My Ssec Capstone Project Chapter 1THE PROBLEM AND ITS SETTING 1

Chapter 1THE PROBLEM AND ITS SETTING 1

Chapter 1THE PROBLEM AND ITS SETTING
1.1 IntroductionPublic Health Sectors are adopting changes for the transformation of health care to a higher quality of life and ensure efficient and effective health system. Most health care managers are trying to enhance their performance through different public health interventions. Public health sector have become more and more interested in embracing Health Information Technology (HIT), and have made a remarkable progress over the last few years. Its implementation does not only transform the way government provide services to its constituents, but also reinvent its internal processes to deliver health services efficiently and effectively.

The decision to bring a new health information technology into the health sector is only the first step in an implementation journey. The process of change is a chain reaction that affects everything in the organization and changing one area can impact another. Challenges on existing organizational structures and practices of health care providers can hinder rather than advance the objectives of health information system.
There’s a need to assist the health care providers in taking advantage of the larger transformation powers of health information system within their organizations. Success of health information system requires more complex reform of examining the factors that contribute to the success of the proposed change. Hence, it is essential for public health sector to embrace innovation and change for an enhanced health information system.
Drawing analysis from the current health information system will help overcome the barriers and minimize the risk of failure during the implementation of the new technological change. 
At varying paces, organizations are aggressively pursuing new information technology strategies with the goal of providing effective and efficient health information system. This thesis will examine some key aspects of health information system towards policy development.

1.2 Background of the Study
Decentralization started in 1991, when Local Government Units (LGU’s) were allowed autonomy and responsibility for their own public health service. By decentralizing the health sector, the Philippines hoped to transfer as many resources as possible from central to peripheral authorities, to extend decision-making authority to lower level managers and to enhance the efficiency and effectiveness of health services management (Grundy et al, 2003: 3-4). Within this decentralized setting, the LGUs continue to receive guidance on health matters from the DOH through its network of DOH representatives under the supervision of the regional centers for health and development (CHDs).
1.2.1 History of eHealth in the PhilippinesThe Department of Health (DOH) by virtue of its mandate holds the over-all technical authority in health with three major roles of leadership and regulator in health, enabler and capacity builder; and administrator of special health services. The Philippines has already developed the eHealth Strategic Framework and Plan for the period 2014 to 2020, which aimed to utilize information and communication technologies in the health sector (DOH 2014). This will support the delivery of health services and manage health systems for greater efficiency and effectivity.

As part of the government’s goal to address these issues and further advance the quality of health care in the country, different government agencies such as the Department of Health (DOH) and the Department of Science and Technology (DOST) spearheaded projects that encourage the inclusion of innovative technology in hospitals and other health care facilities especially in different local government units (DOH MOA 2013). It was planned to implement a national eHealth in the country for greater efficiency in health care, workforce productivity, and optimized use of resource.
The Joint Administrative Order No. 2018-00 aims to establish the policies and guidelines in the implementation of validated electronic health record systems in all health facilities particularly those regulated by the DOH and accredited by Philippine Health Insurance (Philhealth). Part of the strategies in investing in eHealth includes the mandate to use electronic records in all health facilities; make online submission of clinical, drug dispensing, administrative and financial records a prerequisite for registration, licensing, and contracting; commission nationwide surveys, streamline information systems, and support efforts to improve local civil registration and vital statistics; automate major business processes and invest in warehousing and business intelligence tools; and facilitate ease of access of researchers to available data.
The Department of Health had standardized its health information system by using technological resources which has led to the development of Electronic Record Systems (EHRS’s), Integrated Clinic Information System (iClinicsys) and the Integrated Hospital Operations and Management Information System (iHOMIS) as reference models for health centers and barangay health stations as well as health information system for hospitals. This aims to provide relevant, timely and evidence- based decisions more towards a more efficient service delivery and facility management.

1.2.2 City Health DepartmentThe LGUs serve as stewards of the local health system in formulating and enforcing local policies and ordinances related to health, nutrition, sanitation and other health-related matters in accordance with national policies and standards.
The City Health Department of San Juan are in-charge with providing primary care including maternal and child care, nutrition services and direct service functions through public health and primary health care centers. The City Health Department provided health services catering ten health centers and eight health stations in the city’s barangay (Table 1). Free consultation and treatment are being provided daily from Monday to Friday during office hours from eight in the morning till five in the afternoon.
Table1.
Health Centers/ Stations per BarangayBarangay Health Centers Barangay Health Stations
Balong-Bato Health Center Addition Hills Health Station
Batis Health Center Ermitaño Health Station
Corazon De Jesus Health Center San Perfecto Health Station
Kabayanan Health Center Pasadena Health Station
Onse Health Center Rivera Health Station
Pedro Cruz Health Center Progreso Health Station
Salapan Health Center Little Baguio Health Station
Sta. Lucia HealthcenterMaytunas Health Station
Tibagan Health Center West Crame Health Center The goal of the City Health Department (CHD) is to provide accessible, responsive and quality health care. It endeavors to provide promotive, preventive, curative and rehabilitative health care services to the constituents of San Juan through various health programs. Services offered at the health facilities include general consultation, maternal care, child care, nutrition services, dental services, communicable diseases, non-communicable diseases, Human Immunodeficiency Virus/Sexually transmitted diseases screening and sanitary inspection. Case investigation during outbreaks under epidemiology and surveillance program as well as medical services and assistance during a disaster under Health emergency management staff are being provided by the Department. The organization of health department provides communities the capacity to prevent disease, promote health, and prepare to respond in cases of disaster.
1.2.3 City Health Department Structure
Organizational structure refers to organizational subunits and the way they relate to the overall organization (Stair 2006). It is how individual and team work within the organization are coordinated and managed. Figure 1 shows the organizational structure of the City Health Department. From the study done by Klein, a vertical, hierarchical, or pyramid form of organizational structure is the result of having a narrow span of control or span of authority and span of management which is seen in the CHD.
This tall organizational structure of the City Health Department has brought long chain of command from the flow of authority from the highest to lowest levels. The City Health Department is led by the City Health Officer (CHO) appointed by the City Mayor who provides supervision and management support to the Department. The CHO is assisted in managing the Department by the Assistant City Health Officer who is also the City Nutrition Action Officer. It this structure the head of the Department gives instructions and makes the decision. The Assistant City Health Officer handles both the administrative and the technical work in the Department.
Figure 1 City Health Department Structure

There is a technical working group assigned responsible for consolidation of reports including the Iclinicsys and other documents of the City Health Department however, there is no adequate health staff since the team composed of the Assistant City Health Officer, 1 Medical officer and 1 clerk that will do both the administrative as well as the technical work.
Table 2 Health Personnel
Indicators Total
2018
Physicians (including the CHO ; ACHO) 11
Dentists (including the Supervisor) 12
Nurses (including the Supervisor) 13
Midwives (including the Supervisor) 15
Nutritionist- Dietitians 2
Medical Technologists 5
Sanitary Inspectors 9
Dental Aides 9
Barangay Nutrition Scholars 18
Administrative Aide(Clerk) 5
Utility 8
Driver 2
TOTAL 109
Table 2 shows there are only 11 medical officers including the City Health Officer, and the Assistant City Health Officer (ACHO) who is also the City Nutrition Action Officer (CNAO) while the medical officer of the technical working group handles Sanitation Division and is assigned to different health programs.
Duties and Responsibilities of Health Personnel
In hierarchy every member of the organization is assigned a specific position. Each position has special level of decision-making authority as well as specific responsibilities within the organization. The following are the duties and resposibilities of health personnel:
City Health Officer- Supervises the personnel and staff of CHD; formulate program implementation guidelines and rules and regulations for the operation of said office for the approval of the mayor in order to assist him in the efficient, effective and economical implementation of health services’ programs geared for the realization of health-related projects and activities. Formulates and implement policies, plans, programs and projects to promote the health of the people in the city of San Juan.

Assistant City Health Officer- Assist in the formulation of program implementation guidelines, rules and regulations for the operation of the health office and general supervision of all health personnel in the different divisions. Receives directive from the City Health Officer on various matters pertaining to the different health activities in the office.Medical Officer – Plans, integrates, coordinates and supervises the implementation of the various health programs of the local health department and other services of the division in the delivery of primary health care (preventive, curative and rehabilitative) and provides administrative and technical supervision over the personnel of the health districts. Assesses, with the health centers personnel assigned to their health program on their existing health services and relative to the needs of the community in view of sustaining/improving the standard of public health service delivery.

