The role of centralised project management approach on the implementation of large-scale Electronic Health Record systems: A Mixed-methods study

doi:10.21203/rs.3.rs-2719334/v1

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The role of centralised project management approach on the implementation of large-scale Electronic Health Record systems: A Mixed-methods study

https://doi.org/10.21203/rs.3.rs-2719334/v1

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Background: In the last three decades, the Electronic Health Records Systems (EHRS) become on the top priorities of policymakers globally. Nowadays, EHRS reform is fast becoming a priority in developed countries. The introduction of EHRS in Saudi healthcare organisations is considered one of the highest priorities of the policymakers. Saudi Arabian e-health strategy pays reasonable attention to the EHRS implementation project. According to the Saudi vision 2030 E-health transformation will be on top if IT projects in the country. However, an estimation of 50% of EHRS implementation have failed. Project leadership and type of project management have been found to be crucial components of effective EHRS implementation

Aim of the study: To evaluate the role of Centralised Project Management (CPM) on the implementation of large-scale EHRS in PHCs in SA.

Methods: A sequential explanatory mixed-methods approach involving a survey and semi-structured qualitative interview methods were utilised.

Results: Thirty-nine (75%) out of 53 policymakers at the Saudi Ministry of Health completed the survey while 14 policymakers were interviewed. Findings from both illustrated that adopting centralised project management approaches to implementation was beneficial in facilitating large-scale EHRs implementation and helped to overcome barriers that may have otherwise led to the failure of the project. Electronic Health Record System interoperability and software selection were the factors that centralised project management influenced most positively.

Electronic Health Record

Primary healthcare centres

Centralised project management

Large-scale projects

IT implementation

Leadership and type of project management play significant role in the success of the EHRs implementation
Factors such as EHRs end-user’s satisfaction and software selection directly influenced by the project management and leadership.

What this study added to our knowledge

CPM enhance the level of EHRs implementation success, especially in large-scale projects.
Challenges such as EHRs interoperability can be overcome by the adoption of CPM.
Guideline to implement the EHRs in multiple sites such as PHCs

Early research in Health Informatics (HI) has emphasised that the implementation of clinical computing should be a primary goal in order to enhance patient safety and care quality [1–3]. This idea came into existence in the early part of the 1960s and is still being proposed with the modifications such as technological advancements. Such modifications will simplify the procedure so that patient care can be provided accurately and on time [4]. Nowadays, Electronic Health Records (EHR) reform is fast becoming a priority in developed countries [5]. Along with EHR reform, the issue of improving patient safety and quality of care has justifiably been prioritised throughout the world by most healthcare givers [6]. Unfortunately, due to a variety of factors, EHR reform has not received the same attention from the decision-makers in developing countries [7]. However, the introduction of EHRS in Saudi healthcare organisations is considered one of the highest priorities of the policy-makers [8]. However, knowledge about the usefulness and benefits of EHRS as well as the likely implementation costs and other barriers is considered scant in developing countries [9].

Project leadership and management have been found to be crucial components of effective EHRS implementation [10–14]. Leadership and project management have been shown to have a positive impact on EHRS implementation and increase the possibility of successful implementation [14–17].

The project manager position can be occupied by either a technical staff member, physician, or any manager within the organisation [10]. The project manager should have the required skills, receive training, be capable of leading [18], dealing with complex projects [10], and distributing workloads to project team members to encourage them to reach their goals [19]. Moreover, integral to the lead project management role is enabling long-term communication between project team members [18] and ensuring the involvement of EHRS end-users [17].

It has been suggested that such a management concept might not be capable of meeting the requirements of the population’s future healthcare plans and strategies [20]. However, it can become capable if the steps of implementation are well planned, and there are clearly defined roles and responsibilities for lower-level management. A possible solution can be offering more control, authority, and power to the regional directorates at the health affairs in each region [20]. It is worth noting that according to the Saudi vision 2030 all 13 predefined health affairs are now converted to health clusters. Therefore, 13 health affairs spilt down into 30 health clusters [21]. According to Alghamdi and Urden [22], the Saudi MoH is leading and supervising its healthcare sectors in a purely centralised manner. It is responsible for formulating plans, legislation of regulations and policies, and managing and providing financial resources. Ekvall [23] argued that such CPM has several disadvantages such as delaying projects, resistance to change, and a decrease in the level of innovation within the organisation. This is thought to be due to the fact that the major decisions are being made by very few people [23]. However, a very recent study revealed that CPM contributes to the consistency of procedures and quality of any organisation [24].

