Background
In 2019, the World Health Organization defined e-health as the cost-effective and safe use of information and communication technologies to support health and health-related fields [
1]. Given the rapid development of information technology and the tremendous potential of Electronic Health Records (EHRs), it seems these electronic systems will be the predominant form of health record systems and the basis for all patient-related communications in the near future [
2]. EHR is a collection of information related to the health of citizens, from birth to death, which is stored continuously and electronically over time [
3‐
5].
Various studies have acknowledged the benefits of EHR. These benefits include improved health care quality [
6‐
8], customer satisfaction [
9], on-time access to data [
10], access to diverse clinical data [
11], excellent capacity for storing and retrieving medical history, enhanced efficiency of healthcare systems [
12], cost reductions, fewer medication errors, better data accessibility and tracking, and improved clinical outcomes [
13]. Despite all their merits, the challenges associated with the adoption and application of EHRs have been reported in the literature [
14]. These challenges are related to the integrity and availability of healthcare data and the possible risks for patient safety [
15], information privacy [
16], user resistance, poor technological knowledge, and insufficient computer skills, which may widen the gap between developing and developed countries [
17,
18].
Secginli et al. assessed health professionals’ attitudes towards EHRs in primary health care settings in Turkey. Most of their respondents were satisfied with EHRs and agreed with it benefits but were against the barriers. However, the majority of the respondents agreed that EHRs are costly, need frequent revisions, and are frequently down [
19]. In Ireland, the majority of the physicians and nurses agreed that EHR implementation improved patient care and safety, communication, and the legibility and clarity of patient care orders [
20].
According to various studies in developed countries such as the United States, 13% of primary health care centers used EHRs in 2000, which increased to 49% in 2007 [
21]. However, developing countries are at a disadvantage compared with developed countries due to their own challenges such as lack of technological, cultural, organizational, and legal infrastructure and the existence of human obstacles [
22]. Developing countries, including Iran, are no exception when it comes to the developments related to the creation of EHR. In Iran, Integrated Electronic Health System (which is known as SIB: a Persian backronym in Persian meaning
apple) was proposed by the Health Deputy of the Iranian Health Ministry for this purpose. It was put into operation in February 2015 [
23], and to date, EHRs have been created for more than 73 million people in this system [
24]. SIB has been launched in more than 36,000 urban and rural areas, with more than 130,000 healthcare personnel working with it [
25]. Prior to SIB implementation, several electronic health record programs were tried in primary health care centers, all of which were rejected due to a myriad of factors [
26]. Among the projects implemented in this field, SIB can be considered the most complete and up-to-date system because in addition to being online, it can connect to an integrated network that has a nationwide coverage [
3].
All information related to households along with the type of health services required in community health centers is recorded in SIB. Some of the goals of SIB are: issuing EHRs for the public, creating a national database of health, providing integrated health services to the Iranian population throughout the country (especially low-income areas to increase social justice), providing health services based on specific needs of age groups, and establishing a referral system [
3]. The most important functions of SIB include registration of people, registration of events, provision of health indicators, primary screening of diseases, immunization and vaccination system, geriatric care, pregnancy care, identification of risk factors of non-communicable diseases such as cardiovascular diseases, diabetes, cancers, strokes, and the mental health care system. According to the goals and general performance of SIB, the most important and common services are offered in the field of primary health care [
24].
Due to the huge costs of setting up and using information systems, their incorrect selection and failure to address their weaknesses can lead to their failure [
27]. Implementation and internalization of SIB were accompanied with ambiguities and lack of clarifications because the system was designed to meet the needs of all groups of clients, healthcare providers, managers, and screening experts of health programs, as well as policy makers and researchers. Despite the importance of SIB in health management of people, its design and implementation has also faced many challenges. One of the important challenges is that its performance and capabilities are to a large extent affected by the level of acceptance and satisfaction of users [
23]. Kabir et al. assessed the satisfaction of users to be below the average level [
23]. The results of Mohammadi Abnavi and Saeed's research showed that the quality of vaccination registration and its reporting was the strongest aspect of SIB while the performance of user entry and exit was the weakest [
24]. Naqibzadeh and Safari also proposed solutions to strengthen SIB using the experience of users, which include items such as improving the reporting mechanism, providing alerts to perform vital and urgent operations regarding children and women, and identifying babies who whose follow-up care is due or overdue [
28].
