ICT and Ageing in Lebanese Public Hospitals

A Resource based View Perspective on Capabilities

Nabil Georges Badr

, Charbel Chedrawi

and Jamil Arida

Grenoble Graduate School of Business, Grenoble, France

Universite Saint Joseph, Beirut, Lebanon

Keywords: ICT, Ageing, Lebanese Public Hospitals, Hospital Information System.

Abstract: This paper looks into the Lebanese healthcare system and its readiness to care for a growing elderly population

and how ICT is used and how it is perceived by the stakeholders. The paper presents concerns on ageing

population in Lebanon. It first addresses the status of hospital infrastructure in the country, and then discusses

some interviews regarding ICT plans with six general managers of large public hospitals in different regions

of Lebanon.

1 INTRODUCTION

Population ageing, which entails an increasing share

of older persons in the population, is a major global

demographic trend; a trend that is expected to

intensify during the twenty-first century, driven by

remarkable increases in life expectancy and falling

fertility rates. By 2050, old people will outnumber

children on earth (ESA, 2012).

This paper’s setting is the country of Lebanon, a

small middle-income developing country with a

population estimated at around four million,

characterized by unique socio-demographic features

that render the ageing of its population a complex

challenge (Saxena, 2008). A rapidly ageing society of

adults of 65+ years faced by the lack of clear

comprehensive government policy, the unavailability

of accurate comprehensive database and statistics,

limited capabilities of existing institutions

complicated by an increased pressure on a resources

deficient healthcare system (Sibai, 2014). Findings

from the Lebanese National Health Expenditures and

Utilization Survey (Ammar, 2009), indicate that,

while older adults constitute less than 10 % of the

population, they consume over 60 % of the health

care resources.

Key questions arise: Are Lebanese Public

Hospitals ready to face the demands from an ageing

population? What role could ICT have in this shift?

In an attempt to answer these questions, the paper

surveys a selection of 6 geographically distributed

Lebanese public hospitals serving a mixed

demography of patients in order to learn how these

hospitals face the demands of an ageing population

and identify the role of ICT implementations in

addressing this challenge. Grounded in the principles

of Resource-Based View theory (RBV), the paper is

organized as follows: First, an overview on the

relevant literature with respect to ICT

implementations for ageing societies. Followed by a

look into obstacles faced in developing countries with

a focus on the Lebanese healthcare system and related

ICT implementations. After the literature review a

section presents the methodology used in this

research. Then the paper is concluded with the

discussion and suggestions for further research.

2 BACKGROUND

Similar to the work of Bryson et al. (2007),

Rosenberg and Ferlie (2014), and Burton and Malone

(2014), this paper uses RBV theory as a springboard

in assessing the performance of Lebanese hospitals

towards caring for the aging population. A RBV

theoretical lens could shed light on the preparedness

and capability of Lebanese hospitals to deploy

internal resources in order to improve their

performance, under severe financing pressure.

Therefore, the RBV setting in this context does not

assume the existence of competitive market forces but

can be a useful assessment of the strategic potential

Badr N., Chedrawi C. and Arida J.

ICT and Ageing in Lebanese Public Hospitals - A Resource based View Perspective on Capabilities.

DOI: 10.5220/0006096102050212

In Proceedings of the 10th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2017), pages 205-212

ISBN: 978-989-758-213-4

205

of Lebanese public hospital organizations.

Furthermore, rather than financial performance,

healthcare capabilities towards the aging are

considered.

Literature on RBV links firm capability and

performance to its ability to use its tangible and

intangible resources (Eisenhardt and Martin, 2000).

Originally developed in private sector firms

(Wernerfelt, 1984), RBV theory argues that firms

with different resource profiles and capabilities

exhibit different performance levels. Thus, the

effective use of these resources yields ‘core

competences’. Core competences are key internal

resources, which, when effectively developed and

exploited into dynamic capabilities (Teece et al,

1997), allow organizations to perform. These

resources in healthcare could be human, such as

nursing staff for example, financial and infrastructure

such as number of beds, etc. and information

technology. Further, the “level of resource

constraint” in a public hospital setting may mimic

“market volatility” in the private sector.

