International Journal of Medical Informatics 108 (2017) 49–54

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International Journal of Medical Informatics

journal homepage: www.elsevier.com/locate/ijmedinf

Research Paper

Success or failure of hospital information systems of public hospitals MARK

affiliated with Zahedan University of Medical Sciences: A cross sectional
study in the Southeast of Iran
⁎
Jahanpour Alipoura,b, Afsaneh Karimia, Saeid Ebrahimia, Fatemeh Ansaric, Yousef Mehdipoura,
a
Health Information Technology Department, Paramedical School, Zahedan University of Medical Sciences, Zahedan, Iran
b
Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
c
Torbat-E-Jam Health Center 4, Torbat-e-Jam, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: After implementation, evaluation of hospital information systems (HISs) is critical to ensure the
Success fulfillment of the system goals. This study aimed to assess the success or failure of HISs in public hospitals
Failure affiliated with Zahedan University of Medical Sciences.
Hospital information system Materials and methods: A cross-sectional descriptive and analytic study was performed in 2016. The study po-
pulation comprised IT and HIS authorities and hospital information system users. The sample consisted of 468
participants. The data were collected using two questionnaires and analyzed with the SPSS software using de-
scriptive and analytical statistics.
Results: The mean score of functional, behavioral, ethical, organizational, cultural and educational factors from
the users’ perspective was 3.14 ± 0.66, 2.97 ± 0.60, 3.39 ± 0.70, 2.96 ± 0.642, 3.09 ± 0.63, and
2.95 ± 0.74, respectively. The mean score of organizational, behavioral, cultural, technological, educational
and legal factors from IT and HIS authorities’ perspective was 3.51 ± 0.54, 3.35 ± 0.45, 2.75 ± 0.61,
3.58 ± 0.32, and 3.96 ± 0.59, respectively.
Conclusions: The evaluated hospital information systems were considered relatively successful in terms of
functional, ethical, and cultural factors but were considered as a relative failure in terms of behavioral, orga-
nizational, and educational factors form the users' perspective. Only the legal factor showed success, while
organizational, behavioral, technical and educational factors showed relative success and the cultural factor
showed relative failure from HIS and IT authorities’ perspective. Therefore, assessing the users’ needs before
implementing the system, involving them in various stages of implementation, training them, and improving
their computer skills seem to be necessary to achieve a better level of system success.

1. Introduction
Organizing and rendering optimal health services require the
management of huge amounts of information, and automation of health
information management processes is inevitable in today’s competitive
environment. Reducing healthcare costs and enhancing the quality of
the services in the health scope require information systems. Healthcare
information systems could improve the health care practitioners’ per-
formance and the quality of the patient outcome [1]. A Hospital In-
formation System (HIS) is a computer system designed to manage all
the aspects of a hospital's operations such as clinical, administrative,
and financial activities [2,3]. However, implementation of the HIS is
very difficult and complicated. Thus, for relative success of these
systems, items such as human factors, costs, and time should be con-
sidered (3, 4). Jabraeily and Mbananga introduced inadequate training
and resistance of users as the main causes of information systems failure
[4,5].
Success could be defined as achievement of a purpose, business
reputation, or position. Likewise, in health information systems, success
is the usefulness of the information system for users and healthcare
managers [6,7]. Given the complexity of information systems, their
success and failure could be seen in various situations [6–10]. A study
by Fowler showed that only 28% of information systems have a suc-
cessful performance. Furthermore, this report indicated that develop-
ment of an information system, even in the best situation, is gradual
and time-consuming and involves high costs [8].

