Challenges to healthcare information systems development: The case of Jordan

Abstract

This paper investigates the perception of healthcare providers in regard to the challenges that hinder the development of e-health initiative in Jordan based on a classification of challenges that was developed from the pre-existing literature. Twenty-six semi-structured interviews were conducted with various stakeholders of the e-health system. These challenges are Lack of Regulations and Policies to Support Health Information Systems, lack of financial resources, Privacy Concerns, and Nature of Healthcare Sector. The paper concludes that all of the unique findings that emerged in this paper are directly related to human and cultural issues. These two aspects appear to have a huge impact on the development of the e-health in Jordan. In order to ensure a smooth transformation of health services delivery and as an outcome and contribution of this paper to the managers and decision makers in the healthcare sector, a few findings were highlighted and could be of great value to people in charge of e-health initiatives these include: proper laws and policies that support the e-health development, secure the necessary needed funds, addressing privacy concerns of stakeholders, and standardization of e-health development. This paper serves as one of the newest interpretive studies that empirically explore the challenges to e-health in Jordan. It also attempts to bridge the gap found in the existing literature as it investigates the key issues that affect the development of e-health in Jordan from a different angle that was not adequately looked at and discussed previously.

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International Journal of Healthcare Management
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Challenges to healthcare information systems
development: The case of Jordan
Yaser Jalghoum, Asem Tahtamouni, Sahar Khasawneh & Amro Al-Madadha
To cite this article: Yaser Jalghoum, Asem Tahtamouni, Sahar Khasawneh & Amro Al-Madadha
(2019): Challenges to healthcare information systems development: The case of Jordan,
International Journal of Healthcare Management, DOI: 10.1080/20479700.2019.1658159
To link to this article: https://doi.org/10.1080/20479700.2019.1658159
Published online: 27 Aug 2019.
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Challenges to healthcare information systems development: The case of Jordan
Yaser Jalghoum
a
, Asem Tahtamouni
b
*, Sahar Khasawneh
c
and Amro Al-Madadha
d
a
Business Operation, The University of Texas, MD Anderson, Houston, TX, USA;
b
Banking and Finance Department, American University of
Madaba, Amman, Jordan;
c
Business Administration Department, Jordan University, Amman, Jordan;
d
Business Administration Department,
Princess Sumaya University for Technology, Amman, Jordan
ABSTRACT
This paper investigates the perception of healthcare providers in regard to the challenges that
hinder the development of e-health initiative in Jordan based on a classification of challenges
that was developed from the pre-existing literature. Twenty-six semi-structured interviews were
conducted with various stakeholders of the e-health system. These challenges are Lack of
Regulations and Policies to Support Health Information Systems, lack of financial resources,
Privacy Concerns, and Nature of Healthcare Sector. The paper concludes that all of the
unique findings that emerged in this paper are directly related to human and cultural issues.
These two aspects appear to have a huge impact on the development of the e-health in
Jordan. In order to ensure a smooth transformation of health services delivery and as an
outcome and contribution of this paper to the managers and decision makers in the
healthcare sector, a few findings were highlighted and could be of great value to people in
charge of e-health initiatives these include: proper laws and policies that support the e-
health development, secure the necessary needed funds, addressing privacy concerns of
stakeholders, and standardization of e-health development. This paper serves as one of the
newest interpretive studies that empirically explore the challenges to e-health in Jordan. It
also attempts to bridge the gap found in the existing literature as it investigates the key
issues that affect the development of e-health in Jordan from a different angle that was not
adequately looked at and discussed previously.
ARTICLE HISTORY
Received 18 September 2018
Accepted 9 August 2019
KEYWORDS
E-health; health information
systems; barriers; challenges;
recommendations;
healthcare sector; developing
countries; Jordan
1. Introduction
Unquestionably, the accessibility of digitized infor-
mation along with the widespread usage of the Inter-
net, such as social media outlets, web 2.0
technologies, and ICTs provide enormous opportu-
nities to all sectors to globally advance and modernize
their structure as well as to improve interaction with
stakeholders. Therefore, it is apparent that different
sectors are striving to reap the full benefits of the digital
revolution and are putting to use new technologies
within their structures aiming to innovate the current
existing systems and transform the traditional way of
doing business [1,2].
