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XJM
20,1 Health-care information systems
adoption – a review of
management practices
130 Emil Lucian Crisan and Alin Mihaila
Babes, -Bolyai University, Cluj-Napoca, Romania and Iuliu Hațieganu University of
Received 26 April 2021 Medicine and Pharmacy, Cluj-Napoca, Romania
Revised 1 June 2021
Accepted 14 June 2021

Abstract
Purpose – The purpose of this paper is to provide practitioners and researchers a more condensed and
structured perspective on the adoption of information management systems by the health-care industry,
given the spread and the increased amount of research concerning the topic.
Design/methodology/approach – This paper is a literature review. A Technology (What?) – Context
and before adoption Analysis (When and Why?) – Implementation (How?) – Outcomes (What for?) framework
is used to present the trends concerning information technology adoption in an accessible manner.
Findings – The main finding is that small or large health-care organizations should no longer focus on
information systems’ adoption but should adopt a digital transformation paradigm. By considering this
paradigm, management practices related to information technologies’ adoption projects should be
complemented by practices related to the continuous organizational changes and readaptation of the
organizational strategy, to benefit the advantages information systems can offer.
Practical implications – The main recommendation for health-care industry managers is to adopt
specific practices to manage the digital transformation process of their organizations, as they should
understand that it is no longer about adopting information technologies, but about managing the associated
organizational change.
Originality/value – Instead of focusing on specific information systems’ adoption as other papers do, this
paper provides a holistic understanding of the information technologies and management practices which are
used in the field.
Keywords Management practice, Information technology adoption, Electronic health records,
Health-care industry, Digital transformation, Health-care information system
Paper type General review

1. Introduction
We live in a new well-connected world, dominated by the internet. Health care is recognized
as an industry with a low acceptance of information technology. Only few information
technology (IT) systems, such as Electronic Health Records (EHRs), have been widely

© Emil Lucian Crisan and Alin Mihaila. Published in Vilakshan – XIMB Journal of Management.
Published by Emerald Publishing Limited. This article is published under the Creative Commons
Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative
works of this article (for both commercial and non-commercial purposes), subject to full attribution to
Vilakshan - XIMB Journal of
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Management creativecommons.org/licences/by/4.0/legalcode
Vol. 20 No. 1, 2023
pp. 130-139 This work was supported by the grant Partnership for the transfer of knowledge in biogenomics
Emerald Publishing Limited
0973-1954
applications in oncology and related fields – BIOGENONCO, Project co-financed by FEDR through
DOI 10.1108/XJM-04-2021-0121 Competitiveness Operational Programme 2014 – 2020, contract no. 10/01.09.2016.
accepted by the US industry (Hopper, 2015). The rate of implementation of integrated health- Health-care
care IT systems, similar to business Enterprise Resource Planning software, is low, and the information
basic solutions provided by Microsoft (e.g. Microsoft Word) and Google (Google Drive)
dominate the market. This poor acceptance has been associated with different causes such
systems
as the different revenue streams within the industry (public, individuals, companies), the adoption
multiple employees categories and the lack of their proper training, the complex outsourced
infrastructure for different and not interconnected organizational processes, the high costs
for computerization, and the organizational culture as a whole (Hopper, 2015). This low 131
acceptance of integrated solutions diminishes continuous improvement capabilities, since
most used techniques as lean management, Six Sigma, and Lean Six Sigma are implemented
based on data availability (Henrique and Godinho Filho, 2020).
The research concerning health-care information technology has been focused in time
with analyzing the impact of technology adoption, more papers providing evidence on the
positive impact it has towards medical outcomes (Kruse and Beane, 2018), but the outcomes
concerning costs are contradictory (Chaudhry et al., 2006). In this context, being a manager
who must take IT solutions’ adoption or replacement decisions is not an easy job. This
article is an analysis of different literature reviews concerning how managers should adopt
information technology in health care, the results being a structured and condensed
perspective, using a Technology (What?) - Context and before adoption Analysis (When and
Why?) – Implementation (How?) – Outcomes (What for?) framework. This framework is
similar to the frameworks used for design propositions in general (Denyer et al., 2008) and it
can be used as a reference by practitioners during IT systems’ adoption. The construction of
this framework is required by both practice and research since most papers cover narrow
topics concerning IT adoption and fail to cover the needs of clinicians, health-care
administrators, and health-care policy makers (Jones et al., 2014).
The paper is structured as followed: Section 2 details the used methodology, Section 3
contains the results by the use of the already specified framework, while Section 4 presents
the discussion and conclusions.