This research conducted at the headquarter of the Saudi Ministry of Health (MoH). The Saudi MoH manages and oversees healthcare organisations in Saudi Arabia. According to the latest statistics, more than 430000 employees work for the Saudi MOH [25]. Both semi-structure interviews and self-administrated questionnaire were used to collect the data of the current study. Therefore, the adopted method refers as explanatory mixed-methods [26]. The purpose of doing sequential explanatory mixed methods was to seek further description and clarification of the impact of CPM from same population.

2.1 Survey questionnaire

The authors used self-administrated questionnaire to collect their quantitative data. [27–29]. The questionnaire asked for specific details regarding individual perceptions of the impact of CPM. This part was made up of nine items (or questions). The respondent was required to answer the questions using a seven-point Likert scale response: Strongly disagree (1), Disagree (2), Somewhat disagree (3), No opinion (4), Somewhat agree (5), Agree (6), Strongly agree (7). The authors conducted a pilot study to the preliminary questionnaire prior to use in the study.

2.2 Semi-structured interviews

According to Miles and Gilbert [30] Semi-structured interviews are useful to gather comprehensive and in-depth information. Therefore, the authors decided to conduct semi-structured interviews due to its ability to provide comprehensive understanding and explanation of the influence of CPM in the implementation of large-scale EHRS. Although the role of CPM was assessed quantitatively, it was difficult to gain further information about certain implications of CPM on pre-defined factors that influence the EHRS implementation, such as EHRS interoperability [31], or project planning and strategizing [32]. Therefore, semi structured interviews provided additional and detailed information to allow a better understanding of previously examined aspects. This approach was previously termed the sequential explanatory mixed-methods [26]. Therefore, questions in the interview guide were driven by the analysis of quantitative study.

Thirteen one-to-one interviews took place with the selected participants. The interviews were conducted over a two-month period. We scheduled up to two hours for each interview, however, no time limits were applied with regard to how long the interview could last. Participants were informed that they could withdraw from the interview at any time. The interviews were digitally recorded using an iPad and an iPhone. In addition, field notes were taken during the interview to avoid interruption when new questions emerged during the interview. This allowed me to generate more questions to overcome the omissions and also to clarify any comments made.

2.3 Population and sampling

The study population comprises all project team members directly or indirectly involved in implementing a large-scale EHRS project in Saudi PHCs. These consisted, for example, of heads of relevant departments (IT and PHC departments), senior managers, IT engineers, and technicians. This potential population of participants within the Saudi MoH has varying backgrounds and experience, departments, occupations, and genders. The target sample was therefore all project team members (n = 53).

Participant involvement in project implementation and knowledge they held about EHRS implementation in PHCs in SA were considered when selecting our survey sample. To reach the most appropriate participants for this study ), non-probability, purposive, snowball sampling was used [26, 33]. The survey questionnaire was sent to all project team members (n = 53).

Identification of the study sample was conducted over two phases. Initially, we visited the relevant departments at the Saudi MoH (IT department and PHC department). We requested a list of names and contact details of project team members who were involved in the EHRS implementation. The lists contained only twenty-seven names. Secondly, snowball sampling technique was done to determine if there were other members of the project team that were not identified on the lists, in particular those from outside the selected departments. For semi-structure interviews, we followed the same procedures adopted above. Therefore, a total of fifty-three participants met selection criteria for the semi-structure interviews, due to their involvement, knowledge, expertise and participation in EHRS implementation projects in PHCs in SA

2.4 Data analysis

All data from the questionnaire was coded in numerical categories into SPSS Version 22 [34]. Firstly, a Cronbach’s alpha test was used to examine the data collection reliability. Thereafter, an initial descriptive analysis of the questionnaire data was undertaken.

The number of participants responding to each Likert response and percentages were included in the descriptive statistics. These responses were used to calculate a total agreement percentage for each question. The total agreement percentage was used to determine which items within a given scale had the highest level of agreement. The total agreement percentage was calculated by summing all those responding positively to a specific question (i.e. somewhat agree, agree, or strongly agree). The total agreement percentage scores were then ranked in order based on the total agreement within the scale. This can assist with ranking those items that have the same median.

