E-Health Implementation Challenges in Iranian Medical Centers: A Qualitative Study in Iran

Abstract

Background: E-health encompasses a wide scope and has excellent potential to grow in the future. Growing numbers of experts believe that e-health will fuel the next breakthroughs in health system improvements throughout the world. There is frequent evidence that largely indicates failures or unsustainable e-health implementations in different countries for different reasons. Iran is also a developing country that is presently applying this promising technology for its traditional healthcare delivery. Materials and Methods: Two phases of research have been carried out for this study. In the first phase, a general Internet search was performed in different databases to extract e-health implementation activities in the world, particularly in Iran. MEDLINE and laboratory research were used for this purpose, using the key words “information technology,” “e-health,” “health IT,” “health informatics,” “health,” and “Iran.” In the second phase, a panel of experts from Isfahan, Iran, who specialized in e-health applications, was selected for a qualitative survey. Results: Efficient administration of e-health implementation improves the quality of healthcare, reduces costs and medical errors, and enables transfer of healthcare resources to rural areas, among other benefits. However, there are numerous issues affecting the successful implementation of e-health such as lack of standardized e-health applications, deployment costs, training costs, legal challenges, privacy and security fears, implementation and acceptance time of such applications, technical difficulties, educational issues, resistance to change, and pilot projects or small implementations with limited numbers of patients in healthcare organizations. Conclusions: The implementation of e-health in Iran, particularly Isfahan, is subject to similar challenges as in other countries throughout the world. Hence, e-health implementers need to adhere to the proposed solutions in order to overcome the mentioned challenges in such complex projects.

Introduction

Computerization of medical information was introduced about 30 years ago¹ under different names such as electronic medical records, health informatics, health information systems, health information technologies, or medical informatics, emphasizing the intersection of several fields including information science, computer science, healthcare, and business. Hereafter, all of these terms will be called e-health. It is considered as a type of service in quality improvement² aiming to improve the efficiency and effectiveness of healthcare delivery.³ As yet, there is no universal definition for e-health,^4,5 but one of the most comprehensive definitions refers to e-health as the cost-effective and secure use of information and communications technology (ICT) in support of health and health-related fields, including healthcare services, health surveillance, health literature, and health education, knowledge, and research.⁶

The progressive usage of e-health brings a wide range of benefits that this promising technology delivers to healthcare, which can be categorized into six different areas: clinical, economic, organizational, patient-related, professional, and technical issues.⁷ These areas can be divided into more detailed motivation drivers, like operational cost reduction, business process rationalization, fraud prevention, online authorization, data availability, high visibility of the projects to citizens, health service coordination, and citizen's privacy protection.⁸

In spite of promising advantages of e-health, it is the least developed e-technology⁹ compared with other fields such as e-commerce and e-banking. The main challenges of a successful and sustainable e-health initiative in almost all countries can be classified into categories of (1) political, social, and organizational, (2) technical, and (3) semantic-level challenge.¹⁰ There is evidence that largely points to failures or unsustainable e-health implementations in both cases and countries^11,12 with different reasons such as lack of standardization of e-health applications,¹³ cost of such systems,^14,15 training costs,¹⁵ and the diversity of platforms resulting in technical difficulties.^16,17

However, e-health in Iran dates back to when medical laboratories started to autoanalyze medical kits and print out the results for the patients. Then 5.25-inch floppy disks were the most common storage devices in healthcare offices. Later, in the mid-1990s, the first domestic software packages covering from patient registration until discharge were developed and used in several hospitals. At the end of the1990s, the Social Security Organization started to equip its own medical centers with informatics equipment and also HL7 as well as Electronic Data Interchange For Administration, Commerce and Transport standards introduced to Iranian healthcare sectors. In the decade of the 2000s, several different plans were initiated, including open source standard customization based on Iranian healthcare domestic needs, the strategic plan of the National Health ICT agency (locally it is named the TAKFAB plan), development and distribution of a specific software application for cancer records in the hospitals, and finally pharmacies' mechanization.

