funding and Reimbursement for Services

The data collected appear to be explaining the issue of finance in a more subtle paradigm. It was clear in the data that the lack of finance was not fully responsible for low HIT adoption in Ghana, although a small proportion of the participants agreed availability of funding was inevitable if e-Health initiatives were to sustain. Majority of the participants contend that the problem was more of share lack of recognition for the potential of IT to improve healthcare delivery by various ranks of leadership, corruption and misplaced priorities by politicians as some respondents relate:

“Is not about funding. Because people are always attracted to things that work. They are able to source funding for things that work and even chase you with the funding”. R1.

“If they will not get their share, they will work hard at it [funding]” R13.

“They know how to get it, but I think there is simply no commitment to projects of this sort” R3.

When explored further concerning “things that work”, the respondent explained further that most people in authority especially top government officials lack the understanding of the context of using ICT to improve healthcare delivery. The explanation relates back to the concept of the need for key knowledgeable people as an important ingredient in promoting a wider adoption of HIT among public healthcare institutions in Ghana.

“Once you don’t get the leaderships of every facility to understand the need to use technology to drive or prove to the person that in the long run… they might be looking at immediate benefits, which you will not see once you don’t get the people to understand then releasing basic funds…” R4.

“But leaders of these projects must also be able to demonstrate that they are aware of the ongoing cost which can be contained”. R1.

Discussion

The description of a strategic plan by the respondents appears to imply that it is an “approach that helps people make informed and justifiable decisions that accomplish desired results” [64]. The importance of HIT strategic plan is tied to its ability to execute and yield the needed outcomes. In the data, it was evident that most public hospitals in Ghana were gearing towards the adoption of some form HIT and preparations were underway. The ultimate goal of IT strategic planning was to provide a broad and stable vision of how IT contributes to the long-term success of the organization [65]. However, for the strategic plans to be put to action and potential contributions of HIT to manifest, there would have to be an important organizational cultural and mindset shifts among top non-IT-oriented management in how IT is perceived in the healthcare environment in Ghana.

To achieve targeted goals in strategic plans, as found in this study, a needs assessment was necessary in determining the type of health services to deliver using HIT and systems needed. It is essential for proposed HIT systems to meet some fundamental needs that satisfy relevant stakeholders including but not limited to being user-friendly and beneficial to care providers and care consumers alike, beneficial to host organization such as cost effective and interoperable with legacy systems [66]. These functionalities of the system will not only help achieve set targets, but also cement the evidence of HIT effectiveness for future references. With the help of a national coordinating HIT office, information about relevant HIT programs can be made available to assist in future decision making about HIT adoption. Like in the advance countries, the Office of the National Information Technology Agency (NITA) in Ghana according to this study is expected to lead the strategy to increase electronic access to health information, support the development of tools that enable people to take action with that information and shift attitudes related to the traditional roles of patients and providers [67]. A comprehensive needs assessment including special health characteristics and needs of the population [68, 69] will involve a combination of methods that allow the organization to “see the full picture” while employing multiple approaches to form a valid and reliable assessment becomes fundamental [52]. The analysis suggested respondents’ strong opinions on the need for individual healthcare services to be given the necessary consideration and consultations with relevant stakeholders to verify the value, which will be driving that program.

From the perspective of IT managers, this will help provide some form of impetus among top management in a form of assurance towards achieving set targets.

The issue of knowledgeable individuals and groups was also present in the study as an important ingredient of planning. It is understood that assurance of the availability of key knowledgeable personnel was necessary should any HIT initiative be sustainable. However, recognition of IT as integral to improving healthcare delivery services was crucial to enticing the required skills. In the analysis of the data, majority of respondents compared their ranks with those of their counterparts in non-health sectors such as banking, where IT departments are integral to the banking and finance industry.

IT governance has emerged as a fundamental business imperative, and rightfully so, because it is key to realizing IT business value [70]. In the healthcare environment in Ghana and perhaps most developing countries, IT has not attained a recognizable status. A few top executives made decisions, which subordinates did not questioned, and boards rubber-stamped decisions [71]. This was evident in the responses from respondents. IT managers could not attend heads of departments meetings. Effectively, they did not have any decision-making right. IT governance provides a framework for judicious IT investment in an organization [70, 72]. The absence of IT managers in the ranks of the chiefs (C) level impedes the abilities of IT departments to make any effective or meaningful decision. The application of Information Technology Governance (ITG) was motivated by the private sector in the 1990s, as a way to achieve excellence, provide new services and increase profitability of IT investments [73]. A governance cycle defines who has a decision right (the right and responsibility to make a decision) and an input right (the right to provide input to a decision but not make the decision) [71]. As found in the analysis, IT managers in the healthcare domain appear to not have much decision-making right.

