FACTORS AFFECTING THE USERS’ SENSE OF SECURITY AND TRUST IN INTEGRATING ELECTRONIC HEALTH RECORD TO CLOUD
Factors
Affecting the Users’ Sense of Security and Trust in Integrating Electronic
Health Record TO CLOUD
By
Lloyd Enyrebe Johnson
Presented to
Prof. Steve Page, S-Master of Science, Information System
Management (S-MScISM)
University of Salford,
Manchester
United Kingdom
30th of June 2017
PREFACE
I am grateful to God who has made this journey a success. To
everyone who have assisted me thus far, I say a big thank you. I wish to
acknowledge and sincerely thank my dissertation Supervisor. Prof. Dr. Steve
Page For his guidance, patience and constant encouragement. During my
thesis, he was
instrumental in inspiring
me to work
towards solving a well-defined
problem that would
result in a
publishable article and
paper. It would not have been possible
for me to complete this thesis and graduate without his guidance. My lecturers Dr
Radu Negoescu, Mr Alin Stefaniu, Prof. Dennis Crossen, Dr Susan Harwood, Dr. Alistair
Benson, Dr Patrick Reid, the
participants who took their time to read and take part in the study. My wife
Charlotte Khapwale, Uduak Johnson, Jesse Ryan for their immense guidance,
encouragement and support. My brothers and sisters for their prayers and
support.
TABLE OF CONTENTS
PREFACE………………………………………………………………………………….. .I
TABLE OF CONTENTS…………………………………………………………...............II
CHAPTER I.........……………………………………………………………………. …...
1.0.......................................................................
Background of the Problem
1.1 Research Questions and Objectives
1.3 Research Aim/Objective…..…………………………………………….........
1.4 Justfication of the Research………………………………….......…………....
1.5 Research Methodology - Outline..........................………………………….... 7
1.6 Dissertation Structure……….……………………………………………….. 8
2.0
Introduction....................................................................................................10
2.1 The Electronic Health Record (EHR)................................
2.2 The Importance of the EHR System..............................................................12
2.3 Integrating EHR to Cloud..............................................................................13
2.4 Security and Privacy Concerns in
Integrating EHR to Cloud.......................14
2.5 Summary........................................................................................................15
CHAPTER III.......………………………………………………………………………..16
3.0:
METHODOLOGY......................................................................................................16
3.1
Introduction.............................................................................................................18
3.2
Research
Philosophy...............................................................................................19
3.3
Research Strategy....................................................................................................20
3.4
Research
Design......................................................................................................21
3.4.1
Questions directed to the expert participants..........................................................22
3.4.2
User Interviewees...................................................................................................23
3.5
Research Administration...........................................................................................24
3.6
Research Ethics.........................................................................................................25
3.7
Chapter Summary......................................................................................................24
CHAPTER
IV................................................................................................................25
4.0 RESULTS AND FINDINGS..................................................................................25
4.1
Introduction...............................................................................................................26
4.2
Demographics, Healthcare and
EHR........................................................................27
4.2.1
Tabled Representation of the Participant’s Place of Residence.............................28
4.2.2
Sampled Participants by Age.................................................................................29
4.3
Accessing Hospitals or Healthcare Services.............................................................30
4.4
The Importance of Medical History in the Provision of Healthcare Services..........31
4.5
Information Required in Healthcare Facilities.........................................................32
4.6
Electronic Information
Storage................................................................................33
4.7
Confidentiality in Handling Healthcare Information ..............................................34
4.8
Management of Health Information ........................................................................35
4.9
Digital Medical Records and Respondents’ Knowledge of Cloud Security System.36
4.10
Ethical Concerns......................................................................................................37
CHAPTER V.................................................................................................................38
5.0 ANALYSIS AND CONCLUSION.........................................................................38
5.1
Introduction ..............................................................................................................39
5.1.1 Critique
of the Adopted Approach.........................................................................40
5.2
Analysis of the Findings............................................................................................41
5.3
Overall Conclusion....................................................................................................42
5.4
Limitations of the Study ...........................................................................................43
5.5
Opportunities for Further Research...........................................................................44
BIOGRAPHY.......................................................................................................................38
APPENDICS........................................................................................................................39
Chapter I - Introduction
1.0
Background Information
The
continuous quality improvement in health care delivery requires the continual
improvement of the system. Information management is one of the essential
health care components that ensure quality, secure, and efficient delivery of
health care services. According to Ajami and
Baqheri-Tadi (2013) and Wang, et al.
(2016), effective information management plays a critical role in
minimizing medical/healthcare risks and errors by facilitating efficiency and
quality. In the recent past, the implementation of electronic health record
(EHR) has improved storage and management of patient records significantly. It
stores and allows easier retrieval of the information thus enhancing efficiency
in delivering services
Subashini and Kavitha (2011), points out a
growing concern about the safety of the Cloud environment and increasing trust
issues among the users. The authors assert that there is a significant
reluctance to allow integration of business in the Cloud
1.1
Research Question and Objectives
The
EHR offers a patient-centered recording of patient information and allows
easier access and retrieval of the information by authorized users. In the
recent past, the continued integration of EHR to Cloud promises a more
efficient, easier, and low-cost management of the information. According to Deshmukh (2016), the integration of EHR to
Cloud comes with benefits but poses various concerns, which continue to limit
implementation in the healthcare system. The users’ sense of security and trust
are major concerns in the implementation of a Cloud-based EHR. Therefore, there
is a need for the investigation of factors that influence the users’ sense of
security and trust in order to develop a better understanding of the issue and
formulate effective measures of addressing it. This leads to the development of
this study’s research questions:
1.2
Research Questions
-
What
process has been used to integrate EHR to the Cloud?
-
What
factors influence the user's sense of security and trust of such integration?
-
To
what extend do the users' sense of security and trust affect the implementation
of a Cloud-integrated EHR system? and
-
What
implications does this have to the integration process and the future of
managing EHR?
This research question will be addressed effectively
by focusing on achieving the following research objectives.
1.3 Research Aims/Objectives
The research aims to:
-
Critically
discuss the integration of EHR to Cloud.
-
Comprehensive
discusses the factors that influence users' sense of security and trust in
integrating EHR to the Cloud.
-
Outline
the extent to which users' of security and trust has affected the
implementation of a Cloud-integrated EHR system.
-
To
assess the implication of users' sense of security to the integration process
and the future of managing EHR.
1.4
Justification for the Research
There
is increasing pressure for the integration of EHR in healthcare. The efficiency
of EHR in developing digital identities for patients and improving their
interoperability in various heterogeneous systems has resulted in significant
success for Cloud computing in healthcare. However, numerous concerns influence
the users’ sense of security and trust in EHR integration to Cloud. According
to Lyu, et al. (2016), security and
privacy are the major concerns in Cloud computing, especially in the
incorporation EHR into the technology. Many patients and healthcare providers
worry about the possible violation of patient privacy. Moreover, Deshmukh (2016) cites an increasing trend
towards the integration and use of Cloud technology in EHR. The author states
that while technologies are increasingly becoming popular for sharing data and
communicating online, the applications' storage of personal information makes
such data when the security requirements are unmet. Lyu, et al. (2016) states that Cloud storage servers store users’
records including patient health information, locations, and other personal
information. Access to the information by unintended people breaches the users’
right to privacy.
Even
when technological advancement has improved the security of Cloud computing and
data storage, various factors continue to influence the users’ sense of
security and trust. Deshmukh (2016) states
that there is limited research in the area, mainly on the factors that
determine the trust and sense of security. According to Ashibani and Mahmoud (2017), and Subashini and Kavitha (2011) most
research on integrating EHR to Cloud revolves around its effectiveness in
improving healthcare delivery, security, and efficiency amongst others. There
is minimal literature on what influences the users’ sense of security.
Therefore, this research identifies this gap and focuses on offering a
comprehensive research on the topic. The information presented in this research
forms a basis for future research. Information on the users’ sense of security
and trust adds to existing knowledge to enhance understanding of the factors
that influence these user aspects.
1.5
Research Methodology – Outline
According to Creswell (2014), the effectiveness of the research methodology
influences the accuracy and precision of data and results, which determine the
credibility, validity, and reliability of the research. This research places
emphasis on the factors influencing users’ sense of security and trust in the
integration of EHR to Cloud. Therefore, it focuses mainly on outlining and
understanding users’ perceptions and experiences. According to Çuhadar (2014), the integration of these
aspects into research demands the application of the phenomenological research
technique. Çuhadar (2014) describes a
phenomenological study as a qualitative research method that captures
participants’ experiences and perspectives on the issues under study. Further,
considering that the integration of EHR into Cloud affects large populations,
the integration of the qualitative research approach was deemed essential for
representing these populations precisely and accurately. An interview was the
most effective method applied for the collection of data. Therefore, this
research applies the qualitative and numerical research methodology. The
application of this technique enhances the credibility and reliability of
research (Kuada, 2012).
Furthermore, the methodology
includes a comprehensive literature review, a studious research design, and a consideration
for ethics. Creswell (2014) argues that
existing literature and research informs current and future research.
Integrating existing literature in research offers a ground for developing meaningful
research and new insights, and sets ground for further research. This research
integrates credible resources from peer-reviewed journal articles and other
scholarly materials that enhance its credibility and validity whilst knitting ideas
coherently and logically to facilitate a better understanding of the concepts
covered. Effective data collection tools and methods are applied to gather
credible information/data
Dissertation
Structure
Chapter
I - Introduction
This chapter offers a background of
the study by discussing the application of EHR to Cloud. It outlines the
influence of the new technology on the EHR and a glimpse of the users’
perceptions. The discussion of the Cloud-based EHR identifies the users’
security concerns and trust issues. This section also includes the research
question, a justification thereof, and its aims. It presents the outline of the
methodology, and the structure of the dissertation.
Chapter
II - Literature Review
This chapter acknowledges the
importance of an informed research and offers a comprehensive discussion and
critical analysis of existing literature. The review focuses on integrating
expert knowledge and opinion in the research. The different areas covered
include - the influence of new technologies in the development of the
healthcare system, the integration of information technology in improving and
promoting efficiency in information management, and integrating EHR to Cloud.
Most importantly, the literature review discusses the security and privacy
concerns and their influence on trust. It creates a basis for research on the
factors that influence the sense of security and trust in integrating EHR to
Cloud computing.
Chapter
III - Methodology
This chapter outlines the research
methodology applied in conducting this study.
Chapter
IV - Findings
This chapter presents the data/information
and findings of the research.
Analysis
and Conclusion
The analysis and conclusion section
offers an extensive yet articulate discussion of the findings and a summary of
the research.
Summary
The incorporation of new
technologies in the healthcare system continues to improve the quality and
safety of services. This chapter discusses the inclusion of EHR to Cloud and
the influence it has on the management of patient information and the
healthcare in general. The discussion offers a background for the development
of the research. The research questions and research justification areas point
out a major research gap in the area. The introduction breaks
ground for a succinct research on the factors that influence the users’
sense of security and trust in EHR to Cloud.
CHAPTER
II
Literature Review
2.0
Introduction
Quality improvement in healthcare
remains a broad space of research considering the different elements that
contribute to the achievement of success in the sector. The improvement of the
efficiency of healthcare systems through the adoption of numerous strategies
and measures for enhancing performance, quality, safety, and cost-effectiveness
amongst other elements has in the recent past showed significant progress
Young, et al. (2017),Deshmukh (2016),
and Roehrs, et al. (2017), as well as
other scholars alike, argue and endorse the importance of the EHR in enhancing
the efficiency of healthcare systems.
The implementation of the health record system has simplified the storage of
patient information, access, and retrieval during the processes of delivering
care. Sermeus, et al. (2016) poses that
the EHR continues to influence improvement in service delivery but that there
are challenges affecting the use of EHR. This section offers an in-depth review
and analysis of existing literature on the EHR and delves deeper into the
concerns surrounding the implementation of the system. The analysis places
greater emphasis on the integration of the EHR to Cloud. While Coats and Achary (2014) point out that though
the integration of the EHR to Cloud is fundamentally important to promoting
efficiency in the system, Rodrigues, et al.
(2016) asserts that the implementation is greatly affected by the issues
of insecurity and data breach amongst others. Therefore, this literature review
goes deeper into outlining the factors that influence the users’ sense of
security and trust in integrating the EHR to Cloud.
