2008:043

MASTER'S THESIS

Adoption of Electronic Patient Records

by Iranian Hospitals Staff

Mahbod Hamidfar

Lule University of Technology

Master Thesis, Continuation Courses

Marketing and e-commerce
Department of Business Administration and Social Sciences
Division of Industrial marketing and e-commerce

2008:043 - ISSN: 1653-0187 - ISRN: LTU-PB-EX--08/043--SE

 MASTERS THESIS
Adoption of Electronic Patient Records by
Iranian Hospitals Staff

Supervisors:
Dr. Moez Limayem
Dr. Seyed Hessameddin Zegordi

Referees:
Dr. Amir Albadvi
Dr. Esmail Salehi-Sangari

Prepared by:
Mahbod Hamidfar
846831009
Tarbiat Modares University Faculty of Engineering
Department of Industrial Engineering

Lulea University of Technology

Division of Industrial Marketing and ECommerce

Joint MSc PROGRAM IN MARKETING AND ELECTRONIC COMMERCE

2008
Abstract

There has been an increasing interest in the area of Electronic Patient Records
(EPR) and more and more hospitals all over the world try to keep their patients records
electronically. The adoption of EPR has become a major concern in the healthcare
industry, as it is a key factor to the healthcare quality improvement. Today, despite the
immense investment in EPR systems in hospitals, these systems are not used by the
clinical staff in most Iranian hospitals. The usage of these systems would be the key to
the return on investments in these systems.

The purpose of this study is to gain a better understanding of the factors affecting
Iranian hospitals staff intention to use EPR. To do so, the literature on EPR and the use
and importance of Information Technology (IT) in healthcare industry is reviewed.
Different technology adoption theories are introduced and compared. Consequently, an
extension of the Unified Theory of Acceptance and Use of Technology (UTAUT) is
proposed to perform the study. Finally, the proposed research model is statistically tested
using the data from the conducted survey in 6 Iranian hospitals.

The findings provide strong empirical support for most of the main constructs
mentioned in the research model, which posits five direct determinants of intention to use
EPR as follow: performance expectancy, effort expectancy, social influence, facilitating
conditions and personal innovativeness in IT. In addition the results show that the effect
of social influence on behavioral intention is even stronger for women.

Considering the fact that the achieved conceptual framework considers the
particular characteristics of the medical profession, contributions and implications of this
study are noteworthy at the theoretical level as well as the practical level.

Keywords: Electronic Patient Record (EPR), Healthcare Industry, Information

Technology (IT), Technology Adoption, Unified Theory of Acceptance and Use of
Technology (UTAUT)

1
Acknowledgement

This dissertation concludes my Master of Science degree in Marketing and e

Commerce at Tarbiat Modares University joint with Lulea University of Technology.
Completion of this work has been both interesting and challenging to me. I would like to
extend my gratitude to all the people who helped and supported me during this process.

I wish to express my deepest appreciation to members of Industrial Engineering

Department of Tarbiat Modares University and Industrial Marketing and eCommerce
division of Lulea University of Technology, especially my supervisors, Prof. M.
Limayem and Dr. S.H. Zegordi for their guidance and encouragement that gave me an
opportunity to progress and broaden my knowledge.

I would like to especially thank managers of Day, Kasra, Laleh, Shahid Rajaee,
Dr. Shariati and Toos hospitals and all the doctors and nurses who took the time to
answer my questions, for their cooperation and patience.

Last but not least, I wish to express my sincere gratitude to my family and friends
for their love and support. I hereby dedicate this piece of work to my beloved parents to
whom I owe all the joy and success in my life.

March 2008

Mahbod Hamidfar

2
Table of Contents

Abstract...................................................................................................................... 1
Acknowledgement ..................................................................................................... 2
List of Tables ............................................................................................................. 8
List of Figures.......................................................................................................... 10
Chapter 1 ................................................................................................................. 11
Introduction............................................................................................................. 11

1. Introduction.................................................................................................. 11

1.1 Overview.................................................................................................... 12

1.2 Background ................................................................................................ 12

1.3 Motivation of the Study ............................................................................. 13

1.3.1 IT in Healthcare Industry ................................................................. 14

1.3.2 EPR and Healthcare Quality ............................................................ 15

1.3.3 Role of Hospital staff ....................................................................... 16

1.4 Review of the Current State of Iran ........................................................... 19

1.5 Problem Statement ..................................................................................... 20

1.6 Research Objective .................................................................................... 21

1.7 Research Question ..................................................................................... 21

1.8 Importance of the Study............................................................................. 22

1.9 Terminology............................................................................................... 23

3
 1.10 Structure of the Study .............................................................................. 23

1.11 Summary .................................................................................................. 24

Chapter 2 ................................................................................................................. 25
Literature Review ................................................................................................... 25

2. Literature Review......................................................................................... 25

2.1 Definition of EPR ...................................................................................... 26

2.2 Benefits of EPR.......................................................................................... 27

2.3 Technology Adoption ................................................................................ 28

2.4 Adoption Theories ..................................................................................... 32

2.4.1 Innovation Diffusion Theory (IDT) ................................................. 32

2.4.2 Theory of Reasoned Action (TRA).................................................. 35

2.4.3 Theory of Planned Behavior (TPB) and Decomposed TPB ............ 36

2.4.4 Technology Acceptance Model (TAM) and Extended TAM (TAM2)

............................................................................................................................... 38

2.4.5 Combined TAM and TPB (CTAMTPB) ..................................... 39

2.4.6 Unified Theory of Acceptance and Use of Technology (UTAUT) . 40

2.4.6.1 Model of PC Utilization (MPCU)............................................. 42

2.4.6.2 Motivational Model (MM)........................................................ 43

2.4.6.3 Social Cognitive Theory (SCT) ................................................ 44

4
 2.5 Comparison of Theories............................................................................. 45

2.6 Other Important Factors Influencing the Intention to Adopt ............... 47

2.6.1 Facilitating Conditions.................................................................. 47

2.6.2 Perceived Time Risk ..................................................................... 48

2.6.3 Personal Innovativeness in IT....................................................... 49

2.7 Research Model ................................................................................... 51

2.8 Research Hypotheses ........................................................................... 54

2.9 Summary .............................................................................................. 55

Chapter 3 ................................................................................................................. 57
Methodology ............................................................................................................ 57

3. Methodology ................................................................................................ 57

3.1 Research Purpose ....................................................................................... 58

3.2 Research Approach .................................................................................... 59

3.2.1 Theoretical Approach....................................................................... 59

3.2.2 Methodological Approach ............................................................... 60

3.3 Research Strategy....................................................................................... 62

3.4 Sampling .................................................................................................... 63

3.4.1 Defining the Target Population........................................................ 63

3.4.2 Selecting the Sampling Technique................................................... 64

5
 3.5 Measurement of Constructs ....................................................................... 66

3.6 Questionnaire Design................................................................................. 67

3.7 Pilot Study.................................................................................................. 68

3.8 Data Collection .......................................................................................... 69

3.9 Summary .................................................................................................... 70

Chapter 4 ................................................................................................................. 72
Data Analysis ........................................................................................................... 72

4. Data Analysis ............................................................................................... 72

4.1 Statistical Analysis Method ....................................................................... 73

4.1.1 Covariance Analysis versus Partial Least Squares .......................... 74

4.2 Quality Standard: Reliability and Validity ................................................ 75

4.2.1 Reliability......................................................................................... 75

4.2.2 Validity ............................................................................................ 76

4.3 Demographic and Descriptive Statistics .................................................... 81

4.4 Results of Hypotheses Tests ...................................................................... 82

4.4.1 Antecedents of Behavioral Intention toward EPR Adoption ........... 83

4.4.2 Explaining Performance Expectancy............................................... 84

4.4.3 Explaining Effort Expectancy.......................................................... 84

4.4.4 Explaining Social Influence............................................................. 84

6
 4.4.5 Explaining Facilitating Conditions .................................................. 85

4.4.6 Explaining Perceived Time Risk ..................................................... 86

4.4.7 Explaining Personal Innovativeness in IT ....................................... 86

4.4.8 Explaining Moderating Effects ........................................................ 87

4.5 Summary .................................................................................................... 88

Chapter 5 ................................................................................................................. 89
Conclusion................................................................................................................ 89

5. Conclusion ................................................................................................... 89

5.1 Discussion and Conclusion ........................................................................ 90

5.2 Contributions of the Study ......................................................................... 95

5.2.1 Theoretical Contribution.................................................................. 96

5.2.2 Empirical Contribution .................................................................... 96

5.3 Practical Implications................................................................................. 97

5.4 Limitations of the Study............................................................................. 98

5.5 Recommendations for Further Research.................................................... 99

References .............................................................................................................. 100

Appendices ............................................................................................................. 110

Appendix A. Abbreviations ........................................................................... 110

Appendix B. Questionnaire............................................................................ 112

7
List of Tables

Table 1-1 IT Adoption Related Studies in Healthcare Industry ........................... 14

Table 1-2 Healthcare Professionals Technology Acceptance Related Studies..... 17

Table 2-1 EPR Adoption Related Studies............................................................. 30

Table 2-2 IDT ....................................................................................................... 33

Table 2-3 Refined IDT. Source: Venkatesh et al., 2003....................................... 34

Table 2-4 TRA. Source: Venkatesh et al., 2003 ................................................... 35

Table 2-5 TPB and DTPB. Source: Venkatesh et al., 2003.................................. 36

Table 2-6 TAM and TAM2. Source: Venkatesh et al., 2003................................ 38

Table 2-7 CTAMTPB. Source: Venkatesh et al., 2003 .................................... 39

Table 2-8 UTAUT................................................................................................. 41

Table 2-9 MPCU. Source: Venkatesh et al., 2003................................................ 43

Table 2-10 MM. Source: Venkatesh et al., 2003 .................................................. 44

Table 2-11 SCT. Source: Venkatesh et al., 2003.................................................. 44

Table 2-12 Performance Expectancy Root Constructs. Source: Venkatesh et al.,

2003................................................................................................................................... 46

Table 2-13 Effort Expectancy Root Constructs. Source: Venkatesh et al., 2003 . 46

Table 2-14 Social Influence Root Constructs. Source: Venkatesh et al., 2003 .... 46

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 Table 2-15 Facilitating Conditions Root Constructs. Source: Venkatesh et al.,
2003................................................................................................................................... 47

Table 3-1 Relevant Situation for Different Research Strategies. Source: Yin, 1994
........................................................................................................................................... 62

Table 3-2 Definition of Constructs ....................................................................... 66

Table 4-1 Cronbach Alphas .................................................................................. 76

Table 4-2 Factor Loadings .................................................................................... 77

Table 4-3 Factor Structure Matrix of Loadings and CrossLoadings .................. 79

Table 4-4 AVE and Square Root of AVE............................................................. 80

Table 4-5 Correlation of Latent Variables ............................................................ 81

Table 4-6 Demographic Characteristics of the Respondents................................ 81

Table 4-7 Results of Hypotheses Tests................................................................. 83

9
List of Figures

Figure 1-1 A Model of DataDriven Healthcare Quality. Source: Lorence and

Jameson, 2002................................................................................................................... 16

Figure 1-2 Structure of the Study.......................................................................... 23

Figure 2-1 Innovation Decision Process. Source: Rogers, 1995 .......................... 30

Figure 2-2 IDT. Source: Rogers, 1995.................................................................. 33

Figure 2-3 Refined IDT. Source: Moore and Benbasat, 1991 .............................. 35

Figure 2-4 TRA. Source: Fishbein and Ajzen, 1975 ............................................ 36

Figure 2-5 TPB. Source: Ajzen, 1991................................................................... 37

Figure 2-6 DTPB. Source: Taylor and Todd, 1995a............................................. 37

Figure 2-7 TAM. Source: Davis, 1989 ................................................................. 39

Figure 2-8 TAM2. Source: Venkatesh and Davis, 2000....................................... 39

Figure 2-9 CTAMTPB. Source: Chau and Hu, 2002........................................ 40

Figure 2-10 UTAUT. Source: Venkatesh et al., 2003 .......................................... 42

Figure 2-11 Proposed Research Model................................................................. 52

Figure 5-1 Results ................................................................................................. 92

Figure 5-2 Final Theoretical Model...................................................................... 93

10
Chapter 1
Introduction

1. Introduction

The first chapter presents the research overview and background, the motivation
of the study and a review on the current state of Iran and, then introduces the reader to
the problem statement, research objective and question which leads to the importance of
the research. Subsequently it reports the structure of the thesis.

