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A systematic literature review of health information systems for healthcare.

1. Introduction

2. material and method, 3. discussion, 3.1. the evolution of health information systems, 3.2. his structural deployment, 3.3. health information systems benefits, 3.4. information system and knowledge management in the healthcare arena, 3.4.1. information system, 3.4.2. knowledge management, 4. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Epizitone, A.; Moyane, S.P.; Agbehadji, I.E. A Systematic Literature Review of Health Information Systems for Healthcare. Healthcare 2023 , 11 , 959. https://doi.org/10.3390/healthcare11070959

Epizitone A, Moyane SP, Agbehadji IE. A Systematic Literature Review of Health Information Systems for Healthcare. Healthcare . 2023; 11(7):959. https://doi.org/10.3390/healthcare11070959

Epizitone, Ayogeboh, Smangele Pretty Moyane, and Israel Edem Agbehadji. 2023. "A Systematic Literature Review of Health Information Systems for Healthcare" Healthcare 11, no. 7: 959. https://doi.org/10.3390/healthcare11070959

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• v.24(1); 2016 Feb

Factors Affecting Successful Implementation of Hospital Information Systems

Mehrdad farzandipur.

Health Information Management Research Center, Kashan University of Medical Sciences, Iran

Fatemeh Rangraz jeddi

Esmaeil azimi, background:.

Today, the use of information systems in health environments, like any other fields, is necessary and organizational managers are convinced to use these systems. However, managers’ satisfaction is not the only factor in successfully implementing these systems and failed information technology projects (IT) are reported despite the consent of the directors. Therefore, this study aims to determine the factors affecting the successful implementation of a hospital information system.

The study was carried out as a descriptive method in 20 clinical hospitals that the hospital information system (HIS) was conducted in them. The clinical and paraclinical users of mentioned hospitals are the study group. 400 people were chosen as samples in scientific method and the data was collected using a questionnaire consisted of three main human, managerial and organizational, and technological factors, by questionnaire and interview. Then the data was scored in Likert scale (score of 1 to 5) and were analyzed using the SPSS software.

About 75 percent of the population were female, with average work experience of 10 years and the mean age was 30 years. The human factors affecting the success of hospital information system implementation achieved the mean score of 3.5, both organizational and managerial factors 2.9 and technological factors the mean of 3.

Conclusion:

Human factors including computer skills, perceiving usefulness and perceiving the ease of a hospital information system use are more effective on the acceptance and successful implementation of hospital information systems; then the technological factors play a greater role. It is recommended that for the successful implementation of hospital information systems, most of these factors to be considered

1. INTRODUCTION

Today, the use of information systems in health environments, like any other fields, is necessary and managers these areas are convinced to use these systems. However, managers’ satisfaction is not the only factor in successfully implementing these systems and failed information technology projects (IT) are reported despite the consent of the directors; therefore, to run such projects a set of factors affecting the success and failure of information systems should be considered ( 1 ).

Numerous studies show that a significant number of large scale information system projects are faced with failure because of various reasons. Although, the project management and software have improved, but at the same time each year, tens of billion dollars are spent on failed projects. Based on research findings of the Standish Group International Inc., 49 percent of very large projects that cost over ten million dollars, rejected before the end and only 51 percent have been implemented, which spend more time and money, without any special attention or having to be involved all comments that were defined and predicted for the project basis ( 2 ).

Failure of information systems projects cannot be easily defined, because success and failure factors of projects are diverse. Every person has a different understanding of the meaning of failure, but from the overall view, a project is failed when not being an optimum qualified to meet the goals and expectations as well as the project specification ( 2 ). Studies showed that the factors affecting the acceptance of HIS have been identified as human, organizational and technology categories. In these studies, the ease of use, the benefits and continuing education are as human factors, end users’ corporation, economic factors and planning are the organizational factors, and finally privacy, system development, and support the system are as technological factors( 1 , 3 ).

Many studies have been done about the user role in the success of information systems. In most of these studies, human factors, either individually or as a group, are very important and decisive. Actually, neglect or inadequate care to human factors that may lead to defects in proper communication with users and an inability to develop a sense of ownership of the system for the user is known as the biggest factor in the failure of information systems to achieve their goals ( 4 ).

