INFORMATION TECHNOLOGY AND SERVICES DELIVERY IN NIGERIA
CHAPTER TWO
LITERATURE REVIEW
2.1 Information Communication Technologies (ICT)
Information and Communication Technologies (ICTs) have the potential to improve the lives of people in the society. According to the United Nations Development Program (2006), increased use of ICTs enhances service delivery by: delivering economies of scale to improve access to basic services, optimizing service delivery, providing incentives for development and transfer of new technologies and products and increasing efficiency through enhanced connectivity and exchange of knowledge enabling regions to focus on delivering services where they have a comparative advantage providing access to digital development for continuous improvement.
ICTs are changing rapidly, as are businesses surrounding their implementation (Louw & Hanmer 2002). Much of the attention paid to ICT is focused on the producers and their products. Much less attention is being paid to how ICT is shaping the way society is changing and, in turn, being shaped by society. The need to develop and organize new ways to provide efficient healthcare services has thus been accompanied by major technological advances, resulting in a dramatic increase in the use of ICT applications in healthcare and e-health.
2.2 ICT and Healthcare
E-Health is defined as the use of information and communication technologies (ICT) in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research ((Joaquin et al., 2010). An example of areas where E-Health is used includes treating patients, conducting research, educating the health workforce, tracking diseases and monitoring public health. (World Health Organization, 2013) In short E-Health is a useful term to describe the combined use of electronic communication and information technology within the healthcare sector (Mitchell, 2009).
With today's advanced information and communications technology the distances between the inhabitants of the country, countryside as urban dwellers, is reduced and information for people in rural areas have become much more accessible (Chavula, 2013). Basically, in the current situation it can be expected that all the inhabitants of our planet, wherever they are located, in 2015 will be able to get access to the information needed to get the treatment he or she needs for their illness (Healy, 2008). In reality, this goal will probably be reached later than 2015.
E-health, when it is used with mobile phones and handheld computers, is called M-health. Both these versions of E-Health can contribute with information systems that can be of enormous value in providing health care. They can support health workers during their work in the clinics when there is no doctor around and also helps the workers to keep track of patients and accessing their patient history. In recent years this has helped technologies for information delivery within healthcare systems to be proliferated (Chan et al, 2010). But without electricity, a good infrastructure and a constant flow of money it will be difficult to maintain a successful technical system. Countries such as Uganda have been through thousands of E-Health facilities that have subsequently come to nothing because financiers pulled out (Cameron, 2013).
2.2.1 Electronic Health Records (EHR)
Initially known as computer patient records, the concept of electronic health records has revolutionized to what it is today from the 1960’s (Hanson, 2006). EHR can be relied on to act as a backup in cases of emergencies and when patients change locations unlike the case of paper based records given the fact that they are easily accessible (Blair, 2007). Essential functions of EHR include shared health records, support for external information requests, and provision of security and message transfer of health records (Edwards, 2007). The benefits of using EHR include improved quality of healthcare, reduced medical errors and reduced costs, access to medical record information and time savings (Miller and West, 2007).
2.3.2 Health Information Systems (HIS)
Health Information systems or health management information systems are according to the literature systems used to collect, analyze, retain, retrieve and evaluate health information (Tan, 2002)). The WHO (2005) article on “Issues in health information’’ adds to this definition by stating that a health management information system incorporates all the data needed by policy makers, clinicians and health service users to improve and protect population health.
The goal of a Health Management Information System is to check quality by comparing perceptions of services delivered with the expected standards and to provide timely and accurate information leading to better health care planning and improved diagnosis and more patients getting access to health services for an entire country (Tan, 2002). A health information system usually describes one of these several separate subsystems containing data (WHO, 2005): disease surveillance and outbreak notification, data generated through household surveys, registration of vital events and censuses (births, deaths and causes of death), data collection based on patient and service records and reporting from community health workers, health workers and health facilities, program-specific monitoring and evaluation (for example for TB, HIV/AIDS, and EPI) and administration and resource management (including budget, personnel, and supplies).
The function of a health information system is to bring together data from all these different subsystems, to share and disseminate them to the many different audiences for health information and to ensure that health information is used rationally, effectively and efficiently to improve health action. A strong health information system is an essential component of sound program development and implementation, and is a requirement for strategic decision making, providing the basis upon which improved health outcomes depend.
Clinical managers and health planners rely on information in order to make decisions regarding effective functioning of health facilities, allocate resources and also to make strategic policies (AbourZahr and Boerma, 2005). Therefore, HIS consist of different software that are integrated in order to capture data in specific sections of the hospital, handle the work flow of daily medical services and also assist in managing financial, administrative and clinical data. The benefits of using HIS include improved quality, better communication, staff efficiency, reduced transcription costs and increased patient safety and increased revenues (Garrido et al., 2004).