In this decade also some pilot and small-scale e-health projects were initiated, and the ICD-10 standard was introduced to hospitals to record patients' information. Iranian hospitals were equipped with hardware and communication infrastructure, and hospital information systems were being used. The latest efforts in this area in Iran by the Ministry of Health and Medical Education are electronic health records (EHRs) definition clarification, integration of several different hospitals with different hospital information systems together, and development of the SEPAS (meaning “thanks”) plan, which is a long-term plan to gather and record health-related information of all citizens but still is in the initial stage.

Nevertheless, the main aim of this article is to clarify those challenges associated with e-health implementation in medical cares in Iran based on the example of Isfahan, as one of the most advanced medical cities in Iran, and provide some solutions to mitigate them.

Research Setting and Methods

This section describes the research setting and research method adopted. At first, using a MEDLINE and laboratory search with the key words “information technology,” “e-health,” “health IT,” “health informatics,” and “health,” a general Internet search was done in the different databases, including IEEE, Emerald, Scopus, Springer, Elsevier, Engineering Village, and some other repositories. Later the same terms plus the term “Iran” applied in those mentioned databases were used to extract e-health-related activities in Iran. The aim of this article is to identify the definition and coverage of e-health, successful experiences of e-health implementations and reported projects' failures, and challenges faced during e-health implementation as well as the e-health situation in Iran, but rarely were results obtained, particularly for the last part.

Later, during the second effort as the execution phase, a panel of experts who have experiences in the area of e-health applications implementation and are active in the zone of Isfahan City were enlisted to approach the topic of e-health with medical staff and organizations selected using convenient sampling. The 15 professional experts, engaged on several different e-health implementation projects and with different backgrounds such as physicians, medical managers, health information technology staff and informatics academics, and healthcare system designers, contributed to this research with several interview sessions. The process of selection of experts from the beginning continued until the obtained information was saturated.

Having enough information within the first phase allowed preparation of in-depth semistructured questions to ask during interview sessions. The meeting sessions lasted between 57 min to 118 min and took place from April until May 2011.

The Collaizi method was used to analyze data obtained in the form of content analysis, and subject coding was applied. The main aims were to investigate associated challenges of e-health implementation in medical organizations such as hospitals as well as their solutions to overcome those mentioned challenges. For example, whether and which negative factors were affecting e-health implementation, how the project managers acted, and what were the lessons learned/solutions within the Iranian context were asked.

Definition and Coverage of e-Health

Because the e-health topic covers a broad area, including giving and managing healthcare, “there is no unique definition for it.”⁴ For example, Eng¹⁸ has defined e-health as “the use of emerging information and communications technology, especially the Internet, to improve or enable health and healthcare.” Denise¹⁹ describes “e-health as the application of ICT across a whole range of functions that affect the healthcare industry when it comes to matters relating to health through the various solutions that exist.” The World Health Organization later defined e-health as “leveraging of the ICT to connect provider and patients and governments; to educate and inform healthcare professionals, managers and consumers; to stimulate innovation in care delivery and health system management; and to improve our healthcare system,”²⁰ and, recently, e-health only from a technical point of view has been defined as “a concerted effort undertaken by leaders in healthcare and high-tech industries to fully harness the benefits available through convergence of the Internet and healthcare,”^21,22 emphasizing the versatile objective of e-health.

However, e-health itself covers a wide range of information systems in healthcare, including a patient's electronic medical records, payment and billing information (e-payment, e-billing), employees and hospital information, e-prescription and e-record logs,²³ innovations in healthcare and healthcare delivery, health education, and distribution of health-related information, etc. It can be claimed that using e-health to its full potential manages all operational day-to-day activities and decision and management support systems, infrastructure and communication equipment, mobile e-health telemedicine, and other associated activities. Meanwhile, e-health is also known by other names such as health informatics, health information systems, health information technologies, telehealth (which is an expansion of telemedicine), and medical informatics, emphasizing the intersection of several fields including information science, computer science, healthcare, and business, but it suffers from lack of consensus agreement on its content and coverage due to lack of unique definition for it.

