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Barriers to the Adoption of Electronic Medical Records in Select Philippine

Hospitals: A Case Study Approach

Conference Paper · April 2019

DOI: 10.1145/3330482.3330503

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 Barriers to the Adoption of Electronic Medical Records in
Select Philippine Hospitals: A Case Study Approach
Ryan A. Ebardo Nelson J. Celis
Faculty, Jose Rizal University Faculty, De La Salle University – Manila
80 Shaw Boulevard 2401 Taft Avenue, Manila, Philippines
Mandaluyong City, Philippines +6392855016362
Student, De La Salle University – Manila nelson.celis@dlsu.edu.ph
2401, Taft Avenue, Manila, Philippines
+639178019672
ryan.ebardo@jru.edu

ABSTRACT and reforms within the medical landscape in the Philippines. The
The Philippine healthcare industry is in constant pursuit to provide passage of the Universal Health Coverage Bill 5784 further
quality medical services to every Filipino. Technology plays a contributes to the rising economic activities within the healthcare
pivotal role in this journey as it triggers the mechanism for the industry [29]. In 2017, Filipinos spent an average of Php 6,791
industry stakeholders to innovate and adjust to the dynamic representing a growth of 6.3 % compared to the figures in the
requirements of healthcare. At the core of this technological previous year [28]. The most tangible evidence of this
revolution in healthcare is the digitalization of patients’ medical phenomenon is the establishment of new hospitals providing
records. This paper investigates barriers encountered by primary and secondary medical services to the Filipino
healthcare providers in adopting Electronic Medical Records, a community. Although the industry is still dominated by premiere
technology considered as a basic necessity in majority of healthcare institutions, several firms, partnerships and
developed economies. Data is gathered through the guidance of conglomerates have started to intensify their economic ventures
the Technology-Organization-Environment. A multiple case study within the industry with a forecast value of $19.8 billion by 2021
is operationalized to understand the barriers in the adoption of [20].
EMRs at an organizational level. Technology barriers include To support this growth, technology plays a pivotal role in a more
complexity, weak infrastructure and poor interface design. sustainable implementation of national healthcare policies and
Organizational barriers are user resistance and the lack of plans [24]. In order to realize a more efficient medical service
appropriate skills. Environmental barriers include difficulty in centered on patient care, healthcare institutions have allocated
regulatory compliance and inadequate medical school orientation. financial resources to various technology-enabled solutions [4].
Limitations and future directions are discussed by this paper and These solutions have transformed the way medical services are
followed by its conclusion. delivered to the different sectors of the society [32]. Along with
these developments, unprecedented opportunities brought about
CCS Concepts by advancements in technologies require a seamless strategy in its
• Social and professional topics➝Medical records • Human- integration within the traditional processes of healthcare providers.
centered computing➝HCI theory, concepts and models Despite its promise of streamlined improved business processes,
healthcare providers have been slow in adopting these
Keywords technologies [1].
Electronic medical records; technology assimilation framework;
technology barriers; case study; healthcare technology. Electronic medical records or EMRs represent a technological
solution that provides an array of opportunities for healthcare
1. INTRODUCTION providers. Globally, EMRs have proven to be critical in the
Healthcare is considered as one of the major drivers in national success of technology integration in medical services delivery
economic development. As healthcare becomes more accessible [17]. By lowering costs, attaining accuracy, improved patient care
and affordable, patients are in constant search for better healthcare and data sharing, EMR’s consolidated solutions address the
services delivery. This observation triggered several movements perennial problems associated with manual processes of medical
services delivery [2], [3]. By digitizing medical charts, physicians
Permission to make digital or hard copies of all or part of this work for
personal or classroom use is granted without fee provided that copies are are able to capture, share and maintain patient’s medical data that
not made or distributed for profit or commercial advantage and that are necessary for better delivery of medical services. The
copies bear this notice and the full citation on the first page. Copyrights information captured by EMRs is made accessible to other
for components of this work owned by others than ACM must be medical staff and ancillary services such as laboratories and
honored. Abstracting with credit is permitted. To copy otherwise, or pharmacies [12].
republish, to post on servers or to redistribute to lists, requires prior
specific permission and/or a fee. Request permissions from Prior studies on EMR adoption produced extant research on EMR
Permissions@acm.org. adoption at the individual level with studies focusing on
ICCAI '19, April 19–22, 2019, Bali, Indonesia physicians and nurses. This study contributes to research by
© 2019 Association for Computing Machinery. investigating the barriers to EMR adoption from the
ACM ISBN 978-1-4503-6106-4/19/04…$15.00 organizational perspective. It is critical to understand the role of
DOI: https://doi.org/10.1145/3330482.3330503 technology at the firm level since it can influence the structure,