⁎
Corresponding author at: School of Paramedical Sciences, Zahedan University of Medical Sciences, Khalij Fars Ave., Zahedan, Iran.
E-mail address: yas532004@gmail.com (Y. Mehdipour).

http://dx.doi.org/10.1016/j.ijmedinf.2017.10.005
Received 4 March 2017; Received in revised form 21 August 2017; Accepted 3 October 2017
1386-5056/ © 2017 Elsevier B.V. All rights reserved.
J. Alipour et al.
Nearly three-quarters of all information system projects face with
failure [11]. Even in the United States of America, there are reports of
the failure of half of the healthcare information system projects [7,12].
Although information systems have been used in health care organi-
zations for more than three decades, completely successful cases of
these systems are not commonly encountered [10]. These systems op-
timize operational activities and improve the organizational perfor-
mance as well as the patients’ and users’ satisfaction [13–16]. Failed
information systems are unable to meet theirs users’ and patients’ sa-
tisfaction [6,10].
With the increasing impact of information technology on organi-
zations and their costs, it is critical to evaluate the quality of the ser-
vices offered by these information technologies, especially in terms of
user satisfaction [17,18]. Evaluation of the HISs for improvement of
healthcare services and ensuring their successful implantation and po-
sitive effects on healthcare delivery are very important [17,19,20].
Hospital information systems are frequently implemented. However,
these systems are rarely evaluated to assess whether they have achieved
their main goals although it is critical to evaluate these systems’ ad-
vantages and disadvantages [21]. Regardless of the HIS advantages,
these systems are not without problems [22,23]. Appropriate evalua-
tion guarantees the success of these systems [24,25] and could some-
times solve the existing problems [22,26].
Given the huge investments on the development and implementa-
tion of hospital information systems, evaluation of the success or failure
of these systems seems to be necessary to appreciate their value and
efficiency [27]. The measurement of user satisfaction with information
systems is the most effective method for the evaluation of these systems
[28]. Because of the complexity of hospital health information systems,
numerous factors influence their success or failure such as functional,
technical, cultural, economic [7,29], legal, political, ethical, organiza-
tional, and managerial factors [7]. Evaluation of the users’ perception
of the HIS and quantifying their satisfaction instead of considering
technical aspects of these systems is very important because a well-
developed system is considered weak if its users recognize it as a weak
system [30]. There is no unique standard method for successful im-
plementation of health information systems so that a failed method in
one healthcare facility may work very well in another [31].
Generally, HIS evaluation could provide evidence whether it has
achieved its expected goals and offer reasons for the success of the
system. Furthermore, HIS evaluation is useful for policy and managerial
decision making and budget allocation to promote the HIS [32]. The
present study aimed to evaluate the success or failure of hospital in-
formation systems in public hospitals affiliated with Zahedan Uni-
versity of Medical Sciences. Moreover, we tested one hypothesis related
to the determinants of the success or failure of hospital information
systems and the computer skill level of the respondents as follows:
H1. There is a significant relationship between the respondents’
computer skill level and the surveyed factors.
2. Material and methods
This descriptive-analytical cross-sectional study was conducted in
2016. The research population comprised three main groups: in-
formation technology and hospital information system authorities, se-
nior health care managers, and HIS users (including nursing, medical
records, laboratory, radiology, pharmacy, and financial departments)
working in Ali-ibne-abitaleb, Khatam-ol-anbia, Alzahra, Baharan, and
Buali hospitals affiliated with Zahedan University of Medical Sciences.
The first, second, and third group comprised 32, 12, and 915 in-
dividuals, respectively (745, 56, 35, 33, 28, and 19 persons in the
nursing, medical records, radiology, laboratory, financial, and phar-