11
1.1 Overview

The rapid growth of investment in Information Technology (IT) by organizations

worldwide has made user acceptance an increasingly critical technology implementation
and management issue. While such acceptance has received fairly extensive attention
from previous researches, additional efforts are needed to examine or validate existing
research results, particularly those involving different technologies, user populations,
and/or organizational contexts (Hu et al., 1999b).

The importance of technological change in the health sector is a widely discussed

topic in the economic literature (Selder, 2005). Among these changes is the introduction
of Electronic Patient Records (EPR) which can promote higher quality, lower costs, and
increased patient and clinician satisfaction. Yet one important player in the healthcare
market has so far been neglected in the discussion: the provider of healthcare services
(ibid). After all, it is the physicians and nurses who decide whether to use a technical
innovation such as EPR or not.

Regarding the literature review and the current state of Iranian hospitals, among
the research opportunities in healthcare industry and technology adoption context,
investigating the factors influencing Iranian hospitals staff intention to adopt EPR
systems, is chosen to be studied in this research.

1.2 Background

The shift from industrial to information society has also its phenomena in
medicine (Maass and Eriksson, 2006). Traditionally, medicine is an information
intensive branch where patient treatment is triggered by the availability of diagnostic
knowledge (ibid). Today, healthcare computing or medical informatics is one of the
fastest growing areas of Information and Communication Technology (ICT) applications
(Rogerson, 2000). It is a multifaceted application concerned with EPR, performance
indicators, paramedical support, emergency service, computer aided diagnosis, clinical
governance, research support, and hospital management (ibid).

12
 In the past decade, EPR has become an important tool for the healthcare providers
(McDonald et al., 1999; Sim et al., 2001). Use of an EPR is shown to produce more
complete clinical documentation than the paper record, leading to more appropriate
clinical decisions (Barahona et al., 2001; Daugaard, 2002; Sim et al., 2001). In addition,
EPR is recognized for its potential to implement guidelinebased healthcare and to
identify and limit medical errors (Mikulich et al., 2001; Morgan et al., 1998; Shiffman et
al., 1999).

Years ago, entry of a clinical encounter summary into an EPR meant transcription
of voice files or data entry by clerks (WhitingOKeefe et al., 1988). But now, the
intermediary between the clinician and EPR may no longer be needed, and a great
opportunity exists for streamlining clinical record keeping and increasing clinical access
to medical records (Johnson et al., 2004). Still, despite the increasing availability of EPR
systems, anecdotal evidence suggests that its use has not been well accepted by
physicians and nurses (Anderson, 2000; McDonald, 1997). The investments in this new
technology are immense and seen from a costbenefit perspective most implementations
of EPR are more or less "trialanderror" projects (Nikula, 2005). Therefore, there is a
need for academically investigating the factors influencing the adoption of EPR by the
hospitals staff.

1.3 Motivation of the Study

Public healthcare services have been under scrutiny in terms of productivity and
efficiency for several years now and IT applications are sought to assist the re
engineering of these services (Maass and Eriksson, 2006). Among these IT applications,
EPR is recognized as one of the most important strategic IT tools to improve a hospitals
productivity and competitiveness. In addition, employing EPR systems help to improve
the healthcare quality and patient care in hospitals. On the other hand, it is the physicians
and nurses who decide whether to use EPR systems or not and unfortunately anecdotal
evidence suggests that they have not well accepted the use of these systems (Anderson,
2000; McDonald, 1997). Consequently the researcher is motivated to conduct the current
study in order to identify the factors influencing Iranian hospitals staff intention to adopt

13
EPR systems. The above mentioned motivating areas are more discussed in the following
sections.

1.3.1 IT in Healthcare Industry

To cope with the dramatic changes and fierce competition, healthcare industry is
experiencing major transformation in its IT base (Wilson and Lankton, 2004). By nature,
hospitals are in an informationintensive industry and hence they would gain great
benefit by adopting IT applications, ranging from medical to administration systems
(Chang et al., 2005). IT has had its applications within healthcare for decades now
(Maass and Eriksson, 2006). Primarily, until ten years ago, IT was used for
administrative tasks, such as statistics and personnel data (ibid). Some newcomers are the
Hospital, Laboratory, Pathology and Radiology Information Systems (ibid). Nowadays
Healthcare Information Technology (HIT) is broadly defined as including in patient and
out patient care settings clinical information management systems used by clinicians and
ancillary staff for the purpose of clinical information management, order entry,
documentation of care services, and decision support (Middleton et al., 2005).

IT solutions are sought to assist the reengineering of public healthcare services

(Maass and Eriksson, 2006). Therefore, the importance of technological change in the
health sector is a widely discussed topic in the economic literature (Selder, 2005). Table
1-1 lists several studies which have been conducted in the IT adoption context in
healthcare industry, examining the factors affecting IT acceptance by either healthcare
organizations or physicians and other healthcare professionals.

Table 1-1 IT Adoption Related Studies in Healthcare Industry

Authors Year Title

AlQirim, N. 2007 Championing telemedicine adoption and utilization in

healthcare organizations in New Zealand

Maass, M. 2006 Challenges in the adoption of Medical Information Systems

Eriksson, O.

14
 Table 1-1 IT Adoption Related Studies in Healthcare Industry (Continued)

Authors Year Title

Zheng, J. 2006 A strategic case for eadoption in healthcare supply chains

Bakker, E.
Knight, L.
Gilhespy, H.
Harland, C.
Walker, H.

Lubrin, E. 2006 Exploring the Benefits of Using Motes to Monitor Health:

An Acceptance Survey
Lawrence, E.
Zmijewska, A.
Navarro, K.F.
Culjak, G.

Chang, I. C. 2005 Critical factors for adopting PACS in Taiwan: Views of

radiology department directors
Hwang, H.
Yen, D. C.
Lian, J. W.

Lorence, D. P. 2002 Adoption of information quality management practices in

Jameson, R. US healthcare organizations: A national assessment

Anderson, J. G. 2002 Evaluation in health informatics: Social network analysis

Hu, P. J. 2000 Investigation of factors affecting healthcare organizations

adoption of telemedicine technology
Chau, P. Y.
Sheng, O. L.

Nabali, H. M. 1991 Hospital Information Systems in Arab Gulf countries:

Characteristics of adopters

1.3.2 EPR and Healthcare Quality

Proper and correct adoption of IT can significantly affect the quality and
performance of medical services provided by a hospital (Chang et al., 2005). A
comprehensive EPR system is a viable solution for optimizing patient management and
15
providing high quality care while maintaining costs under economic restrictions (Ratib et
al., 2003). As a result, to increase the hospitals competitiveness, hospital managers try to
employ Hospital Information Systems (HIS) supporting EPR to improve the quality of
patient care and productivity of their staff (Chang et al., 2005).

Figure 1-1 also shows that evidencebased medicine, which is reached as a

consequence of EPR usage, is one of the main datadriven factors to improve healthcare
quality.

Figure 1-1 A Model of DataDriven Healthcare Quality. Source: Lorence and Jameson, 2002

1.3.3 Role of Hospital staff

One of the most challenging areas of EPR development is integrating it into the
workflow of the physicians and nurses (Johnson et al., 2004). In a typical day, as
physicians and nurses visit patients, they document the patients symptoms and any
physical findings discovered during the encounter in the form of encounter summaries
(ibid). These summaries may be initial history and physical reports, followup visit notes,
progress notes, surgical procedure notes, or consult summaries, depending on the reason
for the patient to be seeing the clinician (ibid). The problem is that, not all hospitals staff
adopt IT applications such as EPR without any hesitation (Chang et al., 2005). In fact, the
greatest barrier to EPR adoption is the resistance by physicians and nurses (Brailer and
16
Terasawa, 2003). There have been several researches conducted to study factors affecting
healthcare professionals and hospitals staff technology adoption which are listed in
Table 1-2.

Table 1-2 Healthcare Professionals Technology Acceptance Related Studies

Authors Year Title

Chang, I. C. 2007 Physicians' acceptance of pharmacokineticsbased clinical

decision support systems
Hwang, H. G.
Hung, W. F.
Li, Y. C.

Schaper, L. 2007 ICT and OTs: A model of information and communication

technology acceptance and utilization by occupational
Pervan, G.
therapists

Wu, J. H. 2007 Mobile computing acceptance factors in the healthcare

industry: A structural equation model
Wang, S. C.
Lin, L. M.

Litwin, A. S. 2006 Information technology and the employment relationship:

Examining physicians adoption of health information
technology

Ford, E. W. 2006 Predicting the adoption of Electronic Health Records by

physicians: When will healthcare be paperless?
Menachemi, N.
Phillips, M. T.

Pare, G. 2006 The effects of creating psychological ownership on

physicians' acceptance of clinical information systems
Sicotte, C.
Jacques, H.

Yi, M. Y. 2006 Understanding information technology acceptance by

individual professionals: Toward an integrative view
Jackson, J. D.
Park, J. S.
Probst, J. C.

Liu, L. 2005 The impact of service level on the acceptance of application

service oriented medical records
Ma, Q.
17
 Table 1-2 Healthcare Professionals Technology Acceptance Related Studies (Continued)

Authors Year Title

Lu, Y. C. 2005 A review and a framework of handheld computer adoption

in healthcare
Xiao, Y.
Sears, A.
Jacko, J. A.

Schectman, J. M. 2005 Determinants of physician use of an ambulatory

prescription expert system
Schorling, J. B.
Nadkarni, M. M.
Voss, J. D.

Selder, A. 2005 Physician reimbursement and technology adoption

Zheng, K. 2005 Understanding technology adoption in clinical care:

Clinician adoption behavior of a pointofcare reminder
Padman, R.
system
Johnson, M. P.
Diamond, H. S.

