International Journal of Science Annals, Vol. 6, No. 2, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa SOCIAL AND BEHAVIORAL SCIENCES. Health Care Sciences ORIGINAL RESEARCH Conceptualizing a Model for Cloud-Based Hospital Management Systems for the South African Public Health Sector Authors’ Contribution: A – Study design; Magudulela T. S. 1 ABCDEFG , Kalema B. M. 2 ABCDEFG , B – Data collection; Segooa M. A. 1 ABEG C – Statistical analysis; 1 Tshwane University of Technology, South Africa D – Data interpretation; 2 University of Mpumalanga, South Africa E – Manuscript preparation; F – Literature search; Received: 05.07.2023; Accepted: 10.08.2023; Published: 25.12.2023 G – Funds collection Abstract Background and Real-time access of information in the healthcare environment is essential, as it Aim of Study: not only helps medical personnel to have adequate and timely information, but it also assists patients to be served more easily. Hospitals in rural areas are operating at a low bandwidth and have poor IT infrastructure that causes intermittent networks leading to disruptions and slow service delivery. This necessitates the Hospital Management System (HMS) to be deployed in the cloud environment to reduce the challenges leading to poor service delivery. The aim of the study: to develop a model for cloud-based HMS for the South African public health sector. Material and Methods: This study identified three public district municipality hospitals in Gauteng Province, South Africa, that were already using HMS and used them for data collection. Each hospital had up to 50 healthcare workers, and this formed the population of 150 from the three hospitals, from which a sample size of 108 respondents was selected. Data were collected using a closed-ended questionnaire and analyzed quantitatively using SPSS v25. Results: The results demonstrated that the suggested model has a good prediction power of 60.9% (R2=0.609) and that with the exception of environmental aspects, the rest of the constructs has a significant contribution to the successful implementation of the cloud-based HMS. Social aspects had the highest prediction power of 60.0% (β=0.600) at p=0.001; followed by risk analysis and control with 41.3% (β=0.413) at p=0.009. On the other hand, environmental aspects had the least and non-significant prediction of 12.3%. Conclusions: This study contributes to the ongoing call to have seamless healthcare provision systems. The model developed in this study extends the research of modernizing healthcare provision by leveraging technological innovations. Keywords: cloud computing, hospital management systems, healthcare, public, South Africa Copyright: © 2023 Magudulela T. S., Kalema B. M., Segooa M. A. Published by Archives of International Journal of Science Annals DOI and UDC DOI https://doi.org/10.26697/ijsa.2023.2.5 UDC 614.2(680) Conflict of interests: The authors declare that there is no conflict of interests Peer review: Double-blind review Source of support: This research was supported by HCD-INTERBURSARY received from the Council for Scientific and Industrial Research Information about Magudulela Thembokuhle Sheshile – https://orcid.org/0000-0001-5192-7621; the authors: Master of Computing, Junior Lecturer, Department of End-User Computing, Tshwane University of Technology, Pretoria, South Africa. Kalema Mathius Billy (Corresponding Author) – https://orcid.org/0000-0002- 2405-9088; billy.kalema@ump.ac.za; Doctor of Philosophy in Computer Science, Professor, School of Computing and Mathematical Sciences, University of Mpumalanga, Mbombela, South Africa. Segooa Mmatshuene Anna – https://orcid.org/0000-0002-4190-8256; Doctor of Computing, Lecturer, Department of Informatics, Tshwane University of Technology, Pretoria, South Africa. 40 International Journal of Science Annals, Vol. 6, No. 2, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Introduction Information and communication technology (ICT) is contact person, mostly from the ICT directorate. For universally regarded as a vital tool for improving anonymity, the questionnaire on the Survey Monkey business competitiveness and economic growth of a was designed in such a way that respondents only country as it has the potential to improve the quality, needed to click on the submission button and the filled safety, and efficiency of service delivery. Generally, questionnaire was captured on Survey Monkey database there is a consensus that ICT has significant effects on with the respondents’ particulars on completion of the the productivity of firms, but these effects can only be questionnaire, the filled datasets were exported to the realized if, and when, ICTs are widely spread and used Statistical Package for Social Scientists (SPSS v25) for efficiently. analysis. The questionnaire was designed in such a way ICT has the ability to help people collect, store, manage, that neither the particulars of the individual respondents and distribute knowledge. For instance, in the healthcare nor those of the health institution were asked, so domain the use of information technology (IT) has anonymity was