The qualitative data collected in the semi-structured interviews were analysed using the thematic analysis [26]. Although the thematic analysis was found to be very time-consuming, NVivo assisted in overcoming this issue. For instance, we were able to recall all highlighted quotes related to one code in just one click instead of searching through all the transcripts again to find the quote. Therefore, NVivo V10 (QSR International) was used to thematically analyse the qualitative data. NVivo helps to manage rich text by categorising it and organising it rather than analysing the text, as other quantitative programs do.

3.1. Survey questionnaire

Out of the fifty-three, only thirty-one participated and completed the questionnaire, indicating a response rate of 59%. initially, the findings show no significant differences in terms of participants demographics such as gender, position and involvement in the implementation project. Table 1 shows the percentage of male and female participation in the survey. It is evident that participation was male dominant, with 80.6% of participants being male. Female participation was found to be only 16.1%. This reflects the actual proportion of females and males in the Saudi MoH, where the majority of the staff are male. As seen in Table 1 more than have of the participants recorded their involvement in previous EHRS implementation project. The participants in the survey were found to be from diverse professional roles. The assistants formed the highest number of participants, at twenty-one (67.7%). Only one deputy manager participated in this study, and three participants from other positions. Finally, out of thirty-one participants, twenty (64.5%) declared that they were directly involved in the process of implementation and five (16.1%) declared that they aided the process through an indirect connection. Six (19.4%) participants did not declare the nature of their involvement.

Table 1

Participant distribution based on gender, previous involvement in EHRS implementation projects, position, and role in the implementation project
Gender
Male	25	80.6
Female	5	16.1
Missing	1	3.3
Total	31	100
Previous involvement in EHRS implementation projects
YES	18	58.1
NO	13	41.9
Total	31	100.0
position
General Manager	3	9.7
Deputy Manager	1	3.2
Head of Department	3	9.7
Deputy Head of Department	3	9.7
Assistant	21	67.7
Total	31	100.0
Role in the implementation project
Direct	20	64.5
Indirect	5	16.1
Total	25	80.6

The impact of CPM was explored with nine items Table 2 illustrates the impact of CPM on EHRS implementation. Overall, there was an extremely high agreement on all items (above 90%), with median scores being six or seven. Item 1) “Overall impact is positive”, showed an agreement of 96.8% and a median score of seven, where participants strongly agree that CPM positively influences EHRS implementation in PHCs in SA. Whereas the lowest rank was given to item 9) “Improve project team communication” (90.4%), which is also considered very high with median score of six.

Table 2

Participant responses to items representing the impact of CPM on EHRS implementation in PHCs
Items		Disagree	Somewhat disagree	No opinion	Somewhat agree	Agree	Strongly agree	Median	Total agreement	Rank
Overall impact is positive	N			1		5	25	7	30	1
Overall impact is positive	%			3.2		16.1	80.6	7	96.8	1
Improve systems integration and interoperability	N			1		12	18	7	30	2
Improve systems integration and interoperability	%			3.2		38.7	58.1	7	96.8	2
Better software selection	N	1		1	1	7	21	7	29	3
Better software selection	%	3.2		3.2	3.2	22.6	67.7	7	93.5	3
Easier to manage EHRS implementation in a large number of PHCs that are widely dispersed	N		1	1		12	17	7	29	4
	%		3.2	3.2		38.7	54.8	7	93.5	4
Better project team selection	N			2	4	8	17	7	29	5
Better project team selection	%			6.5	12.9	25.8	54.8	7	93.5	5
Better decision-making	N	1		2		6	22	7	28	6
Better decision-making	%	3.2		6.5		19.4	71.0	7	90.4	6
Improve implementation of the strategic plan	N	1		2	1	9	18	7	28	7
Improve implementation of the strategic plan	%	3.2		6.5	3.2	29.0	58.1	7	90.4	7
Help leading and managing the project	N		1	1	3	10	15	6.50	28	8
Help leading and managing the project	%		3.2	3.2	9.7	32.3	48.4	6.50	90.4	8
Improve project team communication	N			3	1	18	9	6	28	9
Improve project team communication	%			9.7	3.2	58.1	29.0	6	90.4	9

3.2. Semi-structured interviews

The authors invited fifty-three members of project team to participate in the semi-structure interviews. However, only 14 participants accepted to participate in the semi-structured interviews. The project team members who accepted to participate in this study categorised into five different roles. Three of them were General managers (GM), one Software Developer (SD), three Head of Department (HD), two Deputy Head of Department (DHD) and five Data Analyst (DA).