123
processes and culture of an organization [41]. Using the multiple As a developing economy, the Philippines is no exception.
case study approach, data is gathered from healthcare providers Technologies are widely available to support healthcare services
and analyzed through the dimensions of technology, organization delivery [4]. However, literature is yet to produce research
and environment as proposed by the TOE innovation assimilation investigating how organizations can eliminate barriers to the
framework [34]. A review of related literature on EMR adoption, adoption of EMRs. A paper by Zabat [39] introduced an electronic
EMR in the Philippines and studies on the TOE framework are medical record system at the Research Institute of Tropical
discussed in the next section, followed by the details of the Medicine or RITM. The system captures relevant medical data of
methodology. Limitations and future directions are explained in patients diagnosed with the Human Immunodeficiency Virus or
the concluding section of this paper. HIV. While this research presents an early account of electronic
medical records, the scope and findings of the study are limited. A
2. REVIEW OF RELATED LITERATURE recent longitudinal research by captured the Philippine experience
Recent years have witnessed a steady increase in technology in implementing the Community Health Information Tracking
permeation in the healthcare industry [13]. Healthcare information System in rural areas. The project was funded by the government
systems or HIS have been widely accepted as a basic form of and involved multi-sectoral involvement to develop, deploy and
automation solution among hospitals. Within HIS are several sustain the technology [25].
modules that allow organizational members to freely exchange
electronic data and eliminate the need for laborious processes. 3. THEORETICAL BACKGROUND AND
One of the most critical modules of HIS is the electronic medical METHODOLOGY
records or EMR which acquire, process and store sensitive To understand the barriers in the EMR adoption at an
patients’ medical data for the use of the attending physicians and organizational level, this paper adopts the Technology,
other allied healthcare professionals. From their perspective, the Organization and Environment or TOE framework [34]. One of
use of EMRs has been just as revolutionary. Designed as a the established frameworks in research, it posits that an
replacement and to improve upon the traditional medical paper organization’s tendency to adopt innovation is influenced by its
charts, EMRs capture data and accurately represent a patient's three main contexts: technological, organizational and
status in real time. Patients are given better control on how their environmental. The technological context considers the
medical data is accessed and utilized. Portability of EMRs allow availability of technology within the firm and those that are
data sharing among actors in the medical service continuum available in market. The organization’s available technology
[1] ,[32]. influences the decision to adopt innovation, as it will dictate the
EMR adoption has been widely investigated in literature. Studies scope and pace of its adoption. The organizational context
have focused primarily on individual behavior towards the incorporates internal characteristics of the firm. It includes
utilization of this technology. Investigating individual attitudes relationships among members of the organization, the size,
towards electronic medical records, the paper by Dinev et. al. [7] resources and communication processes. Lastly, environmental
empirically gathered data from the general public residing in the context involves external factors that affect an organization’s
United States and Italy to understand the adoption behavior of decision to embrace innovation. This facet of the framework
electronic medical records. While there were benefits that were considers the availability of technology providers, regulatory
significantly identified, the study revealed that privacy concerns environment and industry structure.
and convenience in the use of EMRs are still emerging challenges This study adopts the case study approach [38] which provides an
that merit further inquiry. Using Social Capital Theory and the empirical inquiry to investigate contemporary phenomenon using
Theory of Planned Behavior, the study by Zheng, Chib, Gao and multiple sources of evidence to capture barriers in EMR adoption
Wang [40], physicians from China were studied on the adoption within the theoretical lens of the TOE framework. Barriers are
of EMRs and the difficulty in sharing medical data with other detriments that challenge organizations in integrating a specific
physicians. To understand sustainability of EMRs, physicians innovation within its internal processes. The case study method is
participated in a study conducted by Ayanso et. al. which revealed an appropriate method conduct an organizational analysis in
that perceived risks and perceived usefulness has a direct impact academic research [8], [19], [35]. First, a focused group
on satisfaction among physicians [3]. While the bulk of the discussion (FGD) study is conducted among healthcare executives
literature focused on capturing individual behaviors of physicians to identify key barriers from the perspectives of the management.
and patients in EMR adoption, there has been a steady increase in From the results of the FGDs, a cross-case analysis is used to
research focusing on the psychological behavior of nurses towards ensure generalizability of the study. Second, organizational
EMR adoption. Their critical role in the successful documents are collected and analyzed to add credibility to the
implementation of EMRs in healthcare is widely supported by the results of the FGDs. Results of the data gathering activities are
existing scholarship [27]. To capture nurse’s perceptions on matched to identify key barriers in EMR adoption. For purposes
EMRs, a study conducted in Turkey revealed that the information of this study, three hospitals were invited and identified as
quality in EMR technology is valued most by this specific Hospital A, Hospital B and Hospital C.
segment of healthcare professionals [33].
Three hospitals were approached to participate in this study. All
Difficulties with the adoption and implementation of electronic hospitals are duly accredited by the Department of Health (DOH).
medical records in the context of developing countries have Hospital A was established in 2010 by a group of enterprising
recently gained much attention among scholars. Common medical doctors to cater to the growing needs of patients in the
detriments in developing economies relate to financial constraints, east of Metro Manila. Located 5 kilometers away from Hospital A,
weak infrastructure, and lack of inadequate ICT skills. Hospital B is a tertiary hospital established in 2006. Considered as
Researchers argue that challenges are present not because of non- a leading healthcare provider in the area, services from its almost
availability of technology but other constraints relative to internal 300 accredited medical doctors caters to the varied needs of its
and external factors such as lack of leadership, weak regulation patients. Hospital C is located at the south of Metro Manila.
and inefficient management style [1], [15].