2.1 ICT for Health in an Ageing

Society

New advances in technology make it possible to

integrate previously disparate facility systems to form

an “intelligent” hospital infrastructure (Blumenthal

and Glaser, 2007). A plethora of applications

generically referred to as ‘telemedicine’ (e.g. video

chat, mobile devices, and internet connected medical

monitors) is expected to extend the provider - patient

relationship boundary to remote areas positively

impacting healthcare for the ageing in developing

countries (Lucas, 2008). Assistive technologies have

been proposed to overcome elderly problems such as

fall risk, chronic disease, dementia, social isolation,

and poor medication management, etc. ICT is one of

these technologies along with robotics and

gamification (Khosravi and Ghapanchi, 2015).

In general, there is evidence of benefit to society

healthcare and patient care from access to

Information and Communication Technologies (ICT)

infrastructure, such as communication and systems

for data interchange (Anwar et al, 2011), or online

health information tools (Bolle, et al, 2015) with a

keen emphasis on integrated care for the ageing

(Merino et al, 2015). Progress in the field of health

information systems is rather directly correlated with

more quality and efficiency of care, where ‘‘with

more efficiency of care’’ may in future mean that care

will remain affordable (Haux, 2006). Patient access to

electronic medical records improved patient

communication (Cimino et al, 2002), however might

have impacted aspects of physician - patient

communication (Makoul et al, 2001). Poissant et al

(2005) found that the use of bedside terminals and

central station desktops saved nurses around 25% of

their overall time spent documenting during a shift.

That was encouraging. However, the authors found

conflicting evidence supporting undesirable

outcomes: bedside or point-of-care systems increased

documentation time of physicians by 17.5%. Early

empirical data on cost reductions was not very

consistent (Hillestad, et al, 2005). This could have

been be due to the variability of the health IT systems

in their features and implementations (Chaudhry, et

al, 2006). Later on, as technology advances were

introduced, the benefits of computerized physician

order entry systems CPOE were reported (Khajouei

et al, 2011). More recent studies show measurable

benefits emerging from the adoption of health

information technology; these benefits range from

efficiency and effectiveness of care (McCarthy,

2009), provider and patient satisfaction, preventive

care for chronic diseases (Wildevuur and Simonse,

2015) and patient safety (Buntin et al, 2011)

especially in developing countries where health

resources are scarce (Marful et al, 2015).

2.2 Obstacles to Public Healthcare ICT

in Developing Countries

Since the turn of the century, public authorities have

been encouraging healthcare organizations to adopt

new techniques and systems in order to deliver

services of high quality and low cost (Naranjo-Gil,

2009), especially where adoption of innovations tends

to be slow and fragmented (Fagerberg et al., 2005). In

the public healthcare context, legislation and donor

support are fundamental to the rise of propensity and

ability to adopt ICT into Healthcare even in its basic

capacities (Oak, 2007). In developing countries,

studies underscore the possibility of impact on the

cost of care as hindering the adoption of ICT into

healthcare practice (Panir, 2011), extending beyond

initial implementation over the full life-cycle of

operating and maintaining these systems (Cohen et al,

2015). Cost of acquisition and maintenance and the

lack of ICT skills have been known to present a

significant barrier to implementation of ICT into

hospitals of developing countries. Lack of skilled

resources (Bing-Jonsson, et al, 2015) and the

deficiency in ICT infrastructure hinder the

capabilities of developing countries to acquire and

develop electronic medical records for instance

(Anwar et al, 2011). Physicians may perceive a loss

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of professional autonomy (Esmaeilzadeh et al., 2015)

and English literacy and education levels could curb

the intention to use (Hasanain et al., 2015). The

increasing familiarity of a new generations of

healthcare practitioners is likely to lessen adoption

issues (Hennington and Janz, 2007). Thus,

organizational barriers to ICT adoption in healthcare

have been recognized in the form of structure,

policies, incentives and decision processes (Lluch,

2011).

