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Barriers

to Hospital IS in Nigeria/Benson 1


ISSN 2159-6743 (Online)

Assessing Barriers to
Adoption of Hospital
Information Systems in
Nigeria
Ayodele Cole Benson, MB BCH, PhD DHA *

Abstract
This paper provides detailed information on the mixed method case study research using indepth interviews and a questionnaire-based survey to ascertain the barriers hindering
adoption of hospital information systems in Nigeria. The discussion in this paper provides
the problem that a robust health care policy on implementation of a hospital information
system is lacking in Nigeria and that caregivers in the country have yet to commence
noticeable implementation of hospital information technologies. The objective of the study
was to explore the reasons for the absence of hospital information systems (HIS)
implementation policy in Nigeria and the impact of the lack of adoption of HIS in the health
care delivery system of the nation. In this paper, an elaborate analysis on method is provided
with emphasis on design appropriateness, population, sampling, and data collection
procedure and rationale. Other essential elements of the paper include internal and external
validity approaches, data analysis, organization, and clarity. The analysis method involved
the integration of qualitative and quantitative data sets into two separate data sets of
coherent wholes, thereby presenting the entire research as a holistic, reflective, and
integrative process. Results obtained from the study are summarized in tables.

Keywords: Global health, health information systems, hospital information systems, review of
literature, Nigeria



*Principal, Echo-Scan Services, Ltd.
Correspondence: Ayodele Cole Benson, MB BCH, PhD, DHA, Email: benson_ayodele at yahoo.com


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JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 2

Assessing Barriers to
Adoption of Hospital
Information Systems in
Nigeria
Electronic Medical Record Systems (EMRs) in developing countries facilitate improved data collection
and information retrieval and generation of research reports (Williams & Boren, 2008). The problem is
that a robust health care policy on implementation of hospital information system is lacking in Nigeria.
Caregivers in the country have not yet commenced noticeable implementation of hospital information
technologies (Ouma & Herselman, 2008; William & Boren, 2008). Williams and Boren (2008) posited that a
poor technological base and lack of funding support by the developed countries may be responsible for
poor implementation of electronic medical record systems in the developing countries.
The consequences of non-adoption of hospital information technologies include: mix up with
laboratory results, misdiagnosis, medication order errors, and mismanagement of patients (Keenan et al.,
2006; Okeke, 2008). Williams and Boren believed that successful implementation of the Millennium
Development Goals (MDGs) will hinge on the assistance of the developed countries to poor nations in
Sub-Saharan Africa. Such assistance will be to develop human capital, increase funding aids, and
collaborate with local communities to facilitate implementation of hospital information systems adaptable
to their peculiar environment to improve delivery of care. This mixed method study examined the
perceptions of stakeholders by gathering information on the perceived reasons for the paucity of policy
on health information technology and causes of poor implementation of hospital information systems in
Nigeria.
STUDY PURPOSE
The purpose of this mixed method research was to identify the barriers hindering adoption of
hospital information systems in Nigeria. The study was designed to examine the perceptions of heads of
units at the federal Ministry of Health, members of the House Committee on Health, CEOs of health care
organizations, directors of State Ministry of Health, and COOs of information technology companies in
the six geo-political zones of Nigeria. Research instrument was structured to gather information on the
perceived paucity of health information technology policy in Nigeria and reasons for the poor
implementation of hospital information systems in the country.
Qualitative exploratory data was obtained through a purposive sampling of 18 members of the
sample population by selecting three persons in each geo-political zone. Sampling targeted a participant
each from health care policy makers, health care providers, and information technology experts in the six
geo-political zones of the country. However, interviews were eventually granted by 19 participants
because of additional interview granted by an Internet service provider in the North Central geo-political
zone. A questionnaire-based survey was conducted to gather quantitative descriptive data from 180
participants obtained by proportionate stratified random sampling methods to break the heterogeneous
population into its homogeneous components. Themes and theorems generated from the qualitative
aspect of the study was subjected to content data analysis and compared with SPSS statistical analysis of
the quantitative data. The mixed method approach helped to ascertain the relationship between health

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care policy, health care funding, technological advancement, human capital, and health care
infrastructure as independent variables and the implementation of hospital information systems as the
dependent variable.
METHODS
Sample Size Determination
The determination of sample size is a common task for many organizational researchers.
Inappropriate, inadequate, or excessive sample sizes continue to influence the quality and accuracy of
research. A formula for selecting the sample size for a research problem based on a level of significance
and a set error rate was proposed by Cochran (1977). To obtain the most efficient, representative sample,
in this research, the following Cochrans formula for sample size determination was used:

Z
n / 2

Where;

n = minimum sample size required


Z / 2 = the value of the standard normal ordinate at % level of significance

Hence,

at the 5%level of significance, the computed values are;

Z / 2 = Z 0.025 = 1.96
= 0.22 (is the chosen error rate)
= 1.47 (the estimated population standard deviation)
Table 1 depicts the value of the sample standard deviation, which is an estimator for the population
standard deviation. A sample size of at least 172 is required to arrive at a sample with a sampling error of
at most 0.22. For convenience, a sample size of 180 was used so that the three strata could be included
adequately.
Table 1
Descriptive Statistics

Unclear health care policy on


hospital information systems is a
major barrier to implementation in
Nigerian hospitals

Minimum

Maximum

Mean

Standard
Deviation

180

3.07

1.47

The rest of the computation follows thus;


2

Z 1.96 1.47
n / 2 =
= 172
0.22
Research Questions
Presenting well-articulated research questions is an important step in any research process because
these questions convey the research objective and determine the research methodology. The specific
purpose of a research process is gleaned from research questions (Creswell, 2005; Onwuegbuzie & Leech,
2005). According to Onwuegbuzie and Leech (2005), research questions are evidently more important in
mixed methodology research because researchers employing the mixed methods approach combine
pragmatism with an elaborate system of philosophy. In mixed methods studies, the types of

