1. Introduction
===============

Technological feasibility determining hardware and software components and communication development capability and/or available technologies of the organization are defined to achieve functional objectives of a system ([@b1-epj-08-2942], [@b2-epj-08-2942]). This type of feasibility study is commonly used to evaluate available system function or an organization's ability to implement a new system ([@b3-epj-08-2942], [@b4-epj-08-2942]) and helps to identify required technology, determine problems ahead and measure technical readiness of an organization to use a new system ([@b5-epj-08-2942]). A nursing information system is a computer-based integrated system with a storage for clinical and demographic data that predicates the activities of nursing and patient care outcomes, organizes data in accordance with the need in information structures, and provides access to related knowledge bases and patients' data ([@b6-epj-08-2942]). The main functions of a nursing information system include: care planning, nursing clinical recording, care assessment, discharge planning, personnel management, staff list, attendance record, cost and budget management, and management of complex skills (Skillmix) ([@b7-epj-08-2942]). The results of research conducted in North Africa showed, nursing information systems need better technology to develop, and most of the systems implemented in terms of technology have problems ([@b8-epj-08-2942]), because in addition to the need for access to a computer, an optimized use of these systems requires the presence of new technology tools such as barcode scanner equipment, RFID, advanced equipment for word processing, special software tools such as off-line inquiry software ([@b9-epj-08-2942]), the presence of LAN network communication and integration between systems ([@b10-epj-08-2942]). Currently, reports show that most implemented nursing information systems cannot share patient data and exchange information ([@b11-epj-08-2942]). For this reason, when setting-up a system, considering hardware and software components and network communications, it is very important to prevent problems during implementation. Furthermore, it had been reported in a study that the lack of attention to a network, while setting up a system, led to delayed installation and local networks in the computer system could not be used for six weeks ([@b12-epj-08-2942]). Another study has stated that a network's insufficient speed resulted in poor performance ([@b13-epj-08-2942]). Also, in Iran, despite hospital information systems being implemented for many years, there are contradictory reports of problems with these systems. In some studies it has been pointed out that these systems are faced with technological problems and lack of electronic communication between organizations, lack of proper hardware and software equipment and shortage of technical staff ([@b14-epj-08-2942]--[@b16-epj-08-2942]). While other findings have stated necessary infrastructures in terms of additional equipment, a centralized network, a database to deploy a system and access to external databases as sufficient ([@b17-epj-08-2942]). Therefore, in implementing health information systems, it is necessary to consider various factors, especially technological needs ([@b18-epj-08-2942]). Given that a system feasibility study and analysis leads to a better understanding of the system and can be used to improve health care delivery and enhance the function of each component of the system ([@b19-epj-08-2942]), Mazandaran province in Iran has been selected as a pilot plan. The aim of this study was to determine technological feasibility of NCIS in hospitals of Mazandaran University of Medical Sciences in 2015.

2. Material and Methods
=======================

2.1. Design
-----------

This cross-sectional study was conducted in 2015. The study was carried out in hospitals at Mazandaran University of Medical Sciences, Iran in three steps: 1) developing the tool, 2) tool validation, and 3) feasibility study of implementing of NCIS technologically.

2.2. The first step: Developing the tool
----------------------------------------

Developing the tool of the possibility of implementing technologically of NCIS was carried out by the method of unsystematic literature review of related papers. The international database, including: Science Direct, Google Scholar, PubMed, Proquest, Ovid, Elsevier, Springer, EBSCO, and national databases including Magiran, Scientific Information Database, and Persian Journal Citation Report (PJCR), were searched using the keywords such as Nursing Clinical Information, Nursing Information System, and Technological Feasibility. Only the studies either in English or Persian were selected. The papers derived ([@b3-epj-08-2942], [@b14-epj-08-2942], [@b17-epj-08-2942], [@b20-epj-08-2942]) were investigated by content analysis. Concepts and their themes were extracted and classified. Searching the paper continued until data saturation and accordingly the tool was developed.