2. Methodology
This study is a literature review of the most important and recent sources which deal with
health information systems (HIS) adoption management practices, the methodology
proposed by Tranfield for conducting systematic literature review being considered
(Tranfield et al., 2003).
Identification and screening: since there are many papers which cover this topic, we have
decided to perform a review of existing reviews concerning the topic. The approach used for
identifying relevant sources was searches in google scholar, the most comprehensive online
database, for reviews related to information technology in the health-care industry. The initial
search of the combination “healthcare” “systematic literature review” “information systems”,
conducted in December 2020, has delivered about 14.200 results. The second search of the
combination “health-care information systems” “systematic literature review” led to about 900
results, the decision made was to select from these results the 147 papers with more than 30
citations for screening. To ensure that the articles included correspond to the topic, the inclusion
criteria for the screening of abstracts were used: a) published after 2000; b) address the adoption
of information systems in the health-care industry. A number of 56 papers met these criteria, the
full papers analysis led to the acceptance of 24 papers from the sample. Other four papers
referenced by these papers were included in our sample, which finally equaled 28 papers.
Extracting: Each article has been further analyzed considering its contribution to the
proposed framework. The contribution of articles to the framework categories is presented in
XJM Figure 1, some papers being used in more than one category. Later, for each category the articles
20,1 were analyzed in detail to provide the most important ideas and best practices regarding
information technology adoption. All these ideas are presented in the results section.

3. Results
3.1 Technologies (What?)
132 Digital transformation has been recognized as changing the health-care ecosystem, the main
systems adopted by this industry being EHRs, Health-care Information Systems, HIS and
customer health-care technologies (Mehta and Pandit, 2018). A general perspective
concerning the existing software in the medical area, based on our analysis, is provided in
Figure 2.
Four key stakeholders have been identified, the major users for whom the software is
mainly addressed: health-care organizations, patients, health-care professionals, and
national/regional bodies. For providing medical services, it can be observed that most
technologies are used by more stakeholder categories.

Technology (What?) - 11

Context and before

Contributions to adoption Analysis (When
Figure 1. frame categories and Why?) - 7
Number of articles
contributing to the Implementation (How?) - 5

analysis Outcomes (What for?) - 11

Naonal/regional
Healthcare bodies
organizaons
Naonal/ regional health informaon
system

ERP (Integrated Hospital Process and programmac acon

Informaon system) evaluaon and management systems Paents

Electronic health/ medical record

Human resources
informaon systems Internet of
things
Decision support or Smartphone
recommender systems healthcare apps