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instrumentation and data analysis employed are driven by research questions. The primary research
question in this study is phrased as follows: What factors explain the paucity of policy on health
information technology and the poor implementation of hospital information systems in Nigeria? To
answer the primary research question, the following sub-questions helped elicit the information needed.
1. What are the reasons for the absence of HIS implementation in Nigeria?
2. What are the implications of the absence of a policy on HIS in Nigeria?
3. What is the impact of funding on the implementation of HIS in Nigeria?
4. What is the impact of infrastructure on the implementation of HIS in Nigeria?
5. What is the impact of human capital on the implementation of HIS in Nigeria?
6. What is the impact of technology on the implementation of HIS in Nigeria?
Design Appropriateness
The present mixed method case study research using in-depth interviews and a questionnaire-based
survey provided the perceptions of the various stakeholders that could eventually be necessary in
planning a framework for implementation of hospital information systems in Nigeria. The intent of the
qualitative component was to understand the social situation affecting the Nigerian health care system
through an intuitive process in which the researcher gradually made sense of this social phenomenon by
contrasting, comparing, replicating, cataloging, and classifying the object of study (Simon et al., 2008).
Matching the discoveries of the qualitative aspect of the study with the descriptive research data and
the results of the literature review provides triangulation, and ascertain the appropriateness of the chosen
research design. The research questions aided the development and testing the adequacy of research
instruments, and assessing the reliability of the research findings. According to Levy and Lemeshow
(2008), survey objectives should include specification of the information to be gathered and the
population to which the discoveries of the survey were extrapolated. Collins, et al. (2006) asserted that the
mixed method research approach improves instrument fidelity, thereby maximizing the appropriateness
and usefulness of instruments to generate research data. The quantitative aspect of the mixed method
research employing descriptive statistical analysis was appropriate for this study because it enabled the
explanation of a cause and effect relationship and used statistics combined with mathematical models
and philosophy for relevant data analysis and hypothesis testing (Okeke, 2008).
According to Nerurkar (2008), the ultimate use of statistics is to make decisions about hypotheses and
to make inferences using obtained data to answer scientific questions. The mixed method analysis
fulfilled that objective. Whereas a qualitative case study alone would have been an appropriate design,
the large volume of data to be obtained from a large population would have become a limitation as biases
could be introduced during the various interviews that were conducted. Typically, as the size of a dataset
grows large, the complexity of questions that one addresses with it also increases, thereby introducing
problems of multiple variables and challenges of regression in time (Creswell, 2005).
A quantitative study alone would have eliminated the possibility of exploring relevant themes about
hospital information systems in Nigeria from major health care stakeholders that made up the study
population. Second, using a quantitative research approach would have involved primarily collecting,
analyzing, and interpreting numeric data, but the addition of non-numeric data from a qualitative design
provided valuable insights into the subject. The dual quantitative-qualitative feature evoked both
deductive and inductive reasoning and provides future researchers an avenue by which to verify,
validate, or replicate the study (Onwuegbuzie & Leech, 2005).
Although listening to the story about a social situation to gain participant's viewpoint was the
strength of qualitative research, the story also provided rich descriptive information that helped to
triangulate quantitative results and set them into their human context. Thus, the mixed method research
was appropriate for the study because it presented the exploratory-confirmatory continuum on the
hindrances to adoption of hospital information systems in Nigeria. Onwuegbuzie and Leech (2005)
elaborated that exploration demands using primarily inductive tools to examine a concept or construct,
and research a phenomenon or situation with an aim of developing tentative hypotheses or

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generalizations. The descriptive component of research involves identification and explanation given to
antecedents, nature, and etiology of a phenomenon.
Validity
Almost two decades ago Maxwell (as cited in Onwuegbuzie & Leech, 2005) conceptualized that
validity can be classified into five types: descriptive validity, interpretive validity, theoretical validity,
evaluative validity, and generalizability. Maxwell further differentiated generalizability into internal and
external generalizability; with internal pertaining to generalizability within a particular setting or studied
population. Whereas, external generalizability, that also denotes external validity, is defined by Sproull
(2003) as the ability to generalize the results of a research to other populations, settings, treatment
variables, and measurement variables (p. 138). Threats to external validity are research shortcomings
that affect the ability to glean correct information from sample data and apply the same to other
populations, settings, past, present, and future situations (Creswell, 2005). The mixed method design
used in this research study that gathered data across the six geo-political zones in Nigeria creates a highpotential for generalizability of results in both current research and future studies.
Combining qualitative and quantitative paradigms in this study ensured that internal validity was
maintained. Sproull (2003) defined internal validity of research instruments as the ability to measure in
totality what it intends to measure from the population. Carter and Belanger (2005) suggested that using
factor analysis, the internal validity of research constructs are measured; most items are assessed if they
load properly on their expected factors. In the present study, research instruments were subjected to
factor analysis before using them to gather data. Such assessment of research instruments and application
of corrective measures to identify flaws were expected to ensure reliability.
Reliability of the Instruments
According to Carter and Belanger (2005), reliability is a measure of the degree to which an instrument
measures the same way each time it is used under the same research conditions on the same sample. The
reliability of a research instrument (questionnaire) is best measured by the Cronbachs alpha statistic
(Salkind, 2003). Cronbachs alpha is designed as a measure of internal consistency; that is, a test of
whether all items within the instrument measure the same thing. This simply means a measure of
reliability of the question items. Alpha is measured on the same scale as the Pearsons product-moment
correlation coefficient and typically varies between 0 and 1.
Although a negative value is possible, such a value indicates a scale in which same items measure the
opposite of what other items measure. The closer the alpha is to 1.00, the greater the internal consistency
of items in the research instrument. At a conceptual level, coefficient alpha may be thought of as the
coefficient between a sincere response and all other sincere responses of the same item drawn randomly
from the same population of interest (Salkind, 2003). In the present study, the researcher included 12
construct question items in the questionnaire to evaluate and assess the barriers to adoption of hospital
information systems in Nigeria using three categories of participants. The formula that determines
Cronbachs alpha makes use of the number of variables or question items in the scale (k) and the average
correlation between pairs of items (r):

kr
1 + (k 1)r

Based on the formula of alpha, a rule of thumb that applies to most situations for the interpretation of
reliability is as shown in Tables 2-4.