2.3 Ageing and the Lebanese

Healthcare System

Research on ageing in Lebanon involves three

themes: living arrangements, social relations, and

health (Abdulrahim et al, 2015). Ageing was related

to health in terms of practices and social statuses that

encourage good health (Ajrouch et al. 2013), nutrition

(Boulos et al, 2014), and discussing threats to good

health such as chronic conditions (Waked et al, 2011),

even the role of religion (Chaaya et al, 2007). Yet, the

literature is scarce when it comes to discussing the

contribution of hospitals to the well-being of the

elderly in Lebanon. The Lebanese healthcare system

is described by a wide network of public (28) and

private (136) hospitals and counts 26 beds per 1000

population making this one of the highest ratios in the

Middle East; however, only 17% of these hospitals

and 16.6% of the beds are in the public sector. There

are few geriatricians practicing in the country; few

hospitals and health centers, both private and public,

have geriatric units. In 2011 the Ministry of Public

Health (MOPH) report (Table 1) shows that there

were 377,470 of elderly individuals in Lebanon, 65%

of them aged between 65 and 74. The number of

hospitals and the number of beds don’t reflect the

effective need (6 hospitals and 470 beds in Mount

Lebanon for 145,558 elder versus 5 Hospitals and 365

beds in Nabatieh for 26,033 elderly). Hospitalization

rates (days per year spent at hospitals) among older

people exceed 28 % which is almost two-fold the

national average (Kronfol, 2006). Older persons in

Lebanon continue to rely on their relatives for

healthcare. The transition from large extended

families to small nuclear ones, accompanied with

high rates of emigration among young Lebanese, an

increased entry of women into the labor force have

created a relative shortage in family members

available for the provision of care (Sibai and Kronfol

2011). Concerns are growing about providing the

elderly with a better quality of life (Silbermann et al.,

2015).

2.4 Development of ICT in Lebanese

Hospitals

In the Lebanon, the ICT sector witnessed significant

growth over the period stretching from 2009 to 2014,

growing by an average annual rate of 7.9% to reach a

market size of USD 381 million in 2014 (MOPH).

Though Lebanon has the required capacity,

innovation, and skills required to improve its ICT

sector, the country’s lack of adequate infrastructure

and regulations have so far slowed the development

of ICT in hospitals. Furthermore, budgetary

constraints and the lack of ICT competence in

physicians present a challenge in rolling out ICT

applications and services (Nicolian et al, 2015). Thus,

ICT empirical research in Lebanese hospitals is

limited and health data statistics present a daunting

task in a fragmented health information system.

Studies treating the use of technology tackled the

effect of total quality management implementation on

innovation skills of hospital staff (Aoun and Hasnan,

2015). Extant studies range from the discussion about

Healthcare IS for data mining (Shahin et al, 2014) to

a review job satisfaction of nurses is related to the

level of information system use in their work

(Maamari and Chaanine, 2013). Little research has

focused directly on ICT in the care of the aging.

Table 1: Public hospitals capacity overview in relationship with the elderly in each region. Source: CAS, 2007 (The National

Survey of Household Living Conditions), and MOPH 2011.

Region Beirut Bekaa

Mount

Lebanon

Nabatieh

North

Lebanon

South

Lebanon

Total

Number of public

hospitals

2 5 6 5 7 3 28

Number of beds

in public Hospitals

595 430 470 365 455 235 2,550

Elderly population (% of

population in region)

36,156

(10%)

50,311

(13%)

145,558

(39%)

26,033 (7

77,281

(21%)

42,131

(11%)

377,4

ICT and Ageing in Lebanese Public Hospitals - A Resource based View Perspective on Capabilities

207

3 METHODOLOGY

Our research employed a qualitative methodology in

an exploratory approach (Eisenhardt, 1989). Data

were collected by means of semi-structured

interviews conducted between May 2015 and May

2016. In this study we interviewed general managers

of six public hospitals, in six different regions in

Lebanon covering a cross section of the Lebanese

demography. Largest ranked by number of beds (by

MOPH, 2011), these hospitals have stated that they

have implemented or are in the process of

implementing components of a Hospital Information

System (HIS) as part of their ICT strategy. HIS

provides the underpinnings for health-related

decision-making that affect health outcomes of the

ageing (mortality, morbidity, disease outbreaks,

health status, disability, wellbeing). These hospitals

were coded (H1…H6) to maintain the desired

anonymity of the participants. Data consolidation was

carried out by means of the software N*VIVO.