Opportunities in and Challenges of e-Health

E-health covers a wide scope and has excellent potential to grow in the future. E-health has this potential to collect patients' information, to exchange it for diagnostic purposes, and even to support some sorts of clinical decisions.⁹ It also has the potential to support data collection and access to transactions between several parties including patients' healthcare providers, healthcare professionals, policy makers, and law legislators.⁹ As the Information Technology Advisory Committee²⁴ has stated, “fragmented and inaccessible clinical information affects negatively on the cost and quality of healthcare and IT [information technology] could be an essential tool to improve and promote better healthcare in future.” In addition, Bangert and Doktor²⁵ have articulated that “e-health can ground enhanced patient access to better healthcare, reduced total healthcare costs and, as a consequence of easy access to the most appropriate specialist expertise, higher overall quality of the healthcare delivered.” Dzenowagis²⁶ stated, “technological developments in the health sector have brought new relationships between consumers and providers and also between consumers and suppliers.” Fitzgerald et al.⁷ also have categorized e-health benefits to six different areas: clinical, economic, organizational, patient-related, professional, and technical issues. Finally, Peng⁸ has listed economic and political drivers of motivation for e-health programs, like operation cost reduction via streamlining of administration efforts, business process rationalization, and secure information exchange and prescription and claim management. Also, prevention of fraud via electronic identification, online authorization, and visual security comply with well-managed healthcare services to protect human capital via emergency data availability, high visibility of the projects to citizens, improving services to citizens, coordinating health services, and protecting citizens' privacy. As a whole, the most important factors to deploy information technology to healthcare are to acquire efficiencies in the delivery and administration of healthcare,^13,23,27 improve the quality of healthcare,^{17,23,28

–31} cost reduction,^{13,17,22,23,29,32,33} reduction of medical errors,^23,32,34 providing healthcare resources to rural areas,^23,29,35 ethical improvement through privacy issues,²¹ education and e-learning,²¹ equity of healthcare,^28,36 patients and their families' awareness,^30,31,37 integration of enterprise-wide systems,²⁹ time and workflow efficiencies,^38,39 and allowing data mining techniques on information to predict risks and measure medical care against benchmarks.⁴⁰ For example, comparison of different factors affecting a particular disease using data mining administrative functions on a huge amount of data in databases that manually takes long time or even seems impossible and video broadcasts of surgeries are some exemplar advantages of potential benefits of e-health. Finally it should be noted that the term e-health is known by 10 famous Es, namely, (1) efficiency, (2) enhancing quality of care, (3) evidence-based, (4) empowerment of consumers and patients, (5) encouragement, (6) education, (7) enabling information exchange, (8) extending the scope of healthcare, (9) ethics, and (10) equity.⁴¹

In spite of many expected advantages of e-health, it has not fulfilled those mentioned expectations, which Varshney²³ believed is mainly because of financial and technological issues. According to Jordan et al.,¹⁰ the main challenges blocking broad, successful, and sustainable e-health in almost all countries can be classified by political, social, and organizational challenges and technical and semantic-level challenge categories. Fitzgerald et al.⁷ also have categorized e-health barriers in different areas such as clinical, economic, organizational, patient-related, professional, and technical issues. The main reasons of these challenges can be traced to these facts that healthcare organizations are (1) much larger than single-organization systems, (2) technically more heterogeneous, and (3) organizationally more complex because of many actors. Often, no single actor is in control, leading to long processes of power struggles, compromises, and complex coordination.⁴² However, the findings so far largely point to failures or unsustainable e-health implementation,^11,12 by which they have categorized in Table 1.

Table 1.

The Cited Challenges for e-Health Implementation Projects in Some Countries

REASONS	REFERENCES
Lack of standardization of e-health applications	Lorenzi et al.¹³ (2009)
Cost of such systems	Ferreira et al.¹⁴ (2008)
	Richards et al.¹⁵ (2005)
	Sprague⁴³ (2004)
	Miller and Sim⁴⁴ (2004)
Training cost	Richards et al.¹⁵ (2005)
Legal challenges	Ball and Lillis³² (2001)
Privacy and security fears	Griener⁴⁵ (2005)
	Swartz³⁰ (2004)
Implementation and acceptance time	Richards et al.¹⁵ (2005)
	MacKinnon and Wasserman²⁹ (2009)
Technical difficulties	Ammenwerth et al.¹⁶ (2003)
	Aoki et al.¹⁷ (2003)
	Ball and Lillis³² (2001)
Educational issues	Sprague⁴³ (2004)
	Miller and Sim⁴⁴ (2004)
Resistance to change	Lorenzi et al.¹³ (2009)
	Walker and Whetton⁴⁶ (2002)
Pilot projects or small implementations with limited numbers of patients	Hebert and Korabek⁴⁷ (2004)
	Barlow et al.⁴⁸ (2003)