ensured. After data had been captured on improved communication between medical personnel the Survey Monkey database, the questionnaire was and patients (Djock, 2023). Previously, patients would exported to SPSS. However, for easy analysis the queue for hours to get help in hospitals as everything questionnaire was coded in such a way that the was done manually. This trend has, however, changed constructs and their attributes are shorted to carry with the increasing use of automated healthcare systems meaning while observing originality of the question item such as Hospital Management Systems (HMS) that have and the construct. increased the speed at which patients’ information is The population of this study was health personnel in accessed and retrieved (Khan et al., 2014). The use of IT public hospitals that are using HMS in Gauteng and its application has propelled developments that have Province, South Africa. This study identified three improved service delivery in all sectors, inclusive of public hospitals that were already using HMS. public health. Recent developments in remote healthcare According to Massyn et al.’s (2020) report, South systems have witnessed significant interest from the IT African hospitals are human resource constrained and on industry, which provides universal and easily average, there are between 30 to 50 medical personnel deployable healthcare systems (Djock, 2023; Profetto et and health workers in district hospitals and slightly more al., 2022). numbers in provincial hospitals. Hence, the population Katuu (2018) asserts that well-formed hospital of the study based on the district hospital level was 150 management workflows involve important decision- respondents. making that should be done efficiently and quickly. By using the Krejice and Morgan’s tool for determining Katuu (2018) indicates that it is becoming difficult in the sample size of a finite population, the derived sample many health sector facilities to improve efficiency size for this study was 108. Based on this sample size, a without the use of HMS. The HMS assists in the total of 130 survey links were distributed and out of this handling of the different directions of hospital 98 completed questionnaires were returned though 83 workflows, and it helps in managing smooth healthcare were usable. performance along with administrative, medical, legal, Research is conducted to collect relevant information and financial control (Djock, 2023). Further still, HMS that can be used to solve the identified research problem is essential in managing automated operations of the (Babbie, 2016). Hence, a high level of reliability and hospital, using radio frequency identification (RFID) validity should be maintained when collecting data. tags to secure access (Profetto et al., 2022). Additionally, the measuring instrument must be The aim of the study. To develop a model that informs designed such that it consistently measures what it is the deployment of the Hospital Management Systems supposed to measure, and research should ensure that within the cloud. while collecting data, the obtained results are To realize the research goal, the following objectives trustworthy in order to develop future forecasts (Yin, were set to be achieved: to determine factors that 2014). Research standards are based on credibility, influence cloud-based HMS implementation, to reliability, and conformity of data hence validity and determine the extent of cloud-based HMS integration in reliability must be ensured for the quality and research the South African health institutions and also rank and standards. use the identified factors for the development of a cloud- Reliability refers to the measuring instrument’s capacity to produce similar results with duplicated or replicated based HMS model for the South African health sector. tests (Yin, 2014). This study used the Cronbach’s alpha also known as Materials and Methods alpha co-efficient to determine the reliability or internal This study followed a quantitative research approach. consistence of the questionnaire and its constructs. The The study used close-ended questionnaires to collect overall reliability of the questionnaire with 32 items as data. Due to increased restrictions of visitations at many demonstrated in Table 1 was found to be 0.960, which institutions, data was collected online. The reliability was considered good since it was above the questionnaire with close-ended questions was uploaded recommended threshold of 0.7, and also comparing the onto Survey Monkey and the link leading to the survey number of items in the questionnaire (Heale & was sent to the contact person to distribute to the Twycross, 2015). respondents. At each hospital, the researcher got a 41 International Journal of Science Annals, Vol. 6, No. 2, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Table 1 According to Cohen et al. (2018), a significance level of Overall Reliability Statistics of the Measuring 0.05 is regarded as acceptable. By providing a Instrument relationship between the variables that could be used to Reliability statistics predict the values of the