Lee, T. T. 2004 Nurses' adoption of technology: Application of Rogers'

innovationdiffusion model

Gagnon, M. P. 2003 An adaptation of the theory of interpersonal behavior to the

study of telemedicine adoption by physicians
Godin, G.
Gagne, C.
Fortin, J. P.
Lamothe, L.
Reinharz, D.
Cloutier, A.

Chismar, W. G. 2002 Does the Extended Technology Acceptance Model apply to

physicians
WileyPatton, S.

Chau, P. Y. K. 2002 Investigating healthcare professionals' decisions to accept

telemedicine technology: An empirical test of competing
Hu, P. J. H.
theories

18
 Table 1-2 Healthcare Professionals Technology Acceptance Related Studies (Continued)

Authors Year Title

Johnston, J. M. 2002 Physicians' attitudes towards the computerization of

clinical practice in Hong Kong: A population study
Leung, G. M.
Wong, J. F. K.
Ho, L. M.
Fielding, R.

Croteau, A. M. 2002 Telemedicine adoption by different groups of physicians

Vieru, D.

Hu, P. J. H. 1999 Examining the technology acceptance model using

physician acceptance of telemedicine technology
Chau, P. Y. K.
Sheng, O. L.
Tam, K. Y.

Hu, P. J. H. 1999 Investigating physician acceptance of telemedicine

Sheng, O. R. L. technology: A survey study in Hong Kong

Chau, P. Y. K.
Tam, K. Y.
Fung, H.

Hu, P. J. H. 1999 Physician acceptance of telemedicine technology: An

empirical investigation
Chau, P. Y. K.

Succi, M. J. 1999 Theory of user acceptance of information technologies:

An examination of healthcare professionals
Walter, Z. D.

Jayasuriya, R. 1998 Determinants of microcomputer technology use:

Implications for education and training of health staff

1.4 Review of the Current State of Iran

According to the interviews conducted with different hospitals staff and EPR
software developer companies, at the time being there are different levels of using
computers in Iranian hospitals. In some hospitals patients files are still kept paperbased

19
and the systems which are computerized are only the administration of the patient and
financial affairs, of course their laboratories, radiology and other parts taking
examination from patients might have computerized systems of their own but it does not
join a main system recording everything for a single patient. Other hospitals have
implemented HIS supporting EPR, but for each patient it only includes the items that are
needed later for calculating the patients paycheck. For example, there is an order for
different blood tests for the patient in his/her file but there is no result entered. In this
case, it is nearly only a system for their financial records not an EPR, and physicians and
nurses are not forced to use the clinical part of the system.

Software developer companies claim that their software supports clinical issues
but hospitals staff (doctors and nurses) do not use those items and therefore managers
are not interested in those parts, either.

Even in hospitals most using HIS, details of daily observations and notes of
physicians and nurses are not entered to the computerized system, and as a result they do
not have a complete EPR. According to Johnson et al. (2004), there are two key aspects
of the observation notes that make them attractive and important for inclusion in the EPR.
First, they represent a rich source of data about the patient. These data may be used to
generate reports about the quality of care being delivered, and they may be useful for
research or for billing. Second, the act of completing this documentation is typically
associated with decision making.

1.5 Problem Statement

Over the past years, the adoption of information and communication technologies
in the healthcare sector has been the focus of many studies (Gagnon et al., 2003).
Physicians and nurses represent one of the principal groups of EPR users and their
acceptance of this technology constitutes one of the prerequisites to the usage and
sustainability of EPR systems (Hu et al., 2000).

20
 The problem stated in this research is that Iranian hospitals spend a great deal of
money on buying EPR software and implementing EPR systems but the hospitals staff
(physicians, nurses) do not use it.

1.6 Research Objective

EPR adoption refers to physician or nurses psychological state with regard to

his/her intention to use EPR in his/her practice (Croteau and Vieru, 2002). EPR
acceptance can be defined in different manners and adoption (or utilization) represents a
common indicator of the degree of EPR acceptance (Gagnon et al., 2003). An
individuals intention to use EPR is considered as an appropriate measure of his/her
actual use of the technology (Hu et al., 1999a). Moreover, metaanalysis on the use of
psychosocial models in the study of healthcare professionals behaviors has found high
correlation between the intention to perform a given behavior and the actual behavior
(Godin and Kok, 1996). Thus, the dependant variable measured in this study is the
intention to use EPR.

Regarding the problem statement, this study is an attempt to understand how the
hospitals staff, those directly involved in the care and treatment of patients, accept and
utilize the new technology in this case, the EPR. Therefore, the research objective is to
investigate the factors affecting physicians and nurses intention to use EPR. This
objective is achieved, using an extension of an already existing adoption theory which
has not been applied to the hospitals staff EPR acceptance context before, and
conducting a survey as the research strategy through a quantitative approach.

1.7 Research Question

Regarding the literature review and current state of Iranian hospitals, among the
research opportunities in HIT and technology adoption contexts, investigating the factors
influencing Iranian hospitals staff intention to adopt EPR systems, is chosen to be
studied in this research. Thus, the research question is: What are the factors influencing
the Iranian hospitals staff intention to use EPR?

21
 It should be noted that this study does not focus on the applications or how daily
routines linked to patient treatment or care is affected but how the technology is viewed.

1.8 Importance of the Study

The development, implementation and adoption of IT is a highrisk undertaking

(Maass and Eriksson, 2006). Regarding the increasing usage of IT, the determinants of IT
usage have been widely studied in different researches as a key dependent variable
(Davis, 1989, 1993; Davis et al., 1989; Hartwick and Barki, 1994; Mathieson, 1991;
Thompson et al., 1991). The usage of IT is a necessary condition to ensure the
productivity payoffs from IT investments (Davis, 1989; Mathieson, 1991). It is common
knowledge that a number of projects fail (Lyytinen and Robey, 1999). The main reason to
this failure is that when a new technology is implemented, it changes the work practices
of the organization members and consequently they may not accept its usage (gerfalk
and Eriksson, 2004). Therefore, understanding why people use a technology and
investigating the factors influencing the new technology adoption, helps to ensure
effective deployment of IT resources in organizations and ensure a successful
implementation (Taylor and Todd, 1995a).

EPR software which is used to record histories, physical exams, and progress or
procedure notes, is touted as an important addition to the HIS (Johnson et al., 2004).
Although EPR has great influence on improving the healthcare quality, its functionality
has remained static over the past 30 years, which may be because of the limited adoption
of this tool (ibid). Despite the increasing availability of EPR, anecdotal evidence suggests
that its use has not been well accepted by physicians and nurses (Anderson, 2000;
McDonald et al., 1999). The vast investments and great expectations from the system,
present a challenge (Nikula, 2005), and yet few researches have been conducted to
investigate the factors influencing the hospitals staff acceptance of EPR. Much more
needs to be known about the adoption of EPR and in particular how the new technology
is taken into use.

22
 To conclude, the vast investment in IT in organizations, the need to understand
the factors influencing IT adoption in healthcare industry, the numerous effects of using
EPR on healthcare quality, and the role that hospitals staff play in this context, brings
great importance to this study.

1.9 Terminology

Electronic Patient Record: EPR embraces all departmental sources of patient

information (Maass and Eriksson, 2006). EPR system is a similar system to the analogue
patient record (ibid), supporting text documents and clinical data in electronic format
(Chang et al., 2007).

1.10 Structure of the Study

This dissertation is organized into 5 chapters as shown in Figure 1-2.

Figure 1-2 Structure of the Study

23
1.11 Summary

Regarding the increasing usage of IT in different industries and organizations,

understanding why people use a technology has become an important factor to
researchers. Healthcare industry is also an informationintensive industry and many
researches have been conducted so far to gain a better understanding of technology
adoption in this industry.

Due to the fact that, it is the healthcare professionals who decide whether or not to
use a new technology, finding out about the determinants of their decision to use a
specific technology is of great importance. Among these technologies is EPR which is
one the key factors to quality improvement in healthcare industry. Unfortunately,
although many Iranian hospitals have implemented HIS supporting EPRs; these systems
are not well accepted by the hospitals staff. Consequently, the vast investment in IT in
organizations, the need to understand the factors influencing IT adoption in healthcare
industry, the numerous effects of using EPR on healthcare quality, and the role that
hospitals staff play in this context, brings great importance to this study. Therefore the
research objective is to find out what the factors influencing the Iranian hospitals staff
(physicians, nurses) intention to adopt EPR, are.

24
Chapter 2
Literature Review

2. Literature Review

Chapter two is structured along several themes. First of all, this chapter explains
the basic terminology of Electronic Patient Record (EPR) and its benefits. Second, it
outlines the definition of adoption and different intention based adoption theories.
Finally, the research model and hypotheses are introduced.

25
2.1 Definition of EPR

Computing technologies were introduced to the clinical setting as early as the

mid1960s when a number of hospitals rapidly began clinical information system
projects for storage and retrieval of medical documents (Saba and McCormick, 1996).
Progress slowed as the complexity of such projects became apparent with limited success
in implementation but with the abandonment of mainframe computers and the advent of
the smaller microcomputers and minicomputers, interest in computerized clinical
information systems resumed in the 1970s and 1980s (Chamorro, 2001). Today,
computer has become integral to healthcare delivery, driven in part by accelerated
development of digital applications and communication technologies over the last two
decades and consequently diagnostics ranging from laboratory tests to more complex
imaging studies are healthcare functions that may be totally computerdriven (ibid). EPR
is a key infrastructure requirement in information management which is essential to
maintaining a scientific basis for healthcare (ibid).

Functional EPRs embrace all departmental sources of patient information (Maass

and Eriksson, 2006). In this scenario, the EPR is a similar system to the analogue patient
record (ibid), supporting text documents and clinical data in electronic format (Chang et
al., 2007).

According to Chamorro (2001), EPR is achieved through the integration of the

following items:

Admission, discharge, and transfer systems

Scheduling systems
Order entry and results reporting systems
Point of care clinical data entry systems, including
o Physician documentation
o Nursing information systems
o Ancillary healthcare provider documentation
Laboratory information systems
Pharmacy information systems
Radiology information systems
Medical logic modules aiding decision support
Research databases
26
 Charge capture and patient billing

Throughout this research the term EPR will be used but since healthcare industry
lacks a commonly accepted set of definitions and terminologies for clinical information
tools, many different terms are used throughout the literature to describe EPR (Brailer
and Terasawa, 2003). These terms are as follow (ibid):

Automated Medical Record (AMR)

Clinical Data Repository (CDR)
Computerbased Patient Record (CPR)
Computerbased Patient Record System (CPRS)
Computerized Medical Record (CMR)
Computerized Patient Record (CPR)
Electronic Health Record (EHR)
Electronic Medical Record (EMR)
Electronic Patient Record (EPR)
Lifetime Data Repository (LDR)
Virtual Health Record (VHR)
Virtual Patient Record (VPR)

2.2 Benefits of EPR

EPR is indicative of the advances in medical informatics and allows providers,

patients and payers to interact more efficiently and in lifeenhancing ways (Rogerson,
2000). It offers new methods of storing, manipulating and communicating medical
information of all kinds, including text, images, sound, video and tactile senses, which
are more powerful and flexible than paper based systems (ibid).