Qualitative Interviews of Experts

As stated before, e-health is a cost-effective and secure use of ICT in support of health and health-related fields but facing several challenges during its implementation in healthcare organizations. The advantage of the selection of different professional experts with different backgrounds was a multidimensional viewpoint toward e-health implementation challenges in Iran. For example, physicians mainly look at users' perceptions of such challenges as lack of users' training, weakness of the relationship between doctors and patients, limitation of digital signature, unsuitable data entry format, and noneffective services for data retrieval and editing in e-health applications. On the other hand, medical center managers have mostly emphasized issues such as cost of e-health systems, lack of financial support for e-health applications implementation, lack of common language between designers and users, users' resistance, legal restrictions, and lack of readiness for data interchange among organizations. Moreover, health information technology staff, informatics academics, and healthcare system designer experts have stressed a wide range of challenges from financial issues to technical issues, including the cost of software and hardware, electronic data interchange standards' constraints, users' restrictions, infrastructural shortages (i.e., as communication speed), lack of proper data entry management in different health centers, no possibility of accessing EHRs by external bodies such as insurance companies or judicial courts, and finally no integrity of medical data for every citizen and between medical centers.

Having previous information about e-health implementation in different reports within different countries enables comparison of them with experts' claims in Iranian medical care centers as shown in Table 2. Moreover, the advantage of applying a qualitative approach for this study allows collection of manifested cases, applied approaches, and propositions for every case.

Table 2

Comparison of e-Health Implementation Challenges in Other Countries with Iranian Cases

IN OTHER COUNTRIES	SITUATION IN IRAN	HOW MANIFESTED (IN IRAN)	HOW APPROACHED (IN IRAN)	WHAT IS PROPOSITION (IN IRAN)
Lack of standardization of e-health applications	✓	Multiple data formats	Local agreements to use same data format	Nationwide data format/standard
Cost of such systems	✓	Huge demand for hardware, software, and maintenance	Government support	Centralized policies to mitigate overlap and duplicate costs
Training cost	✓	Workshop, etc., training costs	In-house trainings	Extension of e-health courses at the medical universities
Legal challenges	✓	Rejection of acceptance e-documents and e-evidences in judicial courts	Not solved, yet	Legal agreement between the judiciary and Ministry of Health and Medical Education
Privacy and security fears	^*	Offline systems	Acceptance for the moment	Applying appropriate firewalls and antiviruses
Implementation and acceptance time	✓	Management queries, concerns, etc.	Top management meetings	Issue of instructions, enforcing, and awards
Technical difficulties	✓	Network down, server down, etc.	Back-up services and firefighting	Business continuity management instructions' adoption
Educational issues	✓	Different shifts of nurses	Different learning sessions	Different learning sessions and brochure publication
Resistance to change	✓	Resistance of nurses, medical staff, etc., to follow new rules and instructions	Punishment and enforcement	Education and awareness of potential benefits of such applications
Pilot projects or small implementations with limited numbers of patients	^*	Large-scale implementation in hospitals	—	—

A checkmark (✓) indicates fully claimed, an asterisk (^*) indicates partially claimed, and a dash (—) indicates not claimed.

These results show that the reported issues and constraints of e-health implementation systems in Iran are almost the same as in other cases in the world. Beside lack of proper attention to the security and privacy issue due to existence of offline e-health applications and also the use of operational enterprise hospital information systems instead of pilot e-health applications in medical organizations, the remaining challenges were mentioned during interview sessions. The financial, technical, security, and social aspects and interchangeability of data are crucial success factors for the team of e-health implementers, and they have to find applicable approaches to overcome such challenges; otherwise, their efforts would be unproductive.