Dentist Supervisor- Supervises the implementation of dental health programs (records, reports and accomplishments).Provide technical assistance to the District Health Office in relation to the implementation of health programs within the city. Monitors, conducts field visits, and evaluates dental performances in coordination with the City Health Office and give necessary recommendation/immediate measures to problems/gaps.

Dentist- In the absence of the Physician in charge in the Health Center, he dentist acts as the OIC Supervising the dental aid coordinate and the medical staff. Accomplishes and submits weekly, monthly, quarterly, and annual reports on time.Consolidates, analyzes, and submits all reports to the immediate supervisors.

Nurse Supervisor- Participates in the planning and implementation of the health programs of the agency. Guides the public health nurse II interpret the nursing policies, operational instructions, techniques and standard requirements of the service within the area of assignment and supervises the same in the performance of nursing techniques and procedures.
Medical Technologist- Submits reports of activities and accomplishments reports of the unit on time. Performs routine laboratory reports and consolidates all quarterly laboratory reports.

Midwife Supervisor- Provides technical support to midwife. Update and maintained proper recording and reporting of all DOH program. Consolidate and Submit monthly accomplishment report to nurse.
Midwife- Carries out medical and nursing functions in the clinic as first level worker in primary health care programs. Submits and assists nurse accomplishment of reports.Update and maintain proper recording and reporting of all reports. Supervise Barangay Health Aide and Barangay Health Workers.

Nutritionist- Provides administrative support and technical assistance to City Health Office and Barangay Nutrition Scholars. Analyze OPT of all Barangays for City Nutrition Situation. Accomplished and analyze City Nutrition Reports for monitoring and evaluation purposes.

Sanitary Inspector Supervisor- Assist the CHO/Medical Coordinator in planning the program for environmental sanitation and request necessary budget and supplies to authorities concerned to promote the health in the community.

Barangay Nutrition Scholar- Prepares and submit well accomplished written report of all programs and projects in the barangay. Assist in the conduct of primary health care programs and medical / dental preparations.

Dental Aide- Prepare, keeps and updates the patient’s records and files under the supervision of the Dentist.

Administrative Aide/ Clerk- Receives and records all official communications, correspondence, reports, memoranda, orders and course thru channels and files them in their corresponding files. Records, files, and keeps all appointments and other pertinent papers relative thereto of all personnel in the office and releases them only when directed by the proper superiors.
Administrative Aide/ Driver- Service all health staff to their requested destinations (trainings/seminars). Pick up and deliver all medicines at all health center.

Operational structure
The operational level are being catered by the different divisions in the health facilities such as medical, dental, laboratory, sanitation and nutrition headed by the Medical officer of the facility. The number of health staff reporting to each health facility tends to be smaller which provides greater opportunity for the medical officers to supervise and monitor their health staff. The operational structure of the City Health Department is divided into Health Centers and Health Stations as seen in Figure 2 and Figure 3.

Figure 2 Barangay Health Center Structure

Figure 3 Barangay Health Station Structure

Out of 11 physicians, there are only 9 medical officers assigned to 10 health centers that still manage the 8 health stations on top of the different health programs assigned to them. With this kind of set up there has been difficulty in ensuring adequate and appropriate distribution of health services staff to deliver both preventive and curative services in San Juan. According to Kumar et al (2012), the position of the organization as well as its structure directly affects the adoption of health information technology.The transformation of health information of San Juan has contributed to the structural complexity of the health department; hence it is vital to understand the factors that can influence the health staff’s intention to utilize the new health information system for successful implementation of the desired change.
Role of Health Staff to IclinicsysCity Health Officer/ Assistant City Health Officer
Overall supervision and decision making in planning management task in the City Health Department,
Create and implement policies, goals, and procedures for City Health Department
Provide Capacity-building programs for the health staff on how to use and manage IClinicsysStrategic policy-making and resource allocation
Evaluation of the overall and individual quality of the staff’s work. 
Iclinicsys medical coordinator
Assume primary responsibility for supporting the National Health Information System (Iclinicsys), ensuring that data are being collected, entered and processed in accordance with standard of procedure and in a timely fashion.

Implementation of recommendations and monitoring of results for delivery of expected Iclinicsys value and benefits, collection, sharing, exchange and submission/reporting of required data and information among concerned eHealth agencies
Conduct monitoring and evaluation on the performance of the system
Medical Health Officer/ Physician-
Take decisions regarding the effective functioning of health facilities and of the health system as a whole.

Coach and mentor health staff, to enable them to assume expanded roles and an increasing level of responsibility for Iclinicsys, while ensuring the quality and completeness data
Supervise and support the Health Information System, ensuring that data from patient are being processed in a routine, accurate and timely fashion
Produce monthly and bi-annual Health Information System Reports, based on the existing templates.

Conduct monthly visits to government health systems to provide feedback and training on their use of the National Health Information System.

Nurses/Midwives
Create and update documents within the electronic health record (EHR),
Locate and retrieve information in the electronic health record for various purposes. encode the data for Iclinicsys,
Ensure completeness of data
Use Iclinicsys to generate reports
Dentists/ Nutritionists/ Sanitary Inspectors/ Barangay Nutrition Scholars
Provide data for IclinicsysAnalyze and evaluate the accuracy of data
Clerk
Ensure completeness of data
Encode data for IClinicsys1.2.5 Health Information System of the CHD
One of the principal goals of any health care system is to improve health through the provision of clinical and public health services. In the study done by Jerry Mechling, the leadership of government in information technology innovation is a determining factor for rapid economic growth. The use of information technology helps transform the government health services to a more efficient, responsive and effective health system. It aims to deliver effective and efficient social service and technologically advance governance.

With the decentralized setting, the City Health Department continues to receive guidance on health matters from the DOH through its network of DOH representatives under the supervision of the regional center for health and development (CHDs).
The Health Information System of the City Health Department has been paper-based and manually driven. During the decentralization process, the existing paper-based data collection system, called the Field Health Services Information System (FHSIS), was adopted by the City Health Department. This electronic data reporting aims to minimize the recording and reporting burden of service delivery and provides more time for patient care. However, it did not provide evidence-based population health decision-making at the community level. At the health facility level, data is collected on all patient admitted and entered into the summary table by health personnel. Tally sheets track disease incidents, which are summarized into standard monthly reporting forms for submission to the FHSIS coordinator. At the health facilities, nurses and midwives are tasked with collating and the medical officer is assigned for analyzing data from their areas, however due to multi-tasking of the medical officer data are submitted directly to the FHSIS coordinator for analysis and approval. It is not standard based, health centers and health stations still submit their accomplishment reports monthly to the FHSIS medical coordinator who solely has the health computer system, and in turn pass these reports electronically to the DOH for data interpretation, analysis and come up with appropriate interventions. Most health facilities still uses manual reporting leading to duplication and delayed submission of reports.

As pursuant to the administrative order of the Department of Health (DOH) no. 2015-0037, all health facilities need to comply with the national implementation of health data standards for Health information system standardization and Information Interoperability (Garin 2015). Continuous development and implementation of information technology is one strategic instrument of the DOH to support and facilitate the achievement of the national health system goals for better health outcomes. In an effort to respond to the demands for growth and success, the City Health Department shifted to an electronic data reporting system. It is now on the process of implementing a wider coverage of electronic health system known as IClinicsys, an Integrated Clinic Information System of the Department of Health that would improve overall patient treatment, quality and safety.
1.2.2.2 IClinicsys
The “iClinicSys” is a reference model for electronic medical records and health information system for primary care facilities that satisfies Philippine Health Insurance Corporation (Philhealth) requirements for benefit packages through capitation and DOH reporting necessities including national health data standards. It aims to automate service delivery processes to efficiently and effectively monitor patient care in the health facility (DOH).
Iclinicsys aims to improve overall patient treatment, quality and safety while reducing unnecessary cost and paper works through the use of managed and coordinated technological information for quality health data collection and submission.
Its features include, hybrid software that can run in an offline and online environment, generates electronic medical record of patient that allow providers to track patient’s data overtime, compliant to health data standards for system interoperability with DOH, Philippine Health Insurance Corporation (PHIC) and other government agency’s reporting requirements, produces the required national health statistical requirements such as Field Health Services Information System (FHSIS), Disease Registry Reports etc. and includes SMS notification for patient’s schedule of next visit Free installation and maintenance cost of the software.