macy department, respectively). Because of population limitations in
the first two groups, sampling was not done and the whole population
was selected as a sample. In the third group, sampling was done only for
50
International Journal of Medical Informatics 108 (2017) 49–54
nursing users. According to the Cochran formula, 253 persons were
required, and stratified sampling was used to select samples in each
hospital.
All facilities were public hospitals that had key HIS subsystems in-
cluding the financial information system (FIS), admission, discharge,
and transfer (ADT), nursing information system (NIS), laboratory in-
formation system (LIS), and pharmacy information system (PIS). These
subsystems were implemented for 5–10 years. Administrative in-
formation systems (ADT and FIS) and clinical information systems (NIS,
LIS, and PIS) were implemented from 2005 and 2010, respectively. All
subsystems used in all hospitals were considered.
We used a questionnaire designed by Sadoughi et al. [7] based on a
systematic review of the factors influencing the success or failure of
hospital information systems. The questionnaire was divided into 3
separate questionnaires based on the evaluated factors and population
according to the opinions of three faculty members in the field of health
information management (HIM). These questionnaires contained 120
questions for IT and HIS authorities (47 questions), senior healthcare
managers (40 questions), and users (33 questions). Each question was
scored by the respondents for importance. For each question, a five-
point Likert scale (from 1: very low to 5: very high) was used to rate
each sub-factor.
The first questionnaire contained 47 questions and was divided into
six factors including organizational (n = 7), behavioral (n = 10), cul-
tural (n = 4), technical (n = 18), educational (n = 5), and legal factors
(n = 3). The second questionnaire had 40 questions and was divided
into six factors including organizational (n = 7), managerial (n = 20),
cultural (n = 4), strategical (n = 3), economic (n = 3), and political
factors (n = 2). The third questionnaire comprised 33 questions and
was divided into six factors including organizational (n = 7), beha-
vioral (n = 10), cultural (n = 4), functional (n = 5), educational
(n = 5), and ethical factors (n = 2). Since only two managers com-
pleted the questionnaires properly, the data of this population were
excluded from the study.
The questionnaires were then validated by a panel of three health
information management experts. The test-retest reliability was con-
ducted for determining the reliability of the questionnaires. The first,
second, and third questionnaire had a Cronbach’s alpha of 0.92, 0.88,
and 0.93, respectively. The data were analyzed in terms of descriptive
(mean ± standard deviation) and analytic (spearman and Pearson
correlations) statistics using the Statistical Package for Social Sciences
(SPSS) software.
The mean score of the factors was used to evaluate the success or
failure of the evaluated hospital information system. A mean score of
3.75 or more out of 5 was considered as complete success, a mean score
between 3 and 3.75 out of 5 was considered as relative success, a mean
sore between 1.5 and 3 was considered as relative failure, and a mean
score of less than 1.5 out of 5 was considered as complete failure of the
information system.
3. Results
A total of 468 questionnaires were distributed, of which only 338
were completed and returned (return rate = 72.2%). Fifty-three ques-
tionnaires that were too incomplete or inaccurately completed were
excluded. Of these 53 questionnaires, 23 were completed by managers,
of which 21 were discarded because too many items were unanswered,
and only two questionnaires were completed properly. Thus, managers
were excluded from the study. The remaining 30 questionnaires were
excluded due to incompleteness related to the users of nursing (17),
medical records (5), radiology (2), laboratory (3), and financial (3)
departments. Therefore, excluding these questionnaires did not affect
the results of the main sample.
Most of the IT and HIS authorities were female (70%), half of them
were between 25 and 30 years of age, and the majority of them had less
than five years of work experience (70%) and a bachelor’s degree
J. Alipour et al. International Journal of Medical Informatics 108 (2017) 49–54