SIB was designed as the main information basis for health systems and is currently implemented all over the country; hence any problem in the performance of this system can affect the whole health system function [
23]. Since the results of studies conducted on EHR in developed countries are not necessarily applicable in developing countries, it is necessary to conduct independent research in countries like Iran. If sufficient studies are not done, the challenges of these systems will not be identified, bringing about disruption in the service provision process and dissatisfaction of users and clients. Studies on SIB are more focused on topics such as the degree of the realization of its outcomes [
26], evaluation of its usability [
29], evaluation of its success [
25], measurement of satisfaction with it [
23] and evaluation of the level of acceptance of users [
30,
31], and very few studies have investigated the challenges and benefits of SIB. The results of these few studies also indicate that more research is still needed on various dimensions of SIB in Iran, namely the structure, the process, and the outcome. To the best of our knowledge, no study has yet investigated the challenges and benefits of SIB based on the three items of structure, process, and outcome. Given the importance of achieving the goals and applications of SIB as well as the role of SIB in health information management in Iran and its effect on the quality of the service delivery process, a study addressing these dimensions will provide a deeper understanding of the subject. Therefore, this qualitative study was conducted to identify the challenges and benefits of SIB through a detailed examination of the views of SIB users and experts. By highlighting its strengths and proposing solutions to its challenges, the results of this study can provide the basis for improving the capabilities of SIB and making it more efficient so that it can be successfully implemented and provide better services. The qualitative method adopted in this study contributes to a better understanding of the data and people's points of view and making more valid conclusions from them in this regard. The present qualitative study aimed to identify the benefits and challenges of SIB in health centers of three cities in Khuzestan Province, Iran.
Results
There were 30 interviewees in this study (24 users and 6 experts of SIB). The majority (
n = 27) of the interviewees were female, and most of them were in the age range of 25 to 35 years and had a bachelor's degree. As far as work experience was concerned, 19 participants had 1–10 years of work experience and only 2 had managerial experience. Table
1 shows the demographic characteristics of the participants.
Table 1
Demographic characteristics of the interviewees
Gender | Female | 27(90) |
Male | 3(10) |
Age | < 25 | 3(10) |
25–35 | 18(60) |
> 36 | 9(30) |
Educational attainment | Bachelor’s degree | 24(80) |
Master’s degree | 3(10) |
General Practitioner | 3(10) |
Work experience | 1–10 | 19(63.33) |
11–20 | 8(26.67) |
21–30 | 3(10) |
Managerial experience | No experience | 28(93.33) |
With experience | 2(6.67) |
Job position | Family health expert | 12(40) |
Nutrition expert | 3(10) |
Mental health expert | 3(10) |
Midwife | 3(10) |
Physician | 3(10) |
System leader | 1(3.33) |
Evaluation expert | 3(10) |
Network development unit expert | 1(3.33) |
IT expert | 1(3.33) |
| Total | 30(100) |
Totally, 42 components (24 components for benefits and 18 components for challenges) were extracted from the analysis. Three themes of Structure, Process, and Outcome were extracted from these components. The theme of Structure included four subthemes of “Financial resources”, “Human resources”, “Facilities”, and “Access to the Internet”; the theme of Process included three sub themes of “Training”, “Providing services” as well as “Time and workload”; the theme of Outcome included five subthemes of “Quality of health services”, “Access”, “Safety and personal distance”, “Screening and evaluation”, and “Research”. Extracted components and themes which highlighted benefits and challenges are presented in the following table.
In Table
2, components and sub-themes of the theme of Structure are classified based on benefits and challenges of SIB.
Table 2
Benefits and challenges of using SIB in health centers and frequency (%) of the participants who mentioned the statement (Theme of Structure)
Structure | Financial resources | Reducing expenses associated with paperwork, and printing, recording, correcting, evaluating, and retrieving information | 27(90%) | Cost of purchasing and installing software and hardware, telecommunication costs, cost of converting paper documents into electronic records | 21(70%) |
Cost of continuous training of personnel to work with the system and learn about the updated services of the system | 12(40%) |
Improving the management of Health and usable drugs | 9(30%) |
The cost of replacing defective hardware and improving software | 18(60%) |
Human resources | Improving management of human resources | 18(60%) | Unwillingness of the personnel who do not have a positive attitude towards working with computers | 7(23.3%) |
Lack of enough interest | 10(33.3%) |
Providing services based on population | 17(56.6%) | Reluctance of experienced users to work with the system (younger users were more willing to use the system) | 12(40%) |
Facilities | Need of users to computers | 5(16.6%) | Delayed delivery of support facilities and services | 23(76.6%) |
Access to the Internet | Providing Internet access for all sections of the system | 10(36.6%) | Internet disconnections during working hours | 14(46.6%) |
Many interviewees cited financial resources as a significant factor in implementing SIB. Reduced costs associated with elimination of paperwork was one of the identified benefits. “After the implementation of SIB in the centers, the costs related to paperwork significantly reduced” (Participant 7). One of the challenges related to financial resources was the cost of continuous training of staff. “Due to the novelty of this system, SIB users need training to work with the system, which imposes costs on the health sector” (Participant 12). Another challenge in establishing SIB was related to the human resources. “Personnel who did not have sufficient experience of working with a computer did not readily accept the system and did not have sufficient motivation to work with it” (Participant 23).
Table
3 shows the components and subthemes related to benefits and challenges of adopting SIB for the theme of Process.