The utilization and application of ICTs and the
Internet in the healthcare sector with the purpose of
advancing and delivering healthcare services which is
acknowledged as Electronic Health (E-Health) [3].
The authors affirm that E-health and the adoption of
information technologies (IT) in the healthcare sector
is one of the groundwork steps towards open govern-
ance as it involves developing innovative and creative
approaches and functions to healthcare organizations.
For example, it has the potential to facilitate the man-
agement of the scarce resources [4,5]. IT is no longer
perceived as just a supporting tool, but has become a
strategic necessity for developing an integrated health-
care IT infrastructure that can improve services and
reduce medical errors [6]. Healthcare information
technology is a key factor in improving quality and
reducing cost in healthcare, and yet, the successful
implementation of health IT varies greatly among
healthcare systems [7].
Additionally, it introduces new opportunities for
various types of coordination collaboration and allows
for healthcare providers to be faster, more responsive,
offers high-quality services, gives fast services delivery,
increases effectiveness and efficiency, as well as
empowers stakeholders [8,9]. Furthermore, infor-
mation systems (IS) and new technologies in the field
of healthcare assist providers to minimize medical
errors, better streamline expenditures, save time,
enhance communications, increase accountability,
become more transparent, acquire up-to-date and
immediate real-time information and as a result
make better decisions [10,11].
However, despite the many advantages that are
related to the implementation of ICTs in the healthcare
sector, the sector is ranked in the very bottom amongst
the information-intensive industry in regard to invest-
ments in ICTs; and [10]. Additionally, evidence clearly
shows that the majority of e-health initiatives are not
© 2019 Informa UK Limited, trading as Taylor & Francis Group
CONTACT Asem Tahtamouni a.tahtamouni@aum.edu.jo
*The Corresponding Author and made same contribution in this paper as the first author.
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT
https://doi.org/10.1080/20479700.2019.1658159

progressing as predicted [12], and that most of e-health
initiatives eventually end up as failures when being
assessed especially with those implemented in develop-
ing countries [4,13] due to the enormous challenges
and barriers that impede the development. A research
suggests that there are some factors are considered cri-
tically influence the mobility of service in enhancing
the healthcare in southwest Africa such as the respond-
ing time; understanding of the actors; ICT artefacts;
actors’alliance; categorization of patients; and actors’
participatory to service delivery [14]. Moreover, a
research by Cheng, et al [15] states that:
A basic requirement to provide patient-centric care is
to have identifiers serve to link all patient data across
multiple systems together to provide a coherent ser-
vice. In most hospitals today, the lack of a unique
patient identifier that works across multiple hospital
information systems such as HIS means that health-
care providers typically rely on a patient’s name,
date of birth, and other personal information to ident-
ify their medical records in the electronic health
record systems. However, this information is not guar-
anteed to be unique to an individual. It also takes a
considerable amount of time to check on this or
more information and requires much human inter-
vention. As a result, providers often have a difficult
time properly identifying patients, thus increase the
risk of associating medical information with a wrong
patient.
It was discovered that empirical research studies in
regard to the challenges within the context of Jordan
are rare, and out of those limited research studies;
interpretive qualitative studies are either old (i.e.
[16]) or they focus more on the patients’perceptions
[17]. Four core key challenges were identified to
effect and influence the development of E-health within
the context of Jordanian; Lack of Regulations and Pol-
icies to Support Health Information Systems (HIS),
Limited Budgets, Privacy Concerns, and Nature of
Healthcare Sector.
1.1. E-health definition
There is no consensus about the definition of e-health
among scholars. For example, Eysenbach [18] identifies
E-health as an emerging field that delivers medical
information and healthcare services by utilizing the
Internet and other related technologies, he character-
ized e-health as a technical development, and sees it
as long-term commitment to develop healthcare locally
and internationally.