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Table 2
Rules for Reliability Test
Cronbachs Alpha

Remark
Excellent

0.9
0.8 < 0.9
0.7 < 0.8
0.6 < 0.7
0.5 < 0.6
< 0.5

Good
Acceptable
Questionable
Poor
Unacceptable

Table 3
Case Processing Summary
Status of Participants
Policy makers

Items
Cases

Valid
Excluded*

Healthcare providers

Cases

Valid
Excluded*

Internet service providers

Cases

Valid
Excluded*
Total

Percent

60

100.0

0.0

60

100.0

0.0

60

100.0

0.0

180

100.0

* Listwise deletion based on all variables in the procedure.


Table 4
Reliability Statistics
Cronbach's Alpha

Cronbach's Alpha
Based on
Standardized Items

Number of Items

Policy makers

0.924

0.921

12

Healthcare providers

0.897

0.893

12

Internet service providers

0.896

0.899

12

Status of Participants

Apart from the already discussed measures, other approaches were used to ensure instrument
reliability in the study was as encouraged by Creswell (2005) that included the following:
1. Designing a research instrument to ask the same question in different ways to increase the
validity of the responses.
2. Avoiding causal arguments during interviews to avoid making cause-and-effect statements
that compel participants to introduce biases in their responses.
3. Staying within the study scope to ensure interpretative validity.
Based on the results in Table 5, the Cronbachs alpha of 0.924 for the instrument used for the policy
makers implies that the policy makers instrument is reliable. The Cronbachs alpha of 0.897 for the
healthcare providers implies that the healthcare providers instrument is also reliable. Last, the

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Cronbachs alpha of 0.896 for the Internet service providers implies that the Internet service providers
instrument is also reliable. Hence, all instruments have excellent reliability indicative of internal
consistency.
Table 5
Summary Item Statistics
Status of Participants
Policy makers

Mean

Minimum

Maximum

Range

Variance

N of Items

2.967

1.383

4.467

3.083

0.880

12

Healthcare providers

2.744

1.300

4.467

3.167

0.974

12

Internet service
providers

3.104

1.867

4.567

2.700

0.743

12

Population
Population is defined as a larger pool of entities on which a generalization can be made at the end of
a research study (Creswell, 2005; Neuman, 2003). The target population involves the subset of the larger
pool of entities from which the sample is drawn (Creswell, 2005). The Nigerian population stands
currently at more than 140 million people (National Population Commission, 2007). Nigeria is the largest
country in Africa with a land area of 910,000 square kilometers. For ease of political administration, the
country is divided into six geo-political zones. The target population in the present study was drawn
from heads of units at the Federal Ministry of Health, members of the House Committee on Health, CEOs
of health care organizations, directors of state Ministry of Health, and COOs of information technology
companies in the six geo-political zones of Nigeria. The sample was restricted to persons who form part
of health care policy-making in Nigeria, health care providers, and information technology experts and
service providers.
Sampling
The sampling method and sample size vary significantly in mixed method research. Collins, et al.
(2006) asserted that one rationale for the mixed method research is to optimize the sample size, which
includes increasing the number of research subjects. The sample was restricted to persons who form part
of health care policy-making in Nigeria, health care providers, and information technology experts and
service providers. Only CEOs of 100 bedded hospitals and above was included because such hospitals are
considered to have the financial capability and understands the need for adoption of hospital information
technology to service their large customer base. COOs of information technology companies included in
the research were those working in large corporations that have 500 or more workers in their
employment. These subjects are those professionals with requisite training and job experience that makes
them experts in their various fields of endeavor. Therefore, their opinions and judgments on the issue of
hospital information systems could be considered as expert opinion.
The purposive expert sampling approach was intended to examine the perceptions of persons with
demonstrable knowledge or experience in hospital information systems. In purposeful sampling, the
researcher intentionally selects participants who have experience with the central phenomenon or the
key concept being explored (Creswell & Plano Clark, 2007, p. 112). The qualitative part of the study ran
concurrently with the quantitative descriptive aspect of the study in which the sample was randomly
selected from the same population subset. Ten participants was drawn from each group made up of
health care policy makers, health care providers, and information technology experts in the six geopolitical zones of the country to make up the total of 180 participants for the quantitative aspect of the
mixed method study.
A letter explaining the study accompanied by a survey questionnaire was delivered by hand to the
180 potential participants inviting them to sign the consent form and return the form and the completed