independent variables. The Cronbach’s alpha findings demonstrated in Table 1 show that all the Cronbach’s based on Number of hypothesized relationships were accepted, with the alpha standardized items exception of environmental aspects in order to develop items the final research model. The population of the study 0.960 0.960 32 based on the district hospital level was 150 respondents. Age, level of education, work experience, job position Results and cloud awareness were the different demographic The set of hypotheses were evaluated using regression and situational variables that were identified as being analysis, with the findings being reported. The statistical relevant for this study. Participant’s demographics are analysis of the data were performed using SPSS 25.0. shown in Table 2, which is broken down into the relevant categories.. Table 2 Frequencies of Participants’ Demographics Frequency Factors Items People (n) Percentage (%) Cumulative percentage (%) 21-30 years 27 32.5 32.5 31-40 years 36 43.4 75.9 Age 41-50 years 20 24.1 100.0 Total 83 100.0 100.0 Grade 12 and below 6 7.2 7.2 Diploma 24 28.9 36.1 Level of Advanced diploma 7 8.4 44.5 education Degree 27 32.5 77.0 Post Graduate 19 22.9 100.0 Total 83 100.0 100.0 0-5 years 38 45.8 45.8 6-10 years 26 31.3 77.1 11-15 years 7 8.4 85.5 Experience 16-20 years 3 3.6 89.1 21-25 years 3 3.6 92.7 26 years and above 6 7.2 100.0 Total 83 100.0 100.0 Administrator 13 15.7 15.7 Cleaner 5 6.0 21.7 Doctor 8 9.6 31.3 Driver 1 1.2 32.5 Filing Assistant 1 1.2 33.7 Job position Lab Assistant 1 1.2 34.9 Matron 2 2.4 37.3 Nurse 41 49.4 86.7 Porter 2 2.4 89.2 Surgeon 9 10.8 100.0 Total 83 100.0 100.0 No 16 19.3 19.3 Cloud Yes 67 80.7 100.0 computing Total 83 100.0 100.0 As demonstrated in Table 2, over 67.5% (n=56) of the The age as a demographic variable has been found by respondents were above the age of 30 years. These other researchers (Kalema, 2013; Venkatesh et al., respondents had a good level of education with only 2012) to be a good predicting factor in the studies of 28.9% (n=24) having an education level of a diploma. technological innovation implementation. This implies The implication of these findings is that such that in terms of migrating HMS in the cloud-based respondents could make a good decision about the asked environment, mature individuals are more responsible in question that improved the validity of the results observing controls and measures, security rules as well obtained for this study. The respondents’ level of as guidelines. Consequently, this also implies that the education is presented graphically (Figure 1). questionnaire was answered by responsible people within the healthcare facilities. 42 International Journal of Science Annals, Vol. 6, No. 2, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Figure 1 Respondents’ Level of Education It is also demonstrated in Table 2 that 15.7% (n=13) of experience, 31.3% (n=26) have between 6 and 10 years, contributions to this study were from hospital 8.4% (n=7) have between 11 and 15 years, 3.6% (n=3) administrators, 7.0% (n=5) were from cleaners, doctors have between 16 and 20 years, 3.6% (n=3) have between contributed 9.6% (n=8), drivers, filling assistants, and 21 and 25 years, and 7.2% (n=6) have more than 26 lab assistants each contributed 1.2% (n=1). A years. Experience places an individual in a position of contribution of 2.4% (n=2) was from matrons, nurses responsibility, source of knowledge and wisdom as one contributed 49.4% (n=41), porters 2.4% (n=2) and with a good experience within an organization is surgeons contributed 10.8% (n=9). Relevance of the job considered a master of processes and operations. title as well as seniority plays an important role in Previous researchers (Tripathi, 2018; Williams et al., maintaining data integrity that leads to better decision- 2016) note that individuals with good experience are making. The role of an individual’s position within an considered as the knowledge base of the organization. organization has been identified in various technological This implies that since a good number of respondents of innovation based studies as being critical and having this study (54.2% or n=45) had experience of 6 years and high interacting effects on the overall prediction of above, it signifies that data for this study was collected models explaining technology acceptance and use from the “knowledge base” of the hospitals’ financial (Kalema, 2013; Rahim et al., 2022; Venkatesh et al., institutions. The work experience of the respondents is 2012). presented graphically (Figure 2). Results demonstrated in Table 2 indicate that 45.8% (n=38) of the participants have at least 5 years of work Figure 2 Overall Working Experience Respondents were also asked to show the awareness of Regression Analysis the cloud environment. Results indicated that 80.7% Further to descriptive analysis, a regression analysis was (n=67) of the participants had knowledge or were aware conducted to determine the prediction of the overall of the cloud whereas 19.3% (n=16) indicated that they model as well as how much each independent variable were not aware of the cloud computing concept. When contribute to the overall prediction of the model. The users are aware of a technological innovation, its model was found to have a good prediction power of implementation becomes less complicated as little 60.9% (R2=0.609). The prediction contribution for each sensitization will be needed during the implementation independent variable is illustrated in the results of process. regression analysis (Table 3). 