Pretlow [19]defined e-health as the practice of offer-
ing healthcare services and information through the
electronic means of communication especially the
Internet. That includes monitoring, educating and
interacting with healthcare providers. Moreover,
Healy [20]affirms that e-health is a tool that assists
to achieve secure and cost-effective usage of
technologies for healthcare and other related fields
and that it offers innovative solutions to enhance health
care delivery in both the public and private sectors.
Healy perceives e-health as a vehicle for the change
and transformation of the health situations and the
conditions of people around the globe in general and
for those living in developing countries in particular.
1.2. Overview of the healthcare setting in
Jordan
The healthcare in Jordan is equally shared among
three main service entities each of which has its own
administration, staff, budget, and centers. The first
of these providers is the Ministry of Health (MoH)
under the government of Jordan. The second is Jordan
Armed Forces through the Royal Medical Services
(RMS). The third entity is the Private Hospitals. [1].
In October 2009, Hakeem is a national e-health
initiative that was created and launched in Jordan by
his majesty King Abdullah II aiming to revolutionize
the healthcare sector. Electronic Health Solution; a
not-for-profit organization is the main body respon-
sible to assist and facilitate the implementation pro-
cess of Hakeem in the Kingdom. The vision of
Hakeem is to improve the Jordanian healthcare sys-
tem in order to become a superior national and
regional system known for its excellent quality of ser-
vices [21]. Jordan is currently taking significant steps
to implement electronic healthcare records (EHRs)
in hospitals [22].
1.3. Aim of the paper
This paper explored the relevant existing literature and
discovered that there are multiple theoretical and
empirical research works in the literature that deal
with the challenges that influence the implementation
of e-health initiatives in both developed and developing
countries. This paper intends to investigate the percep-
tion of healthcare providers in regard to the challenges
that hinder the development of e-health initiative in
Jordan based on a classification of challenges that was
developed from the pre-existing literature.
1.4. Paper significance
This paper has a significant value for many reasons.
First, it serves as one of the newest interpretive studies
that empirically explore the challenges to e-health in
Jordan. Second, it not only focuses on the challenges
but also investigates the drivers to e-health develop-
ment in Jordan which has been completely neglected
in the reviewed literature. Third, it attempts to bridge
the gap found in the existing literature as it investigates
the key issues that affect the development of e-health in
Jordan from a different angle that was not adequately
2Y. JALGHOUM ET AL.

looked at and discussed previously; that is the perspec-
tive of the healthcare systems’providers.
2. Literature review
There are a number of factors that have hampered the
progress of HIS implementation worldwide, including
the privacy and security of patients’information, mis-
use of the electronic healthcare data, high costs of
many technologies, stakeholders’resistance to technol-
ogy, lack of standardization to the way data are gath-
ered, processed and analyzed making their
importance limit for research use, as well as lack of
defined legal implications about automated medical
patients’records [21,23,24].
According to Marconi [8], stakeholders in the
healthcare sector must be aware of the quality, safety
and legal implications that might result from utilizing
a digital medium, such as the Internet, to meet their
educational and informational needs. Marconi
affirmed that the application of HIS is linked with
many risks such as privacy of sensitive information,
unauthorized dissemination of electronic information
of patients, security, disclosure of privileged infor-
mation, confidentiality, liability, and quality concerns.
A research analyzed how hospital information sys-
tem (HIS) is used as a comprehensive, integrated infor-
mation system designed to manage the financial,
administrative, and clinical aspects in the Indian hospi-
tals. Moreover, the research discussed how the HIS
ensures financial returns by enhancing accounting
and administration, timeliness of patient care, manage-
ment reporting, and record keeping. The research
found that there are benefits for all stakeholders by
implementing HIS [25].
A study by Mohamadali and Ab Aziz [24] highlights
that although several implementations of computer-
based healthcare systems have been successful, many
others have been big failures and seen as disasters,
cost overruns, incurring significant delays, as well as
vulnerable work actions. These failures are the result
of many hindrances such as changes in roles and
responsibilities within the healthcare team, changes
in teaching patterns, and also the organizations’
policies.