Iclinicsys will enhance health workforce productivity in retrieving patient information, record keeping, administration and referrals. It will improve the quality of care, monitoring and reporting and will increase opportunity for continuing innovations and growth (UHMIS DOH).
1.2.2.2 Preparation of IClinicsysIt was only on November 2016, when San Juan City Health Department presented to the Local Health Board the idea of the having eHealth system as initiated by the DOH. The software for iClinicSys was provided by the DOH and the system was installed for free. To ensure success implementation of Iclinicsys, health care organization must educate and train the health care providers. A training orientation was conducted last February 2017 under the fund of DOH Health System Development Program. A 2-day capacity building symposium among health staff were set. Roll out activity to the other health staff was given on April 2017. Funding of computers or laptops was secured from the LGU fund and partly from the Philhealth capitation fund, setting up of internet connections were requested and provided by the LGU. Software was installed at the health centers. Memorandum of agreement was done with different stakeholders.
1.2.2.3 Process of IClinicsysThe Iclinicsys is being used for decision-making and improving operational health services performance. All health centers and stations are to collect process and report routine data relevant both to the national policy and health program objectives and to the needs of health and health providers. The system is integrated in one computer in each health facility so that all existing health programs and general information are encoded together to avoid duplication of health data. Specified data and information flows are included such as the internal flow of information among the health facility, encoding done in different facilities are being checked by the Iclinicsys coordinator.
Data processing and analysis were intended to be primarily conducted by the physician in charge in each health facility, processed into summary values to show changes over time and provide performance indicators at health facility, health department and DOH. It is only after the consolidation of all the reports coming from different health facilities will decision-making is done to provide meaningful data.
Information derived from IClinicsys is intended to be used for formulation, monitoring and evaluating of annual investment plan, monitoring and improvement of health facility service delivery. Reports generated from different health facilities will be used by the City Health Department and DOH for planning and policy formulation.

1.2.2.3 Challenges of IClinicsys
The implementation of IClinicsys is dependent upon individual’s ability and role. The health providers saw the IClinicsys as new and integrated with fewer forms, new strategy for holding information. The implementation of Iclinicsys was not as effective as it should be. Only few sponsored members were encoded and submitted online. Late submission of reports ensues despite many initiatives taken to implement information technology. Health facilities did not process information as expected, many health workers could not graph the data and the IClinicsys coordinator is the only one doing this. Innovation adoption at health units was only partial. There is late in decision-making from the data collected due to late submission of reports. Planning and policy formulation has always been delayed.The major challenges confronting health information system in the CHD are the completeness, accuracy, timeliness and accessibility of health data. One of the challenges of the existing health system is the access to the updated quality health information vital for evidence-based decision making both at the national and local level.

Access to health information technology has transformed the work of the health sector in what they do and how they carry out activities. It changes the way health services are delivered, how information is exchanged within and between organizations. With the increase access to various eHealth services, there is a need to assess the health information system for effective implementation and policy development
The City Health Department is face with challenges on the implementation of IClinicsys. Academicians have reviewed that some of the reasons of project failure is due to the fact that the role of the key actors and activities are not properly analyzed, the same with staff attitude to work – resistance to change (Lam 2005). Most Information Communication and Technology (ICT) projects fail due to various factors including organizational issues and leaders who did not sufficiently consider the organizations reactions to the desired change.
The aim of my study is to assess the health information system of San Juan towards policy development. While the City Health Department moves toward IClinicsys, the need for better understanding of organizational actions and behaviors will provide important aspect for policy development towards successful implementation of the new health information system.
1.3 Theoretical Framework
1.3.2 Leavitt’s Organizational Change Framework
The Leavitt’s organizational change framework provides theoretical base in looking at any change within an organization. The act of change within an organization requires decision-makers to take a step back and considers the impacts. Determining the response of the organization is necessary for the acceptance of new information technology in health settings. The Organizational change framework as seen in Figure 4 provides new approach to look at the organizations. Within this framework, we can notice that each of the four variables interacts with the others.

Figure 4 Leavitt’s Organizational Framework

Every organization consists of four interactive components: Structure, People, Task, and Technology. The interaction of these four components determines the fate
of an organization. Leavitt noted that any alterations in any of these components results in the alteration in the other three (Burke 2002). Before you bring about change in any one of the four components, you should evaluate the impact on the other three components. Each component need to be tweaked to implement change successfully and find the right balance between all of them.
In order to use the model effectively, defining each component is vital to know the exact situation of the organization. The first component is the structure; it determines how the people are grouped within the work unit, the role expectations and rules for who should or can do what and how each task should or can be done. It provides guidelines and framework. Organizations are inter-connected structures, where changing one part can impact many others. With current set up of the City Health Department, the introduction of IClinicsys provided a great impact in the organizational structure; hence it requires modification for the adoption of change.
The next component to be considered is the people, those who carry out the task. The people involved within organization are the integral part of the project. People are often the key consideration in any change initiative, because skill sets, efficiency, knowledge and attitudes greatly affect the success of change in any organization. The people should be trained accordingly as what has been done in the CHD. According to Sargent et al (2012) the user need to change their current methods and procedure to integrate the new task that affects directly their tendency to apply it. Health personnel should continuously upgrade their skills and learn how to adopt and use the new technology.
Another component is task; it is the organizations purpose to provide a service. When change occurs in a system it is often seen that most of the old tasks and job descriptions are replaced with modern task force requirements. Like in the City Health Department, the adoption of Iclinicsys resulted to unintended changes in the way tasks are performed. This change provided great impact to the work and productivity of the health personnel. The new tasks and goals should be properly evaluated and the requirements and benefits of the new task should be identified and should be checked whether it is relevant to the user.
The fourth component is the technology which includes the tools and computers. A simple technological upgrade in one organization will clearly have large effects throughout
the organization. The introduction of the new technology such as the IClinicsys, holds a great potential for transforming the structure, task and people in the City Health Department.
Technology and Task
The tasks of the health providers are most subjected to IClinicsys influences and potential. The introduction of IClinicsys transforms significantly the task of the health staff; it will increase the task efficiency, shorten the required time for executing a task, facilitate and improve information and management (Wigand 2007). However problems may arise as the ambiguity, complexity and non-routineness of a task increases leading to decrease frequency of use of the new technology.
Technology and Structures
Information technologies have the potential to affect the role people play in the process of change. The roles, responsibilities, relationships and distribution of jobs in the health care workforce should always be considered. The new technological change should not be seen by the health care providers as threats. According to Watson (2007), the new technological change could fail if people are not given importance they deserve. Leaders have to balance the need for adaptability in meeting the advantages of the new technology with an atmosphere of stability and concern for the interests of staff. The way technical change is introduced into the organization will influence the health provider’s attitude towards work, the behavior of individuals and groups, and their level of performance.

Technology and People
With the introduction of new information technology, health staff should have to gain new skills and knowledge for successful implementation of IClinicsys. The level of training that people need to upgrade their skills and learn how to use new technologies may also be an obstacle for technology application (Gichoya 2005). Leaders must be able to combine their technological knowledge and develop strategic program management. Inadequate staff competencies hinder utilization of IClinicsys.

For the change to be successful all the components stated above should be analyzed, evaluated and assessed. The Leavitt’s dynamic equilibrium framework will provide an in-depth understanding of the impact of technological change in the health system of San Juan.

1.4 Conceptual Framework
Figure 5 Conceptual Framework
2378075234950PROCESS
00PROCESS
4331335306070OUTPUT
00OUTPUT

2132381302335Assessment, through survey questionnaire
Focus Group
Discussion
Presentation, Analysis and Interpretation of results
00Assessment, through survey questionnaire
Focus Group
Discussion
Presentation, Analysis and Interpretation of results
39782351502INPUT
00INPUT

412940524765Identify Problems in terms of information system
Recommendations to facilitate enhancement of Health Information System
00Identify Problems in terms of information system
Recommendations to facilitate enhancement of Health Information System
11338717602Health Information System
10Perception of the respondents to Health Information System
– Technology
– People
– Task
– Structure
-Willingness towards Policy Development
Actions taken
00Health Information System
10Perception of the respondents to Health Information System
– Technology
– People
– Task
– Structure
-Willingness towards Policy Development
Actions taken

3699164568450014662154445000
39973251308100028003501248910050292018145700
1935480118110FEEDBACK
00FEEDBACK

1.5 Research Paradigm
The researcher perceives the conceptual framework of this study based on the Input- Process- Output (IPO) system approach which is shown in Figure 2. This approach is composed of different elements that are connected with each other and will be the basis for the concept structure required in the research investigation. The study aims to assess the organizational response for the proposed technological change.

The first element is referred to as the Input. The data from the organizational response will provide information on the how the respondents assess the current Health information system, perception of the enhanced health information system according to technology, people, task, structure, willing ness towards Policy Development, actions taken for the development of health information system, thus this will offer valuable input for the execution and completion of this study.
The second factor is the Process. The process will help the researcher acquire information needed for the analysis and interpretation of result in order to provide outcome for the final output. The researcher will use likert survey questionnaire and focus group discussion.