Not only EPR assists the handling of patient information but also facilitates
organizational and structural changes within healthcare delivery due to the enhanced
accessibility to patient information in time and space that it provides, and therefore the
main benefit of EPR is seamless care i.e. coordination between institutions involved in
the care and treatment of the individual patient (Nikula, 2005).

It is obvious that implementing EPR makes it possible to simplify the routines

concerning the patient record; no more looking around for the record, the physician can

27
countersign his notes almost anywhere (ibid). In addition, research is greatly facilitated,
investigations are completed on a timelier basis through the acquisition of aggregate data
directly from EPR databases for analysis and medical management of the patient is
accelerated (Chamorro, 2001).

By using EPR, aside from reducing paper cost and human energy, medical
expertise becomes available regardless of the location of the patient, which increases
patient democracy and quality of care (Maass and Eriksson, 2006).

Chamorro (2001) summarizes the advantages of EPR systems as follow:

Accessible simultaneously to multiple users and multiple settings

Integrates variable types of data media
Data are legible
Reduces medical errors
Prompts user for completeness and quality data
Supports structured data entry
Processes are accurately calculated
Can provide tools for decision support
Allows analysis if backed by database
Vehicle for health outcomes research that will drive practice changes

2.3 Technology Adoption

Rogers (1995) describes that adopters of any new innovation or idea could be
categorized as innovators (2.5%), early adopters (13.5%), early majority (34%), late
majority (34%) and laggards (16%), and each adopter's willingness and ability to adopt
an innovation would depend on their awareness, interest, evaluation, trial, and adoption.
Some of the characteristics of each category of adopters are as follow (ibid):

Innovators are venturesome and educated, with multiple information sources

and greater propensity to take risk.
Early adopters are social leaders, popular, and educated.
Early majority are deliberate, with many informal social contacts.
Late majority are skeptical and traditional, with lower socioeconomic status.
Laggards main information sources are neighbors and friends and have fear
of debt.

28
 A potential adopter passes through certain stages before decision is made on
whether to adopt or reject an innovation (ibid). Rogers (1995) defines the adoption
process as the process through which an individual or other decisionmaker unit passes
from first knowledge of an innovation, to forming an attitude toward the innovation to a
decision or rejection to implementation of the new idea, and to confirmation of this
decision. Regarding Rogers and Shoemaker (1971), consumers go through a process of
knowledge, persuasion, decision and confirmation' before they are ready to adopt a
product or service. The stages of innovation decision process are graphically presented in
Figure 2-1 and described as follow (Rogers, 1995):

1. Awareness: Socioeconomic characteristics, personality variables and

communication behavior all relate to innovativeness. Innovativeness is the
degree to which an individual or other adoption unit is relatively early in
adopting new ideas compared to other members of a system.
2. Persuasion: The potential adopters attitude towards the innovation is formed
in this stage. By anticipating and predicting future use satisfaction and risk of
adoption, the potential adopter develop positive or negative attitudes toward
the innovation, which plays an important role in modifying the final decision.
Perceived attitudes of an innovation as its relative advantage, compatibility
and complexity are especially important here.
3. Decision: The decision stage occurs when an individual engages in activities
that lead to adoption or rejection of the innovation. In this stage the adopter
starts to actively seek out information about the innovation that assists the
decision making.
4. Implementation stage: In this stage, mental information processing and
decision making come to an end, but the behavioral change begins.
5. Confirmation stage: After the adoption of innovations, the adopter keeps
evaluating the results of his/her decision. If the level of satisfaction is
significant enough, the use if innovation will continue; however, it is also
possible that the rejection occurs after adoption. In the latter case, the reverse
of previous decision is called discontinuance.

Finally adoption is defined as the acceptance and continued use of a product,

service or idea (Rogers and Shoemaker, 1971).

29
 Figure 2-1 Innovation Decision Process. Source: Rogers, 1995

Table 2-1 lists the researches conducted studying the adoption of EPR but none
has quantitatively investigated the EPR adoption by the hospitals staff.

Table 2-1 EPR Adoption Related Studies

Authors Year Title

Simon, S. R. 2007 Correlates of Electronic Health Record adoption in

Kaushal, R. office practices: A statewide survey

Cleary, P. D.
Jenter, C. A.
Volk, L. A.
Poon, E. G.
Orav, E. J.
Lo, H. G.
Williams, D. H.
Bates, D. W.

30
 Table 2-1 EPR Adoption Related Studies (Continued)

Authors Year Title

Anderson, J. G. 2007 Social, ethical and legal barriers to ehealth

Tang, P. C. 2006 Personal Health Records: Definitions, benefits, and

strategies for overcoming barriers to adoption
Ash, J. S.
Bates, D. W.
Overhage, J. M.
Sands, D. Z.

Ford, E. W. 2006 Predicting the adoption of Electronic Health Records

by physicians: When will healthcare be paperless?
Menachemi, N.
Phillips, M. T.

Nikula, R. E. 2005 A study of the adoption and definition of the

electronic patient record by clinicians

Middleton, B. 2005 Accelerating U.S. EHR adoption: How to get there

Hammond, W. Ed. from here. Recommendations based on the 2004
ACMI retreat
Brennan, P. F.
Cooper, G. F.

Berner, E. S. 2005 Will the wave finally break? A brief view of the
adoption of electronic medical records in the United
Detmer, D. E.
States
Simborg, D.

Rose, A. F. 2005 Using qualitative studies to improve the usability of

an EMR
Schnipper, J. L.
Park, E. R.
Poon, E. G.
Li, Q.
Middleton, B.

Ash, J. S. 2005 Factors and forces affecting EHR system adoption:

Report of a 2004 ACMI discussion
Bates, D. W.

31
 Table 2-1 EPR Adoption Related Studies (Continued)

Authors Year Title

Johnson, K. B. 2004 Brainstorming about nextgeneration computer

based documentation: An AMIA clinical working
Ravich, W. J.
group survey
Cowan, Jr J. A.

Walsh, S. H. 2004 The clinician's perspective on electronic health

records and how they can affect patient care

Brailer, D. J. 2003 Use and adoption of computerbased patient records

Terasawa, E. L.

Lorence, D. P. 2002 EPR adoption and dual record maintenance in the

U.S.: Assessing variation in medical systems
Spink, A.
infrastructure
Richards, M. C.

Van Ginneken, A. M. 2002 The computerized patient record: Balancing effort

and benefit

2.4 Adoption Theories

Several researches have focused on identifying the determinants of intention to

use a technology and therefore employed intentionbased theories, using behavioral
intention to predict usage (Davis et al., 1989; Hartwick and Barki, 1994; Mathieson,
1991). The following sections briefly introduce each of the theories most employed in the
studies of technology adoption by healthcare professionals.

2.4.1 Innovation Diffusion Theory (IDT)

Innovation Diffusion Theory (IDT) is a model that explains the process by which
innovations in technology are adopted by users (Rogers, 1995). The definition and core
constructs of IDT are explained in Table 2-2.

The validity of IDT has been demonstrated in a study of technology adoption by

nurses by Lee (2004). Also, Wu et al. (2007a) successfully tested a combination of IDT
and the Technology Acceptance Model (TAM) to investigate the mobile healthcare
32
systems acceptance factors in the healthcare industry. The graphical model of IDT is
presented in Figure 2-2.

Table 2-2 IDT

Innovation Diffusion Theory (IDT)

Grounded in sociology, IDT (Rogers, 1995) has been used since the 1960s to study a
variety of innovations, ranging from agricultural tools to organizational innovation
(Tornatzky and Klein, 1982).

Core Definitions
Constructs

Relative The degree to which an innovation is perceived to be better than the

Advantage idea it supersedes (Rogers, 1995).

Compatibility The degree to which an innovation is perceived as consistent with

the existing values, past experiences, and needs of potential adopters
(Rogers, 1995).

Complexity The degree to which an innovation is perceived as relatively

difficult to understand and use (Rogers, 1995).

Trialability The degree to which an innovation may be experimented with on a

limited basis (Rogers, 1995).

Observability The degree to which the results of an innovation are visible to

others (Rogers, 1995).

Figure 2-2 IDT. Source: Rogers, 1995

33
 Moore and Benbasat (1991) developed and refined IDT by adding few constructs.
Croteau and Vieru (2002) have studied telemedicine adoption by different groups of
physicians and validated their research model combining the refined IDT and TAM. Yi et
al. (2006) also performed a research on technology acceptance by individual
professionals and successfully tested a combined model of refined IDT, TAM and Theory
of Planned Behavior (TPB). The definition and core constructs of the refined IDT are
explained in Table 2-3. Figure 2-3 shows the graphical model of this theory.

Table 2-3 Refined IDT. Source: Venkatesh et al., 2003

Refined Innovation Diffusion Theory

Within Information System (IS) domain, Moore and Benbasat (1991) adapted the
characteristics of innovations presented in Rogers and refined a set of constructs that
could be used to study individual technology acceptance. Moore and Benbasat (1996)
found support for the predictive validity of these innovation characteristics (see also
Agarwal and Prasad, 1997, 1998; Karahanna et al., 1999; Plouffe et al. 2001).

Core Definitions
Constructs

Relative The degree to which an innovation is perceived as being better than

Advantage its precursor (Moore and Benbasat, 1991: 195).

Ease of Use The degree to which an innovation is perceived as being difficult to

use (Moore and Benbasat, 1991: 195).

Image The degree to which use of an innovation is perceived to enhance

ones image or status in ones social system (Moore and Benbasat,
1991: 195).

Visibility The degree to which one can see others using the system in the
organization (adapted from Moore and Benbasat, 1991).

Compatibility The degree to which an innovation is perceived as being consistent

with the existing values, and past experiences of potential adopters
(Moore and Benbasat, 1991: 195).

Results The tangibility of the results of using the innovation, including

Demonstrability their observability and communicability (Moore and Benbasat,
1991: 203).

Voluntariness The degree to which use of the innovation is perceived as being

of Use voluntary or of free will (Moore and Benbasat, 1991: 195).
34
 Figure 2-3 Refined IDT. Source: Moore and Benbasat, 1991

2.4.2 Theory of Reasoned Action (TRA)

The Theory of Reasoned Action (TRA) is a widely studied model from social
psychology, which is concerned with the determinants of consciously, intended
behaviors. The definition and core constructs of TRA are explained in Table 2-4.

Table 2-4 TRA. Source: Venkatesh et al., 2003

Theory of Reasoned Action (TRA)

Drawn from social psychology, TRA is one of the most fundamental and influential
theories of human behavior. It has been used to predict a wide range of behaviors (see
Sheppard et al. (1988)). Davis et al. (1989) applied TRA to individual acceptance of
technology and found that the variance explained was largely consistent with studies
that had employed TRA in the context of other behaviors.

Core Definitions
Constructs

Attitude An individuals positive or negative feelings (evaluative affect) about

Toward performing the target behavior (Fishbein and Ajzen, 1975: 216).
Behavior

Subjective The persons perception that most people who are important to him
Norm think he should or should not perform the behavior in question
(Fishbein and Ajzen, 1975: 302).