Jimison et al. [26] identify other obstacles that pre-
vent the successful implementation of HIS. These bar-
riers are lack of trust to the electronic information
provided by the system especially if patients get an
unexpected message that contains an advice which
contradicts their own experiences, lack of convenience
and difficulties in fitting technology intervention into
patients’lifestyles (i.e. users might not use the HIS
continuously which prevents the intervention from
being more useful), lack of perceived benefits. Also,
lack of experience with technologies and Internet,
technical issues (i.e. Internet connection issues that
might lead to data loss, system errors, monitoring
machines problems, and mistaken functioning of
videos), lack of response, lack of experience with
medical data which might create confusion to users,
lack of usage and involvement of HIS by physician
due to time constraints which leads to patients’dis-
pleasure, lack of computer literacy, computer anxiety
(reluctant to try to use computers), inability to
remember username and password, lack of access to
computers, high costs to patients particularly if they
are instructed to be physically present at a specific
site in order to use a touch screen computer, age
issues (most elderly are less concerned with learning
to use new technologies), and also disabilities pro-
blems (for example people with vision issues find it
hard to view the computer screen).
However, Pretlow [19] outlines other factors that he
considers main reasons of failures for e-health projects.
These include unhealthy or unhelpful outlook and per-
ceptions of the healthcare providers about e-health as
they view it as: time-consuming, loss of the human or
personal touch between the healthcare providers and
the patients, inadequate physical assessment par-
ameters, lack of computers inside healthcare providers’
offices, unavailable or poor Internet connections, lack
of computer skills among administrative and medical
staff, personnel inability of communicating with
patients via the Internet and the high costs of e-health
and e-monitoring devices (see also [24]).
Moreover, DePhillips [27] identified that high costs
of technology, difficulty of the implementation, ambi-
guity of financial benefits, disruptions in the workflow,
fear of losing interaction with patients, as well as mar-
ket barriers (1). payers focused and care about volume
rather than efficiency and quality, (2). failure of EHR
implementations due to inconsistent availability of
skilled IT staffin physicians’offices, (3). limited inter-
operability as there is no reasonable health information
exchange infrastructure and the standards are neither
rigorous nor precise), are all legitimate reasons behind
the limited usage and widespread of HIS in the health-
care sector.
A remarkable paper discovered in the literature was
proposed by Paul et al. [12], who outline seven major
concerns that might act as barriers to the development
of e-health initiatives from the patient–user perspective
which is based on the experience of the first author.
These concerns or barriers are (1) the doctor–patient
relationship, (2) physician or patient-centric EHR, (3)
lack of healthcare savings, (4) the vibrant nature of
healthcare, (5) patients’longevity, (6) quality control,
and (7) healthcare failure seen as death. The authors
argue and support their findings by conducting seven
short ethnographic research studies and concluded
that neglecting patients in healthcare systems will
delay the development process and will act as counter-
productive to a successful HIS (see also [28]).
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 3

Additionally, Inokuchi et al. [29] conduct a research
study that they claim is the first comprehensive
national study of the main forces that influence the
implementation of EHR and Emergency Department
Information Systems (EDIS) in hospitals in Japan.
The researchers based their results on the analysis to
the answers provided by ED directors of 215 hospitals
to a survey. Inokuchi et al. report that insufficient fund-
ing to purchase the system in addition to the lack of
financial capital to sustain the maintenance costs, con-
cerns about future help and assistance from systems
providers, as well as the potential of negative effects
of such systems on the flow of work are perceived as
the major barriers to the adoption of EHR and EDIS
(see also [30,31]).
The above-mentioned studies provide unyielding
evidence that the implementation of HIS projects is
not an easy task and must not be taken lightly, and
usually many barriers and challenges are encountered
during the implementation process which necessitate
sufficient attention and action by the health sector
leaders.
After critically assessing the previous literature and
studies about e-health development around the
world, it is obvious that the application of IS in the
healthcare sector can be seen as a double-edged
sword. The benefits and values achieved are not gained
without some pain. However, it can be concluded that
the advantages that are gained by implementing HIS
far outweigh the disadvantages and negatives.