Secondary data from documentation provided by the

hospitals showed (1) occupancy ratios and capacity;

(2) nursing staff information; (3) financing and

government support information; and (4)

infrastructure details mapped to the stages of the

electronic medical record adoption model suggested

by the Healthcare Information and Management

Systems Society (HIMMS).

4 DISCUSSION

4.1 Are Lebanese Public Hospitals

Ready to Face the Needs of an

Aging Population?

The study shows that the most likely answer is “No”

(Table 2). Major challenges were reported by the

informants in this study; mainly high occupancy

ratios and low capacity in terms of number of beds,

short-staffing on nurses, lack of adequate

infrastructure due to a reliance on self-financing, and

little government support.

(1) Hospitals reported challenges of high

occupancy ratios and low capacity in terms of number

of beds; “The hospital has 167 beds and still we face

a daily problem. Sometimes occupancy is above 90%

and the hospital cannot respond to the patients’ needs

as they sit in the emergency waiting (H6)”.

(2) The number of nurses is a major concern for

all the hospitals in this study, as they agreed that they

were adequately staffed by physicians and

understaffed on nurses. This issue is well summarized

by the informant of Hospital 4: “The number of nurses

is a major problem […] but the number of doctors is

adequate. The hospital performs 2000 surgeries

yearly and 70% of these patients are aged more than

65 years”

(3) The hospitals interviewed are still waiting for

the Ministry of Health to define a strategy for quality

health care. The General Manager of H6 explains:

“The government finances each hospital for its

expenses in proportion to the number of beds with a

plus related to the hospital needs. Public hospitals

cannot reject patients even if the hospital cost exceeds

the amount given by the government. The ministry of

health gives our hospital 6 billion Lebanese pounds

yearly (4 Million USD). This number is small if we

compare it to the needs of care for 167 beds. This

places a stress on our operating capability (H6)”.

(4) All hospitals concurred on the lack of

infrastructure to support the growth in demand and

conveyed that most of their operational budgets is

self-funded or financed through donations. “The

hospital upgrades its infrastructure from its own

budget”(H2) and the expansion plans are covered by

auto financing” (H3, H4, H5, H6)“Otherwise, most

of the expansions financing sources in all the public

hospitals in Lebanon come from donations and

contributions from Kuwait, Islamic Banks, Emirates

and Qatar (H1). This confirms the work of Saxena

(2008) and Sibai (2014).

Table 2: Summary of empirical data (last column indicates hospital’s stated readiness to face the needs of an aging

population).

Hospital

Patients 65+ Occupancy ratios Major ailments treated Ready?

H1 50 % 90 + % Heart failure Yes

H2 55 % 85 + % Heart failure, chronic disease (Diabetes, etc.) No

H3 70 % 90 + % Heart failure and obesity No

H4 65 % 80 + % Heart failure Yes

H5 70 % 80 + % Heart failure No

H6 50 % 90 + % Prostate issues, broken hips, obesity, chronic diseases No

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4.2 ICT’s Role in the Enablement of

Care for the Ageing

The general manager of H6 gives a pertinent

summary on the perceived role of ICT in Lebanese

Public hospitals: “Today there is a greater need than

ever to leverage technology to improve health, quality

of life, and social connectivity for older adults, and

assist in clinical care and monitoring of more

impaired older adults. A variety of technology

solutions (such as Web-based applications, remote

sensing technologies, electronic health records and

other devices) support patient engagement. The

impact of ICT is indirect and is contingent on the

redesign of practices and structures also outside

health care. Improvements will only be realized if all

parties involved can coordinate their efforts to take

advantage of new technology.”