The third factor is the expected output. This will be the final result derived from the input and process. The assessment of the respondent’s perception of health information system will be based on analysis from the final output. This will be formulated and offered for policy development.

The output of the study will be recommended to the head of City Health Department. Hence, whatever actions these organization provides to improve their health information system will again be served as an input and the cycle repeats itself.

1.6 Problem Statement
This thesis aims to determine the response of the City Health Department to the new Health Information System. Such understanding could determine the factors for successful adoption of the new technological change.

The first step to assess the Health Information System of San Juan for policy development is to assess the perception of the respondents to the new health information system. The key findings of this thesis will become the foundations towards an enhanced technological change.

How do the respondents assess the current health information system of the City Health Department?
What is the perception of the respondents to the enhanced health information system?
2.1 Technology
2.2 People
2.3 Task
2.4 Structure
2.5 Willingness towards Policy Development
3. What are the actions taken for the development of Health Information System?
4. What are the suggestions or recommendations to facilitate Policy Development / proposed policy options?
1.7 Thesis Argument
1. Because documentation found in health records is crucial evidence of services provided and the quality of those services, many healthcare settings, particularly in public health care have initiated clinical document improvement. The ultimate goal of every health record is to facilitate communication. A well-designed, well-maintained paper-based health record significantly improves communication among health care providers. However, the paper based records has a number of weaknesses such as difficult to update, misplaced, too expensive and difficult to maintain duplicate copies as paper health records back up. For all these reasons the City Health Department shifts from traditional data to an automated data collection. Because the productivity of the public
health sector depends on the quality of the health systems, organizations decision of using information technology is critically important for high quality health service.
The use of electronic computers and related software programs are the technical foundation, the tools and materials of an enhanced information system. Knowing how computers and computer programs work is important in designing solutions to organizational problems, however it is only a tool for improving the health information system. Despite the benefits that information and communication technology offers to support the health sector, there are bottlenecks in terms of its adoption which hampers the delivery of evidence based health service. Information system requires understanding of the organization, its people, structure, task and use of information technology in shaping the system.
2. Understanding the adoption and use of health information system will help in achieving good health governance. However, most Information Communication and Technology (ICT) projects fail due to various factors including organizational issues and leaders who did not sufficiently consider the organizations reactions to the desired change. In order to provide a better understanding of organizational actions and behaviors in the current innovation a thorough analysis is needed to gather information on the response of the health personnel who serves as main administrators of the system.
The use of electronic health information system is determined by the behavioral intention and the perception of its use to the new technology. The attitude of an individual is not the only factor that determines his use of electronic health information system, but is also based on the influence which it may have on his performance. Perceived benefits are the end products that can be used to judge the success of electronic health information
implementation. If the perceived benefits like easier communication, networking, and system integration, timely, relevant, complete and useful information are not realized, then the system will be perceived to have failed.
3. The implementation of health information system helps improve the quality of health services in the health sector. However, one factor that is widely recognized as critical for achieving technology implementation success is the commitment from all levels during implementation. Manpower is one of the requirements for electronic health information system. Taking into account the commitment of the health personnel would be helpful for electronic health information system to be implemented successfully.
4. The attitude of the health sector towards the desired change is a core factor that encourages or reinforces the implementation of electronic health system. Salient features of organizations that must be addressed by information systems include organizational levels, organizational structure, types of task and decisions, the nature of management support and the sentiments and attitudes of workers who will be using the system. Implementation of new information system is often more difficult than anticipated because of organizational change requirements.

The high impact of the strategy dimension on people means that the value of desired change considers people to be a major component, thus focusing on improving their skills and re-allocating them to suitable information and communication technology trainings. The technical proficiency of health professionals respond positively to changes approved and provided by top management, however those who lack knowledge on the new technology will negatively respond to changes. The Organization should call for specialized human resources and to put in place structures to improve technical proficiencies in information and technology that would lead to a more sustainable implementation of health information system.

5. The use of information and communication technology can transform the government health services to a more efficient, responsive and effective health system; however implementation and adoption face certain challenges. Each factors examined within the City Health Department produces a unique, strong impact on the overall adoption of the new health information system. Therefore, a specific focus should be made on the development of a strong, well-formulated, and comprehensive designed strategy for the success of the desired change, and to ensure commitment to its implementation among all levels of organizational management. A strategic direction will provide a backbone of the whole integration process creating new improvement and eliminate barriers that have traditionally suppressed the flow of the new health information system in the long run. The process to transform will neither be quick nor simple. It will require a coherent strategy, beginning with an examination of the organization, resource, as well as the ability of the organization to adopt and make use of planned technologies.
1.8 Significance of the Study
The study was conducted to benefit the following:
1.8.1 City Health Department
A healthy citizenry is of the utmost importance to the City Health Department of San Juan. With increase expectation and demand from the community to quality health service, the City Health Department aims to provide effective and efficient health information system. Improving the health information system by bridging the gap in the implementation of Iclinicsys with the organization will be beneficial to the City Health Department. Having an access to information will allow the health department to lay foundations for policies and make improvements suited to the needs of its people. In order to provide effective delivery of public health service, adoption of the new technology will be essential in the enhancement of the health information system in San Juan.
1.8.2 Department of Health
The designer of the program can find help from the outcome of the investigation because of the inputs it can give will help the organization develop local policy for Health Information System. This will ensure achievement of health system goals for better health outcomes and provide responsive health system.
1.8.3 Health Care Provider
The health care provider will greatly benefit from this study, being the person involved in data gathering and recording of health records. Providing knowledge on the response of the organization to the new technological change will significantly enhance understanding of technology acceptance for effective implementation of Iclinicsys.
1.8.4 Local Government Unit
Government’s responsibility to protect and advance the interests of society includes the delivery of high-quality health care. Leaders in public health sector are under increasing expectation and rising demand to provide higher quality health care with efficient and technologically advance governance for continuous improvement in the performance and delivery of health service. Providing a well-conducted research is vital to the success of the government. The research will form a foundation for program development and implementation of new policies responsive to the needs and desires of the constituents of San Juan.

1.8.5 Future Researcher
This study will be beneficial to the future researcher with the same topic of interest to gain insights from the output of this investigation. This research will surely contribute knowledge and opportunity to future researcher who wants to explore further in health information system.

1.8.6 Researcher
This study will benefit the researcher being the Assistant City Health officer of san Juan to develop a policy for successful implementation of new Health Information System. To address the gaps and issues of the current Health Information System and assist the health staff in adopting the new technological change.
1.9 Scope and Limitation of the Study
Assessing the health information of San Juan entails several factors that need to be considered to attain an enhanced Health Information System.
The researcher decided to limit the study on the internal factors that affect the introduction of new health Information system of San Juan. Limiting the study in this domain would hamper thoroughness, however covering as many domains as possible would be unrealistic. Adding external factors would have presented a complicated framework and focusing on the internal factors were the main concern of the study. To achieve focus, the study concentrated only on critical issues in a macroscopic perspective and discussed other technological issues that needed solutions.
The health personnel who are involved in the process of health information system were included in the study. Identifying the organization’s main task as well as the organizational structure was considered for analysis of organizational response to the new technological change implemented. Assessment of organizational response to IClinicsys was essentially the preliminary step to reduce the risk of failure. The investigation was conducted last September 2018. Any changes in status of the organization beyond this period were not covered by the framework of the study. Health care providers who are not involved in the process of Iclinicsys such as the utility, dental aide and drivers were excluded in the study.

For the assessment of individual response among health personnel, the researcher used a closed-ended survey followed by an open-ended questionnaire that provided further analysis of the current situation. In this thesis confidentiality and voluntary submission of health professionals to the study was considered.
1.10 Definition of TermsChange Management. This is a process and communication plan development within an organization.

Computer-based information system. This rely on computer hardware and software technology to process and disseminate information.

Culture. The way of life of a group of people who share common rules of behavior and thinking of people.

Departmentalization. The process by which an organization is structurally divided. e-Health. This refers to public health services and information delivered through improved Internet and related technologies.
Information Technology. This refers to the use of systems (especially computers and telecommunications) for storing, retrieving, and sending information.

E- Governance. This responds to the needs of its people for an efficient and effective process of disseminating information as well as improving the performance of government health activities.
E-Government. This is the use of information and communication technologies (ICTs) to improve the activities of public sector organizations. 
Electronic Health records (EHR). This is the health record of an individual that is shared among different health facilities and agencies, expected to improve efficiency and quality of care and, ultimately, reduce costs
Electronic Medical Records (EMR). This refers to the electronic-based health information of a patient that can be created and managed by authorized users in one healthcare organization,
Effectiveness. This is the degree to which something is successful in producing the desired result; success
Efficiency. This is the ability to accomplish something with the least waste of time and effort; competency in performance.
Framework. This is a broad overview, outline, plan of interlinked items which supports a particular approach to a specific objective,
Health Care Provider. A person involves in primary health care, treating illness or disability.