2.3. The second step: The tool validation
-----------------------------------------

Face validity of the tool was confirmed by four faculty members of health, information technology, management and nursing disciplines at Kashan Medical Services University. To confirm the validity of the content, the necessity of each question was confirmed by fifteen professors of health, information technology, management, and nursing disciplines at Kashan Medical Services University. The content validity ratio (CVR) was the criterion for determining the necessity of each question, which was measured by three options:" It is necessary", "It is useful but not necessary", and "It is not necessary". The content validity index (CVI) of each question was obtained based on simplicity, relevance and clarity of the questions. Choices and scores of CVI questions included: "No, score 1", "Yes, but needs fundamental revisions, score 2", "It is, but needs minor revisions, score 3" and "Completely Yes, score 3" ([@b21-epj-08-2942], [@b22-epj-08-2942]). Items with CVI\> 0.7 were accepted and CVI \<0.7 were rejected or revised. Items with CVR\> 0.49 were accepted and CVR \<0.49 were rejected or revised. To determine the reliability of the data collection tool, questionnaires were distributed among the 15 members of health, information technology, management and nursing disciplines at Kashan Medical Services University. Cronbach's alpha coefficient was obtained 0.72 using the split-half method.

2.4. The third step- Feasibility study of implementing NCIS technologically
---------------------------------------------------------------------------

Technological feasibility was evaluated by forming a panel of thirty IT experts. Inclusion criteria were considered knowledge of at least 2 years of work experience in the field of hospital information systems and the tendency and adequate time to participate in the study. Sampling was carried out using purposive sampling method. In order to judge the possibility of implementing NCIS, a feasibility study questionnaire was developed, based on the designed tool (the previous step). Data were collected by a 5-point Likert scale from very low (score 1) to very high (score 5). The average score was calculated for each question and multiplied by 5 to convert to 100. Score percentage of less than 30 was considered poor level and undesirable state, score 30 to 70 was considered average level and semi-desirable state and a score of more than 70 was considered high-level and desirable state. Chi-square and Fisher exact tests were used.

3. Results
==========

From a total of 30 IT experts, 60% were male; 23.3% were in the age range of 25--29 years, 50% were in the age range of 30--34 years and 26.7% were in the age range over 35 years. 86.7% had a bachelor degree, 73.3% were employed under a contract and 10% were formally employed. Work experience of 5--9 years was calculated as 50%, whereas 26.7% work experience was 2--4 years and 23.3% work experience was 10--14 years. The results of developing a technological feasibility study tool showed that implementing NCIS requires four main concepts of hardware, software, network and network security ([@b3-epj-08-2942], [@b14-epj-08-2942], [@b17-epj-08-2942], [@b20-epj-08-2942]). In assessing the tool validity, the results showed, the CVI score of all technological items were greater than 0.7 and were accepted. Only in 2 items, the CVR score was less than 0.49 they were removed from the tool and others were accepted ([Table 1](#t1-epj-08-2942){ref-type="table"}). The results of the feasibility study showed that the maximum possibility of implementing NCIS technologically was in software section and the minimum possibility was in the network section. In the hardware area; the minimum possibility was the existence of a barcode scanner and RFID equipment (30%) and the maximum possibility of the implementation of the system was additional equipment (92.6%). In the area of software; the score of off-line inquiry tools was the lowest score (34.6%) and the score of financial software was the highest score (99.4%). In the network area; the score of access to external databases was 26.6%, minimum possibility; and the score of integration with other internal systems was 92.6%, which was the highest score. In the area of network security; the score of a user tracking system was 57.4%, minimum possibility; and the score of a backup version for security purposes was 97.4%, maximum possibility of implementing NCIS ([Table 2](#t2-epj-08-2942){ref-type="table"}). The results showed, a maximum possibility of implementing NCIS in terms of technological facilities in the male community was 72.2%, aged 30--34 years it was 66.7% and staff under a contract was 81.8%. From the perspective of official personnel, the technological feasibility study was not at a high level. Type of employment was statistically significant according to IT experts' opinions (p= 0.014) ([Table 3](#t3-epj-08-2942){ref-type="table"}). Average score of technological feasibility study was 72.11%, and needs' supply percentage was 70% and desirable.