Emerging soware Reminders

Consumer health
technologies
informacs
Internet of things Healthcare
Figure 2. professionals
A framework for
health-care
information systems
At the heart of health-care information systems is the Electronic Health/Medical Records of Health-care
patients, which is the memory of the health-care process. EHRs are systems used to keep information
patients data, as single data files or longitudinal collections covering different medical
processes, used for primary care (Ludwick and Doucette, 2009) or any other medical process.
systems
EHRs are built by considering the side of patients, for whom all their health records are kept. adoption
The same software is called electronic medical record when the organizations which provide
medical care introduce information and data into the system (Ludwick and Doucette, 2009),
and even electronic patient registries (Tomasi et al., 2004). EHRs’ advanced features include 133
human resource information systems, decision support systems, emerging software
technologies as the Big Data, or Internet of things in relation to different available
equipment. The use of human resource information is related to the management strategy of
the organization, and less to the operational benefits, their goal being to motivate human
resources and to increase the transparency concerning human resources performance
(Tursunbayeva et al., 2016). Decision support or recommender systems have been introduced
in health care both for nursing care (Duan et al., 2011), medical care in general (Jones et al.,
2014), or smaller parts of the medical process, as medication administration. This way,
professionals’ decisions are easier since they can consider the actions previously performed
in similar cases by themselves or other colleagues. Medical simulation could be also
included in this category, being around for many years (Vonderembse et al., 2017). Internet
of things is related to the use of multiple internet connected equipment for creating an
interconnected system of individuals, equipment, services and networks anywhere and
anytime (Rajeswari et al., 2018), a continuous connection between things. There are several
examples of IoT in use as the use of ECG equipment, temperature sensors, blood pressure
and glucose sensors. One emerging technology (Kruse et al., 2016) associated with EHRs is
Big Data, which offers the premises for analyzing huge amount of complex data, identifying
patterns which can guide medical decisions, and providing decision support concerning
costs and quality problems, are its major benefits (Mehta and Pandit, 2018).
By considering the same patient in the center approach of the medical service, but also
considering the exchange capabilities of IT systems in general, another type of HIS has
appeared – the regional or national health information system. It is built on the premise that
different stakeholders (clinics, hospitals, pharmacies, laboratories etc.) change information
and improve care delivery at regional/national level (Mäenpää et al., 2009). These systems
are built for improving tailored health-care services, prevention, access to medical care,
adherence of different stakeholders to the same standards and policies, but their use is also
associated to increased informational risks and with increased privacy and hardware
requirements (Mäenpää et al., 2009). These systems can vary in terms of size and features,
like EHRs.
Health-care professionals are addressed by reminder apps, usually associated with HIS,
but also standalone applications, education focused smartphone apps, and consumer health-
care applications in which they communicate with patients. Reminders have been
introduced as extensions of HIS and are used for reminding health-care professionals that
some patients need different treatments or interventions. They increase the quality of
practice given that specific procedures are performed at the right time and in the right order,
but they can also be stressful for professionals (Backman et al., 2017).
Patients’ software has increased its diversity lately, starting with smartphone apps,
consumer health-care applications and also different apps integrated in different medical
appliances which are capable of communicating to the internet, the so-called internet of
things. Consumer health informatics is designed to communicate directly with consumers,
who introduce information concerning their health state, and later receive personalized
XJM health information (Gibbons et al., 2011). Its benefits are related to diminishing the costs for
20,1 reaching consumers, can enhance the interventions performed by professionals, and
improve the feedback provided to consumers/patients (Gibbons et al., 2011).
One category of consumer HIS which is gaining ground is the health-care applications for
smartphones. As smartphone technology becomes cheaper and accessible to everyone, there
are multiple companies which have developed software for different users’ categories:
134 consumers/patients, medical professionals, students, and medical organizations. The main
functions they have are (Mosa et al., 2012): disease diagnosis, drug reference, medical
calculator, literature search, clinical communication, hospital information system, medical
training and education, chronic illness disease management and general health-care
applications.

3.2 Context and before adoption analysis (When and Why?)

There are multiple causes for adopting IT in the medical field (Vonderembse et al., 2017).
These causes, as part of the larger context which contributes to the adoption of these
technologies, are reported as poorly analyzed by literature (Jones et al., 2014). One part of
literature is concerned with building frameworks for evaluating already adopted HIS by
organizations. For example, a set of recommendations are provided by Ammenwerth et al.
(2003): the evaluation should be performed as a project, in an organized manner, by
establishing the goal, the tools, the time needed, in a balanced manner; the evaluation should
be documented at all phases, the use of already used methods of evaluation being
recommended; all stakeholders should be involved, including employees and managers,
especially when further support is needed; a thorough evaluation is recommended, including
the use multidisciplinary methods and triangulation of methods. While analyzing the
frameworks used in the field for analyzing HIS, Andargoli et al. (2017) observed that most
frameworks do not provide proper reporting formats, while the ones that do prove to
enhance the quality of those evaluations. An important observation is that most HIS
evaluations are an ongoing process, not a one-time project, a formative approach which
targets continuous improvement being thus the best practice.
Another approach used for analyzing the existing information systems is the maturity
analysis, which considers different levels for self-assessment: initiation, contagion, control,
integration, data administration and maturity, as previously established by Richard Nolan
(Carvalho et al., 2016). However, depending on the type of organization and the goal of the
evaluation, a maturity model can be identified and used as the existing research provides
multiple models for multiple uses (Carvalho et al., 2016). These maturity models are useful
especially when the self-assessment has a recurring character and this way the progress can
be assessed.