A study in Istanbul has shown that the end-users have experienced the general computer use, but most of them did not want to use a computer. According to a study in Finland, people who had more experience in general use of computer applications, were more used the hospital information system( 3 , 5 ), which refers to the role of human factors in the adoption of hospital information systems; while, Ping Yu in a research on the acceptance factors of IT in long-term care institutions, stats that demographic factors such as age and experience have no effect on acceptance of IT in health care field, by health providers ( 6 ). However, studies conducted in Turkey and Finland have determined the age and work experience as effective factors in the adoption of hospital information system ( 5 ).

In this regard, reports by users have shown that most satisfied people are those who believe the benefits of system and are more motivated to use IT. It seems that the tendency to IT can be a key factor towards the success or failure of information systems’ operation ( 7 ).

A study conducted in the United States of America is reported 50% failure for clinical information systems (CIS) implemented in healthcare organizations. These findings are generalizable to many industrialized countries ( 8 ).

2. OBJECTIVES

Studies show that some of health information providers are not fully convinced to implement HIS in their institutions. This study assesses the factors that may affect the adoption of HIS technology by users of health information systems ( 7 , 9 , 10 ). Therefore, the project managers and professionals with a complete list of the factors influencing the adoption and success of information systems, will be able to better support the project, and according to them, by every moment evaluation provide solutions ( 3 ). Hence, the present study aims to determine the factors affecting the successful implementation of hospital information systems in clinical hospitals in Iran.

This study was conducted as cross-sectional descriptive research. The study group is consists of members of the nursing unit, department secretaries, reception and medical records, clinical laboratory, radiology, pharmacy, and finance department of hospitals with comprehensive hospital information system for at least two years of implementation in their centers. The sample size was determined as 400 people in scientific method. First of all, 20 companies that provide enterprise hospital information systems were identified through the Office of Statistics and Information Technology, Ministry of Health and Medical Education. Then randomly a hospital that uses the software of each company and a total of 20 hospitals (preferably in Tehran) was selected. Comments of members of departments and units, including nurses, pharmacists, and paramedics were examined. In order to determine the number of users of separate units, for the total sample size and number of units under study (400 samples and 20 hospitals) 20 people in each hospital were selected by simple random sampling. The number of samples for eligible users in the categories of nurses, reception and medical records, laboratory, radiology, pharmacy, finance department and clinic was calculated for each hospital, and the average between 2 to 3 people in each job category was randomly selected.

To gather information from questionnaires, the Davis standard was used by adding technical and organizational factors from reliable sources( 11 , 12 ). The questionnaire contains 28 questions (9 questions for human factors, 12 for organizational factors, and 5 for technical factors). For validity of the data gathering tool, the initial questionnaire was given to two of professors, and after reforms were concerned, the validity was confirmed. The reliability of the questionnaire was confirmed by test-retest through the completion of it by 10 members of the study group, twice a week, and the Cronbach’s alpha coefficient of 95%. The questionnaires were completed by visiting researchers in health centers as questioning method. Following the completion of questionnaires, the data was entered into the SPSS software for the analysis. Each response rated from 1 to 5 and unanswered questions was considered zero, and during the calculation, the average was subtracted from the total respondents and at the end, the total score of the questionnaires in the areas of human factors, organizational and management factors and technical factors were calculated; then, using cut-off point on each areas, the factors affecting adoption among users have set as 1-1.8 very low, 1.8-2.6 low, 2.6-3.4 medium, 3.4-4.2 high, and 4.2-5 very high.

Based on the findings, 302 (75%) of the study group are women. The mean experience of respondents’ was 10 years and the average of age was 30 years. 243 (2/61%) people were bachelor’s degree, and 252 (63%) people had ICDL certification. The average of human factors effectiveness was 3.5 points. Table 1 . The average of organizational and managerial factors 2.9 point Table 2 and the average of technical factors was 3 points. Table 3 .

The Impact of Human Factors on the Adoption of HIS

The Impact of Managerial and Organizational Factors in the Adoption of HIS

Technological Factors Affecting on the Adoption of HIS

5. DISCUSSION

In general, human factors have the most influence on successful implementation of hospital information systems and then technological factors, and finally organizational and managerial factors. Among components of human factors, the general knowledge and skills in the use of computer, ease of using HIS and ease of learning how to use it were more effective on successful implementation of the system than other human factors.