4. Discussion
=============

The aim of this study was to determine the technological feasibility study of NCIS in 2015 in Mazandaran University of Medical Sciences, Iran. The feasibility study results showed, the speed of the network lines was 54.6% and the score of existence of portable computers was 49.4%, indicating low number of portable computers and network lines. The score of providing of integration with internal systems and rapid access to records was respectively 92.6% and 86.6%. The results of other consistent studies showed that in clinical information systems, due to the presence of the communication and integration with other systems, rapid access to records ([@b23-epj-08-2942]--[@b28-epj-08-2942]) is generally possible. Also in the present study, the number of portable computers and the network lines' speed are semi-desirable to run a NCIS, which is consistent with the result of a Montini (2013) study, reporting lack of portable computers, poor wireless communication and the network lines' speed in a feasibility study of the backup system of a clinical decision in treating tobacco consumption in a dental clinic ([@b29-epj-08-2942]). But it is not consistent with the results of other studies that reported; the number of portable computers and the network lines' speed are adequate ([@b17-epj-08-2942], [@b23-epj-08-2942], [@b26-epj-08-2942], [@b30-epj-08-2942], [@b31-epj-08-2942]). Given that the study findings show that by using information systems, planning and documentation are enhanced due to the communication and integration with other information systems therefore rapid access to a patient information, documentations are comprehensively presented. Furthermore, due to the absence of hand-written data and writing data, data writing time is reduced and information readability is increased ([@b24-epj-08-2942]). Also the quality of a patient's care is improved through sharing a patient's information during care ([@b23-epj-08-2942], [@b28-epj-08-2942]) and low network speed, results in poor system function, delayed response time, and irregularity, especially at the time of high-volume ([@b13-epj-08-2942], [@b32-epj-08-2942]). Therefore, it is essential to provide a proper ground in terms of adequate computers, the network speed and rapid access to information in medical centers.

The study results showed that existence of additional hardware for implementation of the NCIS was 92.6% which was at a high level and in a desirable situation. Existence of off-line inquiry software tools were 34.6% and feasibility of integration with other external systems was 65.4% which was at an average level and in a semi- desirable situation. Existence of barcode scanner and RFID equipment was 30% and feasibility of access to external databases was 24.6% which were a poor level and in an undesirable situation. The findings of an Ammenwerth et al. (2001) study showed, there were enough computers, and additional software and hardware to set the system ([@b23-epj-08-2942]). In the study of Ozkan (2006) there was no terminal to search web external resources such as PubMed and off-line inquiry software, for users' support ([@b27-epj-08-2942]). Blignaut et al. (2001) also showed that there was no off-line search facility in the database ([@b31-epj-08-2942]). In a study that was conducted to evaluate an electronic system to predicate clinical care, while access to computers and technology was provided, new technology tools have not been predicted ([@b9-epj-08-2942]).

The results are consistent with the results of the present study and the study of Swansburg et al. (2013), which reported lack of hardware, software and advanced equipment for processing words, barcode scanner and RFID equipment ([@b10-epj-08-2942]) together with the results of the Asadi et al. (2012) study, reporting lack of electronic communication between organizations, access to online resources and databases outside an organization ([@b14-epj-08-2942]). But the results are not consistent with studies of Mcbride (2012) which showed that the time of implementing advanced equipment system such as barcode scanner, RFID and off-line search tools was provided ([@b30-epj-08-2942]). Gholam Hosseini et al. (2012) reported that information systems have the ability to communicate effectively with external databases and use online resources ([@b26-epj-08-2942]) and Nasiripour et al. (2008) reported access and use of external databases and online resources were provided ([@b17-epj-08-2942]). Given that, identifying complications using new technologies has improved patient safety ([@b33-epj-08-2942]) and advanced biomedical equipment and technologies can electronically transfer data from medical devices and monitors and facilitate drug compliance using a barcode scanner. Also the use of off-line inquiry software, access and use of databases outside the hospital can facilitate the use of nursing knowledge. Therefore, it is essential to pave the way for greater use of nursing information systems, by the development and application of new information technologies. Given that the presence of necessary hardware and software infrastructures has been allowed to be set in the system, it is recommended that these facilities deploying clinical nursing, national plans and access to scientific sites and external databases are provided.

5. Conclusions
==============

Successful implementation of NCIS is impossible without determining the feasibility of technological resources. According the results, necessary hardware and software infrastructures are technically desirable to set the system. For rapid access to information, providing more portable computers, advanced biomedical equipment and technologies such as barcode scanners RFID, off-line inquiry software, some approaches for increase accessibility of the system, essential databases from other resources and also increase of network lines' speed are necessary. Further research on other aspects on feasibility of the implementation of NCIS such as legal and behavioral are recommended.