35
 Figure 2-4 shows the graphical model of TRA.

Figure 2-4 TRA. Source: Fishbein and Ajzen, 1975

2.4.3 Theory of Planned Behavior (TPB) and Decomposed TPB

The definition and core constructs of TPB and Decomposed TPB (DTPB) are
explained in Table 2-5. The validity of TPB was demonstrated in a study conducted by
Hu et al. (1999b) investigating physician acceptance of telemedicine technology.

Table 2-5 TPB and DTPB. Source: Venkatesh et al., 2003

Theory of Planned Behavior (TPB) and Decomposed TPB (DTPB)

TPB extended TRA by adding the construct of perceived behavioral control. In TPB,
perceived behavioral control is theorized to be an additional determinant of intention
and behavior. Ajzen (1991) presented a review of several studies that successfully used
TPB to predict intention and behavior in a wide variety of settings. TPB has been
successfully applied to the understanding of individual acceptance and usage of many
different technologies (Harrison et al. 1997; Mathieson, 1991; Taylor and Todd,
1995b). A related model is the Decomposed Theory of Planned Behavior (DTPB). In
terms of predicting intention, DTPB is identical to TPB. In contrast to TPB but similar
to TAM, DTPB decomposes attitude, subjective norm and perceived behavioral
control into the underlying belief structure within technology adoption contexts.

Core Constructs Definitions

Attitude Toward Behavior Adapted from TRA.

Subjective Norm Adapted from TRA.

Perceived Behavioral The perceived ease or difficulty of performing the

Control behavior (Ajzen, 1991: 188). In the context of IS
research, perceptions of internal and external constraints
on behavior (Taylor and Todd, 1995b: 149).

36
Figures 2-5 and 2-6 show the graphical models of TPB and DTPB respectively.

Figure 2-5 TPB. Source: Ajzen, 1991

Figure 2-6 DTPB. Source: Taylor and Todd, 1995a

37
2.4.4 Technology Acceptance Model (TAM) and Extended TAM (TAM2)

The definition and core constructs of TAM and Extended TAM (TAM2) are
explained in Table 2-6. Hu et al. (1999a) have empirically tested TAM for examining the
physicians acceptance of telemedicine technology. In the same year Succi and Walter
used an adaptation of TAM to explore the factors affecting acceptance of information
technologies by healthcare professionals. Years later, an investigation of the effects of
creating psychological ownership on physicians' acceptance of clinical information
systems by Pare et al. (2006) also found reasonable support for TAM. As for TAM2,
Chismar and WileyPatton (2002) have studied whether it applies to physicians or not,
and demonstrated its validity. Figures 2-7 and 2-8 show the graphical model of TAM and
TAM2 respectively.

Table 2-6 TAM and TAM2. Source: Venkatesh et al., 2003

Technology Acceptance Model (TAM) and Extended TAM (TAM2)

TAM is tailored to IS contexts, and was design to predict information technology

acceptance and usage on the job. Unlike TRA the final conceptualization of TAM
excludes the attitude construct in order to better explain intention parsimoniously.
TAM has been widely applied to a diverse set of technologies and users. TAM2
extended TAM by including subjective norm as an additional predictor of intention in
the ease of mandatory settings (Venkatesh and Davis, 2000).

Core Definitions
Constructs

Perceived The degree to which a person believes that using a particular

Usefulness system would enhance his or her job performance (Davis, 1989:
320).

Perceived Ease The degree to which a person believes that using particular system
of Use would be free of effort (Davis, 1989: 320).

Subjective Adapted from TRA/TPB. Included in TAM2 only.

Norm

38
 Figure 2-7 TAM. Source: Davis, 1989

Figure 2-8 TAM2. Source: Venkatesh and Davis, 2000

2.4.5 Combined TAM and TPB (CTAMTPB)

The definition and core constructs of the Combined TAM and TPB (CTAM
TPB) are explained in Table 2-7. Chau and Hu (2002) used CTAMTPB and
successfully tested it to investigate healthcare professionals decisions to accept
telemedicine technology.

Table 2-7 CTAMTPB. Source: Venkatesh et al., 2003

Combined TAM and TPB (CTAMTPB)

This model combines the predictors of TPB with perceived usefulness from TAM to
provide a hybrid model (Taylor and Todd, 1995a).

Core Constructs Definitions

Attitude Toward Behavior Adapted from TRA/TPB.

39
 Table 2-7 CTAMTPB. Source: Venkatesh et al., 2003 (Continued)

Core Constructs Definitions

Subjective Norm Adapted from TRA/TPB.

Perceived Behavioral Control Adapted from TRA/TPB.

Perceived Usefulness Adapted from TAM.

Figure 2-9 shows the graphical model of CTAMTPB.

Figure 2-9 CTAMTPB. Source: Chau and Hu, 2002

2.4.6 Unified Theory of Acceptance and Use of Technology (UTAUT)

The purpose of formulating the Unified Theory of Acceptance and Use of

Technology (UTAUT) was to integrate the fragmented theory and research on individual
acceptance of information technology into a unified theoretical model that captures the
essential elements of eight previously established models (Venkatesh et al., 2003). To do
so the eight specific models of the determinants of intention and usage of information
technology were compared and conceptual and empirical similarities across these models
were used to formulate UTAUT (Venkatesh et al., 2003). The eight discussed models
were: IDT, TRA, TAM, TPB, CTAMTPB, Model of PC Utilization (MPCU),
Motivational Model (MM), and the Social Cognitive Theory (SCT).

40
 According to Venkatesh et al. (2003), UTAUT is a definitive model that
synthesizes what is known. By encompassing the combined explanatory power of the
individual models and considering key moderating influences, UTAUT advances
cumulative theory while retaining a parsimonious structure (ibid). The definition and core
constructs of UTAUT are explained in Table 2-8.

Schaper and Pervan (2007) have empirically tested UTAUT for examining the
technology acceptance and utilization by occupational therapists. Chang et al. (2007) also
used UTAUT to explore the factors affecting Physicians acceptance of
pharmacokineticsbased clinical decision support systems. Figure 2-10 shows the
graphical model of UTAUT.

Table 2-8 UTAUT

Unified Theory of acceptance and Use of Technology (UTAUT)

Venkatesh et al. (2003) combined the views of user acceptance from eight previously
established theoretical models to formulate four core determinants of key relationship
and proposed a unified model called Unified Theory of Acceptance and Use of
Technology (UTAUT) to predict user intentions to use IT. This model has been
successfully employed in many technology adoption studies and has provided a useful
tool for managers to assess the success of new IT introductions (Chang et al., 2007).

Core Definitions
Constructs

Performance The degree to which an individual believes that using the system
Expectancy will help him or her to attain gains in job performance (Venkatesh et
al., 2003: 447).

Effort The degree of ease associated with the use of the system
Expectancy (Venkatesh et al., 2003: 450).

Social The degree to which an individual perceives that important others

Influence believe he or she should use the new system (Venkatesh et al., 2003:
451).

Facilitating The degree to which an Individual believes that an organizational

Conditions and technical infrastructure exists to support use of the system
(Venkatesh et al., 2003: 453).

41
 Figure 2-10 UTAUT. Source: Venkatesh et al., 2003

Among the eight theoretical models that Venkatesh et al. (2003) reviewed, IDT,
TRA, TAM, TPB, and CTAMTPB have so far been introduced. In the following
sections, the definition and core constructs of MPCU, MM, and SCT are presented to
help the reader gain a better understanding of UTAUT.

2.4.6.1 Model of PC Utilization (MPCU)

To ensure a fair comparison of the different models in their research, Venkatesh et

al. (2003) examined the mentioned determinants of intention in MPCU. The definition
and core constructs of MPCU are explained in Table 2-9.

42
 Table 2-9 MPCU. Source: Venkatesh et al., 2003

Model of PC Utilization (MPCU)

Derived largely from Triandis theory of human behavior, this model presents a
competing perspective to that proposed by TRA and TPB. Thompson et al. (1991)
adapted and refined Triandis model for IS contexts and used the model to predict PC
utilization. However, the nature of the model makes it particularly suitable to predict
individual acceptance and use of a range of information technologies.

Core Definitions
Constructs

Jobfit The extent to which an individual believes that using [a technology]

can enhance the performance of his or her job (Thompson et al.,
1991: 129).

Complexity Based on Rogers and Shoemaker (1971), the degree to which an

innovation is perceived as relatively difficult to understand and use
(Thompson et al., 1991: 128).

Longterm Outcomes that have a payoff in the future (Thompson et al., 1991:
Consequences 129).

Affect Toward Based on Triandis (1977), affect toward use is feelings of joy,
Use elation, or pleasure, or depression, disgust, displeasure, or hate
associated by an individual with a particular act (Thompson et al.,
1991: 127).

Social Factors Derived from Triandis (1977), social factors are the individuals
internationalization of the reference groups subjective culture, and
specific interpersonal agreements that the individual has made with
others, in specific social situations (Thompson et al., 1991: 126).

Facilitating Objective factors in the environment that observers agree make an

Conditions act easy to accomplish. In an IS context, provision of support for
users of PCs may be one type of facilitating condition that can
influence system utilization (Thompson et al., 1991: 129).

2.4.6.2 Motivational Model (MM)

Venkatesh et al. (2003) examined the constructs of MM and their effects on

intention in order to enrich their research model justification. The definition and core
constructs of MM, are explained in Table 2-10.

43
 Table 2-10 MM. Source: Venkatesh et al., 2003

Motivational Model (MM)

A significant body of research in psychology has supported general motivation theory

as an explanation for behavior. Several studies have examined motivational theory and
adapted it for specific contexts. Vallerand (1997) presents an excellent review of the
fundamental tenets of this theoretical base. Within the IS domain, Davis et al. (1992)
applied motivational theory to understand new technology adoption and use (see also
Venkatesh and Speier, 1999).

Core Definitions
Constructs

Extrinsic The perception that users will want to perform an activity because it is
Motivation perceived to be instrumental in achieving valued outcomes that are
distinct from the activity itself, Such as improved job performance, pay,
or promotions (Davis et al., 1992: 1112).

Intrinsic The perception that users will want to perform an activity for no
Motivation apparent reinforcement other than process of performing the activity per
se (Davis et al., 1992: 1112).

2.4.6.3 Social Cognitive Theory (SCT)

Venkatesh et al. (2003) examined the predictive validity of SCT in the context of
intention and usage to allow a fair comparison of the models. The definition and core
constructs of SCT, are explained in Table 2-11.

Table 2-11 SCT. Source: Venkatesh et al., 2003

Social Cognitive Theory (SCT)

One of the most powerful theories of human behavior is social cognitive theory (see
Bandura, 1986). Compeau and Higgins (1995) applied and extended SCT to the
context of computer utilization (see also Compeau et al., 1999).

Core Definitions
Constructs

Outcome The performancerelated consequence of the behavior. Specifically,

Expectations performance expectations deal with jobrelated outcomes (Compeau
Performance and Higgins, 1995).

44
 Table 2-11 SCT. Source: Venkatesh et al., 2003 (Continued)

Core Definitions
Constructs

Outcome The personal consequence of the behavior. Specifically personal

Expectations expectations deal with the individual esteem and sense of
Personal accomplishment (Compeau and Higgins, 1995).

