Development of a tripolar model of technology acceptance: Hospital-based physicians’ perspective on EHR

Highlights

• Many barriers of EHR implementation concern Armenian physicians.

• Current study reconciles individual-oriented and environment-oriented theories.

• Tripolar model combines patient, practitioner, organization pillars of healthcare.

• Projected collective usefulness links perceived usefulness to behavioral intention.

• Patients emanate social influence affecting physicians’ technology acceptance.

Abstract

Background and purpose

In health care, information technologies (IT) hold a promise to harness an ever-increasing flow of health related information and bring significant benefits including improved quality of care, efficiency, and cost containment. One of the main tools for collecting and utilizing health data is the Electronic Health Record (EHR). EHRs implementation can face numerous barriers to acceptance including attitudes and perceptions of potential users, required effort attributed to their implementation and usage, and resistance to change. Various theories explicate different aspects of technology deployment, implementation, and acceptance. One of the common theories is the Technology Acceptance Model (TAM), which helps to study the implementation of different healthcare IT applications. The objectives of this study are: to understand the barriers of EHR implementation from the perspective of physicians; to identify major determinants of physicians’ acceptance of technology; and develop a model that explains better how EHRs (and technologies in general) are accepted by physicians.

Methods

The proposed model derives from a cross-sectional survey of physicians selected through multi-stage cluster sampling from the hospitals of Yerevan, Armenia. The study team designed the survey instrument based on a literature review on barriers of EHR implementation. The analysis employed exploratory structural equation modeling (ESEM) with a robust weighted least squares (WLSMV) estimator for categorical indicators. The analysis progressed in two steps: appraisal of the measurement model and testing of the structural model.

Results

The derived model identifies the following factors as direct determinants of behavioral intention to use a novel technology: projected collective usefulness; personal innovativeness; patient influence; and resistance to change. Other factors (e.g., organizational change, professional relationships, administrative monitoring, organizational support and computer anxiety) exert their effects through projected collective usefulness, perceived usefulness, and perceived ease of use. The model reconciles individual-oriented and environment-oriented theoretical approaches and proposes a Tripolar Model of Technology Acceptance (TMTA), bringing together three key pillars of the healthcare: patients, practitioners, and provider organizations. The proposed TMTA explains 85% of variance of behavioral intention to use technology.

Conclusions

The current study draws from the barriers of EHR implementation and identifies major determinants of technology acceptance among physicians. The study proposes TMTA as affording stronger explanative and predictive abilities for the health care system. TMTA paves a long overlooked gap in TAM and its descendants, which, in organizational settings, might distort construal of technology acceptance. It also explicates with greater depth the interdependence of different participants of the healthcare and complex interactions between healthcare and technologies.

Introduction

Health care systems face challenges related to a continuously increasing demand for services due to an aging population and a rising prevalence of non-communicable diseases [1], [2]. In addition, the efficiency and quality of health services can be compromised because of a lack of coordination of care at different levels, a lack of health information management, and a lack of integration of scientific evidence into health care practices and decision making [3]. Proper health information management is needed for achieving effective and efficient health care for the whole population [4]. To reach this goal, many countries, including Armenia, are upgrading their healthcare systems through application of information technologies (IT), specifically Electronic Health Records (EHRs). An EHR is defined as “an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed and consulted by authorized clinicians and staff across more than one healthcare organization” [5]. There are several studies reporting on EHR-related experiences in different countries [6], [7], [8], and there is an emerging consensus that adoption of EHRs can lead to numerous advancements related to health information quality and usage, quality of care, efficiency and cost of care [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19].

In 2012 Armenia began implementation of a national EHR [20]. In 2013, in cooperation with the World Bank, Ericsson Nikola Tesla was contracted to adapt its EHR solution with the goal to develop an “…integrated Health Information System (HIS) for Armenia” [21], [22].

The Armenian health care system serves a population of about 3 million, 1.9 million of whom reside in urban areas. Services are provided through 509 primary care facilities and 130 secondary and tertiary care facilities. Seventy-two percent (72%) of primary facilities are under public ownership, as are sixty-eight percent (68%) of secondary and tertiary care facilities [23], [24]. The public sector of the health care system is decentralized and is distributed between 3 administrative tiers: national, regional and municipal [25]. However, regulation and planning are mainly overseen at the national level [26]. The country’s total health expenditure comprises 4.5% of its gross domestic product, and 41.7% of that expenditure is state financed and 54.7% is covered out-of-pocked [27], [28].

There are several governmental bodies in Armenia involved with health-related data collection, and – as in other countries – there are different “stovepipe” information systems. Significant gaps and limitations are reported with the health information systems of Armenia. Routine reporting of data from health facilities is fragmented and incomplete [29]. Information exchange and utilization of data in decision and policy making is weak [30]. Penetration of electronic medical records is very limited in hospitals, however there is a national electronic system covering primary care facilities [31].

The EHR implementation project in Armenia adopted a centralized approach as the system will be mandatory for all health-care facilities planning to provide care on the basis of state financing and will operate an integrated database connecting different stakeholders: physicians; nurses; facility administration; insurers; several government bodies; and patients [20], [32]. The implemented system will feature the following components: patient documentation/records; practice management; computerized physician order entry (CPOE); clinical decision support; electronic prescribing; patient portal; healthcare resources register; public health reporting; and preventive medicine tracking. The system has been deployed and tested at several pilot sites at the end of 2015 and the national rollout has been on hold.

Many countries that implement EHR nationally face many barriers. The main objectives of this study are to: understand the barriers of implementation from the point of view of end users; identify major determinants of physicians’ technology acceptance; and develop a deeper understanding of the various factors impacting implementation through the development of an enhanced Technology Acceptance Model, with particular consideration given to the sociotechnical dimensions of technology acceptance. When such sociotechnical factors are not considered, EHR implementations can be ineffective and unsuccessful, threatening the fate of the endeavor [13], [33]. Conversely, if these factors are identified and successfully managed beforehand, then EHR system implementation can provide sounder benefits to health care system [34], [35].