The present paper is the result of a master thesis in Health Information Technology. The Vice Chancellor for Research at Kashan University of Medical Sciences is highly appreciated for financial support in carrying out the present study (Project No. 9370) and we would also like to thank the participants in the collaborative project.

iThenticate screening: June 18, 2016, English editing: August 12, 2016, Quality control: September 01, 2016

**Conflict of Interest:**

There is no conflict of interest to be declared.

**Authors' contributions:**

All authors contributed to this project and article equally. All authors read and approved the final manuscript.

###### 

CVI and CVR on Technical Feasibility of Study of Implementation NCIS

  Technical Feasibility Questions                                                          CVI    CVR    Status          
  ---------------------------------------------------------------------------------------- ------ ------ -------- ------ --------------
  Sufficient Number of Computer Hardware Engineers                                         0.87   0.80   0.87     0.60   Accepted
  Sufficient Number of Computer Software Engineers                                         0.93   0.87   0.93     0.73   Accepted
  Sufficient Number of System Analysis Engineers                                           0.93   0.93   0.87     0.73   Accepted
  Existence Auxiliaries Equipment                                                          1      1      1        0.73   Accepted
  Enough Portable Computers (Laptop, Tablet)                                               0.93   0.93   1        0.60   Accepted
  Existence Workstations and Mainframes                                                    0.93   0.93   1        0.87   Accepted
  Existence Scanner and Printer                                                            0.93   0.93   1        0.87   Accepted
  Existence Point-of-Care Mobile Terminals                                                 0.93   0.93   0.93     0.60   Accepted
  Existence RFID and Barcode Reader                                                        1      1      1        0.60   Accepted
  Existence Backup Tools                                                                   0.93   0.93   1        0.87   Accepted
  Support Services                                                                         0.87   0.93   0.93     0.60   Accepted
  Reducing Nurses Resistance through the Training                                          1      1      0.93     0.87   Accepted
  The Possibility of Currency Support                                                      0.87   0.93   1        0.73   Accepted
  The possibility of Farsi language Support                                                0.87   0.93   0.93     0.87   Accepted
  Designing User Interface                                                                 0.87   0.87   0.87     0.87   Accepted
  The Possibility of Software to Customize User Interface                                  0.87   0.87   0.87     0.60   Accepted
  The Possibility of Software for Sending and Receiving Information                        0.93   0.93   0.93     0.60   Accepted
  The Ability of Support for Data Storage                                                  0.93   0.93   0.93     1      Accepted
  Data Management Tools                                                                    0.93   0.93   1        0.87   Accepted
  Query Offline                                                                            0.93   0.93   1        0.87   Accepted
  Tool Reporting                                                                           0.93   0.93   1        0.87   Accepted
  The Possibility of Support to Integration and Combining Data                             0.93   0.93   1        0.87   Accepted
  Existence Software for Quick Access to Records                                           0.87   0.87   0.87     0.73   Accepted
  Existence Network Equipment                                                              0.93   0.93   1        0.87   Accepted
  Appropriate Cabling                                                                      0.80   0.87   0.87     0.60   Accepted
  Sufficient Network Speed                                                                 0.93   0.93   0.93     0.87   Accepted
  Existence Internet and Intranet                                                          0.93   0.93   1        0.87   Accepted
  Integration with Internal Information Systems                                            1      1      1        0.87   Accepted
  Integration with External Information Systems                                            0.93   0.93   0.93     0.60   Accepted
  The Possibility of Access to External Databases                                          1      1      1        0.60   Accepted
  Existence Standards of Sending Massages, Security, Confidentiality and Data Definition   1      1      1        0.87   Accepted
  Existence Database                                                                       0.93   1      0.93     0.73   Accepted
  Access to Websites (virtual sites)                                                       0.93   1      1        0.47   Not accepted
  The Possibility of Electronic Communication between Hospitals and Medical Centers        0.87   0.93   0.93     0.47   Not accepted
  Taking Advantage of the Data Protection Method                                           1      1      0.87     0.87   Accepted
  The Ability to Use User Tracking System                                                  1      1      0.93     0.87   Accepted
  Ability to Backup for Security Purposes                                                  1      1      1        0.87   Accepted