2.1
The Electronic Health Record (EHR)
The electronic medical and health
record systems have the healthcare information that is meant to facilitate the efficiency
of the healthcare system. The development and implementation of the EMR
resulted in better clinical and medical data collection. The EHR builds on the
EMR but it is more comprehensive. According to Duckert
and Rose (2013), the EHR goes beyond the collection of data in the
healthcare provider’s office to the inclusion of a more integrated patient
history. The author asserts that EHR systems are designed for containing and
sharing information from providers of healthcare services to a particular
patient. The EHR makes sure that all providers can access timely information
concerning the history of a patient under their care. In discussing the EHR
system, Steele (2016) argues that the
system has played a significant role in improving the management of patient
information and consultation by authorized personnel in different healthcare
organizations. The inclusion of the EHR allows a patient to receive quality
healthcare services across different healthcare institutions. As Sinha, et al. (2013) put it, the system allows
patients to move with their health records and gives them the opportunity to
authorize its use by other healthcare specialists, providers, and institutions
across the country.
The EHR builds on the benefits of
the EMR in the provision of care. According to the Health IT (2017), the EMR is
a paper chart generated electronically or digitally that contains the medical
or clinical history of the patient from a practice. The application of the EMR
in the diagnosis and treatment of a patient enhances effectiveness in the
process. However, the provider lacks a comprehensive patient history, which the
EHR provides. The importance of the EMR is undeniable. Jawhari, et al. (2016) and Keenan,
et al. (2016) argue that the effective implementation of EMR systems
allows for data tracking over time, the identification of the patients due for
screenings and preventive visits amongst others. Moreover, the EMR facilitates
patient monitoring and determination of how they measure up to clinical/medical
parameters. These parameters may include vaccinations and readings such as
blood pressure and sugar levels amongst others. Keenan,
et al. (2016) states that the implementation of the EMR expedites quality
improvement and practice efficiency.
The EHR builds on the EMR system and
offers significant efficiency and improvement of the quality of care. Keenan, et al. (2016) posits that the EMR
allows the storage of data but data-sharing among providers and specialists
outside one practice is difficult. The author argues that despite the
implementation of the EMR, healthcare provision remained inefficient and
limited due to the challenges of sharing information that the system poses. The
electronic health record improves on the electronic medical record by, mainly,
facilitating the effective sharing of the information
Elkhenini, et al.
(2015) offers a
similar definition of the EHR as Jawhari, et al.
(2016). The author defines the system as capable of holding the
patients’ medical and treatment histories and places it at the disposal of
authorized staff and providers for use in delivering health care services. Bell and Thornton (2011) offer a similar
description of the EHR and states that it goes beyond the storage of standard
data to include the medical/health history, previous diagnoses, medication and
treatments, scheduled dates for certain services, health concerns such as
allergies, laboratory results, test results, and radiology images among others
2.2
The Importance of the EHR System
Different authors, Darko-Yawson and Ellingsen (2016), Steele (2016), and The AORN (2013) point out
that the effective implementation of the EHR system is critical for the
achievement of healthcare goals. The EHR supports the improvement of quality
and safety in healthcare by promoting efficient patient care. Bell and Thornton (2011) assert that the
implementation of the EHR guarantees the improvement of the quality and
convenience of the health care. The EHR gives providers quick and easy access
to patient information and health records. According to
Elkhenini, et al.(2015)
and Goldberg,
et al. (2012) describe the EHR as a critical system for the improvement
of the quality of services. EHR facilitates efficiency information access and
availability, which influence the whole process of health care service
delivery. EHRs offer a platform for storing health information of patients in a
single place making it possible for the providers from different health centers
to access the information when the patient requires care. Additionally, the EHR
gives articulate and accurate health information for integration in providing
health care. According to Steele (2016),
the reliable information available in the system is essential for effective
decision-making. Goldberg, et al. (2012) state
that decision-making is a critical component of healthcare provision that
requires accurate and reliable information. The providers utilize information
from the EHR to make decisions on what approach to take to manage or treat
certain conditions. Wickramasinghe
(2016) adds that the
EHRs provide clinical reminders and alerts, allow improved aggregation, and
assist providers in integrating the safeguards for preventing adverse events
when offering health care.
Darko-Yawson and
Ellingsen (2016) discuss
the improvement of patient participation in the processes of care as another
essential benefit of the system. The platform for sharing patient history and
medical/clinical information and data allows the integration of the patient in
the process of providing care. The EHR allows the healthcare providers (HWCs)
and patients to share and access the patient’s information. This creates room
for the development of collaborative approaches to managing certain conditions.
Health IT (2017) describes the EHR as
critical for the management and treatment of chronic conditions such as obesity
and asthma among others. Additionally, Lorenzi,
et al. (2009) and Deshmukh (2016) assert
that the implementation of the EHR in the recent past has recorded success in
improving patient participation in the processes of health care provision. Jawhari, et al. (2016) state that the system
contributes greatly towards quality improvement and creates an efficient
communication avenue that empowers the patients to take part in health care
processes. The creation of schedules and programs for medication and attendance
of clinical and medical appointments improves enhances the provider’s ability
to identify the symptoms.
Lorenzi, et al. (2009)
state that the EHR is important for
the improvement of diagnostics and patient outcomes. It offers the providers
medical/clinical history and all information concerning the patient’s health
history. The EHR carries information such as the vital signs that the patient
shows, medical histories, immunization schedules, diagnoses, and progress notes
among the others that enhance the process of diagnosis in the future. The
healthcare providers use the information with permission to understand the
history of the patient to make decisions. The provision of accurate and
complete information about the patient ensures the provision of better medical
care. According to Young, et al. (2017),
the EHRs allows the utilization of the information to diagnose thus improving
the ability of the specialist to perform effectively. Roehrs, et al. (2017) state that the integration of the information
in medical care reduces cases of errors and promotes better outcomes. A study
done by Bell and Thornton (2011) shows
that more than 94 percent of healthcare providers who use the information
available in EHRs effectively report enhanced effectiveness in accessing the
readily available information when required. Additionally, 88% and 75%
respectively state that EHRs are critical for practice and improves the ability
to provide superior patient care.
Moreover, Houser, et al. (2012) supports the idea that EHRs continue to play a
fundamental role in assisting providers in diagnosis. The access given to providers
to the EHR places the full information required for understanding the patient’s
medical and health background. Understanding the history, as Health IT (2017) asserts, helps providers to
diagnose the patient’s health issues fast. The quick identification of the
health problems affecting the patients makes it possible for the provider to
determine the most effective measures for treating and managing the conditions.
Amatayakul and Amatayakul (2013) argue
that effective EHRs equip the providers with the necessary information for the
identification of the greatest risks a patient faces and reduces cases of
errors. The inclusion of histories of chronic conditions or allergies, for
instance, gives the provider sufficient enough that makes him or EHR avoid
using medications or approaches that may cause the recurrence of a certain
condition or other health complications
Research shows that
the application of HER improves quality and enhances satisfaction. Duffy (2010) points out that the application of EHRs leads to
quality improvement and an increment in patient satisfaction. The author cites
statistics that show 92 percent of patients were happy when their doctors used
the EHRs to prescribe. The application of the EHRs minimizes time wastage and
serves the patients effectively
Additionally, the EHRs improves the
quality of care through the transformation of the clinical process. Goldberg, et al. (2012) state that any hospital
that implements the EHR stands a better chance for improved health care and
better outcomes than those that do not. While this does not mean that hospitals
that do not have the system are outright inefficient, the implementation of
EHRs enhances clinical processes. According to Sinha,
et al. (2013), the implementation of the EHRs results in better clinical
processes. The research identifies the case of a Vermont hospital that
implemented the system causing a significant decrease of 60 percent in
near-miss healthcare/medical events
The integration of EHR into the
healthcare systems results in improved efficiencies and cost-effectiveness.
These two elements define the acceptability and accessibility of the health
care. The AORN (2013) notes that EHR
improves efficiency in medical practice. A research done by Kumar and Bauer (2011) identified that 79% of
providers who are ready for meaningful use find the EHR important for
application in enhancing the efficiency of the practice. Doctors and other
providers understand the need of reviewing the client’s history before
diagnosis and medication. Further, 82 percent and 75 percent participants of
the study find e-prescription and the reception of lab results via the EHRs
more respectively to be more effective, less time-consuming, and faster. The
integration of the form of information collection and storage has improved
efficiency in offering Medicare significantly. Most importantly, the EHRs leads
to a significant cost reduction and higher profit efficiency. Kumar and Bauer (2011) state that financial
benefits may range between$37 million and $59 million in five years. The
automation of numerous time-consuming and labor-intensive processes reduces the
costs of operation and improves efficiency. Efficient practices results in
improved quality, patient satisfaction, and profit-efficiency among other
benefits.
2.3
Integrating EHR to Cloud
The application of the ICT in
healthcare plays a fundamental role in improving the quality of care. According
to Chen, et al. (2012), the technological
advancement recorded in the past years has resulted in the development of all
aspects of life. The integration of new technologies in the healthcare setting,
for instance, triggers continuous quality improvement by enhancing efficiency,
safety, and effective management. The adoption and implementation of the EMR
and the EHR are some of the most significant improvements in the healthcare
sector
According to Alabdulatif, et al. (2013) the number of people using the EHR
integrated to Cloud is increasing considerably. However, there are numerous
concerns of challenges surrounding the development of the healthcare sector
using technologies. Mirza and El-Masri (2012) cite
some of the challenges as the high cost for implementation and use of the
services, security and privacy security concerns, and the maintenance of the
systems. The EHR faces these challenges, which make many institutions desist
from implementing. However, institutions that have implemented the EHR benefit
significantly. According to Niles (2017),
many institutions are adopting and implementing the EHR but many others are
fearful of the costly implementation and maintenance. Health institutions that
lag behind will soon find themselves incapable of surviving or competing
effectively. Chen, et al. (2012) state
that there is a shift towards the integration of EHR to Cloud computing for the
enhancement of the efficiency of the system. The major purpose, according to Elkhenini, et al.(2015), is the achievement of
improved healthcare efficiency, better healthcare and patient outcomes, and
improved systems’ efficiency among others.
In the analysis of the influence of
Cloud computing to EHR, Stair and Reynolds (2016)
offer an in-depth discussion of the topic and integrates a comprehensive
Cloud computing system for an integrated EHRs. The author argues for the need
to ensure an effective Central Database and a Unifier Interface Middleware to
mask the heterogeneity and standardize the communication between the Cloud EHR
and the EHR standards. Mirza and El-Masri (2012)
cite different studies that outline the major challenges facing the
integration. The study shows that the high costs of development, maintenance,
physician’s resistance, insufficient IT personnel, and uncertainty concerning the
return on investment pose a significant challenge in adopting and implementing
the Cloud-integrated EHRs. The implementation of the strategy would be
important in the enhancement of efficacy in healthcare systems’ handling of
patient information
Mirza and El-Masri
(2012) describe the
technology of Cloud computing as a new, comprehensive, and thought-provoking solution
in Information Technology. The author points out the ability of the technology
to leverage Intranet and Internet allowing people using the Internet to share
information without any barriers. According to Stair
and Reynolds (2016), by integrating the technology to EHR healthcare
institutions stand a better chance for enhanced efficiency in the management of
patient information and the effective use of the information in promoting care.
Implementing the technology into EHR improves cost-effectiveness and
scalability. Mirza and El-Masri (2012) cite
the definition of Cloud as "a model for enabling convenient, on-demand network
access to a shared pool of configurable computing resources (for example,
networks, servers, storage, applications, and services) that can be rapidly
provisioned and released with minimal management effort or service provider
interaction.” The definition shows the
possible impact Cloud can have when integrated into a service such as the EHR. The
application of Cloud offers a securable and multitenant platform managed
by the provider of the Cloud.