Koivunen, in a study in 2009 found that, there is a significant relationship between motivation to use computers and have experience in using computers. Those with more experience in using computers, compared with those with less experience in this field, use hospital information systems more and are motivated to perform computational processes ( 5 ). Anderson also, in a study in 2007 in eHealth suggests that more than half of the population, have been mentioned the lack of knowledge about the use of computers and information technology as a barrier to use the Information Technology ( 13 ). The study by Sheikh Shoaei and Olumi also in 2007, shows that whenever a system depended on information technology be more useful and easier to learn, it will be used more ( 11 ).

In numerous studies, research findings indicate that the system that the user can easily work with and trust it, and increase data availability will be accepted more and its implementation will be successful ( 3 , 14 , 15 , 16 ). These findings indicate that the knowledge and skills to use computers and the users’ understanding of the ease of use of hospital information systems are the main human factors affecting the successful implementation HIS as well as a greater tendency for users to use the system. Ease of learning how to use HIS will lead users to be familiar with the system and in addition to saving time and cost, will cause the successful adoption and implementation of systems by end users.

The effect of technological factors on the successful implementation of the HIS is after the human factor, in the second grade. Amongst, the impact of the factor the system development capability and HIS reliability in safe keeping of information have gained higher score than other factors. In Andersen’s study, the inability of suppliers to deliver acceptable products has been described as a major obstacle to the application of information technology ( 13 ). In some studies, technical concerns such as the ability to communicate systems are the biggest obstacles to the implementation of health information systems, and electronic interchange and communication facilities have been mentioned as the biggest benefit of systems ( 13 , 16 , 17 ).

It seems that this priority difference, in the effect of technological factors in the adoption and successful implementation of a hospital information system in this study, compared to other studies, arising from the nascent state of implementation and running hospital information systems in the country, so that these systems are in the early stages of the installation and implementation and still have not reached the stage of complete implementation and installing necessary infrastructures in all health-care centers, and the exchange of information between the centers is not of their priorities.

Therefore, the ability to develop the hospital information systems to ensure the safety of information are important factors for adopting and implementing a successful information system by users, since, the increasing development of technology and high speed of entering new and efficient products as well as more developed paraclinic systems, and the different requirements of hospitals, have created a complex and variable environment in the hospitals. On the other hand, because health care providers will have no chance to re-run HIS ( 9 ), the health information systems must be able to coordinate with these changes, and with the development and change of use of the system could meet the user’s needs and increase their motivations and tendency to use the system.

Based on the results, organizational and managerial factors have less influence than other factors for successful implementation of HIS. Meanwhile, project management, training the use of the system, and maintaining the confidentiality of the information in hospital information system are more effective in the successful implementation of organizational and management HIS than other factors. In a study by Kimiafar et al, most users have considered the lack of related and sufficient education as the primary cause of low quality of HIS ( 18 ).

In another study by Sagiroglu et al, the problems in the use of an integrated hospital information system are reported as causes for educational problems of the systems ( 1 ) which is consistent with current research. In the study by Minal in 2005, the biggest barriers to adoption of electronic health records in the United States are reported as the cost of software, hardware and physician participation ( 17 ). In another study in 2009, the end-user participation in implementation strategy was the main factor associated with successful adoption of HIS/CIS ( 16 ) that is at variance with the findings of the study. Part of this difference is due to the lack of appropriate policies and incentives for users to participate in the system training courses, as well as the lack of written policies and procedures about the confidentiality of information. On the other hand, because most of hospitals in the country are public, and therefore the implementation of HIS needs the budget approved by the state which is not the major barrier to the adoption and implementation HIS in the country. Therefore, it is recommended that the necessary guidelines to be codified and the projects be managed by skilled and competent people and some mechanisms be considered for training and participation of users.

6. CONCLUSIONS

The human factors, generally, and then the technological factors and the organizational and managerial factors have an important role in the adoption and successful implementation of hospital information systems. Among human factors, general knowledge in using computer, ease of using HIS, and ease of learning how to use HIS, among technological factors, the future development of the hospital information system and reliability of the system in protecting the information, and among the organizational and managerial factors, training users, project management and information confidentiality have the greater influence on the acceptance and successful implementation of hospital information systems. Given the nascent state of hospital information systems of country, and the inability of design and implementation of many of these systems, by both providers and users, and sometimes, the problems in the use of these systems, it is expected to see the successful implementation of these systems in the country by the increase in experience and capabilities of both groups, while strengthening the human and technological factors during the installation and implementation of these systems and leading the project by empower individuals and professionals.