3. Methodology
This research adopted a single-case study method,
which is widely used approach in qualitative research
aim to examine new phenomena or innovations that
are still in their early stages of development as it assists
in investigating how the phenomena and its context
interact. This method assists in discovering the
phenomenon within its real life context and makes
possible acquiring a rich insight and in-depth infor-
mation about the area of the research based on the
experiences and feelings of the participants involved.
Case study method was a good choice for the research-
ers as it provided them with the opportunity to interact
directly with the participants who clarified our under-
standing to their actions and perspectives as they were
able to share their honest opinions about their real life
experiences [32].
The researchers implemented semi-structured inter-
views as the main source of data collection since this
style of interview is simple and easy to be prepared,
allows interviewees to provide more clarifications to
their answers if required, and also permits for altera-
tions of the questions’order depending on the inter-
view flow. Additionally, it helps studying critical and
sensitive topics in order to get privileged, private, and
confidential information that participants might be
hesitant to share via other methods [33].
Data collection process started with a purposive
sample by purposely locating participants who are
more likely to offer valuable information and extra
opportunities to learn about the research topic and
address the research aim adequately. The engagement
of various stakeholders’perceptions is extremely valu-
able for this research study; because the participants
chosen are from diverse backgrounds, and at various
stages of their profession, and are exposed to various
schemes and different e-health initiatives, which
means that their preferences, knowledge, and percep-
tions for e-health would differ from one another, and
as a result they can add value significantly to this
research study. Soon after in the study, snowball and
convenience sampling techniques were followed in
order to improve the appropriateness and adequacy
of data [24,34].
Over all, twenty-six interviews were conducted by
the researchers with individuals that hold diverse
roles in the sector including hospital chairmen, board
members, senior managers, CEOs, legislative bodies,
university professors, IT directors, IT trainers, IS
engineers, and health workers (i.e. medical doctors,
laboratory technicians, nurses, and pharmacists). The
participants represented members of Electronic Health
Solution Company, Hakeem program, public hospitals,
centers, and clinics under the Ministry of Health, hos-
pitals, and centers under the RMS, private hospitals,
Hakeem academy training center, the parliament, ven-
dor companies, universities, and associations in the
private sector.
Data saturation generally comes about after inter-
viewing eight participants. However, data saturation
in this study was noticed after the 19th interview
due to the fact that the participants’sample is hetero-
geneous, so new information and themes kept arising.
So, it was concluded to do more interviews in order
to reach a larger set which could help in decreasing
data bias and increase the reliability of the research.
The template analysis approach was followed as it
assists in analyzing large sets of data. It starts with
the construction of themes by coding the textual
documented data into segments, then grouping the
similar segments together in order to produce
broader themes and categories. The researchers
uploaded all interview transcripts to the NVivo soft-
ware in order to organize, simplify, and accelerate
the analysis process [35].
4. Research findings and discussions
Four key challenges have been identified to impact the
advancement of e-health within the context of Jorda-
nian (Lack of Regulations and Policies to Support
HIS, Limited Budgets, Privacy Concerns, and Nature
4Y. JALGHOUM ET AL.

of Healthcare Sector). These challenges will be dis-
cussed next.
4.1. Lack of regulations and policies to support
HIS
It was established that regulations, policies and law that
support the usage of information systems in Jordan are
problematic. This finding is in agreement with [36]
who affirm that the realization of HIS in many
countries is hindered due to lack of proper laws, lack
of appropriate regulations and policies. Some partici-
pants pointed out that this concern is not only on the
national level rather it extends to the intra-organiz-
ational level (see also [24]).
It will be a while before Jordan establish the proper
regulations and policies in order to protect users and
organizations using the electronic environment. This
is a serious matter and it should not be taken lightly
as it requires the approval of many political parties,
and the time factor here plays a major role since the
parliament has to introduce and then has to approve
the needed legislations and after that takes place
other responsible bodies have to also approve and
start executing the new laws which could end-up taking
a long time.