2.3.3 Telemedicine
Telemedicine can be referred to as the provision of medical services from a distance (Wooton, Craig and Patterson, 2006). This includes diagnosis, treatment and prevention of diseases. The types of telemedicine can be categorized as real-time or pre-recorded telemedicine. Information is sent and received by the participants almost immediately in the case of real time telemedicine while in the case of pre-recorded telemedicine, information is captured and then transmitted later for subsequent reply (Anthony et al., 2005).Examples of pre-recorded telemedicine include tele-electrography, tele-obstetrics and tele-radiology (Mea, 2006). Examples of real time telemedicine include teleconsultation, tele-pathology and tele-dermatology (Wooton, Craig and Patterson2006).
Telemedicine is considered a powerful tool for improving health care delivery which has been successfully implemented in pilot facilities in many countries. It can improve diagnosis and treatment of specific conditions dramatically but has proven to be very costly. Telemedicine is an implementation which requires high bandwidth and sophisticated remote equipment and has only proven practical in cases where money is not an issue or as an alternative to high-cost air transportation and lodging. Used wisely, however, telemedicine can be a cost-effective method that richer countries can employ to aid capacity building in the health care systems of poorer countries (Chetley et al., 2006). In Africa, for example, the use of telemedicine has helped people in rural areas by saving money and time for travelling and long queuing lines. Clinical staff can now sent patient information by email to specialists in the cities and symptoms can now be analyzed a day ahead from a distance.
2.3.4 The Internet
The role of the Internet in healthcare cannot be ignored. The Internet provides a platform where various stakeholders of e-health are able to achieve various goals. Key among the solutions that the Internet provides in healthcare includes:
There are various types of business operations that are conducted by organizations and individuals online within the healthcare industry. These business models include business to business to consumer models, business to business and business to consumer models (European Commission Enterprise Directorate General, 2004). Some examples of business models within the healthcare industry include virtual doctor visits, online medical suppliers and automated systems (Tan, 2005).
The Internet has provided a platform for conducting a lot of research in healthcare. This has led to the use of online experiments, randomized trials and surveys (Couper, 2007). Additionally the numbers of publications on healthcare issues have increased tremendously (Curry, 2007).
Medical learners can now share a lot of digital information from the various digital libraries on the Internet which have been reviewed by various researchers (Ruiz, Mintzer and Leipzig, 2006). Additionally various professionals in medical fields can now access various web pages in order to take continuous medical education hence improving current standards of healthcare by use of the availed technologies on the Internet (Dario et al., 2004).
Patients are using the Internet to get information, interact with their physicians and order pharmaceutical products online (Podichetty and Biscup, 2003). Hence the patients are now taking charge of their health status by staying informed with issues regarding to their health (Lorence, 2006).
2.4 Challenges to the Adoption and Usage of E-Health
The literature analysis on the adoption of e-health standards revealed that the slow pace of the adoption of standards (both by developed and developing nations) is due to several factors. This section presents relevant literature on the factors perceived to affect the implementation of e-health facilities.
Many African nations have a large number of its citizens living in rural areas. In the majority of cases, these rural communities lack even the most basic infrastructure, such as, electricity. There is also limited ICT infrastructure; broadband Internet connectivity is very low compared to developed countries. Foundational infrastructures, such as client and provider registries, as well as common terminology services are largely absent. Where ICT infrastructures are in place, they are neither standardized nor based on common platforms, making it difficult for them to interoperate (Anon, 2010).
EHealth infrastructure pertinently affects adoption of eHealth (Qureshi et al., 2013). In a study conducted in Nigeria, which focused on adoption of ICT in SMEs in the health sector, quality of ICT systems is noted as a significant factor in determining adoption of ICT (Muathe, Wawire & Ofafa, 2013). In their study focusing on establishing the infrastructural barriers to eHealth implementation in developing countries, Qureshi et al, (2013) indicated that internet connectivity is vital for successful adoption of eHealth.
In another study conducted in Nigeria, it was revealed that doctors are willing to conduct e-searches in order to access and share health information with their colleagues in others parts of the world. However, insufficient ICT resources limit them in performing the searches (Gatero, 2010). In yet another study, it is indicated that cost of computers and lack of computers hinder adoption of eHealth amongst hospitals in the rural areas (Ouma & Herselman, 2008).