Information system. This is an organizational and management solutions based on information technology.

Health Information System. This is a system that provides information support for the decision-making across all health system, essential for health system policy development and implementation.

Health Management System. This is an information system specially designed to assist in the management and planning of health programs, as opposed to delivery of care
Managers. This is the person responsible for planning and organizing what is needed to be done.

Organization. This is an organized body of people with the same goal, vision, missionPerception. The process by which an individual gives meaning to the environment, it can be attitudes, behaviors and reported interactions of respondents involve in organizing and interpreting various stimuli into a psychological experience.

Technological innovation. This products or process of change
Chapter 2REVIEW OF RELATED LITERATURE AND STUDIES
This chapter provides a summary of related literature significant to the assessment of health information system for policy development. It will explore different kinds of literatures relevant to the study. It will guide the researcher to have an in-depth understanding of the current health information system of San Juan towards policy development.

2.1 E-governance
The world of Information Technology (IT) revolution has taken its course in the 21st century and will bring uprising changes in the next years to come. It has conveyed transformational leadership to the government sector, where benefits of transparency, online government services, feedback on governance and data collection for health services will transform its structure. The adoption of this new technology in government sector emerges new occurrence called e-governance. The e-governance is referred to services provided by government to the citizens, business and local government through information technology.

In order to improve governmental organization and government services, it is expected that governments should start using information and communication technology. “Electronic has brought about glaring transformation in the horizon of Public Administration” (Muhammad et al., 2007). “E-government is the use of government agencies of information technologies that have the ability to transform relations with citizens, businesses and other forms of government (World Bank 2009). For public sector, it would mean to use the most innovative Information and Communication Technology through electronic networks with more convenient access to government information and
services. ‘Electronic government has been defined as a technological application of information and communication in governmental organizations to increase efficiency, effectiveness and transparency’ Tambouris 2001 (as cited by Nejadirani,et al 2011). Government should always aim to provide efficient and effective process of disseminating information as well as improving the performance of government activities. The use of information technology would enhance the delivery of public service from its day to day government work for high quality services and information.
2.3 Policy in Information System
A policy is a deliberate plan of action to guide decisions and achieve rational outcomes. Commonly, governments develop and implement policies to address basic socio-economic issues that are expressed in laws, budgetary actions, international agreements, declarations, contracts or campaigns (ITU 2009). Many governments are seizing the opportunity to establish a government of the information age. The implementation of policy whether legislative, guidance, or action based is designed to initiate change. Policies generally seek to generate improvements in effectiveness, efficiency and more responsive outcomes. The establishment of the National Computer Center (NCC) by Executive Order 322 in 1971 for government computerization is a good indicator of the political will and foresight of the Philippine government for Information and Communication Technology (ICT) implementation (NCC 2012). Governments are ‘reinventing’ themselves to meet new expectations and the priorities of citizens and businesses.
With the advent of the information, many governments create a new vision for their relationship with businesses and citizens, and to create a new organizational structure to fulfill their mandate. This transformation stems from many powerful influences of the information revolution. Leaders in the e-government movement are demonstrating that by combining technology with new ways of operating, government can be more effective and responsive to citizens (Lallana 2002).

2.2 Value of Information System in Health Sector
The introduction of information technology applications has been beneficial to governments in several ways. Most significantly, in the area of public management information system provides information primarily to support manager decision making. Electronic applications have expanded government health sector for continuous quality improvement.
“In delivering public goods and services efficiently and effectively, it is very important that we are aided with support tools enabling the use of all kinds of spatial/data information” (Alex Brillantes Jr., 2008). Information technology improves the quality and safety of the health system through empowerment of health consumers for better management of information thereby reducing medical errors for efficient management of health (DOH 2013). It improves patient healthcare by giving health professionals access to complete, up-to-date health records of past and present conditions. Relevant information is important to deliver the needs of patient, health professionals, and health department. Information technology enhances health services thus increasing the efficiency of the existing flow of work in health facilities. It plays a vital role in establishing a competent organization and modernizes production capacity to deliver better performance in health care.
The application of Information System (IS) within public health administration is used to optimize its internal and external functions and provides health sector, the patients and community with set of tools that can potentially transform the way in which interactions take place, services are delivered, knowledge is utilized, policy is developed and implemented, citizens participation in governance, and public administration reform for good governance to be achieved. It affects every single aspect of modern society.
2.3 Development of Philippine Health Information System (PHIS)
Decentralization of health systems is a common pillar of health sector reform initiatives to improve efficiency and quality of services as well as promote accountability and local governance of the health sector.  A health system consists of all people, institutions, resources, and activities whose primary purpose is to promote, restore, and maintain health (USAID 2015).
Over the years, health care professionals have been used in documenting and storing patient information using paper-based recording. This resulted to overburdened health workers with manually recording and computing all the health programs. In turn, delays ensue because health care workers give it low priority compared to patient’s care. Delay in submission of reports to the national offices ensued.
A potential for healthcare to increase the overall quality of health to be more efficient, effective, transparent, accountable and equitable is by using relevant information technology (Iglesias 2010). Health Information System is considered a prerequisite for the efficient delivery of quality health care. “Health Information System integrates data collection, processing, reporting, and use of information necessary for improving health service effectiveness and efficiency through enhancing management at all levels of health services” (WHO 2004). The Philippine Health Information System facilitates gathering, analysis and dissemination of vital indices for the consumption of different users like planners, policy makers, community leaders and development agencies (Shillabeer 2009).
Every sector is trying to adopt Information system for improving their current working status and to bring efficiency in their operations. The World Health Organization (WHO) identifies Health Information Systems (HIS) as one of the pillars that contribute to the strengthening of Health System (WHO 2010). Enhancing Health Information System can reform and modernize public health administration as well as advance reforms in the ways the health sector conducts their health services from the traditional storage of medical records to a systematic computerized data recording. It aims to provide evidence-based for policy and program decisions to support better health outcomes for individuals and for populations overall.
Access to effective health information system remains a challenge for many Filipinos. The application of information technology in the Philippines has continuously advanced and yielded considerable benefits to an individual and public health (DOH 2013). Adoption and implementation of health information technology produces information that health sector needs for decision making and major organizational solutions to challenges and problems created in the health environment. Coordination, monitoring, evaluation and analysis of health data will boost the quality of health care to provide appropriate health interventions.

Health information systems in the Philippines started in 1960s when the Department of Health (DOH) first ran a national health information system (Marcelo 2010). It was in 1984 in the collaboration with the World Health Organization (WHO) that the system was improved and included primary health care. In 1989, the system was revised with the development of software for Field Health Services Information System (FHSIS) (Manabat 2018). This required health personnel from Rural Health Units (RHU) and Barangay Health Stations to collect data and submit 40 different national health programs through the use of ICT.

With the devolution of health services through the Local Government Code of 1991, the health system faced different challenges such as weakening of the quality of management and services, low staff morale, waning infrastructure, and insufficient funds for operational costs and services (Manabat 2018). Continuous improvement was done which led to the implementation of Modified Field Health Services Information System (MFHSIS) and enhanced with the development of Distributed Field Health Services Information System (DFHSIS).
PHIS data sources come from several government agencies: the National Statistical Office (NSO), National Statistical Coordination Board (NSCB), Food and Nutrition Research Institute (FNRI), National Nutrition Council (NNC), and Philippine Health Insurance Corporation (Philhealth), among others (Canlas 2009). The NSO provides basic census and population data like birth and mortality rates, while FNRI and NNC are sources of information on nutrition. Philhealth is a source of patient records and NSCB is an aggregrator of information to produce vital statistics like national economic and population metrics (Canlas 2009). To facilitate inter-agency coordination, the Department of Health (DOH) spearheaded the creation of the Philippine Health Information Network (PHIN) in 2007 which aims to establish collaboration with different agencies for effective health information (Marcelo 2012). However, several problems were identified such as delay and errors in healthcare decision-making, paper-based and manual reporting systems; all-or-none phenomenon; hierarchical flow of data submission; manipulative target-based reporting; mixing good quality data with bad, fabricated data; disintegrated and paradoxical vertical programs; data cemeteries; and lack of computerized health information standards (Marcelo 2010).