Acknowledgments

Deputy of research of Kashan University of Medical Sciences for financial support of this research (Project No. 9034) is appreciated.

• Clinical Relevance Statement: To improve the general knowledge and skills of users in using computers, it is recommended that the ICDL courses for users should be taken seriously, and during the implementation of hospital information systems, comprehensive educational programs should be developed and implemented for users. Software vendors also should provide software that is designed to facilitate the users’ tasks, and be easy to learn and use. The software development companies should improve their ability to deliver acceptable and feasible products in accordance with changes and needs of health-care variable environment.

• Conflict of interest: The authors declare that they have no conflicts of interest in this research.

• Protection of human subjects: The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects and was reviewed by Deputy of research of Kashan University of Medical Sciences.

• Research article
• Open access
• Published: 25 June 2010

Bridging the gaps in the Health Management Information System in the context of a changing health sector

• Angelo S Nyamtema 1  

BMC Medical Informatics and Decision Making volume  10 , Article number:  36 ( 2010 ) Cite this article

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The Health Management Information System (HMIS) is crucial for evidence-based policy-making, informed decision-making during planning, implementation and evaluation of health programs; and for appropriate use of resources at all levels of the health system. This study explored the gaps and factors influencing HMIS in the context of a changing health sector in Tanzania.

A cross sectional descriptive study was conducted in 11 heath facilities in Kilombero district between January and February 2008. A semi-structured questionnaire was used to interview 43 health workers on their knowledge, attitude, practice and factors for change on HMIS and HMIS booklets from these facilities were reviewed for completeness.

Of all respondents, 81% had never been trained on HMIS, 65% did not properly define this system, 54% didn't know who is supposed to use the information collected and 42% did not use the collected data for planning, budgeting and evaluation of services provision. Although the attitude towards the system was positive among 91%, the reviewed HMIS booklets were never completed in 25% - 55% of the facilities. There were no significant differences in knowledge, attitude and practice on HMIS between clinicians and nurses. The most common type of HMIS booklets which were never filled were those for deliveries (55%). The gaps in the current HMIS were linked to lack of training, inactive supervision, staff workload pressure and the lengthy and laborious nature of the system.

Conclusions

This research has revealed a state of poor health data collection, lack of informed decision-making at the facility level and the factors for change in the country's HMIS. It suggests need for new innovations including incorporation of HMIS in the ongoing reviews of the curricula for all cadres of health care providers, development of more user-friendly system and use of evidence-based John Kotter's eight-step process for implementing successful changes in this system.

Peer Review reports

A health management information system (HMIS) is a process whereby health data are recorded, stored and processed for policy-making, planning, implementation and evaluation of health programs. The system is crucial for evidence-based policy and informed decision-making at all levels from national down to the institutional levels. Evidence-based decision making is critically important for the appropriate use of scarce resources particularly in resource limited countries like Tanzania. The HMIS in most developing countries are inefficient and are greatly affected by unreliability of data resulting from underreporting [ 1 ]. Reports from sub Saharan Africa indicate that vital health decisions, in this context, are made based on crude estimates of disease and treatment burdens [ 2 , 3 ]. Findings from this region indicate that the problem of under reporting is huge and is linked to lack of knowledge and practice among the health workers characterized by insufficient analysis skills, training and lack of initiative for using information [ 4 – 6 ].

In Tanzania the first version of the health management information system was launched in 1993 and the second in 1998 [ 7 ]. The first version was entirely in English and it was soon realized upon testing that the users had limited commands in this language and was therefore technically changed to Kiswahili, the national language. Thus, the Health Management Information System is called in Kiswahili as Mfumo wa Taarifa za Huduma za Afya ( MTUHA ). The latest version involves manual data entry into 12 HMIS booklets. The system covers all health programs and health care services, and requires all health facilities, regardless of ownership, to use this system and report to the district health authority on quarterly basis. The overall goal of this system is to optimize the performance of health services at all levels of administration through the timely provision of necessary and sufficient information needed by the health managers to monitor, evaluate and plan their activities [ 7 , 8 ]. Its success requires a system that is integrated, decentralized, functional and reliable [ 9 ].