3.3 Implementation (How?)

3.3.1 General approaches for HIS implementation. As a general perspective, HIS
implementation should not be made as implementing information technology in business.
Health care has multiple characteristics which differentiates it in comparison to other
industries (Connell and Young, 2007): the multiple stakeholders involved (patients, doctors,
external services providers, managers), the increased complexity of the medical process and
its multiple goals nature, the importance of the clinical function which sometimes is in
balance with the management one, and the need for software to deal with more person-to-
person knowledge transfer than a normal business might. Secondly, a differentiation should
be made between HIS adoption, which means the installation and making available the
software, and HIS implementation, which refers to wide use of the technology by all affected
parties (Sligo et al., 2017). Successful implementation is more related with changing the way Health-care
things are performed, or change management, than adoption of technology. Also called information
digital transformation (Matt et al., 2015), it should be considered an important process by all
managers, and multiple efforts should be allocated for implementing this long-term strategy.
systems
3.3.2 Success factors which can affect HIS implementation process. Project management adoption
success varies by project types, industries, nationalities, individuals and organizations
(Müller and Jugdev, 2012). Based on the performed analysis, these factors have been
135
grouped in different categories by considering the Technology–Organization–Environment
framework proposed by Tornatzky et al. (1990).
Firstly, the technology itself can influence the success of the adoption. Ludwick and
Doucette (2009) has determined that the most important success factors are “systems’
graphical user interface design quality, feature functionality, project management,
procurement and users’ previous experience affect implementation outcomes”. This factor
has been also recognized in other papers (Lau et al., 2010; Ross et al., 2016). Technology
should be fitted to internal context, the continuous adoption to internal changes being
recognized as diminishing the barriers of adaptability and to increase acceptance and
adoption (Ross et al., 2016). Surprisingly, costs of the solution are not the main barrier for
technology adoption, as observed by comparing the barriers identified by Ross et al. (2016).
When it comes to organizational factors, human resources, the most important resources
in health care, have an important role in HIS adoption. Gagnon et al. (2012) observe that
health-care professionals influence the adoption of HIS: their positive perceptions
concerning the benefits of the systems (usefulness), followed by the perceptions regarding
ease of use, were identified as main drivers for adoptions, while the perceptions concerning
the lack of fit between the adopted systems and work practices, the low familiarity with
information technology, and the lack of time were the main barriers for adoption. In some
cases, the major barrier for IT adoption is health-care professionals’ acceptance of these
technologies (Ross et al., 2016; Tomasi et al., 2004), the gradual introduction and continuous
training and communication with human resources being recommended. Other
organizational success factors have been also considered in literature. It is revealed that
there should be a socio-technical fit between the organization which receives the software,
and the software itself (Ludwick and Doucette, 2009; Ross et al., 2016). The existence of
adequate resources and support is recognized as important for the adoption of information
technologies (Mair et al., 2012; Ross et al., 2016). Leadership is a very important determinant
of the success of information technologies adoption (Ross et al., 2016). It appears that clinical
leaders who have technical medical IT skills and prior experience with IT project
management are more committed in performing the adoption of new technologies and to
engage in proactive behaviors and partnerships with IT professionals (Ingebrigtsen et al.,
2014).
The only environmental factor we have identified in the selected papers is the legislation
which can hamper HIS implementation (Ross et al., 2016).