In 2013, a National eHealth Steering Committee, composed of representatives from the DOH, Department of Science and Technology (DOST), Philippine Health Insurance Corporation (PhilHealth), UP Manila, and eventually the Department of Information Communications and Technology (DICT), was formed to lead all eHealth initiatives to implement the Philippine eHealth Strategic Framework and Plan (DOH).

The Duterte administration, led by the DOH, outlined the Philippine Health Agenda (PHA) 2016-2022: All for Health towards Health for All. Under the PHA, the government aims to attain health-related sustainable development goals (SDGs) of financial protection especially for the poor, marginalized, and vulnerable; better health outcomes with no disparity; and a responsive health system where Filipinos feel respected, valued, and empowered. One of the strategies to achieve these goals is to invest in eHealth and health information systems to aid decision-making. The inclusion of eHealth and health information systems in the main thrusts of the DOH points to a high priority given by this administration in developing these initiatives as means of achieving Universal Health Care.

Organizational Factors influencing Health Information System
2.4.1.1 Organizational Structure
Organization is the planned coordination of the activities of more than one person for the achievement of a common purpose or goal. According to Schein (1980), it is accomplished through the division of labor and function and is based on hierarchy of authority and responsibility. According to Weber as cited by Laudon (1995), modern organizations should have the following characteristics: have a clear division of labor, arrange specialists in a hierarchy of authority, with explicit rules and procedures, impartial decision making, technical qualifications for positions and with maximum organizational efficiency. The introduction of a new information system will affect the organizational structure, goals, work, design, values, and competition between interest groups, decision making and day to day behavior (Laudon 1995). The transformation of an organization marked changes in form and nature that occur at all levels of an organization’s environment through the adoption and maturity of new information technology (RNAO 2017).
The people within the organization should be structured for the purpose of achieving its goals and specific purpose for its existing. In hierarchy, every member of the organization is assigned a specific position. Each position carries a specific level of decision-making authority as well as specific responsibilities within the organization.
Organizational structure is a system of formal procedures prescribing the allocation of work and roles and the coordination of employees acting in the framework and around it (Delic 2010). It is a combination of groups and individuals working in a coordinated way in order to achieve the goals of the organization. Organizational structure specifies the way people should act in performing their everyday activities. It is the backbone around which other groups cluster and other organizational components rely on. Organizational structure should deliver on the organization’s mission and objectives and as such has fundamental impact on how employees carry out their tasks, how they behave, and how the organization performs overall (Lynch 2012). An organization’s structure can affect how information systems are viewed and used.

One of the factors that should be considered in assessing the complex process of technological implementation is the role that people play in the process of change. Management plays a key factor for successful adoption of desired change. According to Sayles (2014), there are three basic levels of management: supervisory management, middle management and executive management. The supervisory-level managers work in a small functional workgroups or teams. They direct daily work, create work schedules and monitor the quality of work and productivity of staff. They are important resources in revising procedures and conducting performance reviews because of familiarity in the work unit and performance of individual staff members. The second is middle management. They are concern primarily with facilitating the work performed by the supervisors; they develop, implement and revise organizational policies and procedures under the direction of the executives. On the other hand, the executive-level managers are responsible for setting the organization’s future direction and establishing its strategic plan.
In order to assess the health information system for technological innovation, it is important to understand the organizational structure that influences the implementation of the change initiative most especially the role of managers in shaping the new technological change.

2.4.1.2. People
The effectiveness of an organization is directly linked to the performance of its employees (Belita et al., 2013). Implementation of a new information system is often more difficult than anticipated because of individual change requirements. The proficiency, competency, knowledge, and ability to use the new technology should be taken into account. Implementing the desired change requires remarkable levelling of the system as well as the persons using it. “Individual transformation” refers to the individual forming and restructuring that is enabled by the introduction and sustainment of eHealth solutions in a health care context (RNAO). The people have knowledge and skills that make them important resource to be considered in order to build on and improve the technology being introduced. Like in the case of the implementation of Iclinicsys in San Juan, modification has been done to help the health personnel adopt to the new system.
Manpower planning, programming and development are important in considering technological change. In implementing new technology, people need to adapt and learn to use the new equipment. According to Abrahamse, as cited by Borhani (2016), experienced employees are keen to adopt innovative solutions, however the process to acquire the skills is burden to the employees hence causes barriers to the adoption of the new technology.
2.4.1.3 TasksThe introduction of Iclinicsys transforms significantly the nature of work and daily task of health staff. When a change occurs in a system it is often seen that most of the traditional tasks and job descriptions are replaced with modern task force requirements. The new information technology may disrupt the existing organizational routine, a challenge that usually proves more difficult than anticipated. The implementation of Iclinicsys in the City Health Department has brought change in the daily task of the health personnel.
The qualitative aspect of these new tasks and goals should be properly evaluated and the people should be trained accordingly. Requirements and benefits of the new task should be identified and it should be checked whether it is relevant.

2.4.1.4 Effects of the new Health Information Technology
The impact of information technology has significant effects on the structure, people and task of most organizations.  Conversion to the new technology demands significant changes in workflow, jobs, structure and management of the organization. The introduction of new information technology affects the organizational structure, goals, decision making and day to day behavior. It can change medical health personnel working process and the time spent documenting during the implementation of the new information system.

Assembling an effective, efficient computer system requires an understanding of its relationship between information system and organization (Stair 2006). The new health information system will force changes in basic managerial functions. There will be increased responsibility on management for organization outcomes leading to added emphasis on planning, decision making, control, and coordination (Golson 1997). In order
to reap the benefits of technology, organizational innovations such as changes in culture, values, norms and interest-group alignments must be managed with as much planning and effort as technology changes (Laudon 1995). Creating an information technology that supports the organizations’ goals is of utmost importance. The new Health Information system is one of the many tools available for managers in coping with change. It is an instrument that would require organizational reform for the adoption of change.
Organizations awareness and acceptance of technological change greatly influence the success of the program. A simple technological upgrade in one organization will have large effects throughout the organization. A new information technology requires careful consideration of associated factors such as the organization, its people, structure and the roles of each individual persons involve for the proposed change. People are the most important element in most computer-based information systems. Information systems personnel include all the people who manage, run, program, and maintain the system.

Change is crucial for the organization to function in the most efficient way. Therefore organizations have to embrace change to be more competitive, develop and deliver better public service. The success of health information technology requires fundamental change on how organization works, view and improve their ways. There is no one package strategy but rather requires a holistic change for the success of the desired change. Having an in-depth understanding of the organizational response will help in the transformation process towards an enhanced health information system.

2.11 Management of Information System
Management of Information Systems includes external information in addition to the internal information about the agency’s operation in achieving the goal setting, and
decision-making purposes of the different levels of management in the organization (Orbeta 2016). To understand information systems, one must have a clear view of the problem it is planned to solve and the organizational processes that lead to its solution. To be able to use the information system effectively, one must try to anticipate the various individual reactions of people to the new technological change. An effective and successful implementation of health information system will transform the delivery of health services in accordance with the needs of the organization.
Organizational Change Management is focused on supporting people to change their behaviors in specific, desirable ways, by providing them with the right tools and supports. Those individuals and organizations that directly benefit from the initiative are often the most effective at executing the initiative. However, sometimes employees are inherently resistant to change, and the degree and nature of the resistance affect the successful transition to e-government (Gabrielle Iglesias. 2005). Developments in information technology create organizational responses. Assessing individual and organizational impacts is therefore crucial, as the success of HIS depends not only on the quality of the technology but also on the people and organizations involved (Ammenwerth et al, 2004: 480).