The integration of EHR to Cloud facilitates
the system to adopt EHR for the numerous healthcare institutions. The
technology offers a securable platform and other features such as multitenancy
and scalability, with authorized data interactions under the management of the
Cloud provider
Coats and
Acharya (2014) argue for the importance of integrating the EHR to Cloud and
suggests the identification of the requirements of the system. The author
identifies information ownership, issues of authenticity and authentication,
and non-repudiation as some of the critical requirement in the development of
an integrated EHR. As a system that deals with personal and institutional data
and information, the establishment of clear guidelines on the information
ownership is essential for protecting the user information from access by
unauthorized users
Moreover, the willingness to fulfill
the contractual obligations (non-repudiation), consensual agreement and
authorization, availability, integrity, audit and archiving are other critical
requirements. The parties involved in the must show integrity and
non-repudiation. These requirements ensure consistency and accuracy of the
data, and involve the patient in the process, who must acknowledge and consent
to the use of personal information with other providers
2.4
Security and Privacy Concerns in Integrating EHR to Cloud
As an emerging topic, there is
minimal research on the Cloud-integrated EHR, which makes it a key research
area. However, some authors have explored the topic extensively. For instance,
the Fernández-Alemán, et al. (2013),Niles (2017)
and Ozair, et al., 2015) discuss security
and privacy regarding the EHR and Cloud computing significantly. Ozair (et al.
(2015) define privacy as the claim by a person or group to be let alone. The
author integrates the definition of Justice Louis Brandeis and Dennis Warren
who defined privacy as a person’s right ‘to be let alone’. The application of
this determination allows the protection of patient’s right to privacy. The use
of the EHR, according to Sermeus, et al.(2016),
and adoption of the system in hospitals is mainly affected by the issue of
privacy. The author states that most people do not use the platform for fear of
data breach and theft of personal information.
Fernández-Alemán,
et al. (2013) describe
security and privacy as critical components in the development of EHR and
integration of Cloud computing. The author state that hackers, computer or
Internet worms, and viruses influence the privacy of the EHR user
significantly. Kelley (2016) posits that in the
recent past the healthcare sector has experienced data loss or increasing theft
of patient clinical data.The author’s advises that there is a need for
more effective strategies and tools for the protection of the data and information
from theft and misuse. Young, et al.(2017)
support the author by stating the importance of increased security and creation
of imprenetrable systems. Further, Rodrigues, et al.(2016)argues that the use
of EHRs in the Cloudfor storing
sensitive information requires a comprehensive data protection. Any institution
that integrates and allows the storage of information on the system must
consider the development of an efficient data protection system.
The development of
precautionary measures against the breach of privacy, the assurance of safety,
and the data confidentiality are important components. The confidentiality of
user data is critical for ascertaining the promotion of their privacy.
Rodrigues, et al. (2013) states that the development of trust is essential for
ensuring transparency in parenting. The institution and individual users must
focus on establishing trust with the
Cloud provider. The Cloud service team must ensure that it adheres to
all the contractual terms of an agreement. The continued interaction in good
faith promtes trust and improves the engagement betweenthe Cloud provider and the institution’s
management. This protects the user from data theft and misuse by unauthroised
persons. Kelley (2016) states that the implementation of privacy and security
in an integrated Cloud/EHR system is a
major challenge for most of the healthcare institutions across the country.
Moreover, Ozair, et al. (2015) states that one of the most impactful issues
about the Cloud-integrated EHR is the issue of security breach and involvement
in patient privacy. Security breach prevents the user from enjoying the quiet
of privacy. The implementation of measures for the protection of confidential
information, according to Kelley (2016),
adheres to the rules of individual consent. The loss of the right to privacy
allows any person to use or promote information associated with the person
without privacy. Ozair, et al. (2015) integrates
data from major research by the Howard university Hospital that states that
insecurity or poor data security risks the exploitation of many people. The
implementation of measures such as firewalls, the inclusion of software for the
development, antivirus, and software for determining intrusion are critical for
the development of a comprehensive data security. Additionally, Niles (2017) argues that there is a need for
developing policies and frameworks for the management of the maintenance of
patient privacy and ensuring minimal risks when it comes to confidentiality.
Gavrilov and
Trajkovik (2012) discuss
the issue of security in the Cloud computing extensively by asserting that the
issue of security occurs in terms of trust, identify management, architecture,
software isolation, and data protection. The authors argue that Cloud computing
developed from an amalgamation of new technologies such as service-oriented
architecture, utility computing g, and virtualization. The authors assert that
the major issue of concern is that the infrastructure of Clod computing depends
mainly on trusted computing. Therefore, like Alabdulatif,
et al. (2013) point out, the interconnection between security and trust
is undeniable. The consideration of one without the other would only lead to
the unsuccessful implementation of the technology. The integration of Cloud
computing to EHR requires the institution and patients to develop and maintain
trust on the Cloud server provider. However, according Stair and Reynolds(2016), there is an increasingly growing concern
of about the breach of privacy and access to the patients’ information by
unauthorized people. Gavrilov and Trajkovik
(2012) state that one of the major causes for the continued privacy
concerns is because of the non-existence of a clear privacy regulation in Cloud
computing. The integration of the technology into EHR without distinct
regulation and guarantee of privacy and security will continue to pose a
challenge on the adoption and implementation of Cloud-EHR.
Fernández-Alemán,
et al. (2013) discuss the issues of privacy and security in-depth by
incorporating research from different areas of the world. The authors come to a
simple conclusion that the EHR features, mainly security and privacy, are the
major issue influencing its adoption and implementation forthe enhancement of
efficiency in the healthcare sector. Deshmukh (2016) argue for the need to
identify the most effective data protection techniques for the EHRs. Moreover,
the research identifies security and privacy concerns as the major hinderances
in other countries as well. Wickramasinghe(2016) outlines data security
concerns among EHR users in Denmark, New Zealand, and Germany. The integration
of the EHR, which is mainly affected by people’s data security and privacy
concerns, to Cloud computing shows the possibility of even greater challenges
on the features.People are more likely to continue mistrusting the EHR and the
Cloud computing technology over the concerns of security and privacy
2.5 Summary
This chapter offers
an extensive discussion and analysis of existing literature on theEHR, compares
the technology with the EMR and delves deeper into the analysis of the benefits
of the electronic health record. Further, the review places emphasis on the
integration of the EHR to Cloud computing identifies the challenges hindering
the adoption and implementation in the healthcare setting. Most importantly,
the review of literature covers the major areas of study in this research. The
analysis of research on the security and privacy concerns in incorporating EHR
into Cloud computing sets a pace for the continuation of the research on the
factors that influence the users’ sense of security and trust in integrating
EHR to Cloud.
3.0 METHODOLOGY
3.1 Introduction
The effectiveness of the research methodology determines
the credibility of the study. According to Coyle
and Lyons (2013), the effectiveness of the research methodology is
defined by the methods and techniques applied in conducting of the research.
This study applies different methods to understand the factors that affect the
use of EHR integration to Cloud on the aspects of security and trust. This
chapter explores the research philosophy, strategy, design, and research
administration and ethics. It explores every aspect of research methodology and
explains the choice and application of each method clearly. Every choice is
based on the ability of the method or technique to contribute towards the
effectiveness of the research. This study considers Khan’s argument that the research methodology defines the accuracy
and credibility of the information collected and the overall reliability and
credibility of the research
3.2 Research Philosophy
The development of an articulate, credible, and a
reliable research depends significantly on the effective application of a
suitable research philosophy for the particular study. The choice of a research
philosophy, according to Jost, et al. (2012),
depends on the type of the research, the objectives, and the possible strategies
applicable. This research aims to understand the factors that affect the sense
of security and trust in the integration of EHR to cloud. To meet this aim, the
study seeks to explore the processes that haves been used to integrate EHR to
the Cloud. It would also assess the factors that influence the user's sense of
security and trust of such integration. It would consider the extent to which
users' sense of security and trust affect the implementation of a
Cloud-integrated EHR system and what implications this has on the integration
process and the future of managing EHR. Doing the above will uncover people’s
perceptions and perspectives while enhancing the understanding of why they would or would not like to integrate
their health records with cloud. The application of methods that uncover these
concerns and integrate expert opinion on the matter is critical for the
development of a comprehensive and articulate research
The application of the qualitative research technique
enhances the effectiveness of the data collection and analysis for the
development of a credible and well-researched study. According to Hays and Singh (2012), the qualitative research
method allows the analysis of a smaller sample without the isolation of
variables. The method offers critical insights in the development of studies
that focus on capturing perceptions, thoughts, concerns, and experiences. The
application of this method in this research offers a broad base for the
analysis of the issues of concern. Further, Rubin
and Babbie (2011) argue that the explorative nature of the qualitative
research approach allows an in-depth understanding of issues that influence
people. The use of the method in health care and research in the sector allows
the researcher to capture the experiences and explore them extensively to
understand phenomenon and issues under study. Therefore, the application of
this method in the study is greatly important for the development of an
articulate, credible, and reliable study.
3.3 Research Strategy
The choice of the research strategy is critical for the
development of good research. The sequential development of research from the
identification of the topic, the investigation of the possible, the influence
of such research on the field and the society, and its contribution to the
choice of the research philosophy and other key research areas facilitates effectiveness
and the comprehensiveness of the study. The research strategy influences the
development of a credible and reliable research. According to Rubin and Babbie(2011), the research strategy plays a
fundamental role in shaping the research, the accuracy of the data collected,
and the reliability of the data analysis techniques. The research strategy
determines how accurate the data collected is, in relation to the topic of
discussion or under study. Effective data collection strategy allows the
integration of precise, accurate, and appropriate data in research. Further,
according to Belk (2006), the development
of a good research strategy defines the ability of the research to meet the
objectives of the study and influences the applicability of the research in
future.
According to Hays and
Singh,( 2012), the identification of the most effective research methods
before the commencement of the study is crucial for developing a good research.
This research identified the qualitative research technique and numerical
analysis of the data as central research methods. Moreover, the identification
of the data collection techniques is equally essential for the enhancement of
effectiveness in the development of the study. While the research principles,
universal research ethics, and guidelines for research are important for
research, the research strategy defines and ensures that the researcher(s)
follows all the necessary guidelines/principles and ethical practices in the
collection and analysis of data. In studying the process used to integrate EHR
to the cloud and the factors that influence user's sense of security and trust
of such integration, this research applies a comprehensive research that uses
in-depth interview collection data and content to analyse it. Numerical
analysis is also used to analyse numerical data. Moreover, it integrates
different research components that facilitate the processes of data collection,
analysis, and presentation.
According to Speziale and
Carpenter (2011), a good research strategy comprises of different
research components such as an excellent research design and research paradigms
that enable effectiveness in data sampling, collection, and analysis. In
studying the factors that influence the users’ sense of security and trust in the
integration of EHR into Cloud, the integration of different research components
is essential for capturing the users’ perceptions and experiences. The
development of the information systems in the health care setting is essential
for the enhancement of efficiency in the delivery of care. The efficiency
improves the quality and safety of care and ascertains continued improvement.
Capturing the perceptions and experiences of the users of EHR integrated to
Cloud is important in improving the systems. Achievement of success in the
process requires the incorporation of specific research paradigms that shape
the processes of decision-making in conducting research. As a qualitative
research, this study employs the interpretivist and positivist paradigms to enhance
the effectiveness of the research
The interpretivist and positivist research ontologies
influence the collection and analysis of data in this research significantly. Rubin and Babbie (2010) state
that the application of the interpretivist paradigm is essential in undertaking
a qualitative research. The paradigm places emphasis on the description of the
experiences, feelings, and idiosyncratic explanations for the different
perspectives they hold. Since this research focuses on capturing and explaining
the participants’ feelings, perspectives, and experiences, the application of
the interpretivist's research paradigm is paramount. The interviews will allow
the identification of the perspectives and experiences and the integration of
the paradigm will outline an in-depth understanding of the factors.
Furthermore, Check and Schutt (2011),
relate that the interpretivist approach is flexible enough to allow the
integration of the inductive research philosophy, which integrates qualitative
techniques and facilitates better research. Coyle
and Lyons (2013) state that the inductive approach generalizes specific
reasoning to understand the perspectives and experiences of the participants.
This makes it an effective paradigm for application in qualitative research.