Elderly care is demanding, hospitals must have

the resources to act quickly and effectively with a

solid decision support system in order to minimize

errors and offer quality of care for the elderly (Smith

et al, 2006). In addition to a trained and experienced

staff in the needs of the ageing, “a solid database to

follow up each case is required in order to find the

appropriate solution” (H2). The GM of H4 indicated

that they have installed “24/7 monitoring systems of

health and activities, intelligent devices and

appliances, internet enabled services, predictive

behaviour models, and so on” in order to provide a

better quality of care for their elderly patients”. Such

innovations in stationary and mobile solutions would

allow practitioners to stay in continuous contact,

whether at the patient’s bedside, in examination

rooms, or in emergency treatment centers, to

effectively develop and deliver patient assessments,

and make more informed care decisions based on

collaborative treatment plans. This findings aligns

with the works of Lucas (2008) and Anwar et al.

(2011).

It is expected that such ICT technologies would

(1) Reduce the time of treatments (H1); (2) provide

better access to data for enhanced decision making,

preventive care and disease management (H1, H2,

H3, H4, & H5); and (3) improve interdepartmental

collaboration / Emergency services (H6).

For all 6 hospitals surveyed, the adoption of the

information system is of top importance. “The

adoption of the information system is prominent

practice for today’s hospital, in the use of equipment,

archive, and for more efficient medical results” states

the GM of H1 at the first stages of the interview. All

hospitals have described their adoption of the Health

IS system in advanced stage (Table 3). This is quite

an achievement considering that all these public

hospitals stated that they rely on self-funded

initiatives. Nurses and doctors document patient’s

vital signs in the system, physician prescription

history are tracked by the system, and PACS systems

are connected to the online medical history. (PACS is

the acronym for picture archive and communication

system, a computer network for digitized radiologic

images and reports).

Ultimately, addressing medical research

advancement benefits, the GM of H1 stressed that

“better access to data that can be studied and help to

get better solutions to face the ageing society”. ICT

has become necessary to manage routine function up

close, and monitor vital signs measurements and

control the administration and recording of

medications (type, dose & time). Agreeing, three

other hospitals (H3, H4, H5) pointed out that “ICT in

the form of an integrated information database aims

at disease management to help improve the

awareness and preventive care in the elderly patient

population”. Furthermore, the case summaries

emphasized the role of the hospital senior

management in encouraging adoption. “It was my

responsibility to oversee the implementation of the

new system and to follow it up step by step with the

different actors in order to achieve the results

needed.” Adds the GM of H3.

The Lebanese government did not engage with

any of the 6 hospitals in the decision to adopt their

HIS, such decision was taken by the board of

directors of each hospital independently.

Table 3: Level of HIS use in the hospital (Y= in use at the moment; Y*=Incomplete, but in process).

Level of Use (based on the HIMMS Model for EMR adoption maturity)

H1 H2 H3 H4 H5 H6

Nurses / doctors enter patient’s vital signs in the system Y Y Y Y Y Y

Physician prescription history tracked by the system Y Y Y Y* Y Y

PACS systems connected to online medical history Y Y* Y Y Y Y

Online medical history Y Y Y* Y Y Y

Automated pharmacy, laboratory, and radiology Y* Y Y Y* Y Y*

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209

Three of the hospital surveyed (H6, H3 and H1)

expressed a relatively low barrier to adoption: The

general manager of H6 disclosed that for the

relatively new hospital, HIS was part of the hospital

build out plans. Likewise, H3 pride themselves with

a continual development effort of the HIS: “We had

an integrated information system since the start […]

we develop it continuously based on the growing and

changing needs of the hospital”, affirms the GM. In

the case of H1, their GM shared that “there were no

obstacles in the implementation because all the staff

started using the system since the establishment of the

hospital. No transition was required since the staff

was recruited with an IT IS experience. […] When we

developed the implementation plan, we defined the

different roles of the major actors. I was following

each step to make sure that the plan is well executed.