As mentioned previously we analyzed all transcripts by the semi-structured interview using N-Vivo software which generated seven main themes and thirty-two codes. The findings showed a consensus that CPM had a positive impact on the implementation of EHRS in PHCs in SA. Some of the project team emphasised that CPM was best suited to the nature of the management system in Saudi Arabia. Some of the participants stated that this type of management system was appropriate in SA due to the similarities of the functions and business processes in the PHCs. It was commented by some those decisions related to EHRS implementation should be made centrally by the Saudi MoH to enhance the success of the project.

“…particularly in SA, because the PHCs in SA are similar, are under the Ministry's management and all have the same functions.” (DA 2)

“In the SA, in particular, it is necessary to use CPM to ensure project success.” (SD 1)

However, others suggested that the utilisation of a semi-centralised project management system is more effective for implementing a large-scale EHRS. They argued that the adoption of this type of management represented a major challenge to the Saudi MoH and would be more effective if the MoH involved representatives from regional sub-departments in decision-making. So, decisions regarding EHRS implementation could be made in coordination with representatives from lower levels, such as health affairs’ administrators in the regions or members of the PHCs.

“CPM is a challenge for the Ministry represented by the IT department due to the scale of the project, and therefore must involve sub-departments, health affairs in regions and also PHCs.” (HD 2)

The impact of CPM on decision-making

All participants agreed that CPM has a positive impact on decision-making. For example:

“CPM’s role is very positive to handle large-scale projects while making significant decisions such as selecting the type of EHRS. In addition, CPM can reduce planning and implementation time for large-scale projects.” (GM 1)

“CPM has a very positive impact on decision-making.” (DA 3)

3.4. The impact of CPM on geographical challenges

The geographical nature of SA is considered a challenge that may affect the success of EHRS implementation.

“Geographical nature of SA was a challenge to the MoH. Therefore, CPM assists the project team” (HD2)

Nevertheless, there was some disagreement; the head of the department thought that CPM has a negative impact on geographical factors.

“I think the effect is negative. Because CPM limited the involvement of other members from different regions in SA who could give better insight about their regions, especially geographical challenges” (HD3)

On the other hand, one of the DAs believed that CPM had no impact on geographical factors.

“CPM have no impact on this aspect where geographic challenges consider as technological which then can be overcome by developing appropriate infrastructure.” (DA 2)

The impact of CPM on EHRS interoperability

Interoperability was another measured factor found to be positively influenced by CPM. CPM facilitates communication among project teams to unify decision-making regarding a system that can be interoperable in the future. In addition, this contributes to making the process of communication between the systems more efficient and smoother, and minimises any issues related to future EHRS interoperability. Consequently, this matter will reflect positively on EHRS implementation.

“EHRS interoperability is crucial, it is highly affected by CPM and cannot succeed unless CPM is adopted especially in large-scale projects where different systems may selected and then implemented. We considered interoperable EHRS because the decision related to the interoperability and data exchange was made by one project team at the headquarter of the Saudi MOH. Therefore, communication among the project team was easy and effective for this purpose. So, it has a very positive impact.” (HD1)

The impact of CPM on the scale of the EHRS implementation project

There was agreement on the positive impact of CPM in overcoming challenges related to scale of the project. A general manager believed that the CPM was “Certainly positive” (GM1). Other participants stated, for example:

“Implementing EHRS in very large number of PHCs which exceeded 2000 is not an easy mission due to the complexity of any project related to the IT. If all decisions and procedures related to project will not be made centrally by one project team, many challenges and conflicts may raise, and the project may fail. So defiantly CPM has a very positive effect.” (HD 3)

“The CPM system has a positive effect regarding the implementation of the EHRS in a large number of centres.” (SD 1)

Firmly believing that CPM had a positive impact on the number of PHCs, a proposal was made to divide the PHCs into zones or regions to overcome any issues related to the scale of the project and facilitate the implementation process.