The conception of this study was based on the concerns about the poor quality data and inadequate integration of the HMIS despite a number of changes it has undergone since inception and the need to bridge the gaps in the on-going changes in health sector. In an attempt to strengthen the health services to meet national and international commitments, the government of Tanzania has developed the Primary Health Service Development Program (PHSDP) whose main goal is to accelerate provision of quality primary health care services to all by 2017. This program is implemented by increasing intakes of trainees for health care, reviewing and standardizing curricula for all medical and paramedical cadres to competence-based [ 10 ]. The review of the curricula is spearheaded by the National Council for Technical Education (NACTE) an organ which was empowered by the government through the Act No. 9 of 1997 to coordinate technical education and set qualification standards for the awards. This article explores the gaps and factors for change in HMIS in Tanzania and presents a detailed account on how they could be best bridged in the ongoing changes in country's health sector. It attempts to link the required changes in the HMIS and the evidence-based John Kotter's eight-step process for implementing successful changes in any organizations [ 11 ].

Study area and design

Tanzania is divided into 25 administrative regions that are subdivided into 113 districts that are further subdivided into divisions, wards and villages. Administratively, the ministry of health is the main coordinating body for health information in the country, the regional level is responsible for coordinating activities in the districts and the districts are responsible for coordinating services delivery activities at the health facility levels. The 12 HMIS booklets in Tanzania include the guidelines, summary (from the other books), village profile, inventory (ledger for equipment, drugs and supplies), outpatient services, antenatal services, postnatal services, family planning services, communicable diseases, HMIS report book, dental services and delivery services. These booklets consist of forms and registers, where the registers are pre-set frameworks for data processing.

In an attempt to map the gaps and factors for change in the country's HMIS a cross-sectional descriptive study was conducted between January and February 2008 in Kilombero, one of the most rural districts in Tanzania. Kilombero district is in the southeastern part of the country about 230 km from Morogoro, the headquarters of the region and 420 km from Dar es Salaam, the largest business city in the Tanzania. The district has a total area of 14,018 km 2 , a population of 321,611 people [ 12 ] and 44 health facilities. Among these health facilities are 2 hospitals both owned by non-governmental institutions, 4 health centres (all owned by the government) and 38 dispensaries of which only 15 are owned by the government. The health facilities were as far as 180 km from the district headquarters and are expected to provide all primary health care services, refer complicated cases and complete the relevant booklets.

Sampling and size

A stratified random sampling technique was used to obtain one hospital, one health centre and 9 dispensaries. Of these facilities, 5 were governmental and 6 non-governmental. A total of 11 health facilities were involved in the analysis, fulfilling WHO recommendation to cover at least 25-30% of the health facilities in the area when assessing quality of care [ 13 , 14 ]. The study team aimed to interview at least 5 health care providers including those in-charge of the health facility available on the day of study visit. However, the team managed to interview 43 care providers because many of the facilities had less than five health care providers. At the hospital a list of care providers was obtained from the administration and the following departments were included: outpatient, reproductive and child health (RCH) clinic and labour ward where at least 2 health workers were interviewed from each department.

Data collection, processing and analysis

Data collection was carried out by the author and 4 research assistants. A semi-structured questionnaire was used to interview health care providers and facility administrators to assess their level of knowledge, attitudes and practices concerning HMIS and factors for change (Additional file 1 ). After the interview the research team requested to see the 2007 HMIS booklets (number 6, 7 & 12) in order to review the completeness of records. The parameters recorded in booklet 6 (antenatal services register) included: 1) booking visit: date, registration number, name, age, gravidity, gestation age, height, danger signs; 2) re-attendance visits: presence of anaemia, oedema, proteinuria, lie of the foetus, vaginal bleeding, syphilis test, date of TT vaccine for the index pregnancy, last childbirth (year, live or died) and referral information. The parameters for book 7 (underfive services register) were: date, registration number, date of birth, weight, date for BCG, DPT, polio, measles vaccinations and vitamin A, mother's information (name and TT vaccination status); and those for book 12 (delivery services register) were: date, registration number, name of the mother, age, gravidity, parity, date of admission, date of delivery, mode of delivery, birth before arrival (BBA), complication of labour, status at birth (live birth or stillbirth), condition of the mother at discharge and name of the health provider. The parameters which were mostly not recorded were documented. In the cases of frequent incomplete records, the research team inquired about reasons for the incompleteness. The research team also interviewed the district HMIS coordinator for the factors that affected health information system. The data were entered in the Statistical Package for Social Science (SPSS) version 10 and analyzed by generating frequencies. Exact binomial confidence intervals at 95% were used to compare the proportions of clinicians and nurses with regards to the training, knowledge, attitude and utilization of HMIS data in their health facilities. The permission to carry out this study was obtained from district medical authority and verbal consent was obtained from the interviewees.