Selfefficacy Judgment of ones ability to use a technology (e.g., computer) to

accomplish a particular job or task (Compeau and Higgins, 1995).

Affect An individuals liking for a particular behavior (Compeau and

Higgins, 1995).

Anxiety Evoking anxious or emotional reactions when it comes to performing

a behavior (Compeau and Higgins, 1995).

2.5 Comparison of Theories

Among the adoption theories presented in this chapter, UTAUT was found to be
the most complete model to investigate technology adoption determinants. According to
Venkatesh et al. (2003), UTAUT was tested using data from four organizations over a
sixmonth period and was found to outperform the eight individual models used to
formulate it (IDT, TRA, TAM, TPB, CTAMTPB, MPCU, MM, and SCT).
Explanatory power of UTAUT was then confirmed with data from two new organizations
with similar results (ibid).

Each of the constructs mentioned in IDT, TRA, TAM, TPB, CTAMTPB,

MPCU, MM, and SCT, pertained to one of the main constructs of UTAUT regarding the
substantial similarities that existed among their definitions and measurement items (ibid).
Tables 2-12 to 2-15 present the root constructs of performance expectancy, effort
expectancy, social influence and facilitating conditions, respectively.

45
 Table 2-12 Performance Expectancy Root Constructs. Source: Venkatesh et al., 2003

Construct Theory

Perceived Usefulness (Davis 1989; Davis et al., 1989) TAM/TAM2 and CTAM
TPB

Extrinsic Motivation (Davis et al., 1992) MM

Jobfit (Thompson et al., 1991) MPCU

Relative Advantage (Moore and Benbasat, 1991) IDT

Outcome Expectations (Compeau and Higgins, 1995; SCT

Compeau et al., 1999)

Table 2-13 Effort Expectancy Root Constructs. Source: Venkatesh et al., 2003

Construct Theory

Perceived Ease of Use (Davis, 1989; Davis et al., TAM/TAM2

1989)

Complexity (Thompson et al., 1991) MPCU

Ease of Use (Moore and Benbasat, 1991) IDT

Table 2-14 Social Influence Root Constructs. Source: Venkatesh et al., 2003

Construct Theory

Subjective Norm (Ajzen, 1991; Davis et al., 1989; TRA, TAM2, TPB/DTPB and
Fishbein and Azjen, 1975; Mathieson, 1991; Taylor CTAMTPB
and Todd, 1995a, 1995b)

Social Factors (Thompson et al., 1991) MPCU

Image (Moore and Benbasat, 1991) IDT

46
 Table 2-15 Facilitating Conditions Root Constructs. Source: Venkatesh et al., 2003

Construct Theory

Perceived Behavioral Control (Ajzen, 1991; Taylor TPB/DTPB and CTAM

and Todd, 1995a, 1995b) TPB

Facilitating Conditions (Thompson et al., 1991) MPCU

Compatibility (Moore and Benbasat, 1991) IDT

To conclude, UTAUT advanced individual acceptance research by unifying the

theoretical perspectives common in the literature and incorporating four moderators to
account for dynamic influences including organizational context, user experience, and
demographic characteristics (Venkatesh et al., 2003).

2.6 Other Important Factors Influencing the Intention to Adopt

Other than the factors mentioned in previously discussed adoption models, there
were three other factors influencing the intention to adopt new technologies, which were
recognized based on the results of conducted interviews, previous empirical studies and
literature review (Boyle and Ruppel, 2004; Featherman and Pavlou, 2003; Gagnon et al.,
2003; Limayem et al., 2000; Lu et al., 2005; Rosen, 2004; Wu et al., 2007b). These
factors (Facilitating Conditions, Perceived Time Risk and Personal Innovativeness in IT)
are explained in the following sections.

2.6.1 Facilitating Conditions

According to Triandis (1979), behavior is determined by three dimensions:

intention, facilitating conditions, and habit. Facilitating conditions represent objective
factors that can make the realization of a given behavior easy to do (Gagnon et al., 2003)
and is defined as the degree to which an Individual believes that an organizational and
technical infrastructure exists to support use of the system (Venkatesh et al., 2003).

Facilitating conditions was hypothesized to be linked directly to behavioral

intention in this study. This was done because firstly, the definition of facilitating

47
conditions in UTAUT captured the concept of perceived behavioral control, which was
directly linked to behavioral intention in TPB, DTPB and CTAMTPB (Venkatesh et
al., 2003) and secondly, previous studies that employed Triandis theory had found that
facilitating conditions was an important predictor of behavioral intention (Boots and
Treloar, 2000). Wu et al. (2007b) have also empirically tested the direct effect of
facilitating conditions on behavioral intention in a study of 3G mobile communication
acceptance and found reasonable support for it.

Additionally, in order to confirm the effect of facilitating conditions on behavioral

intention 25 healthcare providers were interviewed as experts and among them 21
interviewees agreed to the findings of literature and confirmed that facilitating conditions
had an important influence on their intention to use EPR, because they believed that
having sufficient organizational and technical infrastructure to support the new
technology in hospitals, was a very important factor to them, when deciding to use EPR.

2.6.2 Perceived Time Risk

Perceived risk (PR) is commonly thought of as felt uncertainty regarding possible

negative consequences of using a product or service (Featherman and Pavlou, 2003). It
has formally been defined as a combination of uncertainty plus seriousness of outcome
involved (Bauer, 1967), and the expectation of losses associated with purchase and
acts (Peter and Ryan, 1976). Featherman and Pavlou (2003) defined perceived risk as
the potential for loss in the pursuit of a desired outcome of using an eservice.

Perceived risk enters the IS adoption decision when circumstances of the decision
create (a) feelings of uncertainty, (b) discomfort and/or anxiety (Dowling and Staelin,
1994), (c) conflict aroused in the consumer (Bettman, 1973), (d) concern, (e)
psychological discomfort (Zaltman and Wallendorf, 1983), (f) making the consumer feel
uncertain (Engel et al., 1986), (g) pain due to anxiety (Taylor, 1974), and (h) cognitive
dissonance (Festinger, 1957; Germunden, 1985).

Cunningham (1967) identified two major categories of perceived risk (a)

performance and (b) psychosocial. He broke performance into three types (i) economic,
48
(ii) temporal, (iii) effort; and broke psychosocial into two types(i) psychological and
(ii) social. Cunningham (1967) further typified perceived risk as having six dimensions
(1) performance, (2) financial, (3) opportunity/time, (4) safety, (5) social and (6)
psychological loss. He also posited that all risk facets stem from performance risk. A rich
stream of consumer behavior literature supports the usage of these risk facets to
understand consumer product and service evaluations and purchases (Featherman and
Pavlou, 2003). The eservices research context does not incur any threat to human life;
therefore, measures of (physical) safety risk are not included in eservice adoption
studies (ibid).

Bellman et al. (1999) reported the importance of time considerations and found it
a significant predictor to online buying behavior. Timeconscious users likely guard
against the possible loss of time, and are less likely to adopt the eservice that they
consider as having high switching, setup and maintenance costs (Featherman and Pavlou,
2003). This research similarly proposed that users were very time oriented and concerned
about potential risks of wasting time implementing, learning how to use, and
troubleshooting EPR. Therefore among different facets of perceived risk, perceived time
risk defined as the degree to which a person believes that he/she may lose time using a
particular system (Featherman and Pavlou, 2003) was the one chosen to be included in
this research.

Additionally, in order to confirm the effect of perceived time risk on behavioral

intention, 25 healthcare providers were interviewed as experts and among them 23
interviewees agreed to the findings of literature and confirmed that perceived time risk
had an important influence on their intention to use EPR, because they thought they
might lose a considerable amount of time by adding the usage of EPR to their workflow.

2.6.3 Personal Innovativeness in IT

In general innovation diffusion research, it has long been recognized that highly
innovative individuals are active information seekers about new ideas (Lu et al., 2005).
They are able to cope with high levels of uncertainty and develop more positive

49
intentions toward acceptance (Rogers, 1983, 1995). Over the years, only a few studies
really integrated personal traits into technology acceptance research and even fewer into
intention to adopt IT/IS innovations.

Agarwal and Prasad (1998) believe that most proximate influence on an

individuals cognitive interpretations of IT is factors related to the individual. They
described personal innovativeness as symbolizing the risktaking propensity that exists in
certain individuals and not in others. They named this influential personal trait variable
on technology innovation adoption behaviors Personal Innovativeness in Information
Technology (PIIT) or simply Personal Innovativeness (PI). Personal innovativeness is a
personality trait that all individuals possess with differences in its degree (Midgley and
Dowling, 1978), as some people characteristically adapt while others characteristically
innovate (Kirton, 1976: 624). PIIT is defined as the willingness of an individual to try
out any new information technology (Lu et al., 2005).

This construct has been generally paid attention to by innovation diffusion

researches (Rogers, 1983, 1995) and particularly studied in marketing researches (Flynn
and Goldsmith, 1993; Midgley and Dowling, 1978; Roehrich, 1994). In the field of
marketing, Eastlick and Lotz (1999) empirically tested a link between personal
innovativeness and electronic shopping, finding that those who were more innovative
were more likely to intend to purchase than those who were less innovative. Agarwal and
Prasad (1998) added this individual difference variable as a new construct to Davis
original TAM model and hypothesized that individuals with higher levels of PIIT are
expected to have more positive intentions toward use of a new IT/IS. Another empirical
study found support for the link between personal innovativeness and intention to
purchase over the Internet using a research model that was an extension of the TPB
(Limayem et al., 2000).

Lu et al. (2005) note that, for adoption of an IT/IS innovation such as EPR, most
people do not have any or much knowledge and experience to help them form clear
perception beliefs. Sheer boldness and curiosity in their characters may not only strongly
amplify their perception of potential benefits, but also heighten their confidence in their

50
capabilities to handle the technology under adoption (Lu et al., 2005). Meanwhile,
because individuals with higher PIIT tend to be more risktaking, it is also reasonable to
expect them to develop more positive intentions toward the use of EPR. Therefore this
study enhanced the understanding of the factors affecting the adoption of EPR by using
an extended model of UTAUT and taking into consideration the important concept of
personal innovativeness in IT. The theoretical justification for testing this concept came
from the statement that Individuals with high PIIT are likely to be impulsive by nature
and may not think through the reasons and implications for their actions. In other words,
they may dive in and try the technology due to their curious and risktaking nature, and
not necessarily base their decision on the concrete advantages for doing so (Agarwal et
al., 1998). This suggested that PIIT as a construct was as important as relative advantage
(performance expectancy) and other perceptions (effort expectancy) in directly predicting
behavioral intentions (Rosen, 2004).

Additionally, in order to confirm the effect of personal innovativeness in IT on

behavioral intention 25 healthcare providers were interviewed as experts and the results
were the same as the findings of literature and showed that the more innovative they
were, the more they intended to use IT means including EPR systems, in their practice.

2.7 Research Model

Most of the studies of technology adoption in healthcare industry that were based
on a theoretical framework employed TPB, TAM, or IDT. Hu et al. (1999a) have
empirically tested TAM for examining the technology acceptance model using physician
acceptance of telemedicine technology. The validity of IDT was demonstrated in a study
of technology adoption by nurses by Lee (2004). An investigation of telemedicine
adoption among physicians in Hong Kong found reasonable support for the TPB (Hu et
al., 1999b).