3.4 Research Design
The integration of an excellent research strategy,
philosophy, and paradigms enables the achievement of accurate data and
information. However, according to Bazeley (2013),
the efficiency of the research design influences the whole process. A research
design involves the different approaches applied for the achievement of the
aims and objectives of the research. In this study, the application of
different research techniques allows the collection of information and analysis
for the identification of the factors that influence the users’ sense of
security and trust in integrating EHR to Cloud. The application of the
qualitative research method and the incorporation of the inductive research
philosophy with an interpretivist approach improves the effectiveness of the
research in achieving its objectives
The research applies the interview method in the
collection of data and information concerning the factors that affect the
users’ sense of security and trust. The process requires the identification of
the participants. It applies the random sampling technique, mainly simple
random sampling to choose the participants. According to Bazeley (2013), the application of the simple
random sampling technique proves effective in the development of a group that
represents the population effectively. Applying the technique allows the
representation of the community by reflecting the concerns of people in the
society well. The participants are mainly patients requested and notified of
the research objectives. Moreover, sample involves individuals in the society
who have or have not used the EHR system integrated to Cloud. The initial steps
of the research sampled 54 participants but seven people did not take part in
the study due to personal commitments or ethical concerns. Therefore, 47 people
took part in the study of whom 18 were interviewed.
a)
Questions directed to the expert participants
Question number
|
Link to the study |
Linked to authorities/references
|
|
1. How
would you describe the importance or impact of the EHR on the quality and
safety in healthcare provision? |
Background on the EHR system and influence on healthcare. Rapport.
Links to: 1.0 Background Information |
Ajami and Baqheri-Tadi (2013);Wang, et al. (2016); Deshmukh(2016) |
|
2. Kindly
describe the process of EHR integration to the Cloud. Do you think there is
success? What can be done to promote efficiency of the system? |
Understanding the EHR system and its effectiveness or lack
thereof. The success of the system in meeting the objectives of its
implementation. Supports or refutes arguments of other experts in the
literature review. Links to: .1 The Electronic Health Record (EHR) 2.2 The Importance of the EHR System 2.3 Integrating EHR to Cloud |
Lyu, et al. (2016); Deshmukh (2016); Ashibani and Mahmoud (2017); Subashini and Kavitha (2011); Ajami and Baqheri-Tadi (2013) |
|
3. From
your expert point of view, how safe and trustworthy is an EHR integrated to
the Cloud? Do you think there is any reason for concern? |
Justification of the research. Identification of research gaps. Outlines safety and efficiency of integrating EHR to Cloud. Identifies concerns about safety of the system and the users’
trust. Links to: 1.4 Justification for the Research 2.1 The Electronic Health Record (EHR) 2.2 The Importance of the EHR System 2.3 Integrating EHR to Cloud 2.4 Security and Privacy
Concerns in Integrating EHR to Cloud |
Roehrs, et al. (2017); Rodrigues, et al. (2016); Steele (2016); Health IT (2017); Keenan, et al. (2016);Sinha, et al. (2013) Schuman (2017); Lyu, et al. (2016); Deshmukh (2016); Ashibani and Mahmoud (2017); Subashini and Kavitha (2011); Ajami and Baqheri-Tadi (2013) |
|
4. What
would you say is the influence of the users’ sense of security and trust on
the implementation of EHR integrated to Cloud? |
2.1 The Electronic Health Record (EHR) 2.2 The Importance of the EHR System 2.3 Integrating EHR to Cloud 2.4 Security and Privacy Concerns in
Integrating EHR to Cloud |
(Lyu, et al.,
2016) (Russo, 2016) (Wickramasinghe, 2016) (Mirza & El-Masri, 2012) AORN
(2013); (Ajami & Baqheri-Tadi, 2013); (Amatayakul & Amatayakul, 2013);
(Bell & Thornton, 2011); (Coats & Acharya, 2014) (Duckert & Rose,
2013); (Darko-Yawson & Ellingsen, 2016;) (Health IT, 2017); (Jawhari, et
al., 2016); (Roehrs, et al., 2017) |
|
5. What
measures do you think can be adopted and implemented to ensure effectiveness
in implementing the system? How well do you think the recommendation may
influence the users’ sense of security and trust positively? |
2.3 Integrating EHR to Cloud 2.4 Security and Privacy Concerns in
Integrating EHR to Cloud |
(Ajami &
Baqheri-Tadi, 2013); (Amatayakul & Amatayakul, 2013); (Bell &
Thornton, 2011); (Coats & Acharya, 2014) (Duckert & Rose, 2013);
(Darko-Yawson & Ellingsen, 2016); (Lyu, et al., 2016) (Russo, 2016)
(Wickramasinghe, 2016) (Mirza & El-Masri, 2012) |
b)
User Interviewees
Question number
|
Link to the study |
Linked to authorities/references
|
|
1. How
would you describe the importance or impact of the EHR on the quality and
safety in healthcare provision? |
Background
on the EHR system and influence on healthcare. Rapport. |
Ajami and Baqheri-Tadi (2013);Wang, et al. (2016); Deshmukh(2016) |
|
2. As
a user of the EHR system, how effective do you find it? |
2.1 The Electronic
Health Record (EHR) 2.2 The Importance of the EHR System 2.3 Integrating EHR to Cloud |
Lyu, et al. (2016); Deshmukh (2016); Ashibani and Mahmoud (2017); Subashini and Kavitha (2011); Ajami and Baqheri-Tadi (2013); Roehrs, et al. (2017); Rodrigues, et al. (2016); Steele (2016); Health IT (2017); Keenan, et al. (2016);Sinha, et al. (2013) Schuman (2017); |
|
3. What
is your perception or attitude towards the use of the EHR when integrated to
Cloud? |
2.2 The Importance of the EHR System. 2.3 Integrating EHR to Cloud. 2.4 Security and Privacy Concerns in
Integrating EHR to Cloud. |
Lyu, et al. (2016);
Russo (2016); Wickramasinghe (2016); Mirza & El-Masri (2012);AORN (2013);
Ajami & Baqheri-Tadi (2013); Amatayakul & Amatayakul (2013); Bell
& Thornton (2011);Coats & Acharya(2014) (Duckert & Rose, 2013);
(Darko-Yawson & Ellingsen, 2016;) (Health IT, 2017); (Jawhari, et al.,
2016); (Roehrs, et al., 2017) |
|
4. What
do you think influences your sense of security and trust in using the
Cloud-integrated EHR system? How does it affect your willingness to use the system?
|
2.3 Integrating EHR to Cloud. 2.4 Security and Privacy Concerns in
Integrating EHR to Cloud. |
(Wickramasinghe,
2016)(Young, et al., 2017) (AORN, 2013) (Subashini & Kavitha, 2011)
(Alabdulatif, et al., 2013) (Ashibani &Mahmoud, 2017) (Coats & Acharya,
2014) (Bell & Thornton, 2011) (Chen, et al., 2012) (Wang, et al., 2016)
(Steele, 2016) (Roehrs, et al., 2017) (Houser, et al., 2012) |
|
5. What
do you think can be done to improve your perception and attitude towards the
use of an EHR system integrated to Cloud? |
2.3 Integrating EHR to Cloud 2.4 Security and Privacy Concerns in
Integrating EHR to Cloud. |
(Ajami &
Baqheri-Tadi, 2013); (Amatayakul & Amatayakul, 2013); (Bell &
Thornton, 2011); (Coats & Acharya, 2014) (Duckert & Rose, 2013);
(Darko-Yawson & Ellingsen, 2016); (Lyu, et al., 2016) (Russo, 2016)
(Wickramasinghe, 2016) (Mirza & El-Masri, 2012) |
3.5 Research
Administration
This study involves different approaches for the
achievement of accurate information and data for analysis to explore the
factors that influence the use of EHR to Cloud. The participants that took part
in the study were engaged differently depending on the method. The 18
interviewees comprised of nine (9) experts in Cloud computing technology and
EHR experts within the health care sector. The other nine (9) were users of the
system integrated with Cloud. Therefore, the questions applied differed
significantly to outline the perspectives and experiences of the users and
capture expert opinion and ideas on the topic. The interviews were conducted
face-to-face between the researcher and the user-interviewees while the experts
were engaged online. The names used in the research, especially those of the
users are fictionalized to ensure that they offered accurate and reliable
information. The experts were sent the interview questions over the email. The
interview method enhanced the achievement of accurate information for
application in the study. The interviews conducted face-to-face were recorded
with the consent of the interviewees and analyzed later.
All the participants were either of EHR integrated to
Cloud or non-users of the service. The interview were conducted in different
health facilities where the potential participants were first informed of the
purpose of the research and allowed to participate without coercion. According
to Belk (2006), interview are effective
for outlining different aspects of the topic under study. In this research,
open-ended interview were administered. Speziale
and Carpenter (2011) posit that open-ended questions allow the
respondents to include personal experiences, perceptions, and attitudes
concerning the topic.
The semi-structured and unstructured interviews and the
open-ended questions used in the interview allowed the participants to offer
information about their perceptions, attitudes, and feelings. The analysis of
the information and data requires the application of an effective approach.
According to Coyle and Lyons (2013), the
application of the content analysis technique allows the effective analysis of
the information. Çuhadar(2014) argues
that the approach is effective in analysing the captured perspectives,
feelings, attitudes, and thoughts. Further, content analysis integrates the
interpretivist and inductive approaches in analysing data and information
sufficiently. The method analyses information from interviews effectively.
Moreover, the application of the numerical data analysis approach enhances the
effectiveness of the analysis of the data for the interview. It allows the
description of the information from interview participants.
3.6 Research Ethics
The concerns under study in this research are ethical.
The major issues surrounding the users’ sense of security and trust are
privacy, security, confidentiality, and safety of patient information. Failing
to consider ethics in the research would end up overstepping the ethical
issues. Therefore, in conducting the research, there is a need for the research
to avoid approaches that might affect participant rights
3.7 Chapter Summary
The research applies the qualitative research
philosophy, which enables the collection of information concerning the
experiences, perceptions, attitudes, and thoughts of the users of the EHR
integration to Cloud. Further, the choice of the research strategy and design
is made depending on the ability of the methods to influence efficiency in the
conduction of the research. The study applies the interpretivist research
technique and the inductive approach in the analysis of the information. The
method applies the interview method conducted through the administration of
open-ended questions for the collection of data. The Interviews applied in the
research create an excellent platform for participants to outline their
attitudes, experiences, and perceptions truthfully and accurately. The effective
administration of the different data collection techniques enhances the
effectiveness of the process. Most importantly, the consideration of research
ethics is a critical component of research. The different participants in this
study participated willingly, without coercion, and promised to offer accurate
and truthful information. They were informed of the intent and objectives of
the research and those concerns about their identity their names were
fictionalized.
CHAPTER IV
4.0 Results and Findings
4.1
Introduction
Understanding
the different factors that affect the users’ sense of security and trust in
using EHR integrated into Cloud requires the researcher to focus on capturing
the perceptions, thoughts, feelings, attitudes, and concerns of the users. The
data collection techniques applied in the conduction of this research focus on
capturing the aforementioned. The application of the phenomenological
qualitative research method allows the integration of interpretivist and positivist
paradigms and a comprehensive research design that included the simple random
sampling technique for the identification of participants. This part outlines
the results/findings and presents them clearly using tables and charts to
outline the factors under study. The study outlines various perspectives,
experiences, thoughts, and captures attitudes and the perceptions of the
cloud-integrated EHR system users. Most importantly, the study identifies and
uses 47 participants from different cities across South Africa. These cities
include Durban, Johannesburg, Cape Town, Pretoria, with an option of other
cities of residence. Only critical information to studying the EHR system and
its integration to Cloud and the factors that influence the users;’ sense of
security and trust are incorporated in this section. The findings captured from
the respondents are presented below for further analysis in the analysis and
discussion chapter.
The
presentation excludes the general information about the cities of residence
because of skewed representation. Additionally, it exempts the perceptions of
patient’s health information to healthcare provider for lack of clarity on the
parameter/factor under study. The focus is on the patient’s or users of the
service and not the healthcare providers. The exclusion of the level of
confidentiality required by respondents and the confidentiality on healthcare
information as presented in question 9 part b is excluded on the basis of
repetition and the inability to measure the parameters used. Further, the
‘should consent be sorted’ question presented in question 12 of the data
collected is omitted in the presentation for redundancy since it is similar to
question 11 and offers contradictory data. The measures for information leak are
disregarded as less significant in studying the phenomenon identified in the
research questions. All the other information is regarded critical for the
development of a comprehensive study.
4.2
Demographics, Healthcare and EHR
Demographics
influence access to healthcare services and the acceptability of certain
technologies significantly. The research sought to find out the access to
healthcare by the participants, their use of the EHR technology, and their
views, perceptions, and attitudes in using the technology when integrated to
cloud. The achievement of success in the process required the application of
the random sampling technique to ensure the fair choice of the participants.