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survey to the researcher. Poor response to postal mails and E-mail communications compelled researcher
to employ the services of two trained field research personnel to administer the instruments in the six
geo-political zones in Nigeria. Using the convenience and opportunity of the one-on-one interaction with
participants, the trained field research personnel arranged convenient time for the personal interviews
with participants in their respective offices. The 18 interview participants handed-in the signed consent
form and completed survey questionnaire to the researcher during the one-on-one face-to-face recorded
interviews.
Participants Consent and Confidentiality
Prior to distributing the survey, the participants were given the informed consent form. The purpose
of this form was to protect the privacy and confidentiality of the individuals who participated in the
study. Prior explanations of the consent and confidentiality clauses to the participant improved
compliance and decreased the incidence of biased responses during interviews. The study participants
were not exposed to any foreseeable risks. However, because of the sensitive nature of the interview
questions, especially with regard to health care policy makers, the consent information was repeated in
advance to participants recruited for the recorded interviews. To avoid physical or psychological stress to
participants, the interview duration was short to last between 15 to 25 minutes. All participants submitted
a signed consent form before becoming involved in the study. A copy of the informed consent letter is in
Appendix A.
To avoid reprisals, backlash, or social stress, each participants interview was discretely conducted as
one-on-one interviews, and their names and any identifying information was deleted from the recorded
data. The codes applied to names were replaced with alphanumeric identifiers in chronological order and
was known only by the researcher to ensure confidentiality. For example, the first participant was labeled
P1; the second participant, P2, up to P18. The surveys are stored and locked in a cabinet and these
materials will be kept for 3 years. At that time, all data will be shredded, bagged, and discarded. The hard
drive and other media will be electronically erased and all paper data will be incinerated. Only the
researcher will have access to the stored research material.
Data Collection
Some qualitative aspect of the mixed method research requires purposive homogeneous data
gathering that usually entails focus group interviewing (Patton, 2002). However, focus group
interviewing may be plagued with gaming behavior and concealment of vital opinions by participants
who may fear backlash, thereby affecting the development of themes in a qualitative study (Somiah,
2006). Numeric and non-numeric data were collected in this research to provide information on the
perceived barriers for poor adoption of hospital information systems in Nigerian hospital. From literature
review, various variables seem to contribute to poor adoption of hospital information systems. Based on
the peculiar Nigerian situation, data from this research were examined to elicit the impact of health care
policy, funding, human capital, infrastructure, and the technological base of the country on adoption of
hospital information systems.
Data were collected using structured questionnaire for the quantitative component of the study and
guided one-on-one, face-to-face interviews for the qualitative component. Nigeria is a country of more
than 140 million people based on last population census in 2006. For effective political administration, the
country is divided into six geo-political zones of almost equal state distribution and balanced population
distribution. Within this framework, a sample selection matrix (see Appendix C) was created to select a
random sample of 10 participants among health care policy makers, 10 participants among health care
providers, and 10 participants among information technology experts.
The participants in the groups lived in the six geo-political zones of the country, comprising a total of
180 participants for the quantitative aspect of the study. A sample of 10% of the 180 participants was
purposively selected to participate in the qualitative aspect of the study. This equitable but randomly
selected sample from the six geo-political zone of Nigeria was aimed at attaining fair representation of
responses across the nation and to arrive at a generalizeable research result devoid of biases. The method

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of data collection was intended to yield desired research results because the findings of the qualitative
aspect of the study would be triangulated with the quantitative research data and the results of the
literature review.
The mixed method research approach improves instrument fidelity, thereby maximizing the
appropriateness and usefulness of instruments to generate research data. The quantitative aspect of the
mixed method research employing descriptive statistical analysis was appropriate for this study.
According to Creswell (2005), surveys are useful in data collection when opinions are sought about the
state of affairs of a particular phenomenon at any time. Surveys permit a quick turnaround time for data
gathering. The quantitative aspect of this mixed method study involved collecting, analyzing, and
interpreting numeric data. The qualitative aspect of the research generated rich non-numeric descriptions
of the hospital information systems phenomena in Nigeria, which required thematic content analysis for
interpretation.
Descriptive coding of responses by application of the keywords and themes numbering 110 from
participants coded P1P18, enabled conversion of the non-numeric responses into quantified numeric
data for subsequent descriptive data analysis using SPSS software and test for significance using various
statistical tools. The present mixed methods research components were conducted concurrently because
the quantitative phase of the study did not determine or drive the qualitative phase, or vice versa..
Descriptive statistical analysis enabled the explanation of a cause and effect relationship and also uses
statistics combined with mathematical models and philosophy for relevant data analysis and hypothesis
testing. Without an offer of financial reward, this approach to data collection yielded unbiased responses,
especially with confidentiality guaranteed.
Face-to-face interviews encouraged open discussion, and using semi-structured questions throughout
the systematic and logical interviews ensures repeatability and improves rigor in a scientific inquiry
(Neuman, 2003). The use of guided interviews also ensured consistency compared to focus group
discussions. Participants were guided to answer specific research questions. Somiah (2006) used the same
methodology to gather data in an ethical dilemma study that explored and examined factors that induced
acceptance of rejection of bribes in Ghana, another West African country that has some demographic
similarities to Nigeria. Somiahs successful research provides some proof of efficacy that guided
interviews deliver appropriate qualitative data in a sensitive study that required the input of serving
government officials.
Data Analysis
Owuegbuzie and Teddlie (as cited in Onwuegbuzie & Leech, 2005) conceptualized that analysis of
mixed method research goes through some of the following steps: data reduction, data display, data
transformation, data correlation, data consolidation, data comparison, and data integration. In the
Owuegbuzie and Teddlie study, data reduction was achieved through exploratory thematic analysis,
reducing the dimensionality of the qualitative data, whereas descriptive statistics compounds
quantitative data. The data display involved the use of tables, and illustrations to represent the
quantitative data. The data display was followed by data transformation in which qualitative data were
quantified by application of numerical coding to permit direct data correlation and analysis of reduced
quantitative data with quantified qualitative data.
Data consolidation was achieved by combining quantitative and qualitative data into a new or
consolidated variables or data sets. The next stage was data comparison, which is crucial for triangulation
in this study. Data comparison involved comparing the data from the qualitative and quantitative aspects
of the mixed method research as a form of triangulation and to strengthen inferences that was made from
the research process. The final stage of the analysis involved the integration of qualitative and
quantitative data sets into two separate data sets of coherent wholes. The entire research study is
presented as a holistic, reflective, and integrative process capable of becoming reference material for
future studies (Onwuegbuzie & Leech, 2005).
In this study, a combination of parametric and non-parametric tests provided the basis for rejecting
the null hypotheses. Analysis of the quantitative data obtained by sorting and scoring of survey
responses was accomplished using the normal descriptive statistics package available in SPSS software.