Table 1 linear significant relationship only between the users’ computer skill
HIS users’ demographics. level and cultural factor (R = 0.103 and p-value < 0.05).
Category Subcategory Total number %
4. Discussion
Gender Male 61 22
Female 212 78 The mean score of the organizational factor in the given hospital
Age 22–31 150 55
32–41 81 30
information system from the perspective of IT and HIS authorities and
42–51 36 13 users was 3.51 ± 0.54 and 2.96 ± 0.64, respectively. Although the
52 years and more 6 2 mean score of IT and HIS authorities showed that the HIS was relatively
Work experience 1–10 183 67 successful, the mean score of the users indicated a relative failure.
11–20 58 21
Farzandipour [33], Ismail [34], and Sadoughi [7] introduced the or-
21–28 32 12
Job level Nursing 173 63 ganizational factor as a determinant of the hospital information system
Medical Records 32 12 success. Moreover, Ojo reported a positive correlation between the
Laboratory 21 8 organizational factor and the health information system [35]. Jabraeily
Radiology 13 5 highlighted the organizational factor as a determinant of the HIS suc-
Pharmacy 9 3
Financial affairs 25 9
cess with a mean score of 3.98 ± 0.72 [5]. This finding is incompatible
Education Diploma 10 4 with the results of earlier studies. This contradiction could be due to the
Associate's Degree 29 11 failure of the evaluated hospital information systems to meet the IT and
Bachelor’s 207 76 HIS authorities’ needs, as well as the difference in the assessment tool.
Master’s 16 6
The mean score of the behavioral factor in the hospital information
PhD 1 0a
Professional doctor 9 3 systems was 2.97 ± 0.60 and 3.35 ± 0.45 from the IT and HIS au-
Unknown 1 0a thorities’ and user’s perspective, respectively. The achieved mean score
Computer skills Poor 6 2 indicated that the HIS was a relative failure from the perspective of IT
Below average 18 7 and HIS authorities but a relative success from the users’ viewpoint.
Average 148 54
Above average 33 12
Sadoughi [7] also found that the behavioral factor was a determinant of
Good 56 21 the hospital information system success. Azizi et al. reported that 34.9%
Excellent 12 4 of the users were satisfied with the hospital information system [36].
Pasandideh et al. also reported a mean score of less than 3.75 out of 5
a
The values of these items were 0.4% that were rounded. for the satisfaction of the HIS users [37]. This finding is in line with the
results of earlier studies.
(80%). Most of them stated their computer skills as good (70%). Regarding the cultural factor in the given hospital information
Table 1 shows that nursing users comprised most of the respondents system, the mean score of IT and HIS authorities and users was
in the users’ population (63%). Most of the users were female (78%), 2.75 ± 0.61 and 3.09 ± 0.63, respectively. These mean scores in-
55% of them were between 22 and 31 years old, and 67% of them had dicated a relative failure from the perspective of IT and HIS authorities
between 1 and 10 years of work experience. Most of them had a ba- and a relative success from users’ point of view in terms of the cultural
chelor’s degree (76%) and reported their computer skills as moderate factor. Escobar-Rodríguez and Bartual-Sopena stated that the cultural
(54%). factor had a determining role in the attitude towards using the HIS.
Table 2 shows that the highest and the lowest mean score was re- Sadoughi et al. [7] and Brender et al. [38] also introduced the cultural
lated to legal and cultural factors with a mean score of 3.96 ± 0.59 factor as a determinant of the HIS success. Jabraeily et al. reported a
and 2.75 ± 0.61 respectively from the viewpoint of IT and HIS au- score of 3.98 ± 0.72 for the impact of the cultural factor on the HIS
thorities of hospital information systems. Also, there was a strong po- success [5]. Moreover, Tabibi et al. found a significant relationship
sitive correlation between cultural and organizational, technical and between the cultural factor and perceived usefulness, and between the
organizational, technical and legal, legal and organizational, technical cultural factor and implementation of the hospital information system
and cultural, and educational and cultural factors. [39]. Kahouei et al. emphasized that the cultural factor should be
As seen in Table 3, the highest and the lowest mean score was re- considered in adoption of electronic systems [40]. This finding is not
lated to ethical and educational factors with a mean score of consistent with the results of previous studies because despite the em-
3.39 ± 0.70 and 2.95 ± 0.74 respectively according to the users of phasis of the previous studies on the cultural factor as a determinant of
hospital information systems. Furthermore, a moderate positive corre- the HIS success, the obtained mean score of the cultural factor indicated
lation was found between ethical and functional, cultural and func- that inadequate attention has been paid to this factor in the evaluated
tional, ethical and behavioral, organizational and ethical, educational hospital information systems. This contradiction could be due to the
and ethical, and educational and cultural factors. Moreover, a strong non-compliance of IT and HIS authorities’ expectations and culture of
positive correlation was found between other surveyed factors form the the evaluated hospital as well as their disinterest in accepting new
users’ perspective. cultures.
Assessment of the hypothesis using the Spearman test showed a Training of end-users has an inseparable and critical role in the