Additionally, even institutions such as hospitals lack
having the proper policies and regulations within its
structure to support the information technology devel-
opment efforts. It causes lots of stakeholders to be
either skeptical to use the new system or sometimes
to avoid it completely as they do not take it seriously
due to lack of policies and regulations to make it man-
datory in order to support the interaction. For example,
some healthcare staffquestions the use of the new sys-
tem and they expressed their opinion for the need of
some assurance that if and when they use the electronic
system they are not the one that should ultimately be
blamed and held responsible by the hospital that they
work for [37,38].
It could be noticed that this problem exists on both
the national level and the institutional level in Jordan.
It also appears that the majority of the developing
countries face problems of this kind due to the fact
that ICT law and policies in these nations are incompa-
tible and mismatched with the culture and context of
the country. Also, research studies reveal that national
decision and policy makers in developing countries do
not take into consideration the effect of the macro-level
context of the society [39].
4.2. Lack of financial resources
Jordan is not an oil-producing country; and it lacks the
natural resources that could benefit the country finan-
cially. Therefore, the government of Jordan tries to bal-
ance its national priorities according to the availability
of monetary resources they have in order to decide on
which projects or cities these resources should be allo-
cated to. More often the focus of the priorities and
financial budgets are given to the capital Amman
because the majority of the population lives there.
However, other considerable size cities (i.e. Zarqa and
Irbid) also get the attention of the government and
they get their own allocated budgets in order to
improve the infrastructure, provide services, and
implement projects intended to develop the urban
areas. But, other less populated cities and small villages
are totally ignored due to lack of financial resources
[21,40].
Most of participants talked about lack of financial
resources that can support the ICT projects in the
country and they articulated their opinions that the
e-health project is being implemented and was kicked
offwith very limited budgets available to start. This is
believed to be hindering the advancement of the pro-
ject and causing delays to some of its parts. Most par-
ticipants appeared aware of the tight budget; but they
also showed that they are utilizing the available
resources to the best of their ability. However, it is
definitely hindering their ability to freely go about the
implementation process according to the speed they
prefer, for example [5,26].
Furthermore, technology in general and medical
equipment in specific are very expensive and can
increase the burdens on the budget and force some
managers to reject the idea of integrating HIS in their
institutions, as described by a health worker:
Technology is very costly, many people or decision
makers are against that idea due to finance issues [41].
4.3. Privacy concerns
It is legally and morally binding that people rights must
be safeguarded and that their sensitive private infor-
mation should be respected and dealt with accordingly.
This issue certainly affects and influence people’s
decisions and behaviors towards information system,
as some participants explained. Herrick et al. [42]
shed light on how privacy concerns and security risks
due to hacking, identity theft, and unauthorized access
to medical data are perceived as a major problem when
institutions implement HIS.
In the same direction, many scholars (i.e. [40])
believe that security and privacy concerns emerge to
be on the top of the list to hinder e-health project devel-
opment and success. Therefore, system providers
should work hard to invest in privacy and security pro-
tection in order to decrease the effect of these barriers
and assure users that the data entered or shared
through the system are safe (see also [31]).
Possessing an integrated information system in the
healthcare sector and establishing electronic medical
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 5

records for patients is aspired by all Jordanians. How-
ever, things of this nature are considered risky and
more often that no patients feel that their private infor-
mation is vulnerable and could be misused by others.
Therefore, security measures and other actions must
be taken into account. For example, healthcare provi-
ders should always state clearly on their websites the
privacy policy in order to make people aware of the
type of information that may be gathered and how
it’s going to be used [43]. Also, healthcare institutions
should offer patients various privacy and security
options in which they can select and decide on the
level of services they prefer [42].
These concerns are rationale; therefore, West [44]
considers investing in privacy protection and security
tools as a very worthy; and institutions should recog-
nize it as a valuable asset. However, patients should
not be too fanatical with security and privacy matters.