Guided by project planning and change management, core activities of the pre-implementation phase focus on communication and end-user involvement in workflow redesign and testing [74]. In exploring what respondents understood to constitute effective engagement as applicable to this present study, findings suggest that engagement was more about creating awareness among stakeholders in order to gain buy-ins or acceptance for the HIT initiative under consideration. Firstly, a large proportion of the respondents believes involving stakeholders from the preliminary stages of the project and feedback taken for consideration can lead to a wider acceptance by sponsors and end-users (healthcare providers and healthcare consumers) respectively. Secondly, the study results also found that the identification of potential collaborating healthcare facilities as well as internal and external champions was more likely to be achieved in the process of engaging stakeholders. Although additional research in this field is needed, findings from this study indicate that majority of providers support using health information technology to share patient information with each other to improve patient care, most healthcare providers; however, still view the “full time” computerized entry of patient information as burdensome. Experience tell us that a successful e-Health system is dependent on the confidence of its stakeholders [75]. The implication of such perception amounts to HIT project failures. In the data gathered and during analysis, majority of the respondents contend that medical and nursing students should be introduced to health informatics courses at some stage in their schooling/training years to familiarize themselves with the systems before they begin their practice.

This study not only confirms the importance of past performance as a predictor of future performance [76], it also reveals the importance of the influence of past successes with HIT-related initiatives on the ability of available change leaders and multi-layer change teams to successfully sell concepts of HIT initiatives to target stakeholder. These findings have important practical implications.

Additionally, what became apparent in this study was that, for HIT to be institutionalized in public healthcare space in Ghana, the type of HIT, the implementation and quality assurance all need to be investigated to assure the continuous availability of systems for use. This was due to the fact that in this study, technology infrastructure (hardware and software), network facilities necessary for developing and operating HIT system successfully were found to be lacking in the rural communities of Ghana [77]. Due to poor economic and communication infrastructure, most e-Health are limited to national and provincial/regional levels leaving behind majority of health workers living in remote/rural areas [78] even though there are some mHealth projects such as the World Vision’s nation-wide mHealth project for the Ghana Community Health Workers Program. This predicament of technology infrastructure presents challenges to collaborations between/among healthcare facilities participating in HIT technologies.

Furthermore, in the analysis of the data collected, there existed evidence to suggest that the successes of HIT also are also tied to their flexibility for technical modification to allow integration into existing systems such the HAMS at KATH and the nation-wide District Health Information Management Systems (DHIMS). In other words, HIT systems must be able to adequately interface with other IT systems and exchange information [79], an important feature that promote acceptance and use.

The problem of skills shortage in HIT is a known one [77, 80, 81] as with the evolvement of HIT in developing countries. However, information technology is well known in developing countries and all HIT advancements seem to be fundamentally emanating from the conventional IC/T. From a very novice point of view, anyone with a good IT background ranging from programming to networking should be able to handle HIT problems. The healthcare industry is very different from other industries because of the intensity of the personal interactions [82]. This different nature of healthcare has brought about the fear of shortage of skills/workforce to handle IT in the healthcare industry. While this seems to be the issue across the globe, it appears to be more acute in developing countries, where incorporating meaningful capacity development including training, networking and resource sharing could be good starts for skills development [83].

The findings from this study suggest further that a lack of understanding and recognition of the potential of IT to help improve healthcare delivery services by leadership in health-related organizations has led to a poor employment structure for IT personnel and retainment, effectively not attracting highly skilled IT personnel compared with other industries such as the banking and manufacturing. Information gathered from this for this study blame the lack of highly skilled IT personnel in the healthcare environment on poor remuneration.

Again, the lack of a proper and reliable policy document was evident in the responses respondents provided. Despite their promise, till date, there exist many legal and ethical questions that need to be addressed to make way for the widespread adoption of HIT in many countries [84] of which Ghana is no exception. These dilemmas have undermined the ability of accountable agencies in Ghana to coordinate the activities of many silo HIT initiatives currently on-going in various parts of Ghana.

The HITs such as electronic health record (EHR) that enable health information to be shared electronically, offer considerable promise for monitoring and responding to individuals’ health behaviour in real time. However, it does also pose risk to the abuse and disclosure of patient health information (PHI) to third parties such as insurance companies and interested organizations [85] proper authorization especially in societies where relevant attention is not paid to the privacy nature of patients’ information. In Ghana, the Electronic Communication Act, 2008 (Act 775) Section 4(2) limits access to electronic personal information of the customers of the communications industry. The problem, though, according to data gathered for this study, is the lack of knowledge in patient information legislations and application of ethics by healthcare providers that posed the highest risk to the deployment HIT in the context HIT regulatory and policy.

The issue of funding for HIT initiatives continue to dominate in both the first and the third world countries respectively. In developing countries, for a long time now, the lack of funding has bore the brand of the blame for the low HIT implementation rate. While it remains a barrier, the findings from this study appear to suggest that it was more of a lack of recognition for IT in the public healthcare environment, corruption, bad leadership and misplaced priorities by people with power.