Table 2
The mean score and correlation of evaluated factors in the given hospital information system from the viewpoints of HIS users.

Factors Mean ± S.D. 1 2 3 4 5 6

1 Functional 3.14 ± 0.66 1

2 Behavioral 2.97 ± 0.60 0.647** 1
3 Ethical 3.39 ± 0.70 0.428** 0.550** 1
4 Organizational 2.96 ± 0.64 0.637** 0.647** 0.478** 1
5 Cultural 3.09 ± 0.63 0.539** 0.820** 0.724** 0.665** 1
6 Educational 2.95 ± 0.74 0.689** 0.894** 0.472** 0.937** 0.595** 1

** P- value < 0.01

51
J. Alipour et al.
Table 3
The mean and correlation of evaluated factors in the given hospital information system from the viewpoints of IT and HIS authorities.
Factors Mean ± S.D. 1 2
1 Organizational 3.51 ± 0.54 1
2 Behavioral 3.35 ± 0.45 0.436
3 Cultural 2.75 ± 0.61 0.787**
4 Technical 3.58 ± 0.32 0.899**
5 Educational 3.48 ± 0.51 0.198
6 Legal 3.96 ± 0.59 0.710*
* P- value < 0.05.
** P- value < 0.01.
prevention of information systems failure [41]. Regarding the educa-
tional factor in the given hospital information systems, the mean score
of IT and HIS authorities and users was 3.48 ± 0.51 and 2.95 ± 0.74
respectively, indicating relative success from IT and HIS authorities’
point of view and relative failure from the users’ perspective. Ajami
et al. found that the educational factor was a key factor in the hospital
information system success [30]. Sadoughi et al. also introduced this
factor as a determinant of the HIS success [7]. Jabraeily et al. calculated
a mean score of 4.24 ± 0.73 for the impact of the educational factor
on the HIS success from the users’ perspective [5]. This finding is in
contradiction with the results of earlier studies, because despite the
emphasis of previous studies on the educational factor as a determinant
of the HIS success, the mean score of this factor in this study indicated
that inadequate attention has been paid to this factor in the evaluated
hospital information systems. This inconsistency may be linked to in-
adequate education of IT and HIS authorities during and after HIS
implementation.
The functional factor is a key factor in adoption, satisfaction, and
success of hospital information systems [42]. The mean score of the
functional factor in the given hospital information systems was
3.14 ± 0.66, indicating its relative success from users’ perspective.
Sadoughi et al. also introduced this factor as a determinant of the HIS
success [7]. Cho et al. showed that implementation of a hospital in-
formation system led to improvement of functional indicators [43].
Saghaeiannejad et al. reported a mean score of 3.32, 2.17, and 3.17 for
functional factors in hospital information systems of the public, private,
and social security hospitals, respectively [44]. Azizi et al. reported that
the users’ satisfaction with the hospital information system was 34.9%
[36]. Kimiafar et al. reported that 47.7% of HIS users were dissatisfied
with HIS functions in decision-making. Moreover, they stated that
53.2% of the users were rather satisfied with the data quality of hospital
information systems [45]. This finding is in accordance with the results
of previous studies.
The mean score of the ethical factor was 3.39 ± 0.70 from the
users’ perspective, indicating its relative success. Kaplan et al. [11] and
Sadoughi et al. [7] introduced this factor as a determinant of the HIS
success. Fritz et al. also reported that the ethical factor is a criterion for
the evaluation of the success or failure of information technology [46].
This finding is rather consistent with the results of similar studies.
The mean score of the technical factor in the given hospital in-
formation systems was 3.58 ± 0.32 from the IT and HIS authorities’
perspective, indicating the relative success of this factor. In the success
model developed by Dlone and McLean, this factor is considered a key
factor for the evaluation of the information system success [47,48].
Kaplan et al. [11], Fritz et al. [46], and Sadoughi et al. [7] reported that
the ethical factor is a determinant of the HIS success. Sheikhtaheri et al.
reported a mean score of 3.6, 2.7, and 3.1 for the nurses’ satisfaction
with the user-interface, functions, and performance of hospital in-
formation system, respectively [49]. Azizi et al. reported that 34.9% of
the users were satisfied with the quality of hospital information systems