43 International Journal of Science Annals, Vol. 6, No. 2, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Table 3 Regression Coefficients* Unstandardized Standardized Collinearity statistics coefficients coefficients Model t Sig. Std. B Beta Tolerance VIF Error (Constant) 0.359 0.062 - 5.790 0.000 - - TechChar 0.429 0.218 0.139 1.967 0.042 0.257 3.889 CloudComRead 0.407 0.148 0.256 2.756 0.023 0.370 2.701 OrgAsp 0.759 0.214 0.284 3.549 0.016 0.234 4.272 EnvtAsp -0.136 0.205 -0.123 -.664 0.509 0.228 4.387 IndChar 0.595 0.195 0.182 3.051 0.017 0.263 3.803 RiskAnCtrl 0.487 0.182 0.413 2.681 0.009 0.331 3.018 SocAsp -0.701 0.193 -0.600 -3.632 0.001 0.289 3.458 Note. *Dependent variable – cloud-based Hospital Management System. Results demonstrated in Table 3 indicate that with the Table 3 also measured the existence of multi collinearity exception of environmental aspects, the rest of the by using the Variance Inflation Factor (VIF). The rule of constructs showed a significant contribution to the thumb indicates that for multicollinearity collinearity to successful implementation of a cloud-based HMS. exist, the value of VIF>10. However, as indicated in Social aspects had the highest contribution with the Table 3, all the VIF values were less than 5, which prediction power of 60.0% (β=0.600) at p=0.001; indicated that multicollinearity does not exist. followed by risk analysis and control with a prediction Based on the findings, the conceptualized model for power of 41.3% (β=0.413) at p=0.009. On the other cloud-based Hospital Management Systems for the hand, environmental aspects’ contribution of 12.3% at South African public health sector was derived as p=0.509 was relatively high, it was found not to be demonstrated in Figure 3. significant. Figure 3 Model for Cloud-Based Hospital Management System *Note. TOE – Technology-Organization-Environment framework. 44 International Journal of Science Annals, Vol. 6, No. 2, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Discussion assist with configuration management, provisioning Based on the results of the study, the implications of the required tools, assisting with log collections, patching significance of the variables demonstrated in Figure 3 systems and ticketing systems, cloud-based activities should be explained. may have little hindrance as compared to the on-premises The Technology-Organization-Environment model IT facilities. developed by De Pietro et al. (1990) underpinned the Individual characteristics development of the cloud-based Hospital Management Individual characteristics have been found in much Systems. previous research of technological innovation adoption, Technological factors implementation and use to be significant (Adler-Milstein The implication of this finding is that on average there et al., 2015; Kalema & Busobozi, 2020). The implication have been challenges of inadequate health institutions of these findings is that individual characteristics like and shortage of healthcare human resource in many attitude and beliefs, perceptions, training, and education developing countries, especially those in Sub-Saharan are crucial for cloud migration because when services are Africa (Kalema & Busobozi, 2020). Hence, technology migrated the success of the administrative tasks will and its innovations are seen as one way to bridge the gap depend on the capabilities of the individuals to manage of resource constraint by providing remote access both the migration processes and the operation. Another capabilities to healthcare resources. The significance of factor to consider is that migration of a Hospital this variable confirms the fact that citizens appreciate the Information System (HIS) to the cloud comes with value and contribution of technology towards healthcare several advantages for both healthcare providers and provision and such good and available technology will patients in terms of quality service delivery and cost- boost the migration of HMS to the cloud environment. efficient solutions to the patients, as well as having On the other hand, technological aspects are perceived to seamless collaborations among healthcare facilities. be a major part of cloud technology and a basis for the These findings concur with those of other researchers cloud to change the computing process from using the (Idoga et al., 2019; Singh et al., 2022) who also noted that HMS as stand-alone systems to a networked system that cloud-based hospital systems support collaborations that solves the challenges of accessibility and governance, bring efficient data exchange with fast feedback for the especially in resource-constrained organizations like