For lessons learned from cases of Ghana, throughout this study, it was clear that there were factors that promote HIT adoption in Ghana and those, which impede HIT adoption respectively as can be referred to in Appendix 2. Given that factors capable of impeding HIT adoption in Ghana were more than those promoting, it implies that a lot more was needed to be done in order to realize a wider and successful adoption of HIT in public healthcare facilities in Ghana as may be the case in other developing countries. The findings from this study, see Appendix 2, were consistent with those of similar studies in other developing countries. These include but were not limited to lack of adequate infrastructure; lack of national-level e-Health strategy to achieve sustainable implementations; uncertainty with respect to privacy and security; the difficulties in achieving seamless system integration and interoperability; the need for a trained workforce in health informatics and existing initiatives for its development; and strategies to achieve regional integration [81, 86–90].

Conclusion

In this study, the findings from the in-depth interviews have been presented. They include detailed analysis of the raw data; the experiences and views of participants gathered from the one-on-one interviews and analysis have led to the identification of key concepts/codes and building of over-arching themes as readiness assessment factors. These factors are Core readiness, Organizational cultural readiness, Value proposition readiness, Technological readiness, Operational readiness and HIT/e-Health regulatory and policy readiness. The analyses have also led to the identification of factors (aspects of identified over-arching themes) promoting HIT adoption in public healthcare facilities in Ghana as well as those impeding the implementation of HIT in public healthcare organizations. Factors found to be promoting e-Health adoption include evaluation of existing e-Health initiatives, clear business cases and stakeholder involvement. Effectively, the results of this study also suggest that issues of e-Health regulatory policies, lack of technical know-how, poorly resourced rural healthcare facilities/low ICT infrastructure and corruption remain barriers to e-Health/HIT adoption and institutionalization (see Appendix 2). It can therefore be concluded that while it is possible to apply existing HIT readiness assessment factors to differing circumstances, the results of this study suggest further context-specific modification of the existing factors may be needed with reliable attributes for rigorous assessment.

Appendices

Appendix 1.

Sample for qualitative data collection

Distribution of sample		No. invited	No. participated
1	Project leaders/Managers	2	2
2	Head of IT	1	1
3	Head of IT, Head of applications and Director General	3	1
4	Coordinator	1	1
5	HIT coordinator	1	1
6	Head of IT, Administrative Manager	2	2
7	lecturers	3	1
8	Director of information management	1	1
9	Head of IT, Senior Admin officer	2	1
10	Head of IT, Senior Admin officer	2	2
Total		18	13

Appendix 2.

Summary of factors promoting and impeding HIT adoption in Ghana

No	Factors promoting HIT adoption in public hospitals in Ghana	No	Factors impeding HIT adoption in public hospitals in Ghana
1	Evaluation of existing projects	1	Lack of evidence of proper functionality of deployed HIT
3	Information about existing HIT initiatives/ Data collection on various HIT projects	2	Lack of funds
4	Lessons learned	3	Lack of lack national standards for HIT
5	Identification of need for HIT services	4	Lack of understanding of the potentials of ICT in healthcare context
6	Clear business cases	5	Lack of recognition of potential of HIT
7	Review of existing policies	6	Lack of leadership
8	Cohesion of existing HIT projects	7	Outdated ICT policies
9	Stakeholder involvement	8	Gaps between HIT plans and practical implementation
10	Strategic planning/ HIT strategies with specified goals/objectives	9	Lack of IT directorate in the healthcare environment
11	Collaboration with relevant agencies	10	Lack of large-scale HIT implementation experience
12	HIT national standards	11	Lack of coordination at national level
13	Establishments of ministerial and technical ICT/IT committees by national health departments in partnership with relevant agencies	12	Lack of experienced workforce
14	Potential for locally/need driven HIT initiatives	13	Lack of IT governance
15	Workforce/Resource availability	14	Corruption
16	Development of telecommunication infrastructure	15	Low- ranked IT positions in healthcare environment
17	Accreditation of HIT sites/partner healthcare facilities	16	Lack of awareness/Cyber phobia among the older and low-level healthcare cadres
18	Change management in health training institutions	17	Misconception about use of computers among low cadre healthcare providers
20	Creation of awareness	18	Lack of IT training in healthcare training institutions
21	Marketing of IT adoption initiative through formal strategic document	19	Lack of understanding of HIT systems
22	Training of end-users	20	ICT not represented at top level in healthcare environment in Ghana (developing countries)
23	Imbedding HIT/IT into medical/nursing curriculum	21	Lack of IT infrastructure for IT personnel by Ministry of health
		21	Easy abandonment of systems by care providers/end-users
		22	Workflow conflict/disagreement
		23	System integration difficulties
		24	Issues of legacy systems
		25	Software continual upgrade and maintenance
		26	Informal economy
		27	Lack of ICT infrastructure in rural areas
		28	Ill-equipped rural healthcare facilities impeding collaboration
		28	Lack of collaboration with agreed/accredited healthcare facilities
		29	Lack of respect for patient information

Compliance with Ethical Standards

For this research, ethical approvals were obtained from USQ Human and Ethics application committee granted approval for the project (H13REA149) as well as the Committee on Human Research, Publication and Ethics Komfo Anokye Teaching Hospital (CHRPE/AP/119/17), Ghana.

Conflict of Interest

The authors declare that they have no conflict of interest.