Characteristics of respondents

A total of 43 health care providers from 11 health facilities were interviewed. Among these 23 (53%) were clinicians and 20 (47%) nurses. While the clinicians included 20 (47%) clinical officers and medical officers 3 (7%), the nurses included 8 (19%) nurse officers, 11 (26%) enrolled nurses and 1 (2%) medical attendant.

Training and knowledge on HMIS

More than three quarters (81%) of respondents had never been trained on HMIS (Table 1 ). There was no statistically significant difference in proportions of health workers trained for HMIS between the clinicians 17% (95% CI: 2% - 32%) and nurses 20% (95% CI: 2% - 38%). Almost two thirds (65%) failed to define properly what HMIS is. Of the respondents, only 7% recalled 7-9 booklets, 18% recalled 5-6 booklets, 42% mentioned 1-5 booklets and more than one third (33%) failed to recall even one out of twelve HMIS booklets. While 54% did know who are supposed to use the information collected at the health facility, 40% didn't know the importance of HMIS. There was no significant difference in knowledge about the importance of HMIS between clinicians 61% (95% CI: 41% - 81%) and nurses 60% (95% CI: 41% - 81%). On the other hand, more than one third (37%) of all respondents did not know the HMIS information flow pattern.

Attitude towards HMIS

Generally almost all respondents (91%) had positive attitude towards HMIS. There was no significant difference in attitudes of health workers towards HMIS between clinicians 87% (95% CI: 74% - 99%) and nurses 95% (95% CI: 93% - 98%). Thirty nine respondents (91%) agreed that the system (HMIS) was worthy for the time and other resources spent filling and processing data, and that it was important to continue with the system. However, 42% of the respondents pointed out that the current HMIS was difficult, complicated and that it needed to be simplified. Although they were generally positive they needed a better system.

Practice on HMIS

Of the respondents 42% had never used the HMIS data collected at the health facility level for planning, budgeting and evaluation of services provision. This was attributed by almost three quarters (70%) to poor knowledge on data analysis. The other major reasons for failure to utilize the local data were poor quality of data and poor managerial skills reported by 16% and 7% of the respondents respectively.

Completeness of HMIS booklets

Of all reviewed HMIS booklets only a single delivery register from only one health facility was judged to be 100% complete. These booklets, however, were not filled in as many as 55% of the health facilities (Table 2 ). The types of information that was found not recorded in the booklets for postnatal services (child vaccination/weight) were measles vaccine, DPT 3, polio vaccine and Vitamin A. These services were not recorded in these booklets despite the fact that it was assumed that these important health interventions had been given to the clients.

The type of information which was mostly not filled in the delivery booklets was the condition of the mother at discharge. The parameters which were commonly missing in the antenatal services' booklets were pregnant mothers' risk factors, VDRL test, TT vaccination and height. Reasons for such incompleteness found were lack of VDRL reagent, workload pressure, forgetfulness and poor knowledge on data recording.

Recommendations for HMIS improvement

Almost all respondents (95%) recommended training of health care providers in order to improve HMIS. Almost a quarter (23%) of respondents recommended for improved supervision and increased staffing levels at the facility level. Only 19% recommended for revision and simplification of the HMIS to be more user-friendly. The respondent from the district authority reported that the process of health data in the current HMIS was long and difficult, with many booklets and forms with some repeating information. Poor knowledge on HMIS among health workers was linked to lack of training on the system and workload pressure. In view of these gaps the system was recommended for revision.