Concerning residence, of the 47 people that participated, the largest number of
participants came from Durban at 78.7 percent while the other cities
contributed smaller percentage at 4.3%, 2.1%, 4.3%, and 10.6% for Cape Town
residents, Johannesburg, Pretoria, and other cities respectively. Undertaking
the study with a particular focus on the city of Durban is the explanation for
the skewed representation of the participants, with the majority coming from
Durban. The results are represented in the table below.
4.2.1 Tabled Representation of the Participant’s Place of
Residence
|
City of Residence |
Counts |
Percent |
Cumulative Percent |
|
Durban |
37 |
78.7 |
78.7 |
|
Cape Town |
2 |
4.3 |
83.0 |
|
Johannesburg |
1 |
2.1 |
85.1 |
|
Pretoria |
2 |
4.3 |
89.4 |
|
Other City |
5 |
10.6 |
100.0 |
|
Total |
47 |
100.0 |
|
While the
residence representation of the other cities may offer inaccurate results if
the discussion is narrowed to the particular regions, the integration of the
results and the analysis in terms of the healthcare access and acceptability in
Durban and the urban areas offers accurate and reliable information. The application
of the results and findings retrieved from the above participants on the
national level would attach inaccuracy in the analysis since people living in
remote and rural areas may have different experiences, attitudes towards the
EHR system and its integration to cloud, and even less access to healthcare
services as compared to those in major cities used for this study. Using the
participants in the research is critical to the development of a dependable and
credible research when it comes to the analysis of the use of the EHR
integrated into cloud. The participants are effectively selected to determine
the factors that influence the users’ sense of security and trust.
The random
sampling technique applied in the course of selecting the participants ensured
that the interviewees come from different ages without discrimination or biased
choice of a specific age or age group. The 47 participants in this study came
from different age groups. The consideration of the issue of age was made to
ensure ethical research and the participation of only people with the ability
to make informed decisions. The age groups targeted are 16 – 20, 20 – 25, 26 –
30, 31 – 35, 36 – 40, 41 – 45, and 46+ years. The percentage of participants in
terms of age groups were 6.4%, 34.0%, 23.4%, 12.8%, 21.3, 2.1%, and zero
representation for the different age groups respectively. That the majority of
participants lie between 21 years and 40 years shows the possibility of
outlining the factors that influence the consumers’ sense of security and trust
in using EHR integrated to cloud. An interesting bit in the sample analysis is
that most people of the randomly selected are between 21 - 40 years. This
resonates with South Africa’s population distribution. According to UNFPA
(2017), 66 percent of South Africans are aged below 35 years. While this is the
case, 24 percent of the population lie in the 15 – 24 age group. That the
sampling led to the selection of a population with a higher percentage
comprising of the youth shows a good representation of the South African
population. The percentage of the SA young population stands at approximately
67 percent
4.2.2 Sampled Participants by Age
|
Age Groups |
Counts |
Percent |
Cumulative Percent |
|
16-20 |
3 |
6.4 |
6.4 |
|
21-25 |
16 |
34.0 |
40.4 |
|
26-30 |
11 |
23.4 |
63.8 |
|
31-35 |
6 |
12.8 |
76.6 |
|
36-40 |
10 |
21.3 |
97.9 |
|
41-45 |
1 |
2.1 |
100.0 |
|
46+ |
0 |
0.0 |
100.0 |
|
Total |
47 |
100.0 |
|
Further, the representation of the results in a bar graph
allows a better understanding of the results. The analysis of the results and
presentation in the following diagram shows the high number of participants
ranging between 21 and 40 years.
The lack of representation of people aged
over 40 years poses a concern of the accuracy of the results if generalized.
However, the concern will be addressed mainly by analysing results per the
group rather than making population generalizations. The older generation is
more concerned about the integration of technologies such as the EHR in the
management of patient information. The general perception among the elder
generation is that they are ineffective and often insecure as compared to the
conventional patient information management techniques. Most people aged 40 and
above are more likely to be sceptical about the integration of EHR into the
management of the information in healthcare facilities. The provision of
healthcare services and the storage and management of the information is perceived
as insecure by most of the older generations. The consideration of this, and
the fact that the research focuses on identifying the critical factors
influencing the sense of security and trust shows the possible ineffectiveness
of the research in identifying the concerns.
The research requires the integration
of views and opinions of users of integrated EHR across the age groups. Leaving
out users above 40 years out of the data collection groups would make it
difficult to attain sufficient views as most of the young people have
contrasting views with the elder age groups. People above 40 are more likely to
perceive the integrated EHR as insecure and, therefore, have difficulty
trusting the technology. That there is only 2.13% representation of the group
makes it difficult to outline the issues influencing their sense of security
and trust in using the system. However, the percentage used is essential in
pinpointing some of the concerns that make it difficult for the generation to
adopt and use the integrated EHR system with confidence and trust. The
integration of the thoughts, views, and experiences of the younger generation
with the 40+ participant allow the development of a comprehensive study that
allows the researcher to identify the key factors that influence the patients’
sense of security and trust when using the integrated EHR.
4.3 Accessing
Hospitals or Healthcare Services
In studying
the factors that influence users’ sense of security and trust in using EHR
integrated into Cloud, the investigation of the visitation to hospitals is
critical. The users must have access to healthcare services and understand the
application of the technology. The frequency of visiting hospitals may not
influence how a person feels about using the technology, determining whether
the frequency is essential. Persons who visit healthcare services have
different experiences of using the EHR system integrated into cloud. People who
never use the service can only speculate or show perceptions, which may
sometimes be misinformed. The consideration of a sample of people who have
access to and use the public healthcare services is essential in the
development of a better understanding of the factors. According to the sample
studied, 14.9 percent of the participants stated that they never visit
hospitals or public healthcare services. The high percentage poses a challenge
in determining articulately the factors that may affect their sense of security
and trust in using the integrated EHR system.
Asking the
participants the frequency of visiting the hospitals was critical to developing
a better understanding of the correlation between the use of the healthcare
services and the technologies applied in the provision of the services. People
who visit the healthcare facilities frequently understand the various
shortcomings and advantages of the various technologies used in providing
healthcare. In the quest to capture the experiences of the participants, their
thoughts and opinions, and their perceptions of the application of the integrated
EHR to cloud, asking the frequency of use of the services was essential. The
question set the ground for other questions focused on enhancing the ability to
capture all the essential elements of the research.
Although people who rarely visit healthcare facilities are
more likely to have limited personal experiences about the services, their input, thoughts and perceptions were critical to
understanding the topic and the development of the study. Arguments by
different authors show that the major concern in using the EHR system
integrated to cloud was security and the breach of confidentiality and privacy
through unauthorized access to information, people who rarely visit hospitals
are less likely to experience these concerns but may still hold perceptions
that may reveal the factors that influence the sense of security and trust in
using the integrated EHR.
The high
percentage of people who often or sometimes (4% and 42.6% respectively) visit
healthcare facilities support the development of a comprehensive study.
Patients who access and use healthcare services understand the processes,
systems, quality concerns, confidentiality, privacy, and any other concerns
that define the acceptability of the services. Of the participants, those who
seek healthcare services often are more likely to have broader experiences
about the technologies applied in the provision of services such as the
integrated EHR. The participants can contribute greatly towards understanding
the issues that influence the senses of trust and security in using the EHR.
While the EHR integration to cloud may be faced with different challenges,
mainly the unacceptability by the users or the lack of confidence or trust in
using the technology. The integration of the views of the people who visit
hospitals often makes it possible to outline the critical issues affecting the
users’ sense of trust or security.
Additionally, in the collection of the data,
it was found that 42.6 percent of the participants visit hospitals and
healthcare facilities often. The high percentage shows the representation of
the South African population where a large population of the people visit the
hospitals every once in a while. The integration of the view of this group into
the research shows the possibility of effectively capturing the views,
experiences, and thoughts of the users of the EHR services while integrated to
Cloud. That the questionnaire-based interviewing data collection technique
identifies this group as the largest in percentage and their conversance with
the healthcare system after receiving services several times. This group has a
greater understanding of the general services offered and can offer perceptions
and thoughts and allow the research to capture them effectively. The
incorporation of the ideas into the research makes it possible to outlines the
key issues under study in this research.
Frequency Table of visit to Public Healthcare Services
|
Number of Times |
Counts |
Percent |
Cumulative Percent |
|
Never |
7 |
14.9 |
14.9 |
|
Rarely |
16 |
34.0 |
48.9 |
|
Sometimes |
20 |
42.6 |
91.5 |
|
Often |
4 |
8.5 |
100.0 |
|
Very Often |
0 |
0.0 |
100.0 |
|
Total |
47 |
100.0 |
|
The representation of the population in terms of access to
and use of healthcare services is as shown in the bar graph outlined below. The
integration of the graph offers an elaborative and visual description of the
data in percentages. 
4.4 The
Importance of Medical History in the Provision of Healthcare Services
Outlining
the importance of the medical history in the provision of healthcare services
is critical to determining the necessity of the application of the EHR system
and its integration to cloud. The determination of the importance of the
medical history of the patient was done by integrating the perspective of the
participants on whether or not they believe the healthcare providers required
their medical history before the delivery of healthcare services. The question
was phrased to inquire “whether healthcare providers are interested in knowing
one’s medical history.” According to more than a half of the participants
(57.4%), healthcare providers show significant interest in the medical history
of the patients. The providers want to understand the medical history of the
patients before administering health services. One sure way of acquiring the
medical history knowledge of a patient is through access to the patient’s
records. The integrated EHR in cloud allows the storage of the medical history
of the patients and easy, convenient, and safe retrieval of the information
when required for the provision of other medical services in the future.
Additionally,
while answering the same question, other participants offered different
answers. 21.3% of the participants asserted that the providers of healthcare
are not interested in the medical history of the patients before the delivery
of healthcare services. Moreover, a similar percentage (21.3%) of interviewed respondents demonstrated the lack
of knowledge as to whether the providers of healthcare services require the
medical history of the patient before the provision of the services. The
integration of the responses and information from the data would be critical in
determining the importance of the EHR system in the improvement of the quality,
efficiency, and safety of healthcare. Additionally, applying the data collected
essential in outlining how the users of the technology perceive or think about
its storage of the medical history and its ability to allow access conveniently
and faster to the healthcare providers when needed.
Table of whether healthcare providers are interested in
knowing one’s medical history
|
Responses |
Counts |
Percent |
Cumulative Percent |
|
Yes |
27 |
57.4 |
57.4 |
|
No |
10 |
21.3 |
78.7 |
|
I Don’t Know |
10 |
21.3 |
100.0 |
|
Total |
47 |
100.0 |
|
The responses of the participants regarding whether the
medical history of patient was essential to the service providers are presented
in the following pie chart to enhance the understanding of the experiences of
the participants and the importance of the integrated EHR.
A pie-chart representation of whether healthcare providers
are interested in knowing the medical history of the patients in the provision
of healthcare services.
It can be argued that the respondents who do not know
whether the healthcare institutions need these information might imply that
they lack knowledge of the falure of such information. It educated on the value
of such information, their responses are likely to differ.
4.5 Information
Required in Healthcare Facilities
Some of the
key objectives of the healthcare system is the provision of quality, safe, and
efficient healthcare services. The achievement of success in the process relies
greatly on gathering and using information effectively. The researcher
understood this aspect of the healthcare services and honoured it through the
inclusion of an important part of the research questions that require the
participant to outline some of the required information in receiving healthcare
in the healthcare facilities. One of the questions was whether the providers
required the medical history of the patient in the provision of healthcare.
28.6% stated that the medical history was essential in the provision of the
quality, efficient, and safer healthcare services. The integration of the part
opened up the ground for asking other questions that outline other requirements.
Further questions focused on identifying other requirements in the provision of
healthcare in Durban and South Africa. These requirements include the details
of the physical examination, treatment details, health evaluation, residence
and other personal details.
The
findings of the data collection show that the 11.4% of the participants
believed that the details of physical examination were required for
effectiveness in the provision of healthcare services. While this is the case,
healthcare evaluation, treatment details, proof of residence, and personal
details were required in healthcare facilities in the percentage of 1.4%, 4.3%,
14.3%, and 40% respectively. The priority placed on the personal details and
the medical history of the user of the healthcare services shows the great of
offering the healthcare providers the necessary information and details to
ensure efficacy in the delivery of the services. Using the information and data
collected in this section allows a better understanding of the importance of
the EHR system in the provision of the services. It further promotes the
understanding of the importance of integrating the system to cloud for easing
the processes of storing and retrieving the critical patient information. Such
details such as personal details, residence, medical history, and physical
examination form a critical part of the healthcare provision process and,
therefore, the need for effective storage.
