Hospital Information Systems in Iranian Military Hospitals: A Multiple Case Analysis


avatar Ramin Hamidi Farahani 1 , avatar Mohammad Sharifi 2 , * , avatar Masarat Ayat 3 , avatar Nader Markazi Moghaddam 4 , 5

Department of Infectious Diseases, School of Medicine, AJA University of Medical Sciences, Tehran, IR Iran
International Business School, University Technology Malaysia, Kuala Lumpur, Malaysia
Department of Engineering, Payame Noor University, Tehran, IR Iran
Department of Public Health, School of Medicine, AJA University of Medical Sciences, Tehran, IR Iran
Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, IR Iran

how to cite: Hamidi Farahani R, Sharifi M, Ayat M, Markazi Moghaddam N. Hospital Information Systems in Iranian Military Hospitals: A Multiple Case Analysis. J Arch Mil Med. 2014;2(4):e22853. doi: 10.5812/jamm.22853.



Hospitals are regarded as the most important part of each healthcare system. At present, all hospitals are using hospital information system (HIS) as an infrastructure in recording, retrieval, and transmission of data, facilitation of decision-making processes, and other healthcare-related domains. However, its position, maturity, and boarder of its coverage are not quite clear. The hospitals affiliated with military healthcare in Iran are facing the same challenges. On the other hand, Electronic Medical Record Adoption Model (EMRAM) is a worldwide-recognized stage-based model that is used to assess the maturity of HISs in the hospitals.


This study aimed to assess the maturity and applicability of HISs in Iranian hospitals.

Materials and Methods:

Two Iranian military hospitals were selected for HIS maturity assessment. Data were collected through interviewing related experts and the use of some software and documentation analysis. Then the data were compared with the EMRAM.


The results revealed that the HISs in these military hospitals had reached different stages of EMRAM while they could reach upper HIS maturity stages.


The maturity of HISs in Iranian military hospitals was almost the same as that of Iranian nonmilitary hospitals. The HISs in these hospitals did not utilize full potentials advantages of HIS and were placed at up to third stages of EMRAM.

1. Background

Computerization of medical information was introduced about 30 years ago and under different names (1). Up to this date, there is no universally accepted definition for e-Health (2, 3), but one of the most comprehensive definitions refers to e-Health as the cost-effective and secure use of information and communications technology (ICT) in support of health and health-related fields including healthcare services, health surveillance, health literature, and health education, knowledge, and research (4). The utilization of e-Health systems in hospitals is almost new. It should be highlighted that hospitals represent the essential components of healthcare systems (5) and are one of the main targets of governments to implement e-Health applications. The applications that are provided through e-Health initiatives within hospitals include hospital management information systems (HMIS), telemedicine services, and internet services (6), which are collectively known as hospital information system (HIS). The importance of HIS becomes clear when the great complexity of the medical practice nature and the large number of interventions that each patient receives cause a high rate of errors in healthcare organizations (7). It is believed that the use of HIS in hospitals is driven by the needs to reduce medical errors (8-10) and healthcare costs (11). Nevertheless, the challenges associated with the use of such systems in the hospitals are due to their content complexity, availability of standards for the integration of various workflows, communication of databases, and involved people (12); however, Jaana et al. (13) believe that hospitals are continually exploring opportunities for investing in information technology (IT) to improve efficiency, promote patient safety, and provide better quality of care (14). Currently, IT priorities are mostly related to reducing medical errors, upgrading/replacing in-patient clinical systems, and implementing HISs in the hospitals (15). Although the potential benefits of HISs in military hospitals are highlighted, no standard maturity assessment of HISs in military hospitals is done. This paper aimed to design a strategy to implement proper HISs in the military hospitals.

2. Objectives

Considering that there was no comprehensive study on the HIS maturity and professional knowledge in this area of expertise in the Iranian army, this study was designed to evaluate the operational HISs in two different military hospitals and to provide enough suggestions to enhance their HIS capabilities.

3. Materials and Methods

To perform this study, two military hospitals were selected. The selection method was convenient sampling and the main selection criteria were based on the feasibility of data gathering from hospitals affiliated with army and their potential to share the required information. The first hospital had 300 beds, which were expanded in different wards including emergency department, operation room, dialysis, and other wards. The second one was one of the oldest army hospitals, which was established more than 140 years ago. This hospital was serving patients with different facilities and almost 100 beds. This research was performed in two rounds. During the first round, using a meta data and laboratory search with the thesaurus terms "information technology," "e-Health," "e-Health Information Technology," "hospital information systems", "HIS", and "e-Health strategy", a general Internet search was done in the different databases, including MEDLINE, IEEE, Emerald, Scopus, Springer, Elsevier, and PubMed, and also some physical repositories including the medical journals and books. The aim of the first round was to identify the definition, coverage, opportunities, and challenges of e-Health and e-Health utilization, as well as HIS-associated issues. During the second round, the Electronic Medical Record Adoption Model (EMRAM) was used as a benchmark model to evaluate the current maturity of HISs in the selected hospitals. The focused groups in these hospitals were IT staff who were working in computer unit/department/center in these hospitals and had enough information about all the aspects of HISs, particularly their related experiences in these hospitals. The meeting sessions were appointed and held several times and lasted between 30 to 50 minutes to reach the expected results. The first round lasted from January to March 2014. Then the process continued to analyze the collected data using the descriptive approach and continued until June 2014.

5. Discussion

There is no statistical result for military hospitals in other countries to compare with those from our study but this situation can be compared with other hospitals under the supervision of the Ministry of Health and Medical Education. According to Himss (17), none of the hospitals in Middle Eastern countries has reached the seventh stage of HIS maturity and also there is no paperless hospital in this area. However, the United Arab Emirates and Saudi Arabia have developed some proper plans and there are hospitals that have reached to sixth stage of HIS maturity. In addition, the current maturity of civil hospital cases in Iran gives a more clear viewpoint. In Sharifi et al. study (18), 11 civil hospitals were evaluated and all of these hospitals were placed in first and second stages of the EMRAM. These results emphasize the similarity of maturity status of different hospitals in Iran, but more researches are needed to come out with a comprehensive view to HIS maturity of Iranian hospitals as a whole. Hospitals are the heart of healthcare systems. Healthcare system of Iranian military is not an exception and the same issues are faced there. HIS has a growing importance in hospitals management in the Iranian military healthcare system. The analysis of two military hospital cases showed the incremental use of different HISs in these hospitals. It was found that EMRAM expectations in these hospitals did not reach the stage 4; a status that was not favorable for armies' healthcare system. The lack of strategic plan for the whole military healthcare system along with lack of professional experts, proper training, excellent HIS system, and inability of external parties to equip them with digital facilities have hampered progression of HIS systems in military hospitals. The use of EMRAM in this context will let the chief information officers (CIOs) and top managers to design a proper and well-defined strategy for HIS development and enhancement in military hospitals. However, to compensate for the use of immature HIS in military hospitals, some solutions were provided.



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