As early as 1960’s the Department of Health already operated a national health information system in 1984 (Marcelo 2010). In 1989, The Field Health Information system was adopted for the collection of data in the different health programs however the existing paper-based data collection system was not reformed. In 1996, the Field Health Services Information System (FHSIS) was modified and enhanced to the development of e-Health, this will provide local decision-makers to make relevant, timely and evidence-based decisions in different health programs.
The Department of Health aims to strengthen the coordination to various programs, projects, standards, systems of policies through a Unified Health Management Information System (UHMIS) (DOH 2016). An electronic health recording of all health programs for data generation, compilation and analysis of the Department of Health. The outputs of the UHMIS will assist in the management and planning of health programs. Providing unified health management information system will transform the current data system to higher
health care. For successful implementation, health care providers must be willing to undergo the transition from the old paper-based system to the new electronic-based HIS. Assessment of the individual and organizational response towards an enhanced health information system will serve as a foundation for successful e-Health innovation.
2.4. Impact of New Health Information System
In spite of the huge potential and opportunities that lie in HIS, more often than not the transformation of health care may appear as reform and modernize as it is on paper. In order for a developing country such as the Philippines to take advantage and apply these readily available tools, an ecosystem has to be built to provide training, implementation, and support for deployment of these technologies in local health organizations (Quesada). Public health often times faced with the challenges of managing the data health records as well as expectations of the community for the health care providers to adopt with technological innovation. According to Goldschmidt as cited by Ngafeeson (2014), the adoption of Information technology in healthcare has been particularly slow and lagging behind compared to the major industries by as much as 10-15 years. Health Information System (HIS) offers the promise of addressing many problems confronting the health care industry, yet their adoption in public health has been slow. Despite the numerous methods and strategies designed to transform healthcare and health care sector, many challenges are evident and need to be considered for successful adoption and implementation.
People
One factor that needs to be considered in the assessment of the complex process of technological implementation is the role health professionals play in the process. Health professionals are the primary users of Health Information System. People should be given special rights and privileges to ensure the system achieve its implementation targets.
From the study done by Mohamadali (2015), the following were the challenges identified among medical practitioners with the implementation of Health Information System in the healthcare; staff resistance in using the implemented system, lack of Information technology knowledge among practitioners in using Health Information System, refuse to share information, and the shortage of Information Technology manpower to regulate the system.
Changes of strategies, structures, and form of service delivery must be accepted by direct care professionals – they must adapt, learn new skills and competences and, above all, acquire and commit to new mindsets and attitudes (Rodrigues 2008). Bringing about changes in the health sector is not merely creating a new system and providing computer in the health facilities, it means much more of installing a new machine.

People need to adapt and learn to use the new technology. Success in the deployment of e-health applications depends on the right mix of skills and commitment to data management responsibilities in all functions at all levels, creating an additional burden to the already demanding professional workload. Resistance to change has become rooted in certain professional roles – the introduction of ICT in healthcare disrupts traditional structures and hierarchies.
There is a view that the health care professionals who have deficiency in Information and Communication Technology skills of management the online health data end up using too much time. Therefore, without adequate ICT knowledge and skills implementation of ICTs becomes difficult (Borketey 2017).

Structure
In order to reap the full bene?t of ICT in a complex environment, organization should have provided a clear de?nition of goals, roles and responsibilities of each health personnel involved in the adoption of the new technology. A low level of awareness about the need for ICT use and Information System implementation may cause delays in the process, which is likely to cause inefficient fund allocation and the overall stagnation of policy implementation.

Health care organizations cannot increase their commitment to e-health applications without strong leadership and vision (Ganesh 2004). For transformation to occur, the new Health Information System must be enabled and supported by the organizational leadership. A shared vision of what the organization is trying to accomplish, a clearly articulated mission and institutional leadership are often crucial determinants of successful e-health programs. Stable, well financed, and coordinated efforts in the areas of resource development, technical services, clinical operations, training, and advocacy for a favorable regulatory and policy infrastructure will go long way in establishing any successful e-health projects. If e-health is to be introduced widely then mobilization of organizational support is essential.
Organizational & Management Challenges includes coordination problems, administrative issues, information sharing problems, standardization of information, availability of multiple and parallel information, organizational culture, fragmented health systems, data interoperability, lack of synchronization, lack of training, absence of strategic organizational processes, Lack of insights and vision, diversity of requirements amongst specialties, insufficient physical assessment parameters, insufficient demonstrability of the outcome, hospital size, level of healthcare, ownership issues, legacy of traditional paper system, variation in health systems, disruptions in workflow, complexity of implementation, diverse sources and user requirements, poor integrations, insufficient health data collection systems, lack of incentives, poor working conditions, lack of agreement amongst stakeholders, logistical issues, inappropriate distribution of the decision making power, low levels of accessibility and availability, services that do not meet the requirements, the dynamic nature of healthcare, variations in purchasing power, neglecting patients’ needs, bad management, lack of guiding principles, type of data as some of it might be on papers whereas others are electronic, concerns about future help from system providers, hospital management, nature of jobs in the healthcare sector, changes in roles and responsibilities within the healthcare team, changes in teaching patterns, vague objectives and values, absence of administrative systems to control operations of health information systems, lack of local champions, performance measurement, change management issues, evaluation issues, in addition to absence of a reform agenda and supportive strategies (Jaros?awski and Saberwal, 2014).

Task
Users’ perceptions about technology can affect exactly how a new information technology is accepted, implemented operationalized. It was established that most users’ are only frightened by the use of ICT in health sector established on their perceptions about it (Achampong, 2012). The perception of health professionals that electronic health record (EHR) would demand and consume additional time adversely influence the duration of time they might spend with patients. Successful implementation of eHealth implementation would demand change of attitudes of health personnel towards eHealth (Achampong, 2012).
From the study done by Murray (2011), new technology was most likely to be successful when implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organizational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of success.

Health Personnel should be taken seriously to ensure that the problems are identified and solutions are provided. In the study done by Jalghoum et al (2016) resistance to change can have severe effects on the adoption of the e-health. Different reasons behind the resistance to change were the work overload that takes place during the change. Several health workers became too overwhelmed when e-health projects were introduced and started to get implemented in their health facilities. Having to work on projects related to e-health in addition to the projects they were already working on has created a huge burden on them and doubled the amount of effort and time needed.
Technology
Technology is an important factor influencing e-government success (NSW, 2001). It comprises Information System structure, hardware, and service quality.
The lack of computerized health information standards is one of the technological challenges in Philippine Health InformationSystem. While the Department of Health and Philhealth maintain their respective computerized health information systems, they are not standard based and cannot easily exchange data with each other.
From the study done by Menko et al (2013), there are technological challenges in the implementation of Information factors identified were lack of technological skills and training, poor reliability of the system, hardware failures, connectivity problems, monitoring machines problems, system errors, lack of computer literacy, unnecessary updates and upgrades to current functional software, mistaken functioning of videos, lack of access to technology, lack of computers, lack of electronic communication capabilities, multiplicity of screens, lack of technical support, difficulties dealing with technology, diversity of options and navigational aids, issues in system maintenance and software updates, lack of feasible technological infrastructure, lack of utilization of computers in health, technical issues and concerns, complicated unfriendly systems, inadequate technical staff, poor network coverage, and the amount of data being transferred.

An effective Health Information System is built through the process that starts with understanding what decisions need to be made by these various players and be able to
2.12 Synthesis
The researcher on related literature integrated the Leaviit Model to investigate the response of the organization and the individual on the desired innovation. This is necessary to sort out the situation so that effective management action can be executed. The related literature and studies serve as foundation for an in-depth understanding on the proposed study.

In pursuing the research venture, the related literature helped the researcher in the assessment of organizational response needed for the enhancement of health information system and policy development. A reliable health information system will serve as a foundation for decision-making of all health related programs and services. The process to transform the health information system of the LGU will neither be quick nor simple. It will require a coherent strategy, beginning with an examination of the people, structure, task and technology as well as the ability of the organization to adopt and make use of implemented technology. The success of adoption of new technology requires fundamentally change on how the organization works and how people view the ways in which organization helps them. There is no “one size fits all” strategy in implementing Health Information System, but having identified the response of the organization and the individual involved will help in the transformation process of the new technological change.