Our findings revealed a wide range of interlinked factors responsible for the inefficiency and ineffectiveness of the HMIS in Tanzania. The lack of clear understanding of the purpose, users and flow pattern of health data collection was linked to poor quality of data collection and suggests that decision-making in the country health system may be less than adequately informed. This study has revealed higher proportion (65%) of care providers who failed to define properly what HMIS is than that (47%) reported in previous studies [ 6 ]. These findings suggest a declining knowledge on this important system. On the contrary, despite such low knowledge on HMIS, the majority of the care providers (91%) had positive attitude towards the system, indicating substantial acceptability, a positive potential factor for improvement. The existing huge gap of knowledge on such an important system can be linked to lack of training which was as high as 81% of care providers. On the other hand the findings suggest lack of emphasis on HMIS in the pre-service curricula and hence a lack of evidence-based training in medical and paramedical training institutions in the country. Considering the ongoing process to develop and introduce competence-based educational curricula for all medical and paramedical training programs in the country and the government 10 year program to expand training of care providers, incorporation of HMIS in the new curricula is greatly suggested. The government of Tanzania through its 10 year PHSDP (2008 - 2017), intends to train 460,000 health care providers by the year 2017 and improve the provision of health services to the level of every village and ward [ 10 , 15 ]. The author believes that incorporation of HMIS in the new curricula will improve not only knowledge, skills, culture and efficiency of HMIS but will also cut-down the investment required for on-the-job training for health care providers.

The failure to collect health data as seen in 55% of the health facilities for HMIS delivery booklets, indicates the high degree of poor documentation, underreporting and data inaccuracy from the district up to the national level. The HMIS guidelines require health care providers to complete relevant booklets immediately after provision of health care services before the patients or clients leave the facility. The impact of such poor compliance with this system is worrisome and suggests that vital public health decisions are made based on crude district and national estimates of burden of the problems. The failure to use health data collected at the health facility level as reported by 63% of care providers indicates that the primary purpose of data collection is to report to higher levels suggesting a high prevalence of the " mailbox syndrome ". The "mailbox syndrome" is a phenomenon whereby a crucial information generated at the health facility level is mailed rather than used locally for quality care improvement [ 16 ]. This syndrome is contrary to the concept of decentralization which is currently implemented in the country. These findings suggest also that the existing HMIS has not been institutionalized in the sense of being integrated into the everyday activities, an important factor for its sustainability and reliability.

Like many other reports the incompleteness and poor use of health data collected at a health facility, found in this study, can be attributed to poor knowledge on HMIS; inadequate financial, human and technological resource capacity; lack of user-friendly systems; lack of coordination and evaluation, as well as inadequate policies to manage the sustainability of the system [ 17 , 18 ]. Considering the lengthy and laborious HMIS procedural requirements for completion of the booklets and the context of acute shortage of care providers, revision for a more user-friendly system is highly recommended.

The fact that these factors have been documented and remained unattended in Tanzania over many years, indicates a high degree of irresponsiveness and unaccountability in the country health system [ 19 , 20 ]. These findings suggest in part poor leadership performance. Carrying out " business as usual ", a static mindset among the key actors and poor supervision of health systems are progress blocking agents which have been reported as the leading factors for poor performance of health sectors in sub-Saharan Africa [ 21 ]. These findings call for more commitment, dedication and accountability within an HMIS organization [ 22 ]. Considering these factors and the fact that Tanzania is already off-track in HMIS, evidence-based John Kotter's eight-step process for implementing successful changes is indicated for effective system in this country. These steps are: to create a sense of urgency for change, create powerful group guiding the change, develop and communicate the change vision and strategy, empower others to act, produce short-term wins, press harder and faster after the first successes and create a new culture for sustainability [ 11 ].

This article has revealed a state of poor health data collection, lack of data-based decision-making at all levels and the factors for change in the country's HMIS. It calls for new innovations including incorporation of HMIS in the ongoing reviews of the educational curricula for all cadres of health care providers, development of more user-friendly system and use of evidence-based John Kotter's eight-step process for implementing successful changes in this system.

Abbreviations

Bacille Calmette-Guérin (Tuberculosis) Vaccine

Diphtheria, Pertussis and Tetanus toxoids

• Health Management Information System

National Council for Technical Education

Primary Health Service Development Program

Reproductive and child health

Venereal Disease Research Laboratory (test for syphilis)

Tetanus Toxoid.

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Acknowledgements

The author would like to thank the Kilombero district medical authority for allowing this study to be conducted in their health facilities and the Tanzanian Training Centre for International Health for funding and reviewing this study. The author would also like to thank all Assistant Medical Officers' students (Mbogo NS, Ntundu RA, Mhezi MP and Killewa FL) for their contributions in the process of data collection and all staff who volunteered to give information.