Among the adoption theories, the UTAUT model, based on justifications brought
up in previous sections, encompassed most of determinants found in the previously
mentioned models. That is why the basis of the research model proposed to conduct this

51
research was UTAUT. This model has not yet been applied to the hospitals staff EPR
acceptance context but it has been successfully employed in many other technology
adoption studies and has provided a useful tool for managers to assess the likelihood of
success of new IT introductions. Schaper and Pervan (2007) have empirically tested
UTAUT for examining the technology acceptance and utilization by occupational
therapists. Chang et al. (2007) also used UTAUT to explore the factors affecting
Physicians acceptance of pharmacokineticsbased clinical decision support systems.

In order to identify the factors influencing the intention to adopt EPR, this study
enriched UTAUT by adding three other constructs as direct antecedents of behavioral
intention which were: Facilitating Conditions, Perceived Time Risk and Personal
Innovativeness. Figure 2-11 shows the graphical model of the proposed research model.

Figure 2-11 Proposed Research Model

Hypothesizing the moderating effects of voluntariness and experience was not

feasible in this study therefore, among the four moderators included in UTAUT only
gender and age were mentioned in the proposed research model. The reason to this was
52
that firstly, as argued previously, in most of the Iranian hospitals which had implemented
HIS supporting EPR, doctors and nurses were not forced to use it, thus this research was
conducted under voluntary setting. Secondly, this research investigated the factors
influencing the hospitals staff intention to use EPR, only in one period of time, and the
effect of experience in using the system could not be verified as the study was cross
sectional.

For performance expectancy, effort expectancy and social influence which were
the antecedents of behavioral intention in UTAUT, both gander and age were
hypothesized as moderators, exactly as it was done in UTAUT.

Organizational psychologists have noted that older workers attached more

importance to receiving help and assistance on the job (e.g.. Hall and Mansfield, 1975).
This was further underscored in the context of complex IT use given the increasing
cognitive and physical limitations associated with age (Venkatesh et al., 2003). Thus, in
this study it was hypothesized that when moderated by age, facilitating conditions will
have a significant influence on behavioral intention. The moderating effect of gender on
the relationship between facilitating conditions and behavioral intention has not been
discussed and proven in the previously reviewed literature. Thereby, according to the
literature review and results of conducted interviews with experts, gender was not
hypothesized as a moderator for the relationship between facilitating conditions and
behavioral intention.

The moderating effect of gender and age on the influence of perceived time risk
on behavioral intention has not been mentioned and proven in the previously conducted
studies. Therefore regarding the literature review and results of conducted interviews
with experts, gender and age were not hypothesized as moderators for the effect of
perceived time risk on behavioral intention.

The relationship between personal innovativeness and age has not been proven.
About half of the many diffusion studies on this subject show no relationship, a few
found that earlier adopters are younger, and some indicate they are older (Rogers, 2003).

53
The relationship between gender and PIIT was tested in a recent study on culture and
information overload, and found to be nonsignificant (Rosen, 2004). Since both gender
and age did not seem to be correlated with PIIT in the literature, and considering the
results of conducted interviews, the influences of gender and age as moderators for the
effect of PIIT on behavioral intention were not hypothesized in this study.

2.8 Research Hypotheses

Hypotheses 1a to 3c were proposed based on UTAUT (Venkatesh et al., 2003),

While Hypotheses 4a to 6 were the contributions of this study, which were chosen based
on the results of conducted interviews, previous empirical studies and literature review
(Boyle and Ruppel, 2004; Featherman and Pavlou, 2003; Gagnon et al., 2003; Limayem
et al., 2000; Lu et al., 2005; Rosen, 2004; Wu et al., 2007b). Later on, these hypotheses
were verified for their validity by empirical data.

Hypothesis 1a: Performance expectancy positively influences hospitals staff behavioral

intention to use EPR.

Hypothesis 1b: The influence of performance expectancy on hospitals staff behavioral

intention to use EPR will be moderated by gender, such that the effect will be stronger for
men.

Hypothesis 1c: The influence of performance expectancy on hospitals staff behavioral

intention to use EPR will be moderated by age, such that the effect will be stronger for
younger users.

Hypothesis 2a: Effort expectancy positively influences hospitals staff behavioral

intention to use EPR.

Hypothesis 2b: The influence of effort expectancy on hospitals staff behavioral

intention to use EPR will be moderated by gender, such that the effect will be stronger for
women.

54
Hypothesis 2c: The influence of effort expectancy on hospitals staff behavioral intention
to use EPR will be moderated by age, such that the effect will be stronger for younger
users.

Hypothesis 3a: Social influence positively influences hospitals staff behavioral intention
to use EPR.

Hypothesis 3b: The influence of social influence on hospitals staff behavioral intention
to use EPR will be moderated by gender, such that the effect will be stronger for women.

Hypothesis 3c: The influence of social influence on hospitals staff behavioral intention
to use EPR will be moderated by age, such that the effect will be stronger for older users.

Hypothesis 4a: Facilitating conditions positively influences hospitals staff behavioral

intention to use EPR.

Hypothesis 4b: The influence of facilitating conditions on hospitals staff behavioral

intention to use EPR will be moderated by age, such that the effect will be stronger for
older users.

Hypothesis 5: Perceived time risk negatively influences hospitals staff behavioral

intention to use EPR.

Hypothesis 6: Personal innovativeness in IT positively influences hospitals staff

behavioral intention to use EPR.

2.9 Summary

EPR systems embrace all departmental sources of patient information in a

healthcare organization. These systems have many advantages such as: seamless care,
accuracy, reduced cost and time and access to legible data.

Due to the rapid growth of IT in healthcare industry, technology adoption theories

have become of great importance to explore the factors influencing technology adoption

55
among healthcare providers. Most of the studies of technology adoption in healthcare
industry that were based on a theoretical framework employed TPB, TAM, or IDT.

Among the technology adoption theories applied to the study of technology

acceptance by physicians and nurses, UTAUT was found to be the most complete one,
outperforming other models and appeared to be a more comprehensive model since it
integrated most dimensions involved in other theoretical models. That is why the basis of
the research model proposed to conduct this research was UTAUT. In order to identify
the factors influencing hospitals staff intention to adopt EPR, this study enriched
UTAUT by adding three other constructs as direct antecedents of behavioral intention
which were: Facilitating Conditions, Perceived Time Risk and Personal Innovativeness.
Among the four moderators included in UTAUT only the effects of gender and age were
hypothesized, and verifying the influences of voluntariness and experience was not
feasible in this study.

56
Chapter 3
Methodology

3. Methodology

This chapter discusses the research methodology of the dissertation. It starts with
the research purpose and research approach. Then it outlines the research strategy and
sampling method. Finally it presents the procedure of questionnaire design, pilot study
and data collection, to the reader.

57
3.1 Research Purpose

According to Robson (1993), research can be categorized into different types

depending on the nature of the purpose or research problem. The purpose of an academic
research can be exploratory, descriptive, or explanatory but the boundaries between the
categories are not always clear (Yin 1994; Zikmund 2000). Saunders et al. (2000) note
that more than one purpose can be employed in a study. The three categories are
described below:

Exploratory Research

According to Zikmund (2000), exploratory research is conducted to clarify and

research a better understanding of the nature of the problem. Therefore, exploratory
research is appropriate to use when there is little prior knowledge of the problem
researched (ibid). Exploratory study is a valuable means of founding out what is
happening; to seek new insight; to ask questions and to assess phenomena in a new light
(Robson, 1993). The purpose of the exploratory research is to decide and demonstrate the
character of the problem by collecting information through exploration (Eriksson and
WiedersheimPaul, 1999). Exploratory studies tend toward loose structures with the
objective of discovering future research tasks (Cooper and Schindler, 2003). Saunders et
al. (2000) argue that exploratory research is advantageous because it is flexible and
adaptable to change. However; the flexibility inherent in exploratory research does not
mean absence of direction to the enquiry (Adams and Schvaneveldt, 1991).

Descriptive Research

The objective of descriptive research is to portray an accurate profile of a person,

event or situation, and may be an extension of, or forerunner to, a piece of exploratory
research (Robson, 1993). Zikmund (2000) elucidates descriptive research as, when
research problem is known but the researcher is not fully aware of situation. The
simplest descriptive study concerns a univariate question or hypothesis in which we ask
about, or state something about, the size, form, distribution, or existence of a variable
(Cooper and Schindler, 2003). According to Zikmund (2000), descriptive research

58
answers who, what, where, when or how much questions and do not give any explanation
for the cause of the findings.

Explanatory Research

The emphasis of explanatory researches is on studying a problem or a

phenomenon in order to establish causal relationship among variables (Saunders et al.,
2000). Explanatory research is sometimes referred to as causal research (Zikmund, 2000).
Normally, Exploratory and descriptive research are conducted first and then explanatory
research tries to establish and explain patterns related to phenomenon of interest
(Saunders et al, 2000).

Since this research aimed to find out, test and describe the factors influencing
physicians and nurses intention to use EPR, and was concerned with finding what by
asking the research question: What are the factors influencing the Iranian hospitals staff
intention to use EPR, the research purpose of this study was descriptive.

3.2 Research Approach

Zikmund (2000) discusses two main aspects regarding research approach, the
theoretical approach and the methodological approach. The theoretical approach can be
either inductive or deductive and the methodological can be either qualitative or
quantitative. These two research approaches are further discussed in the following
sections.

3.2.1 Theoretical Approach

Any research project involves the use of theory. The theoretical approach can be
either inductive or deductive. The two theoretical research approaches propose two
different ways of drawing conclusions when conducting research (Saunders et al., 2000).
The extent to which a researcher is clear about the theory at the beginning of his research
raises an important question concerning the design of his research project and that is
whether the research should use the deductive approach, where the researcher develops a

59
theory and hypothesis and designs a research strategy to test the hypothesis using
quantitative data, or the inductive approach, where he collects data and develops theory
as a result of his data analysis (ibid). The inductive research approach can be defined as
the logical process of establishing the general proposition on the basis of observation of
particular facts, while the deductive research approach can be defined as the logic
process of deriving a conclusion from unknown premise or something known to be true
(Zikmund, 2000).

When deciding what research approach to adopt, Saunders et al. (2000) suggest
number criteria to be considered. The first and perhaps the most important criterion is the
nature of the research topic. If there is a lot of literature about the topic from which a
theoretical framework can be defined, it is often suitable to use the deductive approach.
In opposition, when researching a topic that is new and little existing literature can be
found, it may be more appropriate to use an inductive approach. The time available for
the study is the second criterion that needs to be considered. Inductive researches are
often more time consuming than deductive researches because they are based on a longer
period of data collection and analysis, and the ideas emerge gradually. Finally, the third
criterion is the risk involved. The inductive research approach involves the risk that no
useful data pattern and theories will emerge, while the deductive research approach is
usually a lower risk strategy, even though there are some risks, such as nonreturn of
questionnaires.