Few participants believe that it’s realistic to have some
doubts or concerns about the electronic medical
record. But these concerns should not make individuals
reach the point to completely refuse to have an elec-
tronic medical record. Thus, people in charge of the
implementation of e-health and the utilization of elec-
tronic medical record should take into account all the
possibilities and the all measures in order to protect
patients’information. Also, they should focus on
increasing the awareness level of the importance for
having e-health systems and electronic medical records
for the benefit of all individuals in the society [5].
Healthcare organizations and their computer systems
are required to ensure that the privacy and security
of individually identifiable healthcare information are
maintained [45].
4.4. Nature of healthcare sector
The principal care provision in Jordan is equally shared
between three major healthcare providers: the RMS,
the Ministry of Health, and the Private Hospitals.
The healthcare sector in Jordan consists of a large
number of hospitals and healthcare institutions.
There are 103 hospitals operating in the Kingdom
and the number of clinics and centers overseen by
the MoH is 1510 [46].
Krishna and Walsham [47]affirm that successful
implementation of IS projects involves managing
different processes at numerous levels in complex
environments. Therefore, people in charge of the
implementation process of IS projects in developing
countries should consider the different contextual
characteristics of the institutions, the sector and the
region where they are located (see also [10]).
Additionally, participants discussed the lack of
health standardization to begin with and some of
them think that the issue of standardization should
be the priority for Hakeem. They believed that by
rushing hospitals to adopt HIS and trying to convince
them to adopt the electronic medical records’prior set-
ting adequate health standardization approach is a big
mistake that Hakeem is committing. Setting clear spe-
cifications and guidelines to all healthcare providers
which could be used to ensure that all of them are of
quality and meet the standards is certainly more
important than moving towards e-health, as perceived
by a deputy manager of IS department when he
declared: E-health should be a big motive to encourage
working on health standardization in Jordan. The first
thing Hakeem should work on is getting hospital man-
agers, health staff, and patients together in order to set
health standardization. Once this is done, they can
move on to other priorities.
However, this is a complex task and Hakeem staff
noted that due to hospitals’different environments,
inflexible and rigid policies and procedures as well as
the different visions and agendas, it would be very
difficult to set this as a number one priority and post-
pone all projects related to e-health till this issue is
solved. Hakeem staffinformed the researchers that
they are well aware of this matter and they are listing
it as a high priority; but they are also working in paral-
lel on other related projects also [41,48].
Issues of this nature are extremely challenging and
Hakeem staffis well aware that the majority of them
are trying whatever they can to get all healthcare pro-
viders on board. However, they acknowledge that it is
going to take big efforts and an extended period of
time in order to manage these challenges as an old pro-
verb of the IT business goes ‘If you automate a mess,
you will get an automated mess’. That is why things
ought to be organized and dependable before getting
all institutions on board.
5. Conclusion and recommendations
The Internet has become the most effective medium of
communication that people around the world rely on
to stay connected and exchange information. In fact,
the Internet has caused a massive transformation in var-
ious sectors in both developing and developed
countries. More recently, it has become a valuable tool
for advancement, and those sectors who aim for greater
development, efficient and better services are trying to
fully utilize the benefits that the Internet has to offer.
And one of these sectors is the healthcare sector.
Although the implementation of e-health initiative
in Jordan appears to provide numerous benefits to its
citizen and to the nation, however, the initiative is
facing many challenges and barriers that can signifi-
cantly impact its development. The goal of this
research paper was to explore the perspectives of
healthcare providers on the challenges that hinder the
development of e-health in Jordan based on a
6Y. JALGHOUM ET AL.

taxonomy of challenges that was developed from the
pre-existing literature.
This paper discusses some of the key challenges to e-
health development in Jordan: Lack of Regulations and
Policies to Support HIS, lack of financial resources,
Privacy Concerns, and Nature of Healthcare Sector.
Twenty-six semi-structured interviews were conducted
with heterogeneous individuals. It relied on the tem-
plate analysis approach as well as the NVivo software
to analyze and interpret the data.
The paper found that all of the discussed findings
are directly related to human and cultural issues.
These two aspects appeared to have a huge impact on
the development of the e-health in Jordan and there-
fore E-health decision makers should develop innova-
tive strategies and change management techniques
that can assist in managing or reducing the effect of
these particular issues in order to ensure a successful
and smooth implementation the e-health initiative.