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Established in 2009, it has established itself as a prominent To validate the results of the FGDs, specific documents were
healthcare provider with modern facilities and highly skilled requested from the participating healthcare providers. These
physicians. All hospitals have recently integrated an electronic documents were analyzed to gain deeper understanding of how
medical record (EMR) module in its hospital information systems. organizations are affected by the barriers identified in the FGDs.
In Table 2 – Supporting Documents, barriers are listed with their
To identify key barriers in EMR adoption, focused group corresponding documents to support the validity of the findings in
discussions or FGDs were conducted by this study. FGDs are the FGDS.
widely used in marketing research and have slowly gained
prominence in academic research [26]. This type of method in
research is adopted to gain an in-depth understanding of key Table 2. Supporting documents
issues in a specific research context. FGDs have been widely used
CONTEXT BARRIERS DOCUMENTS
in research domains such as education, media, and communication
[23]. For this study, healthcare executives were invited to Training Needs Analysis
participate in three separate FGDs to identify key barriers in EMR Complexity Reports
adoption. The sessions lasted for 90 minutes each with a break for Weak Information Technology
15 minutes. To ensure homogeneity [10], participants were Technology infrastructure Plans
grouped according to their primary employment which is either
Hospital A, Hospital B and Hospital C. A total of 18 participants Poor interface
divided into three groups from different departments of the design Helpdesk Logs
selected hospitals participated in the FGDs. This sample is User resistance User complaints
consistent with the proposed number of participants in conducting Organization
FGDs [37]. To ensure representativeness of the study, physicians HR recruitment
with different specializations were included as well as managers Unskilled IT staff documents
from other allied services such as nursing services, pharmacy and Privacy
laboratory technicians were included in the groups. regulation Data privacy compliance
compliance reports
To strengthen further the results of the FGDs, a document analysis
Environment Medical school Higher education
was conducted from participating organizations. Document
analysis is a method of qualitative research in which documents orientation curricula
are examined give depth and breadth around the meaning of topics
being investigated [6]. Analyzing documents entails coding
content into categories similar to how focus group or interview Technology barriers are specific characteristics of electronic
logs are investigated [22]. Documents can be classified into medical records that are detrimental to its wide use in healthcare
physical documents, personal records or public documents. environment [1]. Based on the FGDs, medical doctors and other
Document analysis is usually combined with other research healthcare professionals often experience a learning curve in their
methods to preserve rigor in the research process and improve initial experience in using EMRs. This is supported by the training
validity and reliability of the results [36]. needs analysis reports from the participating hospitals that
identified computers skills as weak among the members of the
4. RESULTS AND DISCUSSION healthcare providers. Hospital A and Hospital C have included
The focused group study yielded specific barriers in EMR EMR trainings in their annual employee development plan. The
adoption. The sessions started with an introduction of the weak infrastructure refers to the instability of the technology
moderator, and the topic to be discussed. Participants were architecture within the participating hospitals. It is the collection
oriented on the rudiments of the session and a brief background of of technology resources including hardware, software and
the research. Statements that are specific to the challenges in the connectivity. The FGDs revealed that technology resources are
adoption of EMR from Hospital A, Hospital B and Hospital C not able to support seamless operation of healthcare information
were coded and categorized into the contexts within TOE. system and are often characterized by system shutdowns and
Statements where majority does not agree (n<4) were dropped errors. As proposed by the different IT departments of the
from the list. A cross-case analysis was applied to the results participating hospitals, infrastructure requires upgrades and is
through identifying common barriers from Hospital A, Hospital B evident in their technology budget plans. However, these budget
and Hospital C as proposed by previous studies [9], [30]. The proposals have been partially approved or have been totally
results are detailed in Table 1- FGD Results. rejected. Ease of use has been identified as a driver in the adoption
of healthcare information systems. A vital feature in technology
Table 1. FGD results products is good interface design as it allows faster data capture
CONTEXT BARRIERS A B C and retrieval. As revealed during the open discussions, most
physicians and users find current EMR systems non-responsive to
Complexity 5 4 4 the fast-paced requirements of operations. These findings are
Technology Weak infrastructure 5 6 4 consistent with results of prior studies [5], [14]. Further evaluation
of technical request logs from the IT departments of the
Poor interface design 4 5 6 participating hospitals show that primary users of EMRs often
Organization request assistance in encoding data, navigating the system and
User resistance 4 7 4
producing reports especially during the initial phases of the EMR
Unskilled IT staff 5 6 3 system deployment.
Environment Privacy regulation compliance 6 4 5 In the organizational context, barriers to EMR adoption are
Medical school orientation 5 4 4 internal characteristics of the healthcare provider that prevents