The professional interviewees also according to their experiences and roles within different e-health implementation projects proposed some solutions to mitigate or remove those barriers mentioned to implement e-health applications in medical care organizations. Their propositions can be categorized based on five general sorts of challenges associated with implementations of such applications as follows:

1. Information technology barriers such as improper communication and hardware technology are one of the problems. With respect to the experts' ideas, this issue can be handled using more advanced data transmission technologies to transmit different types of data including video and voice data with wired and wireless technologies, enterprise database applications for huge data management and mining techniques, and more agile and well-known software development methodologies for in-house application developments, as the traditional methods cannot support such complex environments.

2. The legal and privacy violations barrier is another challenge during e-health implementation. The judicial courts still do not accept electronic evidence, and confidentiality of medical cases is very important for the Ministry of Health and Medical Education in Iran. However, applying security methods such as multilevel user access to the available data and limited access time to medical and financial records as well as amendment of imposed law in this area are some solutions to overcome this challenge.

3. The third barrier is the lack of an agreed interchange standard among different healthcare organizations and lack of comprehensive connection between different parties such as medical laboratories, insurance companies, etc. This barrier can be handled using a proper definition of EHR for different medical care centers such as medical laboratories, pharmacies, and insurance companies, and they can be encouraged or it can be enforced that they must participate and collaborate to interchange data. There are still many cases in which the patients have to bring their medical laboratory or image result to another place so that the medical staffs will check and take proper action, which is costly and time-consuming. Initially this problem also stems from the fact that there is not a proper and a mutual standard for medical data exchange, although several different frameworks such as SNOMED, DICOM, LOINC, and HL7 have been proposed.

4. Cultural resistance is another barrier that bothers implementers' teams. There are professional medical experts in healthcare centers whose existence is very important for that particular healthcare center, or nurses who simply do not enter required data for every patient. Such issues can be mitigated using preimplementation plans such as public and special training courses within limited times, distribution of brochures and manuals, and finally users' motivation and probably punishment solutions.

5. The last gap goes back to those implemented e-health applications that do not handle healthcare center requirements because of misunderstanding of their needs and constraints. The implementation team has to meet with the medical authorities before any effort in this area and engage them to collaborate and support their new electronic solutions. Even so, some champions from inside of the organization are needed to provide required data and manage any social and technical conflicts during system analysis, design, development, and implementation. Bearing in mind that top management plays a vital role on successful implementation of such a complex system, several different stakeholders can have an effect on the e-health implementation process and even lead it to failure. Top management also is able to manage financial supports for such e-health applications, which are almost guaranteed to be expensive. If the management board perceives the need for such applications to enhance their operational and administrative activities, they would definitely support the project, and they can successfully achieve their expected objectives.

Conclusions and Future Work

As stated previously, e-health has excellent potential to grow in the future as it will fuel breakthroughs through improvement of efficiency and effectiveness of healthcare delivery in medical sectors. Despite the advantages of e-health applications such as enhanced patient access to better healthcare, reduced total healthcare costs, and higher overall quality of healthcare delivery in different areas such as clinical, economic, organizational, patient-related, professional, technical issues, etc., e-health remains the least developed e-technology compared with other e-technologies because of several challenges. Nevertheless, the challenges of e-health implementation projects are primarily lack of standardization of e-health applications, the cost of such systems, training costs, legal challenges, privacy and security fears, implementation and acceptance time, technical difficulties, educational issues, and resistance to change, as well as pilot projects or small implementations with limited numbers of patients in the healthcare centers. Iran is a developing country that has national plans such as TAKFAB and SEPAS as well as organizational e-health projects such as hospital information systems in hospitals that have been implemented or are under development. The findings of this study emphasize that almost all of these mentioned challenges for other countries occur in Iranian cases. However, minor differences have been uncovered between Iran and other countries regarding this matter, including privacy and security fears due to use of offline systems and also lack of pilot projects or small implementations with limited numbers of patients due to enterprise implementation of such systems in hospitals and big clinical healthcare organizations. These challenges are manifested and approached in different ways in Iran, but the best propositions for these challenges are presented to provide a long-term successful implementation strategy for such projects. Therefore, several solutions within five general areas are proposed to mitigate or remove these challenges.

The authors aim to extend their scope of research to other dimensions within the country. Clarification of ongoing national e-health projects aligned with the Iranian 5-year national plan helps to uncover the government's efforts and achievements and probably provides lessons learned within each challenge during e-health implementation.

Footnotes

Disclosure Statement

No competing financial interests exist.

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