Chapter 3
RESEARCH METHODOLOGY
3.2 Research Approach
Assessing the status of the Health Information System of San Juan should follow a detailed methodology which consists of the following:
The Design phase in which objectives are defined and data collection methods are selected.
The Process phase derived from data collected to develop policy for health information. Current Health Information System is assessed and examined.
The Analysis of Results phase in which the scores gained from the process phase are analyzed to improve the current Health Information of San Juan.
3.3 Research Design
The primary objective of this investigation was to gather relevant information pertaining to the perception of the respondents to the current Health Information System. In this thesis, the researcher conducted a descriptive study to generate information regarding the perception of health information system of San Juan. The objective of the descriptive research is to cast light in the current issues or problems through a process of data collection that enables them to describe various aspects of the phenomenon (Fox 2007). This method provided accuracy on the current situation of the health information of San Juan, perception of the end user and the actions taken during the development of the health information system. The Researcher used a mixed method research design which is a combination of a quantitative closed ended questionnaire and a qualitative open ended questionnaire. A quantitative approach was adopted in this study to measure the perception of health staff on the new health information system. However, the survey questionnaire did not provided an in depth understanding of the current health information system. Hence, a qualitative data was used to allow the researcher to obtain a complete picture about the real health information system situation and the perception of the key informants to the new technological change. A face to face interview was drawn upon the key informants’ in order to provide additional insight in several important issues related to the perception of the respondents to the current health information system and the actions taken during the development.
Research Method
A comprehensive research was undertaken on e-governance, health information system, adoption of information technology, and organizational structure. Such researches helped in identifying all critical success factors for a comprehensive assessment of Health Information System and organizational and individual response to the adoption of new information technology. Analysis of such factors revealed that they can be classified into two main groups: internal factors (specific to the organization such as structure, task, its people, knowledge, skills) and external (related to the whole environment such as, economic, political, and regulatory). Although the external factors such as the environment, governance, regulations are proved to be important in assessing the Health Information System, they were not included in this thesis.
The focus of this research was on the internal factors that exist within the City Health Department. The researcher decided to focus on studying the different factors within the organization such as the health providers’ skills, knowledge, its structure, leadership and management which are all factors that can affect the implementation of the new health information system. Adding external factors would have presented a complicated framework and focusing on the internal factors were the main concern of the study.
Based on the Leavitt model, the researcher focused on the assessment of the Health Information System using the four internal factors such as the Structure, task, technology, and people. The researcher believes that the four dimensions are the pillars of success in any information system.
3.2 Population and Sample size and Sampling Technique
The population of the study was composed of the health personnel of the City Health Department who plays a critical role in the process of Iclinicsys. Included were the physicians, dentists, nurses, midwives, nutritionist-dietitians, sanitary inspectors, barangay nutrition scholars and administrative aide as seen in Table 2.
Table 2 Health Personnel Ratio to Population
Indicators Male Female Total
2018
Physicians (including the CHO & ACHO) 3 8 11
Dentists (including the Supervisor) 5 7 12
Nurses (including the Supervisor) 2 11 13
Midwives (including the Supervisor) 0 15 15
Nutritionist- Dietitians 1 1 2
Sanitary Inspectors 4 5 9
Barangay Nutrition Scholars 0 18 18
Administrative Aide(Clerk) 1 4 5
TOTAL 16 69 85
Table 2 presents the population and sample size of the health care providers included in the study. The population size of male health personnel is 16 while female health personnel is 69, a total of 85 health personnel were included in the study. The population has been categorized by current position as it could be a factor with their response in the survey.
Sampling Design
To gather the needed data through the use of survey questionnaires and interview with structured and semi-structured questions, two-step sampling technique have been employed which are purposive and judgemental sampling procedures. Purposive sampling is a non-probability sampling technique which selects units from a population to be investigated by the researcher. The objective using purposive sampling is to concentrate in evaluating the characteristics of a population.85 Health personnel are scattered in different health facilities in a hierarchical manner. The respondents were chosen using purposive sampling methods based on their involvement in the IClinicsys process.
3.3 Research Instrument
Survey Questionnaire
A quantitative self-made survey questionnaire was used as a main instrument to analyze the status of the current health information system of the Health Department. The first page of the questionnaire contained an introduction that explains some terms included in the questionnaire. The questionnaire consisted of two parts (see Appendix A). The first Part consists of the socio-demographic profile of the respondents such as the age, current position, and years of service. The second three parts measured the perception of the respondents to the health information system where in it is categorized into four parts; the people, structure, technology and task. These research variables were used to know how the respondents rate the current health information system. A ten-point scale was used, 1 being very poor and 10 being very good. Another measurement was done using a 4-point Likert scales, with 1 as strongly agree and 4 strongly disagree. Lastly, a dichotomous survey questionnaire was used to assess the actions taken and the willingness of the respondents for policy development.
An additional set of dichotomous questionnaire was given to the medical supervisors as well as to the middle manager. This will help assess the actions taken for the development of the Health Information System. Comments were asked in each question in order to provide additional information relevant to the study.
Key Informant Interview
A qualitative open ended questionnaire was collected from the key informants using face to face interview. Key informant interviews are considered important in order to provide the researcher additional insight and have an in-depth understanding of the current Health Information System. In this thesis, the key informant was identified as follows.
1. DOH IClinicsys manager- the key informant is involved in the management tasks of the regional health information system (DOH-NCR). The person is assigned at the administrative unit. The justification for selecting this particular person is that he is in the position to give detailed information regarding overall management of current Health Information System in the regional health system.
2. Health Managers- This group represents the actual users of Health Information for Health Management activities. A purposive and judgmental sample of 3 health managers who are involved in planning and management of healthcare services in San Juan Health Department was recruited.
Development of the Interview Guide
Besides conducting interviews, a review of documents has been done to provide great help for analysis of data such as policies and procedures, work process of implementation and the organizational chart. The hierarchical structure is important to understand the different positions and relations between them and to investigate how these positions affected the process of IClinicsys implementation.

There are two types of interviews according to Yin (2002), open-ended interviews prevailing respondents point of views while following the researcher line of inquiry, and interviews producing quantitative data. Qualitative interviews can be divided into structured, semi-structured, and unstructured subcategories which is dependent on the level of formality (Saunders et al., 2009, p. 320). Structured interviews is defined as set of questions for every interview, while semi-structured are based on a set of questions that can be varied dependent on the situation (Saunders et al., 2009, p. 320). Unstructured, or in-depth, interviews are absolutely informal, guided only by the list of topics that might be discussed (Saunders et al., 2009, p. 321) for this thesis a structured and semi-structured interview is used to get comprehensive information. This technique allowed the researcher to focus on areas that were given emphasis by the respondents, while staying within the boundaries of the research topic.

A semi-structured interview with Iclinicsys coordinators and DOH Iclinicsys manager was done by the researcher. This type of interviews did not include specific questions, but just broad areas for investigation aiming mainly to open ideas and thoughts with interviewees. Unstructured interviews encouraged respondents in selected organizations to express their thoughts liberally. This enabled collecting information regarding the main role of Iclinicys in the organization, its value and impact as viewed by the key informant.

Subsequently, semi-structured interviews (see appendix C) – characterised by including a set of questions in a limited time but addressed in a flexible way – were also conducted with top management and IT professionals to allow them to elaborate on issues viewed as crucial from the researcher?s perspective such as, main online and offline services provided by the organisation and the difference between them, level of employees? awareness of the e-government program in the organisation, communication approaches adopted within the organisation and with other public agencies. Semi-structured interviews served also in recognising the number (and availability) of potential respondents capable of answering structured interviews to be conducted later with the employees, and in finetuning the developed questionnaire instrument.
In addition, Observation Method was used to collect data that offered relevant behaviors of the health personnel. Such observations constituted an important source of data that provided significant information on the employees? working environment, the organization’s workflow, the Iclinicsys applications used and their efficiency, the communication mechanisms followed between management and employees, and the communication skills of the employees who have a direct interaction with citizens.
3.4 Data Gathering Procedure
The researcher provided a letter to the City Health Officer Jesus Esteban P. Olano, M.D. requesting permission to conduct the study. Data was gathered after securing the permission from the head Department and collected without hindering the normal activities of the respondents. All permanent health professionals of the City Health Department who are assigned in different health facilities and are involved in the process of Iclinicsys were chosen for this study. The study utilized a survey questionnaire which was given directly to the respondents.

In addition, as a regular routine, the researcher clarified several issues to each questionnaire?s respondent before handing him/her the questionnaire. Each Health personnel were informed about the purpose of the questionnaire and its anonymous nature. Respondents were also told that their participation in this study was voluntary, not required, and that their refusal to participate would not affect them in any way, and that they could withdraw from this study at any time.

3.5 Statistical Treatment of Data
Statistical treatment of data is important for interpretation of data collected vital for the outcome of the study. The following statistical treatment will be used:
1.The Percentage will be used to determine the distribution of the personal related data of the respondents. The formula is:
% = n/N x 100
% = percentage
n = number of respondents
N = total number of respondents
2.Weighted mean will determine the assessments of the respondents with their respondent’s profile. The formula is.

X = F(x) / N
X = weighted mean
F = frequency
x = weight of the response
N = total number of responses
3.Pearson’s Product Moment Correlation Coefficient (r)- a statistical analysis of data will be used to investigate the association or relationship between assessments of the respondents with their respondent’s profile.

4.The Cronbach’s Alpha will be used to test the reliability of the survey questionnaire. It will measure the internal consistency of the test.

5.The Microsoft excel Data Analysis Software will be used to compute the Cronbach’s Alpha.

Key Informant Interview
Introduction
Confidentiality of all answers will be maintained by assigning a code to each response and not recording any personal or identification information. Answers to the study are completely anonymous. Your questionnaire will be destroyed once your responses have been recorded. The summarized findings with no identifying information may be published in an academic journal. There are no foreseeable risks to you as a participant in this project; nor are there any direct benefits. Your sincere reply will provide guidance to the organizational response to the adoption of new technology (iClinicSys).