“It has a positive impact. I would probably recommend dividing them into groups of different regions or zones.” (DA 3)

The impact of CPM on planning EHRS implementation in PHCs in SA

The majority of the project team agreed that CPM had a positive impact on planning for the implementation of an EHRS. For instance, DA 1 said CPM had a “very positive effect”, and GM3 stated that the impact of CPM was “positive”. One of the general managers illustrated that CPM helped to avoid many of the technical and administrative problems that occurred during the planning phase by standardising any decisions and opinions. In addition, CPM helped to reduce the costs of the project, since the planning occurreed centrally at the Saudi MoH.

“It is better to be centralised, because when the planning and entire implementiaon process is centralised the cost and time of the project will be reduced.” (GM2)

On the other hand, one of the DAs believed that CPM had a negative impact on EHRS implementation planning.

“The CPM has negative impact on the planning phase due to the limited involvement of other parties and stakeholders such as members of PHCs or patients” (DA 3)

3.8. The impact of CPM on software selection

According to the participants’ responses, CPM had a positive impact on the software selection process. As illustrated by one of the general managers, “CPM is very positive, without a doubt” (GM1). In this context, software selection should be carried out centrally and under the supervision of the Saudi MoH.

“Such a decision regarding the software selection should be centralised at the top management of the Ministry to avoid any compatibility issue especially for large-scale project where multiple software may implement.” (HD 2)

Likewise, one of the heads of department emphasised the importance of software selection being made centrally at the top level of the Saudi MoH. He believed that lower-level organisations such as regional health affairs do not have the ability to select or even examine an EHRS due to a lack of IT expertise.

“Before choosing a system, we must evaluate and review the EHRS and compare prices, system usability, system efficiency, etc. These things cannot be done in health centres where there are no experts in IT.” (HD 3)

On the other hand, due to previous experience in similar EHRS implementation projects, one of the DAs claims to have adopted the concept of a semi-centralised project management to enhance software selection.

“From the experience of previous implementation projects, there were many notes from regions about the system, so health affairs in the regions should participate in system selection.” (DA 2)

The impact of CPM on team communication processes

There was consensus that CPM had a positive impact on team communication. For instance, HD 2 said “CPM has very positive effect on communications among project team”. As illustrated by some of the participants, project team communications were made at the headquarter in the Saudi MoH in the form of meetings and workshops. All such meetings and workshops also involved the project team at different departments and different regions. This greatly facilitated and accelerated the decision-making process.

“…CPM is better to ensure faster and more effective communication between the project team.” (DA 2).

However, others thought that CPM had no influence on the communications among project team.

“…due to the development of telecommunications and all other media meetings and other form of communication can be made from distance and all stakeholders can be involved remotely via SKYPE or video conferences.” (GM 1).

The impact of CPM on project team selection

Team selection was also positively affected by CPM. according to one of the general managers, team selection was easier and more efficient when conducted centrally by the Saudi MoH. According to GM2, “CPM is the best” in terms of enhancing project selection, and DHD1 said, “It has a very positive impact”.

“…CPM dramatically facilitates this process because project team selection is easier and of more effective.” (GM 1)

This study was conducted to determine the role of COM on the implementation of large-scale EHRS. According to several articles, obstacles to implement the EHRS in SA can be linked to some project management and leadership issues. [14, 35, 36]. Despite this, some of EHRS projects may unsuccess [14, 35–37].

Based on the study findings CPM could enhance the success of large-scale EHRS implementation project in PHCs. These findings are in line with those by and Safdari, Ghazisaeidi [38], who also stated that CPM can contribute to the success of the EHRS implementation. Our findings and those by Safdari, Ghazisaeidi [38] are in disagreement with the findings by [23], who argued that CPM has some disadvantages such as delaying projects, resistance to change, and a decrease in the level of innovation within the organisation.

The impact of CPM was examined with consideration of several factors that influence the EHRS implementation. According to several studies, systems interoperability issues are considered as a big challenge to the EHRS implementation and may cause the overall project to become unsuccessful [39–43]. Consequently, systems interoperability tops the list of factors influenced positively by CPM. Therefore, CPM can be lifeline for many of the organisations and decision-makers which have encountered interoperability issues during the implementation of the EHRS to overcome this issue.