3.4 Outcomes (what for?)

There are many opinions concerning the impact measurement related to information
technology adoption in health care. Backman et al. (2017) consider that information
technology adoption in health care is not too much analyzed, Sligo et al. (2017) consider that
proving the cost-effectiveness of HIS adoption in comparison to the traditional mode of
delivering health care is a challenge, while Rahimi and Vimarlund (2007) consider that a
standard framework for measuring HIS adoption is missing.
XJM There are more reviews which perform a wide analysis of the outcomes or impact of HIS
20,1 adoption by considering all fields and software types. The benefits identified by Tomasi
et al. (2004) are increased standardization of services as physicians adhere to standardized
therapeutic plans, and cost reduction. Another categorization considers the adherence to
guideline-based care by the use of reminders and decision support systems, enhanced
surveillance and monitoring based on large-scale screening and aggregation of data, and
136 decreased medication errors (Chaudhry et al., 2006). A more recent categorization includes
quality of care benefits (improved processes and customer satisfaction), productivity, and
patient safety (Colicchio et al., 2016). Finally, the outcomes refer to quality of care,
medication safety, and efficiency (Sligo et al., 2017).
Wider approaches are concerned with providing analysis frameworks which cover all
benefits. An example is the one provided by Lau et al. (2007), who provide a framework
which explains how different outcomes are interconnected. Quality, referring to system
(functionality, performance and security), information (content and availability), and service
(responsiveness), determines use levels among stakeholders (current use and intention) and
user satisfaction (competency, satisfaction and ease of use). Use and user satisfaction further
influence the net benefits measured as net benefits related to quality (patient safety,
appropriateness/effectiveness and health outcomes), access (access to service and patient/
caregiver participation), and productivity (efficiency, care coordination and net costs). This
framework explains how information systems create value within organizations, being used
as a reference model for managers in evaluating outcomes levels for different adoption
projects (Lau et al., 2010).
Negative outcomes related to HIS adoption have also been observed. The main refer to
process implications, such as order entry, staff interaction, and provider-to-patient
communication (Buntin et al., 2011). Sometimes, after HIS are adopted, the previous
performance is not improved or the adoption process takes longer than considered. These
cases have been however rarely reported and are related to lower number of adopted
functionalities (Buntin et al., 2011).

4. Discussion and conclusions

By considering all the dimensions affected by HIS introduction, namely the health-care
process, the relation with patients, clinician diagnosis support (Sligo et al., 2017), it could be
argued that health-care organizations are part of the digital transformation process, a long-
term process which involves not only the acquisition and use of a software technology, but
the “transformations of key business operations and affects products and processes, as well
as organizational structures and management concepts” (Matt et al., 2015). This paper
provides condensed information regarding HIS adoption by considering this digital
transformation approach.
We have evaluated the available technologies (What?), the practices which should be
followed by managers before adoption (When and Why?) and during the adoption (How?),
and the outcomes which should be targeted in relation to HIS adoption process (What for?).
Technologies are so different and cover different needs of different stakeholders. Based on
the current analysis, some advices are given for health-care organizations managers:
 Begin with the end in mind and establish targets. One major aspect to consider is to
answer the question: which is the goal of HIS adoption before starting the process?
Given the multiple parts involved in technology adoption, it is normal that success
is perceived in terms of time, costs and efficiency by managers, as it is analyzed in
terms of usability, safety, accessibility by clinicians. Any IT system adoption is
 hard to be measured in terms of outcomes (Sligo et al., 2017), but an equilibrium Health-care
between all stakeholders goals should be established; information
 Be aware of the moving target which is digital transformation and measure the systems
current level of your organization into this transformation. The analysis concerning adoption
the needs for information technology can be a one-time effort, but we recommend a
continuous monitoring of information technology and systems from your
organization. A maturity model can be used to track the evolution and also to 137
communicate the targeted goals concerning this digital transformation process. The
advantage of maturity models is that they contain benchmarks or targets for your
organization, targets which can changed in time depending on environmental
changes;
 Re-analyze the available technologies to identify which are the opportunities for
improving your organization services. The number of available technologies and
their complexity increases as they become more accessible. One part of improving
health-care organizations services is related to these technologies, the adoption of
patient-centered technologies being one trend in health care. The digital
transformation is not only about the organization, it is about how people live their
lives. We have provided here a list of the available technologies, but they are in a
continuous development, and they should be monitored this way;
 Manage the context before disruptive adoptions. Medical organizations are complex
systems where the medical process is the most important one. This way, medical
professionals are important participants whose resistance concerning the adoption
of new HIS is related to the poor preparedness made by managers. We have
provided here some success factors which determine the successful adoption of HIS.
They refer to the complexity which describes the nature of health-care organizations
and they should be considered by managers before starting wide changes in their
organizations.

As a general conclusion, HIS adoption is not about adoption itself, but about the change
management which has to be performed in health-care organizations to gain the full benefits
which can be associated with this change process. Future research should focus on the
digital transformation of health-care organizations instead of analyzing the traditional
information systems’ adoption.

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Corresponding author
Emil Lucian Crisan can be contacted at: [email protected]

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