patients through information sharing, but such could only hospitals. The finding of this study is in agreement with be achieved if individuals using the systems have the those of previous researchers (Idoga et al., 2019; capabilities and positive perceptions towards the system. Sadoughi et al., 2020) who also stated that regardless of Social aspects how technology is looked at as either top-down or The significance of this variable implies that cloud bottom-up; its role for cloud migration is enormous. migration has a high dependence on information sharing Organizational factors due to its potential to provide remote access to data. The The significance of this variable implies that social interaction could be either internal or external and organizational aspects that entail factors like top as such supports information sharing and unrestricted management support, budgets and finances, employees’ flow of information in the cloud-based health system, empowerment for knowledge creation through trainings, which leads to effectiveness. Internal social aspects policies and standards, organizational size and structure, include influence of others to accept, and believe and measures for collaboration and knowledge sharing, as trust in the system; while the external is related to well as enhanced business processes play an essential external collaboration when the system is migrated and role in the migration of services and applications to the support during the use of the system. The findings of this cloud. The findings of this study concur with those of study support those of previous researchers such as many previous others on the migration to the cloud that (Venkatesh et al., 2012; Walker & Walker, 2022) who have found organization aspects to have a stronger noted that social aspects play an essential role in significant influence (Alipour et al., 2021; Idoga et al., voluntary technological innovation implementation, 2018; Sadoughi et al., 2020). adoption, and use. Environmental aspects Risk analysis and control Environment aspects have been found in various The significance of this variable confirms the fact that healthcare research of developing countries to be risk awareness starts with identifying and reporting near significant, yet they were found not to be significant in accidents, incidents, complaints, or other undesirable this study (Kalema & Busobozi, 2020; Maphumulo & situations that could be the order of the day in the cloud Bhengu, 2019). The implication of this finding is that environment. This implies that risk management in the when services are migrated to the cloud the issue of cloud should embrace a flexible software platform that environment is overshadowed by the organizational can record and detail the data and its operations, direct aspects. For instance, services will be migrated to the follow up of workflow automation tools, carry out cloud that might reside in a different country or continent analysis of trends of root causes of risks and associated and such migration requires more organizational support challenges, manage dashboards to monitor information, than the environment characteristics. With good support as well as monitor improvement actions. The findings of from the organizational top management in terms of this study concur with those of other researchers (Alipour budgets, training of users, employing the right staff, et al., 2021; Maphumulo & Bhengu, 2019; Rahman et al., signing good service level agreements with vendors to 2017; Singh et al., 2022) who also observed that 45 International Journal of Science Annals, Vol. 6, No. 2, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa managing risks associated with HIS is paramount in that will enable them to use these migrated services. As assuring patients’ safety regardless of hospital size and emphasized by Sadoughi et al. (2020), keeping and structure. Hence, risk management and control is a maintaining cloud security is a pain-staking task that significant factor for migrating HIS to the cloud and needs any organization to remain abreast with healthcare systems should be mindful of the techniques technological developments, and to be many steps ahead that they use to migrate their services. of its adversaries. Cloud migration complacency may be Cloud-based services migration has many implications, limiting in informing a successful cloud strategy; hence, such as budgets and costs to technical aspects including organizations need to have constant evaluation of what maintenance and delivery. This implies that to get a vivid their IT support team can do better and how such can be understanding and generalization of findings for the achieved. migration of HIS to the cloud environment, this study This study revealed that organizational, technological, needed to involve as many stakeholders as possible who individual, and social aspects as well as risk control and interact with the system. However, because this study analysis are important determinants in shaping the collected online data, some stakeholders could not perspective of cloud-based HIS users. However, the participate