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The outputs generated from this analysis include information on the mean, mode, median, minimum
value, maximum value, standard deviation, variance, sum, and the range of values. These values
facilitated the interpretation of the results obtained from the data analysis. The statistical methods were
designed to achieve the objectives of data access, reliability, and acceptability among others (Lind,
Mason, & Marchai, 2000).
The hypotheses of the study was tested using Chi-square (X2) method of data analysis. Based on the
data collected, the hypotheses, which were non-directional, were tested at 95% level of significance (that
is, = 0.05). This formed the basis for rejecting the null hypothesis. Sorting and scoring survey responses
provided data strata for conversion into percentages or proportions. These figures were then used to
compute the observed and expected frequencies needed for testing the hypotheses. For the purpose of
this analysis, definition of the Chi-square (X2) expression will be:
!! =

!! !!
!!

Where:
X2 = Chi-square
fo
= Frequency observed
fe
= Frequency expected
The Chi-square statistical test method has certain assumptions, which are as follows:
1. Where two or more than two samples are used, they are independent of one another;
2. The samples are randomly selected;
3. The data are classifiable and satisfy the nominal level of measurement requirement; and
4. The sample size is between 25 and 250.
For the purpose of hypothesis testing, the degree of freedom (df) was defined as:
df = (r -1) (c 1)
Where:
r = Number of rows
c = Number of columns
1 = Constant
The decision criteria was to reject

H0

if

p < 0.05 and uphold H 0

Analysis of the qualitative data in the study was in two stages. Using the descriptive coding format in
appendix D to conduct thematic analysis, the responses were scored to convert the non-numeric
responses into quantified numeric data. The second stage involved conducting same quantitative analysis
as was done with the survey data as described above using the quantified data.


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RESULTS
The data presented below are the frequency distribution of variables in the questionnaires. First, the data
was classified into logical categories. Subsequently, the desired analytical tables were extracted for the
proper data analysis. The interpretation of the results and implications will come in the next paper in the
series.
Table 6
Responses to Effect of Healthcare Policy on HIS by Participant Status
Status of Participants
Policy makers

Healthcare providers

Internet service
providers

Responses
Strongly agree

Percent

Cumulative
Percent

14

23.3

23.3

Agree

15

25.0

48.3

Undecided

5.0

53.3

Disagree
Strongly disagree
Total

22
6
60

36.7
10.0
100.0

90.0
100.0
--

Strongly agree

13

21.7

21.7

Agree

12

20.0

41.7

Undecided

6.7

48.3

Disagree

17

28.3

76.7

Strongly disagree

14

23.3

100.0

Total

60

100.0

--

14

23.3

23.3

Agree

18

30.0

53.3

Undecided

8.3

61.7

Disagree

11

18.3

80.0

12

20.0

100.0

60

100.0

--

Strongly agree

Strongly disagree
Total
Overall Responses

Frequency

Strongly agree

41

22.8

22.8

Agree

45

25.0

47.8

Undecided

12

6.6

54.4

Disagree

50

27.8

82.2

32

17.8

100.0

180

100.0

--

Strongly disagree
Total


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Table 7
Responses to Relevancy of Healthcare Policy on Nigerian HIS by Participant Status
Status of Participants
Policy makers

Healthcare providers

Internet service
providers

Overall Responses

Responses
Strongly agree

Frequency

Percent

Cumulative
Percent

3.3

3.3

Agree

8.3

11.7

Disagree

27

45.0

56.7

Strongly disagree

26

43.3

100.0

Total

60

100.0

--

Strongly agree

5.0

5.0

Agree

3.3

8.3

Undecided

1.7

10.0

Disagree
Strongly disagree

18

30.0

40.0

36

60.0

100.0

Total

60

100.0

--

15.0

15.0

Agree

6.7

21.7

Undecided

1.7

23.3

Disagree

19

31.7

55.0

Strongly disagree

27

45.0

100.0

Total

60

100.0

--

Strongly agree

Strongly agree

14

7.8

7.8

Agree

11

6.1

13.9

Undecided

1.1

15.0

Disagree

64

35.6

50.6

Strongly disagree

89

49.4

100.0

180

100.0

--

Total


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JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 13

Table 8
Responses to Effect of HIS on Quality of Medical Outcome by Participant Status.

Status of Participants
Policy makers

Responses
Strongly agree

68.3

13

21.7

90.0

Undecided

1.7

91.7

Disagree

5.0

96.7

Strongly disagree

3.3

100.0

Total

60

100.0

--

Strongly agree

38

63.3

63.3

Agree

16

26.7

90.0

Undecided

5.0

95.0

Disagree

3.3

98.3

Strongly disagree

1.7

100.0

60

100.0

--

39

65.0

65.0

18

30.0

95.0

1.7

96.7

3.3

100.0

60

100.0

--

118

65.6

65.6

Strongly agree
Agree
Undecided
Disagree
Total

Overall Responses

Cumulative
Percent

68.3

Total
Internet service
providers

Percent

41

Agree

Healthcare providers

Frequency

Strongly agree
Agree

47

26.1

91.7

Undecided

2.8

94.4

Disagree

3.9

98.3

Strongly disagree

1.7

100.0

180

100.0

--

Total


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JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 14

Table 9
Responses to Effect of Implementation of HIS on Health Care Outcomes by Participant Status.
Status of Participants
Policy makers

Healthcare providers

Responses
Strongly agree

Overall Responses

Percent

Cumulative
Percent
3.3

Agree

15

3.3
25.0

Undecided

43

71.7

100.0

Total
Strongly agree

60

100.0

--

28.3

1.7

1.7

1.7

3.3

Disagree

12

20.0

23.3

Strongly disagree

46

76.7

100.0

Total

60

100.0

--

10.0

10.0

Agree

3.3

13.3

Undecided

3.3

16.7

Disagree

18

30.0

46.7

Strongly disagree

32

53.3

100.0

Total

60

100.0

--

Strongly agree

5.0

5.0

Agree

1.1

1.1

Undecided

1.7

1.7

45

25.0

25.0

Strongly disagree

121

67.2

67.2

Total

180

100.0

--

Undecided

Internet service
providers

Frequency

Strongly agree

Disagree


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JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 15