Frequencies Distribution of Information Required In
Healthcare Facilities
|
Information Required In Healthcare
Facilities |
Responses |
Percentage of cases |
|
|
Counts |
Percent |
||
|
Medical history |
20 |
28.6 |
42.6 |
|
Details of physical examination |
8 |
11.4 |
17.0 |
|
Healthcare evaluation |
1 |
1.4 |
2.1 |
|
Treatment details |
3 |
4.3 |
6.4 |
|
Proof of residence |
10 |
14.3 |
21.3 |
|
Personal details |
28 |
40.0 |
59.6 |
|
Total |
70 |
100.0 |
148.9 |
The contribution of the participants in developing an
understanding of the requirements of the healthcare facilities is crucial in
identifying the criticality of an integrated EHR and in advancing access to the
information by the healthcare providers for the improvement of healthcare
services. The importance of some of the requirements as shown by the high
percentages demonstrates the need for directing focus on the specific areas and
using the participants to determine the issues that influence their sense of
trust security. People want to hold on to their medical history, physical
examination, and personal details and thus the concern in adopting and using
any technology that poses the risk of breaching the confidentiality or the
privacy is a central issue in this research.
4.6 Electronic
Information Storage
Understanding the respondents’
willingness to use the electronic systems for the storage of medical
information is essential in understanding the need whole system. The
willingness of the users to apply the electronic system defines their
perception of the system. While some respondents were willing to shift from the
conventional methods to better and more efficient electronic platforms, others
showed reluctance in using the technologies for security and confidentiality
issues. The assessment of the respondents’ willingness shows the challenges
users of the EHR may face including their perception and views in relation to
their sense of security and trust of a cloud-integrated EHR system. The
findings of the willingness showed that 85.1% of the respondents are willing to
store medical information electronically for effective use in the provision of
healthcare services. While this is the case, 4.3% of the respondents
demonstrated the unwillingness of using the electronic systems for the storage
of their health and medical information. Of the 47 respondents, three
(representing 6.4%) and two (representing 4.3%) stated that they were uncertain
of using the electronic systems or gave no response to the matter respectively.
The integration of the data in the analysis of the factors influencing the
consumer’s sense of security/trust will offer a better understanding of the
topic.
A Frequency Distribution of Respondents’ willingness have their
medical information stored electronically by healthcare providers
|
|
Frequency |
Percent |
Cumulative Percent |
|
Yes |
40 |
85.1 |
85.0 |
|
No |
2 |
4.3 |
89.4 |
|
I Do Not Know |
3 |
6.4 |
95.8 |
|
No Response |
2 |
4.3 |
100.0 |
|
Total |
47 |
100.0 |
|
The pie-chart presentation of the results appears as shown
in the following pie diagram.
4.7
Confidentiality in Handling Healthcare Information
One of the
key elements in the management of the patient information is the consideration
of confidentiality in the process. Patients are protected by the privacy and
confidentiality regulations that if broken result in a breach of the patient’s
right to privacy and confidentiality. Keeping personal healthcare information
confidential is, therefore, an important step in ensuring the provision of
quality and efficient healthcare services. According to the findings of this
research, 91.5% of the respondents demonstrated the importance of the element
of confidentiality in the provision of service by stating that they would like
the confidentiality of their personal healthcare information. The
confidentiality of the personal health information is therefore considered one
of the key aspects that ensure the patient satisfaction. The data collected
further shows that only 6.4% of the respondents do not consider the element of
confidentiality as critical in influencing the provision of healthcare
services. Moreover, 2.1% of the respondents do not know whether they consider
healthcare information confidentiality essential in the provision of healthcare
services.
Keeping personal healthcare information confidential
|
|
Frequency |
Percent |
Cumulative Percent |
|
Yes |
43 |
91.5 |
91.5 |
|
No |
3 |
6.4 |
97.9 |
|
Don’t Know |
1 |
2.1 |
100.0 |
|
Total |
47 |
100.0 |
|
The pie-representation of the findings concerning the confidentiality
is as depicted in the following pie diagram.
Further,
the interest of users of cloud-integrated EHR system have differing interests
on the aspect of confidentiality. Most people perceive confidentiality as
critical in the management of patient information. The study indicates that
different respondents demonstrated different perceptions about confidentiality.
However, most of the respondents (68.1%) showed a great interest on
confidentiality by asserting that they required the handling and management of
the healthcare information systems and records to be very confidential and
protect the privacy of the people who would not wish any other unauthorized
persons to have access to personal and medical history information.
Additionally, 29.1% of the respondents required the process of information
management and handling personal patient information to be confidential.
Attaching confidentiality in the management of the patient’s information may
influence the users’ sense of trust. Only 2.1% of the respondents stated that
they would like the information management to be ‘somewhat confidential’ to
enjoy the services offered by the electronic system. Nevertheless, all
respondents showed concern about confidentiality in the provision of healthcare
services.
Showing respondents’ interest on confidentiality
|
|
Frequency |
Percent |
Cumulative Percent |
|
Somewhat Confidential |
1 |
2.1 |
2.1 |
|
Confidential |
14 |
29.8 |
31.9 |
|
Very Confidential |
32 |
68.1 |
100.0 |
|
I don’t really care |
0 |
0.0 |
100.0 |
|
Total |
47 |
100.0 |
|
The following bar graph represents the respondents’ views of
confidentiality in the handling of patients’ healthcare information. People
want somewhat confidential, confidential, and the very confidential management
of their healthcare and medical records using the cloud-integrated EHR system
as shown in the bar chart shown.
4.8 Management
of Electronic Health Information
When asked
whether they would welcome the idea of electronic healthcare information
management, 51.1% of the respondents gave a positive response while 17.0% said
they would be unwilling to welcome such as idea. Moreover, over 29.8% argued
that they did not know the value of the integration. The respondents gave their
concerns for arguing against the integrated healthcare such as the possibility
of compromised autonomy (12.8%), fear of possible identity theft (29.8%),
unauthorized access (14.9%), breach of confidentiality (14.9%), and the
existence of security limitations (23.4). Additionally, only 5.0% do not
support the electronic management of health data. 22.3%, 10.7%, 21%, and 17% of
the respondents assert that cloud-integrated EHR system allows easy retrieval
in future, improves access to and use of insurance, allows the effective
treatment in cases of emergency, and reduces the time for the collection of the
details respectively. Further, 19.0% of the respondents asserted that the
application of the technology improves the quality of healthcare services.
4.9 Digital
Medical Records and Respondents’ Knowledge of Cloud Security System
In the
determination of the attitudes, perceptions, thoughts, and experiences,
checking the respondents’ understanding of the digital medical records and the
cloud-integrated EHR is important. The respondents show the importance of
digital management of records by stating that the technology in essential in
addressing medical emergencies (76.6%) and saving pre-admission administrative
time (23.4%). The data collected shows that 63.8% know about cloud while 36.2%
do not know about the system.
|
Reasons for Digital Medical Records |
Counts |
Percent |
Cumulative Percent |
|
In case of medical emergency e.g. accidents |
36 |
76.6 |
76.6 |
|
To save pre-admission administrative time |
11 |
23.4 |
100.0 |
|
Total |
47 |
100.0 |
|
|
Have knowledge of Security System of Cloud? |
Counts |
Percent |
Cumulative Percent |
|
I know about Cloud |
30 |
63.8 |
63.8 |
|
I do not know about Cloud |
17 |
36.2 |
100.0 |
|
Total |
47 |
100.0 |
|
4.10 Ethical
Concerns
Ethical
concerns surround the application of the electronic information management
techniques. Some users have raised ethical concerns about the breach of
confidentiality in using the technology. The study showed that 23.8%, 23.8%,
and 19.8% of the respondents were concerned about the access of personal
information without authorization, use of data without the consent of the
patient, and using data for other secondary issues as some of the major ethical
issues in dealing with integrated EHR. Moreover, while 100% of the respondents
argued for the storage of healthcare information on a database to allow reuse
in future, the concerns mentioned cannot be ignored.
|
Ethical issues associated with
linking medical records digitally |
Responses |
Percentage of cases |
|
|
Counts |
Percent |
||
|
Possibility of third party access to confidential health data |
24 |
23.8 |
51.1 |
|
Use of data without my consent |
24 |
23.8 |
51.1 |
|
Use of the data for other non-health related purposes e.g. to medical
aid scheme companies |
20 |
19.8 |
42.6 |
|
I would not disclose all information if the data is going to be linked
digitally |
2 |
2.0 |
4.3 |
|
Leaking of medical information |
17 |
16.8 |
36.2 |
|
Theft of medical information |
14 |
13.9 |
29.8 |
|
Total |
101 |
100.0 |
214.9 |
The consent
of the patient should be sought before authorizing the access and use of
personal information. This research found that 76.6% of the respondents stated
that there was a need to seek the consent of the user while 12.8% say there is
no need. Moreover, on the issue of consent, 10.6% posit that the institution
should consider what is good for the user and institution and does not require
the consent of the user.
|
Should Consent be sought? |
Frequency |
Percent |
Cumulative Percent |
|
Yes |
36 |
76.6 |
76.6 |
|
No |
6 |
12.8 |
89.4 |
|
Whatever is good for the healthcare intuition |
5 |
10.6 |
100.0 |
|
Total |
47 |
100.0 |
|
Chapter Summary
The findings presented in this chapter are critical for the
development of the research and the determination of the factors that influence
the users’ sense of trust and security in using the cloud-integrated EHR
system. People have various and different thoughts, perception, experiences,
and concerns. The consideration of all these elements is essential for the
development of an articulate study. The different questions used to outline and
capture the experiences/thoughts/perceptions, and concerns facing users in the
study are clear and straight-forward to minimize confusion. The
results/findings will be used in the analysis and discussion chapter for
in-depth discussion and analysis.
Chapter V
5.0 Analysis and Conclusion
5.1 Introduction
5.1.1 Critique of the
Adopted Approach
The research
applies the qualitative research method. The method proves effective in
identifying and capturing the users’ perceptions, attitudes, thoughts, and
experiences while using the cloud-integrated EHR system. The application of the
method allows the integration of different research techniques such as specific
research paradigms and philosophies that enhance the efficiency in collecting
and analysing data and information. The interpretivist and positivist paradigms
enable comprehensive analysis. Most importantly, however, the qualitative
method applies data collection techniques that are effective in collecting
information for this study. Using the interview method that incorporates
effective questionnaire-based interviewing makes it possible for the researcher
to outline and capture the attitudes/perspectives/thoughts and experiences of
the respondents. The integration of the method made it possible to capture the
different aspects and analyse them effectively using content analysis, which
ascertains extensive discussion and analysis of the findings. The method applied
in the research attaches credibility and dependability of the research.
Additionally, the
qualitative research method applies the random sampling method and the
interview method, which though effective, may pose significant challenges in
conducting the research. The application of the random sampling technique
allowed ease in selecting the participants. However, it led to
under-representation of the older generation (40+ years) which comprised of
only 2.1% of the participants. This may result in ineffectiveness in capturing
the concerns and the factors that affect people beyond 40 years. Additionally,
while the interview method used ensures the collection of primary information
and captures the different issues under study effectively, it offers research
challenges. The data collection method allows room for subjectivity. The
interviews were time-consuming. The process of selecting, setting up, and
interviewing the respondents required time and incurred costs.
5.2 Analysis of the
Findings
The study finds
that most of the users’ of the cloud-integrated EHR system are the young people
between 16 and 40 years. The finding aligns with the population distribution of
SA where the highest percentage of people lies below 40 years. The cumulative
percentage of respondents below 40 years is 97.9%. The respondents place
certainty in capturing and understanding the factors that affect this group’s
sense of trust and security in using the electronic system integrated to cloud.
The percentage of people above 40 years represented in the research is 2.1%
placing doubt on the fair representation of the group. According to Davis (2012) and Langston
(2015), the older generation visits hospitals more
following old age, reducing effectiveness of the immune system, and trust on
the healthcare providers. Using the 2.1% to outline the concerns, opinions,
experiences, and perception was ambitious and to a certain extent ineffective
in outlining the issues that influence the sense of trust and security among
users who are older (40+).