This was time consuming but effective”. In contrast

the HIS in H5 is older and with limited with disparate

data stores that are not integrated. Obstacles such as

the qualification of the existing staff and the difficulty

of recruiting new talent into the public sector were

indicated. Additionally, budgets that need to be

approved by governmental authorities have not yet

been allocated to this hospital for the refresh of their

system. Budgetary concerns were raised by most

hospitals (H2, H3, H4, and H5), “The process was

time and energy consuming” (H3). “Significant

efforts and investments in time and expertise were

needed” (H6). However, the “novelty of technologies

used posed a reluctance in the staff to embrace new

technologies, with little evidence that this technology

will indeed be useful” (H6).

In H4, the GM reports an irregular focus on the

Information System build out. The lack of IT/IS

knowledge among the practicing staff presented

significant challenges. To encourage adoption and

assimilation, training and awareness sessions were

necessary to highlight the importance of the

implementation for the wellbeing of the patients.

Resistance to adoption was at different levels in

each hospital; at some, the senior staff was non

cooperative at the start (H2 & H5) and for others

healthcare personnel’s attitude towards new

technology was not always positive (H1, H6, H4).

Used to their traditional pen and ink methods, they

were slow to assimilate the benefits of ICT usage for

patient care (H6). The cooperation among project

implementation teams and between IT teams and the

hospital’s staff at all levels was a key issue in order to

reduce this resistance (H2).

5 CONCLUSIONS

Lebanese public hospitals are short of capable to face

the needs of an ageing population. This work has

achieved two objectives to help answer the research

question:

First, the use of RBV theory as a backdrop for this

study has underlined major challenges facing public

hospitals in their ability to use their resources to care

for an aging population. Informants have reported

resource constraints and limitations of multiple

dimensions, namely (1) high occupancy ratios and a

low capacity in terms of number of beds, (2) short-

staffed on nurses, (3) lack of adequate infrastructure

due to a reliance on self-financing, and (4) little

government support. Hospitals in the study

communicated occupancy ratios between 80% and

90%. Most of their patients are above 65 years of age

(reaching 65%). Major ailments treated are heart

failures, chronic disease (obesity, diabetes, blood

sugar, nervous system etc.) that require close

supervision and long residency periods. With this

burden, all hospitals express a lack of adequate

infrastructure and a relatively low capacity to handle

patients (number of beds); they are short-staffed on

nurses and face higher cost with little financing

support from the government. In spite of this self-

funded effort, most of these hospitals recognize the

value of an integrated information system in lowering

their costs and increasing their capabilities to deliver

quality elderly care.

Second, this paper extends the body of knowledge

of healthcare ICT in the country of Lebanon to

provide an account of ICT use in healthcare for the

ageing in public hospitals in settings where uses of

ICT could contribute to the effectiveness of Lebanese

public hospitals to provide quality care for an aging

population.

5.1 ICT as a Dynamic Capability in

Lebanese Public Hospitals

The informants of this study reported use of ICT to

care for the aging to have four significant benefits: (1)

Provide better access to data for an enhanced decision

making for treatment and medication; (2) potentially

reduce the time of treatments; (3) improve the

practice of preventive care, disease management and

promote wellbeing; and (4) improve the resource

allocation for better quality care. However, such

benefits were recognized to impose a significant

investment on hospitals. Investments that await

governmental or donor funding support must be

supplemented by commitment from senior

HEALTHINF 2017 - 10th International Conference on Health Informatics

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management, continual development plans, and a

collaborative approach between all hospital staff to

raise the awareness on the benefits of ICT usage for

elderly patient care.

5.2 Research Limitation

This research presents a methodological limit that

may open up new avenues of future research. One of

the limitations of the study that worth mentioning is

that it relies on information provided by general

managers, thus potentially limiting the credibility of

information. The opportunity to expand the

interviews to IT managers of the hospitals would

provide deeper insights. Further, we are aware that

the results presented in this research depend strongly

on the context of the country. Their generalization

thus requires a certain reserve. Further research must

be done to advance the results of this study possibly

through action research potentially exploiting

principals of organizational development. This

approach could deepen the understanding on how

hospitals are transforming their healthcare practices

to improve their capacity for solving problems and

managing the challenges of care for the aging.

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