Example: International Journal of Information System

International Journal of Social Science and Humanity, Vol. 3, No. 2, March 2013
Implementation Differences of Hospital Information  System (HIS) in Malaysian Public Hospitals

Nurul Izzatty Ismail, Nor Hazana Abdullah, Alina Shamsudin, and Nik Azliza Nik Ariffin
Abstract—Hospital Information System (HIS) is important to
healthcare sector especially in public hospitals as they need to

serve the public with high-quality healthcare treatments. HIS
helps to improve patients care services. Thus, the Malaysian
Government has introduced three (3) categories of HIS namely
Total Hospital Information System (THIS), Intermediate
Hospital Information System (IHIS), and Basic Hospital
Information System (BHIS) among Malaysian public hospitals.
However, only 15.2% of the Malaysian public hospitals are
implementing the system. Moreover, there is limited number of
empirical studies on HIS implementation in Malaysia. Thus,
this paper aims to investigate issues and challenges in HIS
implementation for each category of HIS by using in-depth
interviews. Nine participants were involved in the interviews.
The interview data were transcribed verbatim and analysed
based on Content and Thematic Analysis using NVivo software.
The results showed that different category of HIS faced
different issues and challenges.  

Index Terms—Basic hospital information system, hospital
information system, intermediate hospital information system,
total hospital information system. 

I.  INTRODUCTION
Information technology (IT) has become vital in healthcare
sector including public hospitals. The technology has been
found to play significant role in improving patients care
services. In Malaysia, the healthcare sector is divided into
three healthcare providers, which are public, private, and
Non-Governmental Organisations (NGOs) [1]. Specifically,
public healthcare sector, especially the hospitals, has
complex system. The  public  healthcare  sector  has more
complex workflows than other healthcare providers.
Moreover, the public hospitals have large number of patients
– from the rich to the poor to get medical treatments, unlike
the private hospitals  that  focus only on  the  rich who  could
afford to pay expensive medical  bills. Therefore, the large
number of patients in public hospitals may  lead to complex
and complicated environment.  This may also lead to
inefficient system implementation; patients need to wait for a
long time before getting their medical treatment. This issue is
related to low  quality  of  healthcare  services  in public

Manuscript received November 15, 2012; revised January 16, 2013. This
work was supported by Faculty of Technology Management, University of
Tun Hussein Onn Malaysia and University Technology MARA. The authors
would like to thank Hospital Sultan Ismail, Hospital Keningau and Hospital
Tuanku Jaafar for supportive response to interview data. 
Nurul Izzatty Ismail, Nor Hazana Abdullah,  and Alina Shamsudin are
with the Department of Technology Management, Universiti Tun Hussein
Onn, Johor, 86400 Malaysia (e-mail: zetty_1986@yahoo.com,
hazana@uthm.edu.my, alina@uthm.edu.my). 
Nik Azliza Nik Ariffin is with the Department of Record Management of
University Technology MARA Puncak Perdana, Shah Alam, Selangor,
40450 Malaysia (e-mail: nikazliza@salam.uitm.edu.my).
hospitals.  In fact, the statistics by the Ministry of Health
shows increasing number of negligence cases reported
between 2000  and  2008 [2]. Hence, Hospital Information
System  (HIS)  is hoped to  improve  the quality of healthcare
services. 

II.  LITERATURE REVIEW
A.  Hospital Information System (HIS)
HIS refers to a computer system designed to manage all the
hospital’s medical and administrative information in order to
enable  health  professionals to  perform their jobs  more
effectively and efficiently [3]. Moreover, HIS manages  all
the information processing activities within hospital to
achieve  high-quality  patients  care  services  and medical
research [4]. HIS consists of  at least  two of the  following
components: Clinical  Information System (CIS), Financial
Information System (FIS), Laboratory Information System
(LIS), Nursing Information System (NIS), Pharmacy
Information  System  (PIS), Picture Archiving  and
Communication System (PACS), and Radiology Information
System (RIS) [3].  Each category has its  own  function,
department and users in improving hospital services. Table I
tabulates the description for each component including its
respective function, and department and users of the
component.
HIS has many benefits to hospitals [5-36]. However, in the
same time,  there  are several issues and challenges in HIS
implementation [37-48]. Table II shows  the  benefits,  the
issues and challenges in the implementation of HIS according
to previous researchers.  The table  verifies that HIS
implementation is not easy. 
In terms of division of HIS implementation, Budkin [49]
describes that HIS implementation process is categorised into
planning, design,  implementation,  and operation.  Next,
Houser et al. [50] indicate that HIS implementation process is
divided into three (3) phases, which are preparatory activities
for system implementation, certification and acceptance
testing, and system implementation. But, according to Rossi
[51], HIS implementation process is categorised into two (2)
phases only,  which are preparatory phase and utilisation
phase,  specifically, in Malaysia, Hassan [52], Mohd,  and
Syed Mohd. [5], Abdul Hamid [53],  and Ismail et al. [54]
describe  that HIS  implementation process is divided into
three (3)  stages,  which are pre-implementation stage,
implementation stage,  and post-implementation stage.
Therefore, all these researchers  have similar opinions on
division of HIS implementation.