According to
Langston (2015) and Davis (2012), older people are more likely to have trust
and security concerns when using new technologies owing to the difficult to
change and adopt technology. The older generation users of the EHR are mostly
disdainful of the technology and often term it insecure in handling critical
information. While this is the case, most young people view technology as
critical and efficient. Therefore, more are likely to perceive the
cloud-integrated EHR system as effective and consider using it despite the
existing concerns of mistrust and insecurity
Access to healthcare facilities and the medical history
of the patient are essential for the provision of healthcare
The medical history of a patient is critical in the
provision of healthcare services. According to Schuman (2017), Health IT (2017), and Amatayakul
and Amatayakul (2013), the healthcare professionals
need the history to make informed decisions in the provision of services to the
patient. The history is, therefore, essential for the enhancement of the
quality, efficiency, and safety of the services offered
Ozair, et al.(2015) and Steele
(2016)argue that the storage of the patient information
and health history using the EHR system allows the healthcare providers to
retrieve the information at the point of care. The integration of the health
history in the provision of care services improves effectiveness of the
diagnosis, reduces medical and care errors, and enhances safety
Confidentiality and privacy are critical rights in
healthcare provision that protect other rights and values such as respect,
patient dignity, sense of self-worth, and ethical care among others. Rodrigues, et al.(2016) point out that privacy, security, and confidentiality are the
obligation of professionals who deal with patient records. Handling and
managing patient records requires the consideration of patient rights in
regards to privacy, security, and confidentiality. The study shows similar
concern since more than 91.5% of patients require confidentiality and privacy.
Additionally, approximately 51.1% of patients in Durban would like the
integration of the EHR to cloud for effective management and use of their
records in the acquisition/provision of healthcare services. The percentage
shows the importance of effective management of patient records and the
elements of confidentiality, privacy, and security.
The response to the EHR integration to cloud and
application of the technology to manage patient records requires an in-depth
understanding of EHR and cloud. Bell and Thornton (2011)argue that
most people opposing or showing reluctance on the grounds of security and trust
show minimal understanding of the system. Only 63.8% know about cloud while
36.2% do not. The finding of the research is backed by Sermeus, et al.(2016) and Kumar
and Bauer (2011) who argue that the creation of awareness
would improve people’s perception and thoughts about the innovation. An
informed society would adopt and use the cloud-integrated EHR system since it
enhances efficiency and effectiveness in the delivery of healthcare services
and improve quality and safety. Moreover, negative perception from informed
people would require enlightening the people of the security of the system and
the safety of the information therein.
5.3 Overall Conclusion
The EHR system has
enhanced efficiency, effectiveness, quality improvement, safety, and healthcare
improvement in South Africa. However, concerns remain adamant among some of the
current and potential users of cloud-integrated EHR system about the security
of the system. The importance of privacy, confidentiality, and security are
some of the fundamental elements that patients consider when it comes to their
information and health history
The study meets the
research objectives and answers the questions by studying and offering
articulate discussion of the factors that influence the users’ sense of
security and trust. Capturing the users’ perception, experiences, and thoughts
through the integration of the interview method to enhance the effectiveness of
the phenomenological qualitative research allows efficacy in answering the
questions of the factors, effect on implementation, and possible implications
on healthcare.
5.4 Limitations of the
Study
The method applied
in the conduction of the research ensured effectiveness and allowed the
incorporation of first-hand and credible information. The different techniques
used for data collection, presentation, and analysis ascertain the production
of quality, comprehensive, articulate and credible research. However, the study
has a few limitations. The inability to determine the sincerity of the
respondents and the accuracy of the information makes it difficult to say with
certainty that the information or data they provided was 100% accurate. For
instance, it would have been easy for a respondent to lie about understanding
EHR or cloud. Additionally, the random sampling technique made it difficult to
balance the participants from different age groups and regions. Further,
generalizations are made to ensure the representation of the South African
Durban communities, but the results may not reflect the entire community
accurately.
5.5 Opportunities for
Further Research
The research on the
factors that influence the users’ sense of security and trust in using
cloud-integrated EHR system opens up the topic as an active area of research.
Further research is critical to outlining the issues in-depth. Research on the
security of the system and the consideration of the elements of
confidentiality, privacy, and patient rights can facilitate enhanced
understanding of the topic. Additionally, further research can integrate
specific parameters such as age and discuss the same topic with a particular
focus on people over 50 years. This would consider the fact that currently
there exist an informational/technological gap between the elderly and the
young. Generalizations of results may not represent the entire South African
population and thus the need for researching further on the factors that
influence the perceptions of people over 50 concerning the cloud-integrated EHR
system.
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APPENDICES
Appendıx
A. Questionnaire
Date 8 June 2017
Dear research participant, I am a student undertaking
my masters research thesis in the Salford Business School at the University of
Salford. As part of my course I am undertaking a research study titled: Factors
Affecting the Users’ Sense of Security and Trust in Integrating Electronic
Health RecordTO CLOUD.
The Electronic Health Records (HER) offers a patient-centered recording
of patient information and allows easier access and retrieval of the
information by authorized users. In the recent past, the continued integration
of EHR to Cloud promises a more efficient, easier, and cheaper management of
the information. It also poses various concerns, which continue to limit
implementation in the healthcare system. The users’ sense of security and trust
are major concerns in the implementation of a Cloud-based EHR. Therefore, there
is a need for investigating the factors that influence the users’ sense of
security and trust in order to develop a better understanding of the issue and
formulate effective measures of addressing it.
I can assure you that any data collected will remain confidential. I
have gained ethical approval for the study from the University of Salford
My research is supervised by
Yours sincerely
Mr Lloyd E Johnson
Contact email: lloydits@gmail.com
Appendix B
Research Participant Consent Form
Title of Project: Factors Affecting the Users’ Sense
of Security and Trust in Integrating Electronic Health RecordTO CLOUD
Name of Researcher: Lloyd E Johnson
Name of Supervisor: Prof Steve Page
|
Ø I confirm that I have read and understood the
information sheet for the above study and what my contribution will be. |
Yes |
No |
|
Ø I have been given the opportunity to ask questions
(face to face, via telephone and e-mail) |
Yes |
No |
|
Ø I agree to take part in the interview |
Yes |
No |
NA |
|
Ø I agree to the interview being tape recorded |
Yes |
No |
NA |
|
Ø I understand that my participation is voluntary and
that I can withdraw
from the research at any time without giving any reason |
Yes |
No |
|
Ø I agree to take part in the above study |
Yes |
No |
|
Name of participant |
|
|
|
Signature |
|
|
|
Date |
|
|
|
Name of researcher:Lloyd E Johnson |
|
|
|
Researcher’s e-mail address: lloydits@gmail.com |
|
|
Research Questionnaire and Interview Schedule
Appendix C
1.
Please indicate your city of
residence
a.
Durban
b.
Cape Town
c.
Johannesburg
d.
Pretoria
e.
Other (please
specify)…………………………………
2.
Which of the age groups below
do you fall under?
a.
10-15
b.
16-20
c.
21-25
d.
26-30
e.
31-35
f.
36 – 40
g.
41 – 45
f.
46 and above
3.
How often do you use the
hospital or public healthcare service?
a.
Never
b.
Rarely
c.
Sometimes
d.
Often
e.
Very often
4.
Do you think healthcare workers
are interested in knowing about your medical history?
a.
Yes
b.
No
c.
I don’t know
5.
Which of the following
information are you required to provide in healthcare facilities before you can
be attended to? (tick all that apply)
a.
Medical history
b.
Details of physical examination
c.
Healthcare evaluation
d.
Treatment details
e.
Proof of residence
f.
Personal details
6.
How important is your personal
health information to the healthcare providers?
a.
Not sure
b.
Not important
c.
Somewhat important
d.
Important
e.
Very important
f.
Utmost important
7.
Would you like your medical
information to be stored electronically and available for future use by the
healthcare officials?
a.
Yes
b.
No
c.
I do not know
d.
Provide reasons for your answer
8.
Do you think your personal
healthcare information should be kept confidential?
a.
Yes
b.
No
c.
Don’t know
9.
If you think your personal
health information should be kept confidential, how confidential should it be
kept?
a.
Somewhat confidential
b.
Confidential
c.
Very confidential
d.
I don’t really care
10.
Do you think your healthcare
information should be stored on a database to be reused in case you revisit the
health centre?
a.
Yes
b.
No
11.
Do you think that your consent
should be sought by the medical care institutions before your personal health
data are integrated into an electronic system?
a.
Yes
b.
No
c.
Whatever is good for the
healthcare institutions
12.
If yes, would you agree to
giving or signing consent?
a.
Yes
b.
No
13.
How do you think your medical
record should be managed for optimal use?
a.
It Should be manually captured
and stored in files
b.
It should be electronically
managed for easy retrieval and future use
14.
Would you prefer for your
healthcare information to be managed by the hospital or by an independent third
party organization?
a.
To be managed by the healthcare
provider
b.
To be managed by an independent
organization
15.
Give reasons for your response
to question number 13 above?
16.
How would you feel if your
electronic health data was integrated into an electronic system e.g. Cloud and managed by a third-party ICT
organization?
a.
I would welcome the initiative
b.
I will not welcome the
initiative
c.
I do not know the value of such
integration
17.
What do you think would be the
disadvantage of integrating your health data into an electronic system?
a.
My autonomy might be
compromised
b.
I fear that the information can
be used for identity theft
c.
I fear that the information can
be access by
d.
Other people might find out
confidential information about my health status
e.
The system might have some
security limitations
18.
Which of the following reasons
would you like your healthcare data to be managed electronically? (please tick
all that apply)
a.
I do not support electronic management
of my health data
b.
For easy retrieval against my
future visit to the hospital
c.
For health insurance purposes
d.
For cases of emergency where I
cannot provide the data before treatment
e.
Reduced time needed for
collecting these details all the time
f.
Easy access by the click of a
button.
g.
Improved quality healthcare
administration
19.
For which of the following
reasons would you support that your medical record be digital and accessible
and linked to more than one healthcare facility?
a.
In case of medical emergency
e.g. accidents
b.
To save pre-admission
administrative time
20.
What do you think would be the
ethical issues associated with linking medical records digitally? (please tick
all that apply)
a.
Possibility of third party
access to confidential health data
b.
Use of data without my consent
c.
Use of the data for other
non-health related purposes e.g. to medical aid scheme companies
d.
I would not disclose all
information if the data is going to be linked digitally
e.
Leaking of medical information
f.
Theft of medical information.
21.
In the case of information
leak, what measures would you suggest be taken?
a.
The service providers should
accept liability in case of any bridge
b.
I should be contacted
immediately to alert me of the information leak
c.
I don’t need to be informed
22.
Would like to be informed about
the third party managing the system
What do you know about the security system of Cloud?
a.
I know about Cloud
b.
I do not know about Cloud
Question number
|
|
1.
How important is the EHR on the quality and safety
in healthcare provision? |
|
2.
As a user of the EHR system, how effective do you
find it? |
|
3.
What is your perception or attitude towards the use
of the EHR when integrated to Cloud? |
|
4.
What do you think influences your sense of security
and trust in using the Cloud-integrated EHR system? How does it affect your
willingness to use the system? |
|
5.