Table 3
Benefits and challenges of adopting SIB in health centers and frequency (%) of the participants who mentioned the statement (Theme of Process)
Process | Training | Visibility of updated instruction for users to take care of individuals or record any type of health information (retraining the updated instructions while working with the system) | 8(26.6%) | Lack of enough training classes, the length of classes, and method of teaching regarding coverage of services that SIB has to deliver | 17(56.6%) |
Updating the programs, services and instructions of the Ministry of Health in the simplest possible way | 4(13.3%) |
Providing services | Importing the services in the system based on individual differences (i.e., age, gender, disease, pregnancy, etc.) | 3(10%) | Incomplete definitions or lack of definitions for all services in the guidelines of the system | 3(10%) |
Placing the updated services based on national health plans announced by the Ministry of Health | 7(23.3%) |
Incomplete or temporary recording of services due to loads of referrals and for accelerating the process | 5(16.6%) |
Daily access to list of inquiries (daily) from all health centers and places affiliated to university after transferring the service provider | 5(16.6%) |
Time and workload | Saving time as there are not repetitive requests for information and statistics | 12(40%) | Doctors’ limited time to use and learn how to work with the system | 3(10%) |
No need to search and waste time to find information and health records of a patient | 6(20%) |
Doctors’ increased workload due to using this system | 3(10%) |
Some of the benefits and challenges that the interviewees expressed about this theme were related to time constraints and workload. They described the benefit of establishing SIB as follows: “We no longer need to search for information in the patient's health record in the archive, and we will have access to the information we need in a shorter time. This gives us more time to deal with other tasks (Participant 16). Some physicians stated that implementing SIB will increase their workload. “I am visiting and examining patients all the time and I do not have enough time to learn and use this system” (Participant 9).
Table
4 presents components and subthemes of benefits and challenges related to adopting SIB in health centers for the theme of Outcome.
Table 4
Benefits and challenges related to adopting SIB in health centers and frequency (%) of the participants who mentioned the statement (Theme of Outcome)
Outcome | Quality of health services | Decreased errors and increased quality by service providers due to smart delivery of services and illustrating guidelines particularly required actions | 18(60%) | No modifiability of recording errors | 10(33.3%) |
Access | Possibility of access to quality and planned services for all people | 5(16.6%) | No interoperability of electronic records at different centers (excluding the university), increased errors, and repetitive processes (for not having patients' records) | 3(10%) |
Possibility of access to integrated information for different users at any time and in any place and simplicity of information reporting and transmission | 15(50%) |
Safety and privacy | No possibility of missing patient health records | 6(20%) | High accessibility of clinical data and exchange of information among different centers | 10(33.3%) |
Screening and evaluation | The possibility to receive complete and integrated records related to activities of health units or health service providers at any time | 3(10%) | No discrete access to doctors' care indexes, nutrition experts, and psychology experts at health posts due to their identified roles at health centers | 2(6.6%) |
Removing the problem of illegibility and lack of access to paper records | 2(6.6%) |
Impossibility of changing the time recorded for service delivery | 12(40%) |
Impossibility of changing and amending information after 24 h | 12(40%) |
Providing a framework for documentation | 10(33.3%) |
Providing a dashboard of indices regarding the provider and health unit | 4(13.3%) |
Research | Providing a very proper information center for producing and managing medical knowledge | 2(6.6%) | The possibility of fake recorded services in the system by users | 12(40%) |
Most of the interviewees mentioned the benefits and challenges with respect to security and privacy. “With the implementation of SIB, the availability of people's health information is enhanced, but it must be born in mind that this data is accessible from different centers, and this may endanger its confidentiality” (Participant 26). Some experts believed that one of the most important challenges in establishing SIB is the possibility of registering fake data in system. “We must be aware that the services recorded by users in the system may not be actually provided to individuals, so serious planning is needed in order to control more accurate recording of services” (Participant 14). One of the important benefits mentioned by the interviewees was screening and evaluation. “Because in the previous methods, different people were recording information in paper records, we always had the problem of illegible paper records, which led to careless provision of services and waste of time, but with the implementation of SIB, this problem was also solved” (Participant 29).
Conclusion
In the present study, the benefits and challenges of SIB were examined in three themes: structure, process, and outcome. In theme of structure, reduction of costs related to paper processes and improving human resource management were the main benefits of SIB while lack of sufficient motivation among employees, the costs of converting the paper system into electronic system, and Internet disconnections during office hours were its major challenges. The main benefit of SIB under the theme of process was time saving while its challenges were problems associated with training and increased workload. In theme of outcome, the benefits of SIB included increased quality of services and rapid reporting of information while the possibility of violation of information confidentiality was the main challenge identified for SIB. Most of the identified benefits were related to the theme of outcome, and most of the identified challenges were associated with the theme of structure. In order to solve the identified SIB challenges, it is necessary to pay attention to the following points: using appropriate reward systems to increase people's motivation, comprehensive planning for step-by-step training of SIB users, correct budgeting based on conditions and facilities, using the experiences of other successful countries, and creating appropriate legal infrastructure to increase information security and confidentiality. The results of the present study can help countries that have not yet launched systems like SIB to take the necessary steps to build their own system with minimal challenges.
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