B.  Implementation of HIS in Malaysia
According to Abdul Hamid [53], the planning of HIS
implementation began in 1993, which started under 6th

Malaysian Plan (MP), in Hospital Selayang and termed as
THIS. Then, in 1996, telehealth project was launched on the
1st
 August 1996. Moreover, HIS implementation  took place
along with physical construction under the 7th
 MP. Today,
only 21 out of 138 public hospitals are implementing the
system [2, 53, 54]. Thus, the level of HIS implementation is
still low. 
C.  Categories of HIS
There are three (3) categories of HIS, which are THIS,
IHIS, and BHIS. As mentioned earlier, out of 138 public
hospitals, 21 public hospitals are implementing any of these
categories of the system [2, 5, 53, 54]. Table III tabulates the
hospitals  into  THIS, IHIS,  and BHIS.  Based on  the table,
hospital size is vital to indicate the categories of HIS. THIS is
for the hospitals  with more than 400 beds, IHIS is for
hospitals with more than 200 beds but less than 400 beds, and
BHIS is for hospitals with less than 200 beds. 
Moreover, each category of HIS has different  set of
information system as  shown  in Table III. THIS has more
complete set of HIS than  IHIS  and BHIS. Moreover, the
hospitals  implementing THIS are also known as ―paperless
hospitals‖.

III.  RESEARCH METHODOLOGY
The research design of this study is multiple case studies.
According to Yin [56], this research design supports  the
nature of the study. In this study, three cases were selected for
purposive sampling. According to Merriam [57], purposive
sampling is based on the assumption that the researcher wants
to  investigate  and  understand  an issue based on several
samples. The three cases selected were Hospital Sultan Ismail,
Hospital Keningau,  and  Hospital  Tuanku  Ja’afar; each of
these hospitals represents different  categories of HIS.
Hospital Sultan Ismail implements THIS, Hospital Keningan

International Journal of Social Science and Humanity, Vol. 3, No. 2, March 2013
implements IHIS, and Hospital Tuanku Ja’afar implements
BHIS. Nine participants were selected among Hospital
Directors, IT officers, and HIS users. Moreover, purposive
sampling was used to ensure that the data collection was able
to answer the  research  objectives. Besides that, snowball
technique was used to investigate the HIS implementation
process in Malaysian public hospitals.
Furthermore, qualitative method i.e., in-depth interviews,
was selected to investigate the HIS implementation among
the Malaysian public hospitals in details. According to Kvale
[58], in-depth interviews allow primary data to be collected
and enable the  researchers  to  search and  find further
clarification about  the answers given by  the participants. In
the interview session, which took about 60 minutes for each
participant, an interview guide was prepared for investigating
the HIS implementation process.  Malay and English
languages were used as the main languages in the interview.
The interviews were tape-recorded  and later transcribed
verbatim. For data analysis, Content and Thematic Analysis
using computer software called NVivo was used. The data
were triangulated with other supporting documents obtained
during the study that served as the secondary data to ensure
that the data were valid.
IV.  RESULT
From the analysis, several issues have influenced overall
HIS implementation in Malaysian public hospitals such as
limited financial  sources, maintenance by different
department,  HIS implementation order by the Malaysian
Ministry of Health, addition of new systems, confidentiality
issues, low acceptance level, low satisfaction level, different
vendors, infrastructure issues, system  breakdown,
duplication of data.