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ASN designed the study, was involved in data collection and the analyzed the data and wrote the manuscript.

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Additional file 1: Knowledge, attitude and practice on health management information system in Kilombero district, Tanzania. A semi-structured questionnaire used to assess training, knowledge, attitude and practice on health management information system among health workers in Kilombero district. The tool also explores the gaps and factors for change in the existing health management information system. (DOC 69 KB)

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Nyamtema, A.S. Bridging the gaps in the Health Management Information System in the context of a changing health sector. BMC Med Inform Decis Mak 10 , 36 (2010). https://doi.org/10.1186/1472-6947-10-36

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Informing Complexity: The Business Case for Managing Digital Twins of Complex Process Facilities as a Valuable Asset , William Randell McNair

Designing a Health Coach-Augmented mHealth System for the Secondary Prevention of Coronary Heart Disease , Avijit Sengupta

Impact of Health IT on Practice of Medicine , Deepti Singh

Theses/Dissertations from 2020 2020

Complexities of Data, Tasks and Workflows in Health IT Management , Gaurav Jetley

Understanding the Complex Ethical Landscape of Artificial Intelligence Adoptions , Chrissann R. Ruehle

Theses/Dissertations from 2019 2019

Evaluating Conversation Agent Impact on Student Experience in a Distance Education Course , Grover Walters

Theses/Dissertations from 2018 2018

An Effectual Approach for the Development of Novel Applications on Digital Platforms , Onkar Shamrao Malgonde

Analytics for Novel Consumer Insights (A Three Essay Dissertation) , Utkarsh Shrivastava

Theses/Dissertations from 2017 2017

Essays on Crowdfunding: Exploring the Funding and Post-funding Phases and Outcomes , Onochie Fan-Osuala

Theses/Dissertations from 2016 2016

An Information and Communication Technologies for Development (ICT4D) Decision Framework for Building an Information Economy in Developing Countries: The Case of Palestine , Hasan Nuseibeh

Blind and Visually Impaired Users Adaptation to Web Environments: A Qualitative Study , Raneem Saqr

Theses/Dissertations from 2015 2015

Predictive Analytics of Organizational Decisions and the Role of Rationality , Arash Barfar

Analytics and Healthcare Costs (A Three Essay Dissertation) , Lina Bouayad

Information Technology & Sustainability: An Empirical Study of the Value of the Building Automation System , Daphne Marie Simmonds

Theses/Dissertations from 2014 2014

The Use and Effectiveness of Online Social Media in Volunteer Organizations , Amy J. Connolly

Inter-Organizational Social Network Information Systems: Diagnosing and Design , Matthew T. Mullarkey

Informing Systems, Interventions, and Innovations , William Francis Murphy Jr.

Theses/Dissertations from 2013 2013

Do Personality Tests have a place in Academic Preparation of Undergradute Hospitality Students , Gunce Malan

Applications of Agent Based Approaches in Business: A Three Essay Dissertation , Shankar Prawesh

Theses/Dissertations from 2012 2012

Economic Culture and Trading Behaviors in Information Markets , Khalid Nasser Alhayyan

TagLine: Information Extraction for Semi-Structured Text Elements In Medical Progress Notes , Dezon K. Finch

Learning and Relevance in Information Retrieval: A Study in the Application of Exploration and User Knowledge to Enhance Performance , Harvey Stuart Hyman

Theses/Dissertations from 2010 2010

Contribution to and Use of Online Knowledge Repositories: The Role of Governance Mechanisms , Varol O. Kayhan

Understanding Organizational Adoption Theories Through the Adoption of a Disruptive Innovation: Five Cases of Open Source Software , Delmer Nagy

Organizational Information Markets: Conceptual Foundation and an Approach for Software Project Risk Management , Areej M. Yassin

Theses/Dissertations from 2009 2009

Social Shopping , Rebecca Anderson

Goal Attainment On Long Tail Web Sites: An Information Foraging Approach , James A. Mccart

Theses/Dissertations from 2008 2008

The Impact of Computer Mediated Communication Systems Monitoring on Organizational Communications Content , Carolyn F. Holton

Theses/Dissertations from 2007 2007

Privacy in Database Designs: A Role Based Approach , Gary A. Poe

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