###### 

Technical Feasibility Study of Implementation of NCIS

  Area                                             Needs Assessment Items                                                         Status                        
  ------------------------------------------------ ------------------------------------------------------------------------------ ----------------------------- -----------
  Existence Hardware equipment                     Manpower                                                                       Computer Hardware Engineers   Desirable
  Computer Software Engineers                      Desirable                                                                                                    
  System Analysis Engineers                        Semi-desirable                                                                                               
  Equipment                                        Auxiliaries Equipment                                                          Desirable                     
  Portable Computer (Laptop, Tablet)               Semi-desirable                                                                                               
  Workstations and Mainframes                      Desirable                                                                                                    
  Scanner and Printer                              Semi-desirable                                                                                               
  Point-of-Care Mobile Terminals                   Semi-desirable                                                                                               
  RFID and Barcode Reader                          Undesirable                                                                                                  
  Support                                          Backup Tools                                                                   Desirable                     
  Support Services                                 Semi-desirable                                                                                               
  Training                                         Reducing Nurses Resistance through the Software Training                       Semi-desirable                
  Existence software equipment                     Database                                                                       Desirable                     
  Currency Rate Support                            Desirable                                                                                                    
  Farsi Language Support                           Desirable                                                                                                    
  User Interface                                   Desirable                                                                                                    
  Software to Customize User Interface             Desirable                                                                                                    
  Software for Sending and Receiving Information   Desirable                                                                                                    
  Support for Data Storage                         Desirable                                                                                                    
  Data Management Tools                            Desirable                                                                                                    
  Query Offline                                    Semi-desirable                                                                                               
  Reporting                                        Semi-desirable                                                                                               
  Support to Integration and Combining Data        Desirable                                                                                                    
  Software for Quick Access to Records             Desirable                                                                                                    
  Existence network equipment                      Network Equipment                                                              Semi-desirable                
  Cabling                                          Desirable                                                                                                    
  Sufficient Network Speed                         Semi-desirable                                                                                               
  Internet and Intranet                            Desirable                                                                                                    
  Integration with Internal Information Systems    Desirable                                                                                                    
  Integration with External Information Systems    Semi-desirable                                                                                               
  Access to External Databases                     Undesirable                                                                                                  
  Existence Network security system                Standards Sending the Message, Security, Confidentiality and Data Definition   Desirable                     
  Methods of Information Protection                Desirable                                                                                                    
  User Tracking System                             Semi-desirable                                                                                               
  Backup for Security Purposes                     Desirable                                                                                                    

###### 

Demographic Status of Participants and Levels of Feasibilities of Implementation of Technical NCIS

  -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  Status:\               [\*](#tfn1-epj-08-2942){ref-type="table-fn"} Weak   [\*](#tfn1-epj-08-2942){ref-type="table-fn"} Moderate   [\*](#tfn1-epj-08-2942){ref-type="table-fn"} Upper   p-value     
  Variable                                                                                                                                                                                            
  ---------------------- --------------------------------------------------- ------------------------------------------------------- ---------------------------------------------------- ----------- -------
  Gender                 Male                                                0                                                       5 (27.8)                                             13 (72.2)   N.S

  Female                                                                     4 (33.3)                                                8 (66.7)                                                         

  Age                    25--29                                              0                                                       3 (42.9)                                             4 (57.1)    0.46

  30--34                 0                                                   5 (33.3)                                                10 (66.7)                                                        

  +35                    0                                                   1 (12.5)                                                7 (87.5)                                                         

  Education              BS                                                  0                                                       7(26.9)                                              19 (73.1)   0.56

  MS                                                                         2 (50)                                                  2 (50)                                                           

  Type of Employment     Formal                                              0                                                       3 (100)                                              0 (0)       0.014

  Contract 5 Years Old   0                                                   2 (40)                                                  3 (60)                                                           

  Contractual            0                                                   4 (18.2)                                                18 (81.8)                                                        

  Job Experience         2--4                                                0                                                       5 (62.5)                                             3 (37.5)    0.063

  5--9                   0                                                   3 (20)                                                  12 (80)                                                          

  10--14                 0                                                   1 (14.3)                                                6 (85.7)                                                         
  -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Weak: Less than 30%, Moderate: 30%--70%, High: More than 70%)