Software selection followed interoperability which ranked as the second factor that was affected positivity by the CPM based on the decision-makers responses. Several previous studies have confirmed that the system selection should be carefully considered to ensure that it meets the requirements and is highly efficient [16, 43, 44]. Others have emphasised the importance of the usability as the main criteria during the software selection [3, 44–46]. On the basis of the findings of this study, CPM helps to overcome several difficulties during the software selection and facilitate the software selection. Moreover, there is high degree of agreement amongst the decision-makers on the positive impact of the CPM to facilitate all measures that are conducted during the pre-implementation phase such as planning and decision-making. The positive role of the CPMS is not limited to pre-implementation phase, it is lasts until the post-implementation phase through facilitating the project management and leadership measures.

Although CPM has been found to be beneficial for large-scale projects, it was highly recommended to move toward semi-centralised management. This can enhance other stakeholder awareness, particularly EHRS end-users and, consequently, semi-centralised project management can improve the level of satisfaction of those end-users.

Although, sufficient time were given to collect the required data for the current study, the study faces some limitations. During the data collection phase, several changes were made at the senior management and ministerial level in the Saudi MoH. To the best of our knowledge, during 2014 and 2022, eight different ministers were appointed by the Saudi MoH. These personnel changes impacted negatively on the data collection process, where some study participants had been recently appointed in their new positions and were therefore less knowledgeable about the strategic implementation plan; others had no idea about the former project. Furthermore, several of the project team and policymakers who had been booked for an interview were laid off prior to the interview date, which affected the sample size of the semi-structured interviews.

This study found that CPM can assist in overcoming challenges regarding software selection, interoperability, project team communication and other challenges which accompany larger-scale projects. However, to make better decisions regarding which type of management is better to implement large-scale EHRS, further research is needed in the future to examine the difference between centralised and semi-centralised project management. Comparative studies between PHCs in SA and PHCs in other developing countries, especially Arab Gulf Countries (AGCs), need to be carried out to determine the differences in the level of readiness for EHRS implementation. AGCs may share some of the characteristics of SA, such as the type of project management and the level of FR, therefore, further studies need to be conducted to examine the impact of CPM and FR on EHRS implementation in other AGCs, or in other developing countries.

MoH

Ministry of Health

EHRS

Electronic Health Record System

PHC

Primary Health Care

MoH

Ministry of Health

Saudi Arabia

General Manager

Head of Department

DHD

Deputy Head of Department

Software Developer

Data Analyst

Financial Recourses

SPSS

Statistical Package for the Social Sciences

CITIES

The Clinical Information System Implementation Evaluation Scale

GPs

General Practitioners

Ethical approval and consent to participate

This study is part of a larger study, “Improve strategy to implement the EHRS in widespread PHCs in developing countries with CM organisations”. All methods in this study was performed in accordance with the declaration of Helsinki and was approved by the Institutional Review Board (IRB) of King Fahad Medical City (KFMC) at the Saudi MoH (IRB Log No. 14-189E). All the participants provided informed consent to participate. In the case of the questionnaire-based study, all participants were informed of the voluntary nature, confidentiality, and aim of the study and the nature of their participation before they participated in the study. For the interview purposes, all participants provided written informed consent prior to enrolment in the study.

Consent for publication

Consent for publication: Not applicable as no identifiable information is published in this manuscript.

Availability of data and material (ADM)

The datasets generated and/or analysed during the current study are not publicly available due copyright and ownership. All primary data collected for this research belong to the researchers. The dataset includes other data that will be used for another manuscript but are available from the corresponding author on reasonable request.

Competing of interest

The authors declare that they have no competing of interests

Funding

This project fully funded by Qassim University, project number QU-IF-2-2-3-26969.

Authors’ contributions

Haitham A. Alzghaibi: Conceptualization, methodology, data collection, validation, analysis, and writing.

Hayley A. Hutchings: Conceptualization, supervision, reviewing and editing.

Acknowledgements

The authors extend their appreciation to the Deputyship for Research & Innovation, Ministry of Education, Saudi Arabia for funding this research work through the project number QU-IF-2-2-3-26969.

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The role of centralised project management approach on the implementation of large-scale Electronic Health Record systems: A Mixed-methods study

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