125
technological innovation to persist [1]. In adopting innovation, In conclusion, this paper has identified key barriers in EMR
support from primary users is critical to its successful integration adoption through the TOE perspective. Through a case study
[11]. Initial resistance from the members of organizations often approach in select hospitals, this paper considered factors that
hampers technological advancements. While Hospital A and organizations need to address in order to successfully implement a
Hospital C, have incorporated reforms to address concerns during technology solution such as an EMR. Consistent with prior
the planning stages of the EMR projects, user resistance is a research, key barriers within the technology context include
prominent key barrier in the adoption of EMRs among the complexity, weak infrastructure and poor interface design [13],
participating healthcare providers as discussed during the FGDs. [31]. These barriers can be addressed by ensuring a stronger
A review of user complaints submitted to the IT departments can cooperation between the healthcare providers and the vendor. A
be primarily classified as minor issues and can be addressed by user-centered design that addresses these concerns can be
reading the user manual. In hospital B, documented complaints inculcated by the providers to their developers. Further,
have additional comments requesting an option where the users management will require appropriate orientation on the
request reverting back to manual processes. The lack of IT staff importance of technology to support their strategic initiatives.
equipped with the skills to maintain EMRs was highlighted in the Aligned with previous studies, organizational barriers include user
discussions during the FGDs. Physicians in Hospital B intimated resistance and lack of adequate skills [3], [25]. Since these
that their IT staff lack the necessary knowledge and skills to barriers are internal and therefore the management have control,
address user complaints. On the other hand, Hospital C recently appropriate interventions may include increased resource
hired several IT staff members but are still heavily reliant to allocation to medical staff orientation on the benefits of EMR
vendor support. An evaluation of documents pertaining to the solutions and better compensation to its IT staff. Lastly, earlier
recruitment of IT staff in the participating hospitals reveals that studies have identified several external factors as challenges in
majority of applicants are unsuccessful due to inadequate skills EMR adoption [13], [14], [21]. This study identifies privacy
necessary to support EMR implementation and integration compliance and medical school orientation as detriments to EMR
activities. adoption. A clear public policy and focused guidance specifically
for EMRs should be considered by government bodies to
EMR adoption in the environmental context refers to external encourage automation of EMR records. On the other hand,
constraints that organizations consider in its decision to digitize curricular review with the objective of integrating technologies in
their medical records [1]. In the FGDs, participating healthcare the medical practice should be instituted in higher education
managers discussed the challenges in incorporating data sector. To address these barriers, constructive cooperation among
protection mechanisms on EMRs and have complained on the lack the healthcare industry stakeholders to capitalize on the benefits of
of policies and guidance from the government. This is supported electronic medical records towards a sustainable and better health
by status reports from the compliance committee to the National services delivery should be fostered.
Privacy Commission that highlights the additional burden
encountered by healthcare providers in ensuring data privacy in its 6. ACKNOWLEDGMENTS
EMRs which supports prior investigations [16], [18]. Participants The researchers would like to acknowledge the participants from
of the FGDs from the three hospitals also shared their initial the different healthcare providers who devoted precious time
perceptions on EMRs. Based on their experiences, EMRs were during the focused group discussions. Likewise, this study will not
not incorporated in their courses during medical school. As such, be completed if not for the documents entrusted by the different
most of them will have to rely heavily from their respective IT departments of the participating organizations. Lastly, we thank
departments or have to learn by themselves on the intricacies of the editors and reviewers for the valuable feedback to improve the
EMR solutions. This study reviewed the past curricula of the top manuscript of this paper.
three medical schools in the Philippines and revealed that there is
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