A.  Limited Financial Sources
The implementation of HIS is expensive and the financial
source comes from the Malaysian Government. The costs
include start-up, maintenance, and training. The hospitals
depend on the financial sources from the Malaysian
Government. Although the hospitals obtain financial support
from the Government to build hospitals with IT applications,
the costs to maintain the system and train the users are
increasing. Thus, the hospitals have limited financial sources
other than the Government and they are in need of more
financial sources to upgrade the system as well as to add new
system. However, limited financial sources by the
Government have made the system unchanged or not
improved. 
B.  Maintenance by Different Departments
In THIS and BHIS hospitals, the IT department is
responsible to maintain the system and to train new HIS users.
However, hospitals especially those implementing IHIS have
outsourced the responsibility to maintain the system. Thus,
the difference in the department responsible for maintaining
the implementation of HIS between one HIS category to
another has made it difficult for the system to be
synchronised nationwide. 
C.  HIS Implementation Order by the Malaysian Ministry
of Health 
HIS Implementation is ordered by the Malaysian Ministry
of Health (MOH). Usually, hospitals are built with the IT
system, either THIS, IHIS or BHIS. Thus, the MOH has full
authority of the overall HIS implementation. 
D.  Addition of New Systems
Due to limited financial sources as discussed earlier, the
hospitals have difficulties in adding new systems to the
currently used ones, especially for BHIS. However, the
hospital with IHIS has added several new systems such as
Day Care System, e-notification, e-registration and Registry
Delivery System. These systems are developed as a
cooperation work between the outsource company and the IT
department of the hospital.
E.  Confidentiality Issues 
Hospital records are confidential. Thus, it is vital to keep
all patients’ data and records in a proper way. Thus, the
system is designed to allow only authorised users with ID and
password. However, the security level is not enough  as all
nurses or doctors can get access to all  patients’  data and
records, under or not under their supervision.
F.  Different Vendors 
According to the participants, the hospitals with THIS,
IHIS, and BHIS have multiple vendors to implement HIS.
For example, Cerner is the main vendor for THIS in Hospital
Sultan Ismail. Other than that, GE, Kaizen HR, and People
Soft are also the vendors for Hospital Sultan Ismail  for
imaging, human resource, and billing. Meanwhile, in
Hospital Keningau, I-Soft is the vendor implementing HIS in
the hospital while Hi-Tech works in Hospital Tuanku Ja’afar.
G.  Low Acceptance Level 
There is low acceptance level by HIS users in the hospitals.
According to the participants, most of the old-aged users
especially among physicians have low acceptance towards
the system. They believe that using the system  is
time-wasting because the system is too complex for them. 
H.  Low Satisfaction Level 
Most HIS users have low satisfaction level because they
want a more excellent system than the present one.  They
think that the present system is not good enough. 
I.  Infrastructure Issues 
Due to limited number of computers and laptops, it is
difficult for the hospitals to efficiently implement HIS in all
hospitals. 
J.  System Breakdown 
Sometimes the system breaks down when the users are
dealing with the patients. This is one of the challenges  of
using the electronic system. 
K.  Duplication of Data 
Sometimes the system breaks down when the users are
dealing with the patients. This is one of the challenges  of
using the electronic system. 
L.  Different Systems 
According to interview result, each category of HIS has
difference systems. For example, hospital of THIS has
Radiology Information System, Laboratory Information
System, Pharmacy Information System, Critical Care
Information System, Picture Archiving & Communication
System, Electronic Medical Records, Financial Information
System, Administrative Systems and Dietary Information
System. Moreover, the hospital with IHIS has Clinical
Access, Person Management System, Billing System,
Pharmacy Information System, Laboratory Information
System, e-notification and Registry Delivery whereas the
hospital with BHIS has Patient Management System, Billing
information System, Dietary Information System, Ward
Information System, Electronic Medical Records and Nurse
and Staff Information System. Hence, it confirms that the
different systems are depends on hospital needs.
 
V.  CONCLUSION
In  conclusion, different category of HIS faces different
challenges. THIS has the most complete system whereas
BHIS has the least complete and limited system. In addition,
the most critical issues and challenges in HIS implementation
are low of acceptance level and low of satisfaction level.
Thus, these critical issues and challenges need to be studied
and a HIS implementation model has to be developed using
questionnaire  as a  quantitative approach  for studying these
issues and challenges in future work. 
ACKNOWLEDGMENT
The authors would like to thank the relevant parties that
have directly or indirectly contributed to the success of this
study. Besides that, the authors wish to express their gratitude
to the anonymous referees for their helpful comments and
numerous suggestions to improve the paper.