Table 10
Responses to Dependence on Imported Finished Products as a Major Barrier to Adoption of HIS by Participant
Status
Status of Participants
Policy makers

Healthcare providers

Internet service providers

Responses
Strongly agree

Cumulative
Percent

10.0

10.0

17

28.3

38.3

Undecided

14

23.3

61.7

Disagree

13

21.7

83.3

Strongly disagree

10

16.7

100.0

Total

60

100.0

--

Strongly agree

3.3

3.3

Agree

10

16.7

20.0

Undecided

13

21.7

41.7

Disagree

18

30.0

71.7

Strongly disagree

17

28.3

100.0

Total

60

100.0

--

Strongly agree

8.3

8.3

Agree

11

18.3

26.7

Undecided

11

18.3

45.0

15.0

60.0

Strongly disagree

24

40.0

100.0

Total

60

100.0

--

Strongly agree

13

7.2

7.2

Agree

38

21.1

28.3

Undecided

38

21.1

49.4

Disagree

40

22.2

71.7

Strongly disagree

51

28.3

100.0

180

100.0

--

Total


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Percent

Agree

Disagree

Overall Responses

Frequency

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Barriers to Hospital IS in Nigeria/Benson 16


Table 11
Current State of Local Technological Capabilities in the Adoption of HIS
Status of Participants
Policy makers

Healthcare providers

Internet service providers

Responses
Strongly agree

Cumulative
Percent

10.0

10.0

21

35.0

45.0

Undecided

17

28.3

73.3

Disagree

10

16.7

90.0

Strongly disagree

10.0

100.0

Total

60

100.0

--

Strongly agree

11.7

11.7

Agree

17

28.3

40.0

Undecided

16

26.7

66.7

Disagree

11

18.3

85.0

Strongly disagree

15.0

100.0

Total

60

100.0

--

Strongly agree

13

21.7

21.7

Agree

15

25.0

46.7

Undecided

11

18.3

65.0

Disagree

12

20.0

85.0
100.0

15.0

Total

60

100.0

Strongly agree

26

14.4

14.4

Agree

53

29.4

43.9

Undecided

44

24.4

68.3

Disagree

33

18.3

86.7

Strongly disagree

24

13.3

100.0

180

100.0

--

Total


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Percent

Agree

Strongly disagree

Overall Responses

Frequency

--

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 17


Table 12
Resistance to the Use of Technology by Clinicians is a Reason for Poor Adoption of HIS in Nigerian Hospitals
Status of
Participants
Policy makers

Healthcare
Providers

Internet service
Providers

Overall
Responses

Responses

Frequency

Cumulative
Percent

Percent

Strongly agree
Agree
Undecided
Disagree
Strongly disagree
Total
Strongly agree

8
13
7
19
13
60
7

13.3
21.7
11.7
31.7
21.7
100.0
11.7

13.3
35.0
46.7
78.3
100.0
-11.7

Agree
Undecided
Disagree
Strongly Disagree
Total
Strongly agree
Agree
Undecided
Disagree
Strongly disagree
Total

16
4
19
14
60
11
19
6
14
10
60

26.7
6.7
31.7
23.3
100.0
18.3
31.7
10.0
23.3
16.7
100.0

38.3
45.0
76.7
100.0
-18.3
50.0
60.0
83.3
100.0
--

Strongly agree

26

14.4

Agree

48

26.7

41.1

Undecided

17

9.4

50.6

Disagree

52

28.9

79.4

Strongly disagree

37

20.6

100.0

180

100.0

--

Total


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Table continued
14.4

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 18


Table 13
Clinicians in Nigeria Show Significant Technological Bias in the Provision of Healthcare
Status of Participants
Policy makers

Responses
Strongly agree

Internet service
providers

Cumulative
Percent

10.0

10.0

16

26.7

36.7

Undecided

14

23.3

60.0

Disagree

18

30.0

90.0

10.0

100.0

Total

60

100.0

--

Agree

11

18.3

18.3

Undecided

10

16.7

35.0

Disagree

26

43.3

78.3

Strongly disagree

13

21.7

100.0

Total

60

100.0

--

10

16.7

16.7

Agree

18

30.0

46.7

Undecided

17

28.3

75.0

Disagree

10

16.7

91.7

8.3

100.0

60

100.0

--

Strongly agree

Strongly disagree
Total
Overall Responses

Percent

Agree

Strongly disagree
Healthcare providers

Frequency

Strongly agree

16

8.9

8.9

Agree

45

25.0

33.9

Undecided

41

22.8

56.7

Disagree

54

30.0

86.7

Strongly disagree

24

13.3

100.0

180

100.0

--

Total


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JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 19


Table 14
Funding Support will improve the Adoption of HIS in Nigeria
Status of Participants
Policy makers

Responses
Strongly agree

Frequency

50.0

50.0

24

40.0

90.0

Undecided

1.7

91.7

Disagree

1.7

93.3

Strongly disagree

6.7

100.0

Total

60

100.0

--

Strongly agree

31

51.7

24

40.0

51.7
91.7

Disagree

3.3

95.0

Strongly disagree

5.0

100.0

Total

60

100.0

--

Strongly agree

33

55.0

55.0

Agree

22

36.7

91.7

Undecided

1.7

93.3

Disagree

3.3

96.7

Strongly disagree

3.3

100.0

60

100.0

--

Agree

Internet service
providers

Total
Overall Responses

Cumulative Percent

30

Agree

Healthcare providers

Percent

Strongly agree

94

52.2

52.2

Agree

70

38.9

91.1

Undecided

1.1

92.2

Disagree

2.8

95.0

Strongly disagree

5.0

100.0

Total


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180

100.0

--

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 20


Table 15
Availability of Financial Aid to Healthcare Providers Who will Compromise the Adoption of HIS in Nigeria
Status of Participants
Policy makers