[36]. Saghaeiannejad et al. also stated that 58.5% of the users were
satisfied with the hospital information system quality [44]. This finding
is consistent with [44,49] and inconsistent with [36]. This paradox
52
International Journal of Medical Informatics 108 (2017) 49–54
3 4 5 6
1
0.558 1
0.385 0.639* 1
0.066 0.669* 0.128 1
0.320 0.380 0.806** −0.110 1
could be related to the well-designed user interface of the evaluated
hospital information systems as well as the difference in the assessment
tool.
The mean score of the legal factor in the given hospital information
systems was 3.96 ± 0.59 according to IT and HIS authorities’ per-
spective, indicating the relative success of the HIS. Kaplan et al. [11],
Sadoughi et al. [7], and Brender et al. [38] reported that this factor is a
determinant of the HIS success. Ehab Azhary et al. also mentioned this
factor as a key factor for the health information system success [50].
This finding is consistent with the results of similar studies, because the
obtained mean score of the legal factor indicated that inadequate at-
tention has been paid to this factor in the evaluated hospital informa-
tion systems.
The evaluated hospital information systems were considered rela-
tively successful in terms of functional, ethical, and cultural factors but
were considered a relative failure in terms of behavioral, organiza-
tional, and educational factors form the users' perspective.
Furthermore, from the viewpoint of HIS and IT authorities, only the
legal factor showed success while organizational, behavioral, technical,
and educational factors showed relative success, and cultural factor
showed relative failure. Therefore, assessing the users’ needs before
implementing the system, involving them in various stages of im-
plementation, training, and improving their computer skills seems to be
necessary to achieve a better level of system success.
Hence, based on results of this study, it is suggested that training
courses on the factors affecting the success or failure of hospital in-
formation systems be provided for all internal stakeholders of HISs
(including Administrators, users, IT/HIS authorities); Furthermore,
upon purchase and during software upgrades providing in-service
training for new users and refresher training for all users is necessary;
upon the purchase or design of any new either hospital information
systems or subsystems, needs and expectations of users and IT/HIS
experts be considered; finally, More educations be provided to users
and IT/HIS authorities of hospital information systems before, during
and after implementation of such systems.
4.1. Limitation
Because the commitment of senior managers to implementation,
adoption, and optimization of hospital information systems is critical in
the success or failure of the systems, the managers’ comments are
crucial in the system evaluation. Thus, lack of managers’ participation
in this research was one of the main limitations of this study.
Authors contributions
JA wrote the first and final draft of the manuscript. AK, SE, FA, and
YM contributed substantially to the manuscript.
Funding
This study was supported by the Vice Chancellor for Research and
Technology of Zahedan University of Medical Sciences [Grant No.
J. Alipour et al.
IR.ZAUMS.REC.2015.253].
Competing interests
The authors declare that they have no competing interests.
Summary points
Summary of previous studies:
• Most previous studies evaluated limited factors affecting
hospital information system.
• Few previous studies evaluated hospital information systems
from the perspective of all user groups.
Summary of this study:
• Hospital information systems are complex information sys-
tems and numerous factors affect their success or failure.
• It is very important to consider all the determinants when
these systems are being evaluated.
• Despite the fact that hospital information systems have been
used in healthcare centers in Iran for decades, these in-
formation systems are not very successful.
Acknowledgments
The authors thank Vice Chancellor for Research and Technology of
Zahedan University of Medical Sciences for supporting the project.
They also thankful to the HIS’ users of the given Hospital information
systems who participated in this study for sharing their valuable ex-
periences.
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