What do you think can be done to improve your
perception and attitude towards the use of an EHR system integrated to Cloud?
|
DATA
ANALYSIS REPORT APPENDIX D
Question 1
Frequency Table of Place of
Residence
|
City of Residence |
Counts |
Percent |
Cumulative Percent |
|
Durban |
37 |
78.7 |
78.7 |
|
Cape Town |
2 |
4.3 |
83.0 |
|
Johannesburg |
1 |
2.1 |
85.1 |
|
Pretoria |
2 |
4.3 |
89.4 |
|
Other City |
5 |
10.6 |
100.0 |
|
Total |
47 |
100.0 |
|
A Contingency
table of Age groups and place of residence
|
Age Group |
City of Residence |
|||||
|
Durban |
Cape Town |
Johannesburg |
Pretoria |
Other City |
Total |
|
|
16-20 |
0 |
0 |
1 |
0 |
2 |
3 |
|
21-25 |
11 |
2 |
0 |
0 |
3 |
16 |
|
26-30 |
9 |
0 |
0 |
2 |
0 |
11 |
|
31-35 |
6 |
0 |
0 |
0 |
0 |
6 |
|
36-40 |
10 |
0 |
0 |
0 |
0 |
10 |
|
41-45 |
1 |
0 |
0 |
0 |
0 |
1 |
|
46+ |
0 |
0 |
0 |
0 |
0 |
0 |
|
Total |
37 |
2 |
1 |
2 |
5 |
47 |
Question 2
Frequency Table of Age
Groups
|
Age Groups |
Counts |
Percent |
Cumulative Percent |
|
16-20 |
3 |
6.4 |
6.4 |
|
21-25 |
16 |
34.0 |
40.4 |
|
26-30 |
11 |
23.4 |
63.8 |
|
31-35 |
6 |
12.8 |
76.6 |
|
36-40 |
10 |
21.3 |
97.9 |
|
41-45 |
1 |
2.1 |
100.0 |
|
46+ |
0 |
0.0 |
100.0 |
|
Total |
47 |
100.0 |
|
Question 3
Frequency Table of visit to
Hospitals or Public Healthcare Services
|
Number of Times |
Counts |
Percent |
Cumulative Percent |
|
Never |
7 |
14.9 |
14.9 |
|
Rarely |
16 |
34.0 |
48.9 |
|
Sometimes |
20 |
42.6 |
91.5 |
|
Often |
4 |
8.5 |
100.0 |
|
Very Often |
0 |
0.0 |
100.0 |
|
Total |
47 |
100.0 |
|
A Contingency
table of Number of Visits to Healthcare Services and place of residence
|
Visits |
City of Residence |
|||||
|
Durban |
Cape Town |
Johannesburg |
Pretoria |
Other City |
Total |
|
|
Never |
3 |
0 |
0 |
2 |
2 |
7 |
|
Rarely |
14 |
0 |
1 |
0 |
1 |
16 |
|
Sometimes |
16 |
2 |
0 |
0 |
2 |
20 |
|
Often |
4 |
0 |
0 |
0 |
0 |
4 |
|
Very Often |
0 |
0 |
0 |
0 |
0 |
0 |
|
Total |
37 |
2 |
1 |
2 |
5 |
47 |
Question 4
Frequency Table of whether
healthcare providers are interested in knowing one’s medical history
|
Responses |
Counts |
Percent |
Cumulative Percent |
|
Yes |
27 |
57.4 |
57.4 |
|
No |
10 |
21.3 |
78.7 |
|
I Don’t Know |
10 |
21.3 |
100.0 |
|
Total |
47 |
100.0 |
|
Question 5
Frequencies
Distribution of Information
Required In Healthcare Facilities
|
Information
Required In Healthcare Facilities |
Responses |
Percentage of cases |
|
|
Counts |
Percent |
||
|
Medical history |
20 |
28.6 |
42.6 |
|
Details of physical examination |
8 |
11.4 |
17.0 |
|
Healthcare evaluation |
1 |
1.4 |
2.1 |
|
Treatment details |
3 |
4.3 |
6.4 |
|
Proof of residence |
10 |
14.3 |
21.3 |
|
Personal details |
28 |
40.0 |
59.6 |
|
Total |
70 |
100.0 |
148.9 |
Question 6
A Frequency
Distribution on the perceptions of patient’s health information to healthcare
provider
|
Degrees of Certainty |
Frequency |
Percent |
Cumulative Percent |
|
Not Sure |
13 |
27.7 |
27.7 |
|
Not important |
2 |
4.3 |
31.9 |
|
Somewhat Important |
6 |
12.8 |
44.7 |
|
Important |
13 |
27.7 |
72.3 |
|
Very Important |
11 |
23.4 |
95.7 |
|
Utmost Important |
2 |
4.3 |
100.0 |
|
Total |
47 |
100.0 |
|
Question 7
A Frequency
Distribution of Respondents willingness stored their medical information
electronically by healthcare providers
|
|
Frequency |
Percent |
Cumulative Percent |
|
Yes |
40 |
85.1 |
85.0 |
|
No |
2 |
4.3 |
89.4 |
|
I Do Not Know |
3 |
6.4 |
95.8 |
|
No Response |
2 |
4.3 |
100.0 |
|
Total |
47 |
100.0 |
|
Question 8
A Frequency
Distribution concerning keeping personal healthcare information confidential
|
|
Frequency |
Percent |
Cumulative Percent |
|
Yes |
43 |
91.5 |
91.5 |
|
No |
3 |
6.4 |
97.9 |
|
Don’t Know |
1 |
2.1 |
100.0 |
|
Total |
47 |
100.0 |
|
Question 9
Showing
respondents’ interest on confidentiality
|
|
Frequency |
Percent |
Cumulative Percent |
|
Somewhat Confidential |
1 |
2.1 |
2.1 |
|
Confidential |
14 |
29.8 |
31.9 |
|
Very Confidential |
32 |
68.1 |
100.0 |
|
I don’t really care |
0 |
0.0 |
100.0 |
|
Total |
47 |
100.0 |
|
A Contingency
table on level of confidentiality required by respondents and confidentiality
on healthcare information
|
confidentiality on healthcare information |
Level of Confidentiality |
Total |
||
|
Somewhat Confidential |
Confidential |
Very Confidential |
|
|
|
Yes |
0 |
12 |
31 |
43 |
|
No |
0 |
2 |
1 |
3 |
|
Don’t Know |
1 |
0 |
0 |
1 |
|
Total |
1 |
14 |
32 |
47 |
Question 10
Here, it says
that, out of 47 respondents, they all reported that their healthcare
information should be stored on a database to be reused in case of revisit to
healthcare facility.
Question 11
Frequency Table
|
Should Consent be sorted? |
Frequency |
Percent |
Cumulative Percent |
|
Yes |
36 |
76.6 |
76.6 |
|
No |
6 |
12.8 |
89.4 |
|
Whatever is good for the healthcare intuition |
5 |
10.6 |
100.0 |
|
Total |
47 |
100.0 |
|
Question 12
Frequency Table
|
Should Consent be sorted? |
Frequency |
Percent |
Valid Percent |
Cumulative Percent |
|
Yes |
40 |
85.1 |
93.02 |
93.0 |
|
No |
3 |
6.4 |
6.98 |
100.0 |
|
Total |
43 |
91.5 |
100.0 |
|
|
Missing
Response |
4 |
8.5 |
|
|
|
Total |
47 |
100.0 |
|
|
A contingency
table showing association between respondents’ willingness to sign a consent if
consent are sorted
|
Consent Should be Sorted |
Signing of Consent |
Total |
|
|
Yes |
No |
|
|
|
Yes |
34 |
2 |
36 |
|
No |
2 |
0 |
2 |
|
Whatever is good for the healthcare intuition |
4 |
1 |
5 |
|
Total |
40 |
3 |
43 |
Question 13
Frequency Table
|
Conceptions About Medical Record Storage |
Frequency |
Percent |
Cumulative Percent |
|
It Should be manually captured and
stored in files |
5 |
10.64 |
10.64 |
|
It should be electronically managed
for easy retrieval and future use |
42 |
89.36 |
100.0 |
|
Total |
47 |
100.0 |
|
Question 14
Frequency Table
|
Management of healthcare Information |
Frequency |
Percent |
Valid Percent |
Cumulative Percent |
|
To
be managed by the healthcare provider |
40 |
85.1 |
87.0 |
87.0 |
|
To
be managed by an independent organization |
6 |
12.8 |
13.0 |
100.0 |
|
Total |
46 |
97.9 |
100.0 |
|
|
Missing
Response |
1 |
2.1 |
|
|
|
Total |
47 |
100.0 |
|
|
Question 16
Frequency Table
|
Management of healthcare Information |
Frequency |
Percent |
Valid Percent |
Cumulative Percent |
|
I
would welcome the initiative |
24 |
51.1 |
52.2 |
52.2 |
|
I
will not welcome the initiative |
8 |
17.0 |
17.4 |
69.6 |
|
I
do not know the value of such integration |
14 |
29.8 |
30.4 |
100.0 |
|
Total |
46 |
97.9 |
100.0 |
|
|
Missing
Response |
1 |
2.1 |
|
|
|
Total |
47 |
100.0 |
|
|
Question 17
Frequency Table
|
Disadvantages of integrating Health data |
Frequency |
Percent |
Valid Percent |
Cumulative Percent |
|
My
autonomy might be compromised |
6 |
12.8 |
13.3 |
13.3 |
|
I
fear that the information can be used for identity theft |
14 |
29.8 |
31.1 |
44.4 |
|
I
fear that the information can be access by |
7 |
14.9 |
15.6 |
60.0 |
|
Other
people might find out confidential information about my health status |
7 |
14.9 |
15.6 |
75.6 |
|
The
system might have some security limitations |
11 |
23.4 |
24.4 |
100.0 |
|
Total |
45 |
95.7 |
100.0 |
|
|
Missing
Response |
2 |
4.3 |
|
|
|
Total |
47 |
100.0 |
|
|
Question 18
Frequencies Distribution of Reasons
for Managing Healthcare Data Electronically
|
Reasons for
Managing Healthcare Data Electronically |
Responses |
Percentage of cases |
|
|
Counts |
Percent |
||
|
I do not support electronic
management of my health data |
6 |
5.0 |
13.0 |
|
For easy retrieval against my
future visit to the hospital |
27 |
22.3 |
58.7 |
|
For health insurance purposes |
13 |
10.7 |
28.3 |
|
For cases of emergency where I
cannot provide the data before treatment |
21 |
17.4 |
45.7 |
|
Reduced time needed for collecting
these details all the time |
17 |
14.0 |
37.0 |
|
Easy access by the click of a
button |
14 |
11.6 |
30.4 |
|
Improved quality healthcare
administration |
23 |
19.0 |
50.0 |
|
Total |
121 |
100.0 |
263.0 |
|
Graph Keys |
|
|
a |
I do not support electronic
management of my health data |
|
b |
For easy retrieval against my
future visit to the hospital |
|
c |
For health insurance purposes |
|
d |
For cases of emergency where I
cannot provide the data before treatment |
|
e |
Reduced time needed for collecting
these details all the time |
|
f |
Easy access by the click of a
button |
|
g |
Improved quality healthcare
administration |
Question 19
Frequency Table
|
Reasons for Digital Medical Records |
Counts |
Percent |
Cumulative Percent |
|
In case of medical emergency e.g.
accidents |
36 |
76.6 |
76.6 |
|
To save pre-admission
administrative time |
11 |
23.4 |
100.0 |
|
Total |
47 |
100.0 |
|
Question 20
Frequencies Distribution of Ethical issues
associated with linking medical records digitally
|
Ethical
issues associated with linking medical records digitally |
Responses |
Percentage of cases |
|
|
Counts |
Percent |
||
|
Possibility of third party access
to confidential health data |
24 |
23.8 |
51.1 |
|
Use of data without my consent |
24 |
23.8 |
51.1 |
|
Use of the data for other
non-health related purposes e.g. to medical aid scheme companies |
20 |
19.8 |
42.6 |
|
I would not disclose all
information if the data is going to be linked digitally |
2 |
2.0 |
4.3 |
|
Leaking of medical information |
17 |
16.8 |
36.2 |
|
Theft of medical information |
14 |
13.9 |
29.8 |
|
Total |
101 |
100.0 |
214.9 |
|
Graph
Keys |
|
|
a |
Possibility of third party access
to confidential health data |
|
b |
Use of data without my consent |
|
c |
Use of the data for other
non-health related purposes e.g. to medical aid scheme companies |
|
d |
I would not disclose all
information if the data is going to be linked digitally |
|
e |
Leaking of medical information |
|
f |
Theft of medical information |
Question 21
Frequency Table
|
Measures for information leak |
Counts |
Percent |
Cumulative Percent |
|
The service providers should accept
liability in case of any bridge |
30 |
63.8 |
63.8 |
|
I should be contacted immediately
to alert me of the information leak |
16 |
34.0 |
97.9 |
|
I don’t need to be informed |
1 |
2.1 |
100.0 |
|
Total |
47 |
100.0 |
|
Question 22
Frequency Table
|
Have knowledge of Security System of Cloud? |
Counts |
Percent |
Cumulative Percent |
|
I know about Cloud |
30 |
63.8 |
63.8 |
|
I do not know about Cloud |
17 |
36.2 |
100.0 |
|
Total |
47 |
100.0 |
|
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