Responses
Strongly agree
Agree
Undecided

Healthcare providers

Internet service
providers

Status of Participants
Overall Responses

Frequency

Percent

Cumulative Percent

3.3

3.3

12

20.0

23.3

10.0

33.3

Disagree

18

30.0

63.3

Strongly disagree

22

36.7

100.0

Total

60

100.0

--

Strongly agree

6.7

6.7

Agree

6.7

13.3

Undecided

13.3

26.7

Disagree

14

23.3

50.0

Strongly disagree

30

50.0

100.0

Total

60

100.0

--

10.0

10.0

Agree

10

16.7

26.7

Undecided

13

21.7

48.3

Disagree

15

25.0

73.3

Strongly disagree

16

26.7

100.0

Total

60

100.0

Strongly agree

Responses
Strongly agree

Frequency
12

Percent
6.7

-Table continued
Cumulative
Percent
6.7

Agree

26

14.4

21.1

Undecided

27

15.0

36.1

Disagree

47

26.1

62.2

Strongly disagree

68

37.8

100.0

180

100.0

--

Total


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JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 21


Table 16
Corruption is a Barrier to the Adoption of HIS in Nigeria
Status of Participants
Policy makers

Responses
Strongly agree

Frequency

Cumulative Percent

29

48.3

48.3

Agree

16

26.7

75.0

Undecided

10.0

85.0

Disagree

6.7

91.7

Strongly disagree

8.3

100.0

60
19

100.0
31.7

22
6
4
9
60
28

36.7
10.0
6.7
15.0
100.0
46.7

68.3
78.3
85.0
100.0
-46.7

19
5
2
6
60
76

31.7
8.3
3.3
10.0
100.0
42.2

78.3
86.7
90.0
100.0
-42.2

57

31.7

73.9

Undecided

17

9.4

83.3

Disagree

10

5.6

88.9

Strongly disagree

20

11.1

100.0

Total
Healthcare
providers

Percent

Strongly agree

Agree
Undecided
Disagree
Strongly disagree
Total
Internet Service Strongly agree
Providers
Agree
Undecided
Disagree
Strongly disagree
Total
Overall
Strongly agree
Responses
Agree

Total


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180

100.0

-31.7

--

JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 22


Table 17
Corruption Could Significantly Increase the Adoption of HIS in Nigeria
Status of
Participants
Policy makers

Responses
Strongly agree
Agree

Healthcare
providers

12

20.0

20.0

10

16.7

36.7

3.3

40.0

Disagree

10.0

50.0

Strongly disagree

30

50.0

100.0

Total

60

100.0

--

Strongly agree

Undecided
Disagree
Strongly disagree
Total

10

16.7

16.7

10

16.7

33.3

5.0

38.3

5.0

43.3

34

56.7

100.0

60

00.0

11

18.3

18.3

12

20.0

38.3

Undecided

5.0

43.3

Disagree

8.3

51.7

29

48.3

100.0

60

100.0

33

18.3

18.3

32

17.8

17.8

Strongly agree
Agree

Strongly disagree
Total
Overall
Responses

Cumulative
Percent

Undecided

Agree

Internet service
providers

Percent

Frequency

Strongly agree
Agree
Undecided

--

--

4.4

4.4

Disagree

14

7.8

7.8

Strongly disagree

93

51.7

51.7

180

100.0

Total

--

Level of Agreement by the Participants


Three categories of participants were studied to assess the barriers to adoption of hospital
information systems in Nigeria. The goal was to ascertain the extent to which the policy makers, health
care providers, and Internet service providers concurred in their responses on the various items in the
instrument. Hence, the Kendalls coefficient of concordance was applied as follows.
Kendalls test.
Hypothesis for Kendalls Test.
H0 There is no agreement between the responses by the three categories
H1 There is agreement between the responses by the three categories

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Barriers to Hospital IS in Nigeria/Benson 23


Level of Significance. = 0.05
Test statistic.

2 = k (n 1)W
where

W=

n
12
k (n + 1)

Ri

2
2

2
k n(n 1) i =1

Decision Criterion. Reject

H0

if

p < 0.05

Computations. The computations obtained using the SPSS in the following tables:
Conclusion for Kendalls Test. The descriptive statistics for the three categories of participants are
displayed in Table 18, while the inferential statistics are in Table 19. From Table 19, since
p = 0.026 < 0.05 the null hypothesis is rejected, with the conclusion that there is a weak agreement
between the responses from the policy makers, healthcare providers, and Internet service providers. As
shown in Table 19, the value of the Kendalls coefficient of concordance of 0.215 signified a weak
agreement between the assessment and evaluation of the barriers to adoption of hospital information
systems in Nigeria. The numbers imply that the stratification into the three subpopulations of
participants is vital to acquiring more research information. Stratification has contributed to the accuracy
and precision of the results.
Table 18
Descriptive Statistics for Kendalls Test
Status of Participants
Policy makers

Mean

Mean Ranks

Std. Deviation

60

4.28

1.94

1.106

Healthcare service providers

60

4.47

2.00

0.873

Internet service providers

60

4.57

2.06

0.698

Table 19
Kendalls Test Statistic
Test statistic
N

Test values
60

Kendall's Coefficient of Concordance

0.215

Chi-Square

7.316

Degrees of freedom
Asymptotic Sig.