The low rate of internet penetration and low bandwidth are among the challenges to eHealth adoption in developing countries. Omary et al (2009) points out that due to poor ICT infrastructure and internet penetration in Tanzania, the majority of areas in the country cannot support internet deployment, which in turn, hampers eHealth adoption. Even in developing countries that have high internet penetration, bandwidth may still be a challenge, thereby limiting adoption of telemedicine and other internet based eHealth applications.
African countries generally have low levels of human resources with the requisite expertise to participate in standards development (The Rockerfeller Foundation, 2010). The adoption of international standard by a country often requires localization of the standard to meet the specific requirements of the country. Limited technical expertise in African countries could affect their ability to effectively carry out standards localization. Furthermore, inadequate technical expertise could lead to an absence of, or ineffective government policies regarding the adoption of e-health standards (International Telecommunication Union, 2009).
Legislation and standards on eHealth are vital in any developing countries for successful eHealth adoption. However, sufficient standards for medical imaging, interoperability, software, transmission, infrastructure, architecture, medical informatics, and bioinformatics are yet to be formulated in developing countries (Omary et al., 2009). Inadequate electronic legislation (eLegislation) and eHealth standards for instance have negatively affected eHealth adoption in Nigeria which is also the case for Ghana (Kathryn, 2011).
In Ghana, it appears that apart from a few clauses contained in the Electronic Communication Act, 2008 (Act 775) Section 4(2), limiting access to electronic personal information of the customers of the communications industry, there does not seem to be a dedicated and broad based national legislation on the primary and secondary uses of electronic personal information of the individual (Norman, Alkins & Binka, 2011). This provides a good example of the gap in the legal framework for the protection of privacy when it comes to patient data in the use of information technology and this may negatively affect the adoption of information technology in the health sector.
Funding of the health sector determines adoption of electronic health (Omary et al., 2010; Abdullah, 2012). Due to low funding of health sector in Tanzania, Omary et al (2010) argues that it is difficult to allocate much money for acquisition of ICT resources needed in the health sector.
Adoption of electronic health infrastructure is costly and this calls for increased funding in the health sectors for various developing countries. Findings show that increased funding in health sector is strongly correlated with adoption of eHealth even in the case of developed countries and this should also be the case for developing countries (Yu, 2012). It is worth noting that public funding is tied to individual institutions where the amount allocated to a given health institution is proportional to its size. Larger hospitals achieve easily economies of scale and mainly information and resources needed across the organization. Several studies show positive relationship between ICT adoption and organization size since they have more finances compared to smaller institutions (Pan & Jang, 2008).
The fact that unsuccessful implementations have many causes, it is still, from a technology-driven point of view, assumed that users have a tendency to reject changes as “users often are seen to suffer from a lack of training as well as a lack of sufficient interest” (Millerand and Baker, 2010:138). However, developers do also generate a set of "best practices", understanding that practices can be transferred between contexts. Unfortunately, this tends to ignore the crucial fact that practices are situated and localized actions and knowing in practice is an “ongoing social accomplishment, constituted and reconstituted as actors engage the world in practice” (Orlikowski, 2002: 249).
2.5 E-health and Performance of Health Facilities
Electronic healthcare services offer important economic and social benefits for our society. Patients rely on these services for their safety and care and for improving their quality of life. For physicians, electronic health and wellness services offer sup-port for providing more effective and continuous care. There are various e-health solutions that can be used in improving the quality, efficiency and to reduce costs in healthcare. Key among them includes electronic health records, hospital information systems, telemedicine and the internet.
Nilsson (2012) did a study on information and communication technology as a tool for support in home care among middle-aged people with serious chronic illness and nurses. The findings of the study revealed that using an ICT application improved accessibility for people with serious chronic illnesses living at home. The use of the ICT application also saved time and eased nurses’ work. In the case study, their use also resulted in more direct communication between the ill people and their nurses, which facilitated communication and led to less limitation on everyday life for the ill people, which seemed to mediate the development of more trusting relationships.
Olatokun and Adeboyejo (2009) investigated reproductive health workers’ (RHWs) use of ICTs, the effects of ICTs on their job functions, and the challenges limiting full exploitation of ICTs in Nigeria. The study adopted a descriptive survey design. Stratified sampling technique was used to select a sample of 360 RHWs of the University College Hospital, Nigeria. A questionnaire obtained the data, and frequencies and percentage distributions were the analytical techniques adopted. Findings revealed that RHWs indicated extensive use of ICTs in their job functions. Faster access to relevant medical information, easy exchange of information with colleagues, and increased efficiency were the major impacts of ICT usage on their activities. The information accessed through ICTs was primarily educational, health, and research. Findings equally revealed that the major challenges in ICT use were erratic power supply and inadequate access to ICT facilities. Based on the findings, recommendations were made towards enhancing better utilization of ICTs by RHWs.