in the study for one reason or the other. More cloud-based system characteristics such as ease-of-use, so, this study also needed to triangulate the methods relative advantage, scalability, security, and trust are during data collection whereby some data would have major antecedents in accepting a cloud-based HIS. This been collected qualitatively from policy makers, like top implies that an organization needs to simplify the hospital administrators, through interviews. This study, understanding and use of the cloud by users by enhancing therefore, recommends that future research should their capabilities through training as well as involving increase the scope of data collection by increasing the them in the decision-making process around the number of participating hospitals in the study and try to migration to the cloud. triangulate the methods by using a combination of As observed by recent researchers (Abbas et al., 2020; quantitative and qualitative data collection methods, such Kalema, 2022; Singh et al., 2022) in the current era of the as interviewing policy and strategic decision makers. Fourth Industrial Revolution (4IR), the greatest For conclusiveness of a cloud-based HIS, one needs to do opportunities as well as the greatest threats are the new a follow up of what happens after migration. This could trends in computing. This technology “Big Bang” has also be in the form of observing the adherence to policies and is continuously changing the landscape of every and standards as well as assessment of the reduction in organization, including those in the healthcare sector. the total cost of ownership of the system after migration. Migrating services to the cloud is increasingly becoming Therefore, since a cross-sectional data collection the order of the day for those organizations seeking approach was used, this study recommends that a agility. Since such has made the cloud to move faster, the longitudinal research data collection should be used by earlier organizations gain diversified expertise in using future researchers in order to be in an actual position to and administering services in this environment the better report what will happen after some time. A longitudinal is their future survival. As a result, the model designed survey will also assist in determining whether medical for this study could be a beneficial guide to empirical personnel and healthcare workers are effectively using research on cloud-based systems, not only for the the system. healthcare sector but also for other sectors. The findings Several researchers (Kalema, 2013; Rahim et al., 2022; of this study are intended to help healthcare decision- Tripathi, 2018) note that users of technology may have makers by increasing their awareness of the cloud-based their perceptions change with time. This implies that systems, and to keep in mind the impact of the identified analysis of users’ demographics and situational variables factors on decision-making at all levels within healthcare. should go beyond descriptive and analyse the moderating and interacting effects of these variables in order to make Acknowledgments a better prediction of what happens after some time The authors wish to acknowledge all those that interval. Much as this study appreciates this observation, participated in this study. Thank you so much for support. respondent’s demographics and situational variables Special thanks to the Council for Scientific and Industrial were only analysed using descriptive analysis to show the Research, CSIR (SS-GEN-HR-009 REV 01 2011) for the frequencies. This may cause a limitation in predicting funding of the study. future occurrences in the usage of the cloud services. This study recommends that future research should make Ethical Approval effort to analyse the interacting effects of the moderating The study obtained ethical clearance from the institution factors. Ethics Committee (Ref. No. FCRE/ICT/2021/06/002(1). Conclusions Funding Source Migrating services and applications to the cloud is a big The study was supported by HCD-INTERBURSARY step. However, it is the first step as migration is one thing obtained from the CSIR. and administering the use of the migrated services is another. A successful cloud-based HIS requires the References healthcare system to remain active and vigilant, hence the Abbas, I., Ahmad, M., Faizan, M., Arshed, W., & need to train all stakeholders to achieve advanced skills Khalid, J. (2020, June 12-13). Issues and 46 International Journal of Science Annals, Vol. 6, No. 2, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa challenges of cloud computing in performance Kalema, B. M. (2022). 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Conceptualizing a model for cloud-based hospital management systems for the South African public health sector. International Journal of Science Annals, 6(2), 40–48. https://doi.org/10.26697/ijsa.2023.2.5 The electronic version of this article is complete. It can be found online in the IJSA Archive https://ijsa.culturehealth.org/en/arhiv This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/deed.en). 48