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2
0.026

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Barriers to Hospital IS in Nigeria/Benson 24


Table 20
Descriptive Statistics
Responses to Questions

Mean

Std.
Error

Std.
Deviation

Remark

180

3.07

0.109

1.469

Agree

180

1.87

0.089

1.201

Disagree

Hospital information systems significantly improve


the quality of medical outcome

180

4.50

0.064

0.862

Strongly
Agree

Implementation of hospital information systems


has no healthcare outcome implications

180

1.52

0.073

0.977

Disagree

180

2.57

0.097

1.295

Undecided

180

3.13

0.094

1.257

Agree

Mean

Std.
Error

180

2.86

0.104

1.395

Undecided

Clinicians in Nigeria show significant technological


bias in the provision of healthcare

180

2.86

0.089

1.195

Undecided

Funding support will improve the adoption of


hospital information systems in Nigeria

180

4.31

0.075

1.003

Agree

180

2.26

0.096

1.283

Disagree

Corruption is a major barrier to the adoption of


hospital information systems in Nigeria

180

3.88

0.098

1.317

Agree

Corruption could significantly increase the


adoption of hospital information systems in Nigeria

180

2.43

0.124

1.658

Disagree

Unclear healthcare policy on hospital information


systems is a major barrier to implementation in
Nigerian hospitals
Healthcare policies issues are irrelevant in the
implementation of hospital information system in
Nigeria

Dependence on imported finished products is a


major barrier to adoption of hospital information
systems in Nigeria
Current state of local technological capabilities in
the country could improve the adoption of hospital
information systems in Nigeria
Responses to Questions
Resistance to the use of technology by clinicians is a
reason for poor adoption of hospital information
systems in Nigerian hospitals

Availability of financial aids to healthcare providers


will compromise the adoption of hospital
information systems in Nigeria

Table continued
Std.
Remark
Deviation

Quantification and Analysis of Qualitative Data


The second set of data was collected through a structured interview particularly designed to validate
the data collected from the target population. The same stratification was adopted for the same

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JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 25


subpopulations of policy makers, healthcare providers, and Internet service providers. Similarly, the
interviews were set to explore the barriers to adoption of hospital information systems in Nigeria. After
the interview process, the data were coded and classified into multiple response tables with cumulative
categories as shown in table 21 through 24.
Table 21
Policy Makers Responses on the Barriers Hindering the Adoption of HIS
Responses

Major barriers

Percent of Cases

Percent

Unfavorable government policy

13.9%

83.3%

Lack of funding support

11.1%

66.7%

High cost of hospital information system

2.8%

16.7%

Poor infrastructural base of the country


Inadequate human capital

6
5

16.7%
13.9%

100.0%
83.3%

16.7%

100.0%

Non-implementation causing poor healthcare


outcome
Corruption as part of the barrier

16.7%

100.0%

Problems associated with poor Internet access

2.8%

16.7%

Over dependence on importation

0.0%

0.0%

End-users' resistance

5.6%

33.3%

Total

36

100.0%

600.0%

Table 22
Healthcare Providers Responses on the Barriers Hindering the Adoption of HIS
Responses

Major barriers

Percent of Cases

Percent

Unfavorable government policy

11.1%

66.7%

Lack of funding support

13.9%

83.3%

High cost of hospital information system

11.1%

66.7%

Poor infrastructural base of the country


Inadequate human capital

6
3

16.7%
8.3%

100.0%
50.0%

11.1%

66.7%

Non-implementation causing poor healthcare


outcome
Corruption as part of the barrier

11.1%

66.7%

Problems associated with poor Internet access

8.3%

50.0%

Over dependence on importations

5.6%

33.3%

End-users' resistance

2.8%

16.7%

Total

36

100.0%

600.0%


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Barriers to Hospital IS in Nigeria/Benson 26


Table 23
Internet Service Providers Responses on the Barriers Hindering the Adoption of HIS
Responses

Major barriers

Percent of Cases

Percent

Unfavorable government policy

12.5%

85.7%

Lack of funding support

12.5%

85.7%

High cost of hospital information system

10.4%

71.4%

Poor infrastructural base of the country


Inadequate human capital

7
5

14.6%
10.4%

100.0%
71.4%

14.6%

100.0%

Non-implementation causing poor healthcare


outcome
Corruption as part of the barrier

10.4%

71.4%

Problems associated with poor Internet access

10.4%

71.4%

Over dependence on importation

0.0%

0.0%

End-users' resistance

4.2%

28.6%

Total

48

100.0%

685.7%

Table 24
Cumulative Responses on the Barriers Hindering the Adoption of HIS
Responses

Major barriers

Percent of Cases

Percent

Unfavorable government policy

15

12.5%

78.9%

Lack of funding support

15

12.5%

78.9%

High cost of hospital information system

10

8.3%

52.6%

Poor infrastructural base of the country


Inadequate human capital

19
13

15.8%
10.8%

100.0%
68.4%

17

14.2%

89.5%

15

12.5%

78.9%

Problems associated with poor Internet access

7.5%

47.4%

Over dependence on importation

1.7%

10.5%

End-users' resistance

4.2%

26.3%

120

100.0%

631.6%

Non-implementation causing poor healthcare


outcome
Corruption as part of the barrier

Total


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JOURNAL OF GLOBAL HEALTH CARE SYSTEMS/VOLUME 1, NUMBER 3, 2011

Barriers to Hospital IS in Nigeria/Benson 27


SUMMARY
This paper provides detailed information on the mixed method case study research using in-depth
interviews and a questionnaire-based survey to ascertain the barriers hindering adoption of hospital
information systems in Nigeria. The discussion in this paper provided the problem that a robust health
care policy on implementation of a hospital information system is lacking in Nigeria and that caregivers
in the country have yet to commence noticeable implementation of hospital information technologies. The
data were collected using instruments particularly designed for the target population: health care policy
makers, health care service providers and Internet service providers. After the actual data collection
process, the data were classified into tables with purposeful and logical categories to facilitate the
analysis. The interpretations and implications will be in another paper in the series.

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