2.6 Theoretical Foundation
This section presents the theories which were used in the study. Unified Theory of Acceptance and Use of Technology (UTAUT) and Actor-Network-Theory (ANT) were used in the study.
2.6.1 Unified Theory of Acceptance and Use of Technology (UTAUT)
Venkateshet al., (2003) unified and completed the various models of IT acceptance and they integrated the elements of eight well-known models such as: the Theory of reasoned action (Davis et al., 1989), the Technology acceptance model (Davis,1989), the Motivational model (Davis et al., 1992), the Theory of planned behaviour (Ajzen, 1991), a model combining the Technology acceptance model and the Theory of planned behaviour (Taylor and Todd, 1995), the model of PC utilization (Thompson et al., 1991), the Innovation diffusion theory (Rogers, 1995), and Social cognitive theory (Compeau and Higgins, 1995).
Due to the weaknesses of TAM, a number of modified TAM models were proposed, which are applicable to contemporary technologies (Horton et al., 2001). However, researchers are confronted with a choice among a multitude of models. Hence, a new model was developed to address these limitations (UTAUT). The aim of this model is to understand intention/usage as a dependent variable (Venkatesh et al., 2003). The research model used in this proposal to examine the use of ICT in healthcare is UTAUT.
Venkatesh et al., (2003) tested the unified theoretical model in four different organizational settings for a period of six months and the study showed significant predictions of intention (performance expectancy, effort expectancy, social influence and facilitating conditions), whereas attitude toward using technology, self-efficacy and anxiety were theorized not to be direct determinants of intention. This study therefore used the theory to assess the challenges facing the use of electronic health in health facilities in Nigeria.
2.6.2 Actor-Network-Theory (ANT)
Actor-Network-Theory (ANT) is a useful conceptualization of the relationship between the technical and the social (Walsham, 1997).ANT deals with the social-technical divide by denying that purely technical or purely social relations are possible. The theory considers both social and technical determinism to be flawed and proposes instead a socio-technical account (Tatnall and Gilding, 1999)
ANT assumes that the world is constituted by a heterogeneous network of actors, in which humans, artefacts, manuals, norms, routines and organizational arrangements all shape the network. Each of the actors has “interests” and each will act in accordance with these to achieve their own individual goal (Latour, 1987). According to Latour (1987), “interests” lie between the actors and their goals, creating tension that will make actors select only what, among many possibilities, helps them reach these goals in their own eyes. The actors in a network may include users, facility participants, existing systems, practices, and so forth. In order to make technology work in organizations, it is important to take into account all the different actors and factors that exercise an influence on the network (Law, 1987).
The theory therefore claims that users are important participants in the facilities and that system designers and suppliers regard users as important contributors in the development process. However, users have traditionally had a passive role in such facilities because they are often separated from the designers. To improve reciprocity, users should increase their influence in ICT facilities. In this sense, users should have far greater opportunity to participate in creating the conditions for the systems. This can reduce the distance between designers and users. This theory was therefore be used in this study to explain how the relationship between the implementers and users affects in performance and success.
2.7 Summary of the Literature Review
This chapter has presented relevant literature on the use of ICT in health facilities. Literature has revealed that among the challenges facing the use of ICT in e-health are: inadequate infrastructure, privacy, confidentiality and security, legislation and standards on e-health, availability of funds and individual characteristics. Unified Theory of Acceptance and Use of Technology (UTAUT) and Actor-Network-Theory (ANT) will be used for the study. To fill the knowledge gap which exists, this study therefore seeks to investigate the relationship between electronic healthcare and performance of the health care facilities
2.8 Conceptual Framework
The conceptual framework below presents the relationships between the study variables. The independent variables for the study were: electronic health records, telemedicine, health information systems, the internet and mobile health while the dependent variable is performance of healthcare facilities. The intervening variable for the study were: availability of health infrastructure, technical knowhow of users, legislation and health standards, individual characteristics and inadequate allocation of funds.
Independent Variables Electronic Health Intervening Variable
Records Availability of Dependent Variable
• health Infrastructure
Telemedicine •Technical Knowhow
of users Performance of Healthcare Facilities
•Legislation and •Quality of healthcare
Health Information health standards •medical errors and costs
Systems •Individual •access to medical records characteristics •Time saving
The Internet •Inadequate
allocation of funds
Mobile Health
Figure 2.1 Conceptual Framework