Strategies to overcome any barriers prevent the suc-
cessful implementation of HIS included garnering sup-
port from clinical and IT leadership, validating data
with physicians at local medical centers, and establish-
ing IT communication channels [49].
5.1. Lessons and recommendations
The study of the implementation of e-health delivery
systems in Jordan can be used as a great lesson that
could assist healthcare mangers and decision makers
in other developing countries to benefit from it and
provide specific recommendations which are discussed
below:
1. Enact laws and policies to support the e-health
development. So, before diving in too deep in the
implementation process of e-health initiative, man-
agers and decision makers need to work closely with
governmental entities and legislation bodies in
order to ensure proper laws, regulations and policies
are put in place to lessen hindrances to the develop-
ment of e-health initiatives, which is in agreement
with the finding of [36] and was pointed out also
in other findings (see also [24]).
2. Secure the necessary needed funds for e-health
initiatives from the beginning of the implemen-
tation stage is detrimental in moving ahead uninter-
ruptedly according to this study and also supported
by [5,26].
3. Address privacy concerns as early as possible to pre-
vent hindrances to the implementation of e-health
development which will motivate and gain the sup-
port of all stakeholders [42].
Standardization of e-health development must not
be overlooked as IS projects involve managing different
processes at numerous levels in a complex
environment. So, the developing countries should con-
sider the different contextual characteristics of the
institutions, the sector and the region where they are
located [47].
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Yaser Jalghoum (e-mail: yajalghoum@mdanderson.org) is
Business Operation Project Manager at The University of
Texas, MD Anderson Houston, Texas-USA. He earned his
Bachelor’s degree in accounting from Tampa College/Everest
University, Tampa, Florida-USA, followed by a Master of E-
Business from the University of Huddersfield-UK, and a
Ph.D. in Business and Management, focusing on the Man-
agement of Science, Technology and Innovation from the
University of Manchester-UK. His work has been published
in several international journals. His research interests
include Innovations and Technology, E-Health, E-Business,
E-Government, E-Learning, E-Commerce, E-Banking, Lea-
dership, Human Resources Management, Organizational
Behavior, Change Management, Empowerment, Social
Media, Business Strategy, ICTs in Developing Countries,
and Management Information System (MIS).
Asem Tahtamouni (e-mail: a.tahtamouni@aum.edu.jo)
holds Bachelor’s in Accounting (Jordan, 2006), Master of
Commerce (Accounting) (Australia, 2008) and Ph.D. in
Financial Risk Management (Australia, 2015). He worked
in different companies in Jordan and Australia (the main
duties included: external and internal auditing, accounting,
business researching, consulting, sales and supervisory
assistant). He is currently working at the American Univer-
sity of Madaba (Jordan) as an Assistant Professor and Head
of Banking and Finance Department. He attended many aca-
demic courses, conferences and has many academic pos-
itions as well as has many published papers in
international academic journals.
Sahar Khasawneh (e-mail: sahar_kh5@hotmail.com) is an
Assistant Professor. She earned her Bachelor’s degree in
Computing Information Systems from Jordan University
of Science and Technology-Jordan, followed by a Master
degree in E-Business from the University of Huddersfield-
UK, and a Ph.D. in Informatics from the University of Man-
chester-UK. Her research has been published reputable peer-
reviewed journals.
Amro Al-Madadha (e-mail: a.almadadha@pust.edu.jo)
holds a Ph.D in Management from CardiffMetropolitan
University –United Kingdom, he holds MBA from
New York Institute of Technology. He pursued B.Sc. in
Banking Management from Hashemite University. Cur-
rently, Dr. Al-Madadha teaches is at Princess Sumaya Uni-
versity for Technology, and he is the head of the Business
Administration Department, Amro’s research focuses on
human resource management, empowerment, leadership,
creativity, his research has been published at several inter-
national journals.
ORCID
Asem Tahtamouni http://orcid.org/0000-0002-1218-3620
INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 7

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