Due to the fact that in this research project, firstly theories existed within the area
and conclusion was drawn from theories, secondly the time available for the study was
limited, thirdly there was no great risk involved and fourthly the hypotheses were tested
collecting quantitative data, deductive research approach was suitable to be used as the
theoretical approach.

3.2.2 Methodological Approach

There are two main methodological approaches to choose from when conducting
research in social science: quantitative or qualitative method (Yin, 1994). Qualitative and

60
quantitative methods are two broad methodological approaches to research which
propose two different ways of collecting information (Zikmund, 2000). The qualitative
approach means collecting qualitative data, which is often referred to as soft data,
containing information about actions or functions while, the quantitative approach
involves collecting quantitative data, which implies hard data (ibid).

Qualitative data is often presented as words and observations and involves non
numerical examination and interpretation of observation for the purpose of discovering
the underlying meaning and pattern of relationships but quantitative data involves
numerical representation and manipulation observation for the purpose of describing and
explaining the phenomena that those observations reflect and will often determine the
quantity or extent of some phenomena (ibid).

Qualitative research emphasis the process and meaning that are not rigorously
examined or measured, in term of quantity, amount of intensity or frequency and
therefore the characteristics of qualitative studies are that they are based largely on the
researchers own description, emotions and reactions (Yin, 1994). In contrast,
quantitative study emphasis measurement and analysis of causal relationships between
variables, not processes (Casebeer and Verhoef, 1997; McDaniel and Gates, 1996;
EastebySmith et al., 1991). In quantitative research variables and relationships are the
central idea and a deductive model is used to test the relationship between variables and
to provide evidence for or against prespecific hypothesis (Neuman, 2003). Quantitative
research is useful in providing detailed planning prior to data collection and analysis,
because it provides tools for measuring concepts, planning design stages and for dealing
with population and sampling issues and is especially appropriate when conducting a
wide investigation that contains many units (Yin, 1994).

The main objective of this study was to find the factors influencing the adoption
of EPR by Iranian hospitals staff. For achieving this, a structured framework was
chosen and research hypotheses were developed. Since the researcher decided to explain
the EPR adoption phenomenon by numbers, the conclusion had to be based on the data

61
that could be quantified and analyzed statistically. Thereby quantitative approach proved
to be the most appropriate methodological approach for this study.

3.3 Research Strategy

The research strategy is a general plan of how a researcher will go about

answering the research question(s) he/she has set (Yin, 1994). It contains clear objectives,
derived from the research question(s), specifies the sources from which the researcher
intends to collect data and considers the constraints which he inevitably has (ibid). There
are five major research strategies for reaching an intended research purpose: Experiment,
Survey, Archival Analysis, History and Case Study (ibid). Table 3.1 presents these five
research strategies and the relevant situation for each of them.

Table 3-1 Relevant Situation for Different Research Strategies. Source: Yin, 1994

Requires Control Focus on

Strategy Form of Research Question over Behavioral Contemporar
Events y Event

Experiment How, Why Yes Yes

Who, What, Where , How

Survey No Yes
many, How much

Archival Who, What, Where , How

No Yes/No
Analysis many, How much

History How, Why No No

Case Study How, Why No Yes

According to Yin (1994), there are three conditions that distinguish the different
research strategies:

The type of research question posed

The extent of control a researcher has over actual behavioral events
The degree of focus on contemporary as opposed to historical events

62
 The conditions above need to be considered to be able to select the most suitable
strategy for a research study. Due to the fact that this study focused on contemporary
events, did not require control over behavioral events and the research question was in
form of what, the most suitable strategy was survey.

3.4 Sampling

Survey the strategy chosen to conduct this research is a technique in which

information is collected from a sample of people through a questionnaire (Zikmund,
2000). The basic idea of sampling is that by selecting some of the elements in a
population, conclusion about the entire population may be drawn (Cooper and Schindler,
2003). In order to do the sampling, the target population and the sampling technique have
to be selected.

3.4.1 Defining the Target Population

Sampling design begins by specifying the target population that is the collection
of elements or objects that possess the information sought by the researcher and about
which inferences are to be made (Malhotra and Briks, 2003). The target population
should be defined in terms of elements, sampling units, extent and time (ibid). An
element is the object about which or from which the information is desired which in
survey research is usually the respondent (ibid). A sampling unit is an element, or a unit
containing the element, that is available for selection at some stage of the sampling
process (ibid). Extent refers to the geographical boundaries of the research, and time
refers to the period under consideration (ibid).

The main goal of this study was to investigate factors influencing Iranian
hospitals staff (physicians and nurses) intention to adopt EPR. Therefore, the population
of interest was defined as physicians and nurses working at hospitals which had
implemented HIS supporting EPR but did not force the clinical staff to use it. Since the
interest of the research was in the concept of intention, the respondents were
inexperienced users of EPR (nonusers) who were familiar with the technology, so that
they had an idea of what the system was. On the other hand, as EPR is a new technology
63
used in Iranian healthcare industry, it has mostly been implemented in the hospitals
located in the capital city of Iran and thats why the research was conducted in Tehran.
To conclude, the target population of this study was defined as:

Elements: Inexperienced users of EPR

Sampling units: Physicians and nurses working at hospitals which had
implemented HIS supporting EPR
Extent: Hospitals located in Tehran
Time: Mid October 2007 to the end of December 2007

3.4.2 Selecting the Sampling Technique

The sampling techniques can be divided into two types (Saunders et al., 2000):

Probability
Nonprobability

In probability sampling since the sampling units are selected randomly, the
chance, or probability, of each case being selected from the population is known and is
usually equal for all cases and thereby if done properly, probability sampling ensures that
the sample is representative (Hair et al., 2003). Probability sampling is most commonly
associated with surveybased research where researcher needs to make inferences from
the sample about a population to answer the research questions or to meet research
objectives (Saunders et al., 2000).

In nonprobability sampling the selection of elements for the sample is not

necessarily made with the aim of being statistically representative of the population and
the researcher rather uses the subjective methods such as personal experience,
convenience, expert judgment and so on to select the elements in the sample (Hair et al.,
2003). As a result the probability of any elements of the population being chosen is not
known, but the researcher may still be able to generalize from nonprobability samples
about the population (Saunders et al., 2000).

64
 Nonprobability sampling provides a range of alternative technique based on
researcher subjective judgment (ibid). Different nonprobability sampling methods are as
follow:

Convenience sampling (Hair et al., 2003; Saunders et al., 2000): Convenience

Sampling involves selecting those cases that are easiest to obtain for sample.
The sample selection process is continued until the required sample size has
been reached. Convenience sample enables the researcher to complete a large
number of interviews cost effectively and quickly but they suffer from
selection bias.
Selfselection sampling (Saunders et al., 2000): Selfselection sampling
occurs when the researcher allows a case, usually an individual, to identify
their desire to take part in the research.
Snowball sampling (ibid): Snowball sampling is commonly used when it is
difficult to identify members of the desired population. The researcher
therefore needs to make contact with one or two cases in the population, ask
these cases to identify further cases and ask these new cases to identify further
new cases.
Judgment sampling (ibid): Judgment Sampling enables the researcher to use
his or her judgment to select group of people who have knowledge about
particular problem in order to best enable him or her to answer research
question(s) Sometimes it is referred as a purposive sample because it involves
a specific purpose.
Quota sampling (Barnett, 1991): Quota sampling is entirely nonrandom and
is normally used for interview surveys. It is based on the premise that your
sample will represent the population as the variability in the sample for
various quota variables is the same as that in the population. Quota sampling
is therefore a type of stratified sample in which selection of cases within strata
is entirely nonrandom.

The choice of sampling technique depends on the feasibility and sensibility of

collecting data to answer the research question(s) and to address the researchers
objectives from the entire population (Saunders et al, 2000). Since EPR is a newly born
technology in Iran and thereby at the time the research was conducted there were a few
hospitals which had implemented the system and enabled their staff to use it, it was
decided to target only physicians and nurses working at hospitals which had implemented
HIS supporting EPR located in Tehran and who were nonusers of the system.
Consequently, the method of sampling in this research was nonprobability and based on
the judgment of the researcher to conform to the desired criterion, considering the fact

65
that according to Malhotra and Briks (2003), non probability samples may also yield
good estimates of the population characteristics.

3.5 Measurement of Constructs

The objective of this research was to investigate factors influencing the intention
to adopt EPR from Iranian hospitals staff (physicians and nurses) point of view. Aside
from the literature review, twenty five interviews with a set of openended questions
were conducted with 25 healthcare provider experts. This step was conducted because
different populations may possess different beliefs regarding the same behavior. Open
ended questions were used to identify beliefs regarding the target population behavior,
and to confirm the selection of proposed constructs. Examples of questions were: What
are the key factors influencing EPR adoption among Iranian hospitals staff? or What
do you think are the possible barriers in front of EPR adoption? Consequently, based on
extended literature review and the conducted interviews, appropriate research constructs
which had been validated in prior studies, were developed. Table 3-2 presents these
constructs and their corresponding definition.

Table 3-2 Definition of Constructs

Construct Definition Source

Performance The degree to which an individual (physician Venkatesh et al.

Expectancy (PE) or nurse) believes that using EPR will help him (2003)
or her to attain gains in job performance

Effort Expectancy The degree of ease associated with the use of Venkatesh et al.
(EE) EPR (2003)

Social Influence The degree to which an individual (physician Venkatesh et al.

(SI) or nurse) perceives that important others (2003)
believe he or she should use EPR

Facilitating The degree to which an Individual (physician Venkatesh et al.

Conditions (FC) or nurse) believes that an organizational and (2003)
technical infrastructure exists to support use of
EPR

66
 Table 3-2 Definition of Constructs (Continued)

Construct Definition Source

Perceived Time The degree to which a person (physician or Featherman and

Risk (PTR) nurse) believes that he/she may lose time using Pavlou (2003)
EPR

Personal The willingness of an individual (physician or Lu et al. (2005)

Innovativeness in nurse) to try out using EPR
IT (PIIT)

Behavioral A person (physician or nurse) readiness to Davis et al.

Intention (BI) adopt EPR (1989)

It is to be noted that all constructs were measured with reflective items resulting
from review of the relevant literature.

3.6 Questionnaire Design

Data collection instrument is highly influenced by the strategy chosen to conduct

the research (Saunders et al., 2000). Considering the survey strategy which was applied in
this study, a questionnaire was used as the data collection instrument.

The questionnaire was created with items validated in prior technology

acceptance researches. Performance expectancy, effort expectancy, social influence,
facilitating conditions and behavioral intention scales were adapted from Venkatesh et al.
(2003); perceived time risk scales were adapted from Featherman and Pavlou (2003); and
personal innovativeness in IT scales were adapted from Limayem et al. (2000).

The questionnaire was arranged in three sections. The first section was designed
to collect general information about the respondents among which age and gender were
considered as the moderators of the research model, too. In order to test these moderating
influences, gender was coded as a dummy variable and age was coded as a continuous
variable, consistent with prior research of Venkatesh et al. (2003). The second section
included questions asking about respondents perception about EPR. Five point likert
scales were used for construct measurements, with 1 being the negative end of the scale

67
and 5 being the positive end of the scale consistent with prior study of Limayem et al.
(2000). The third section asked questions about the status of EPR usage in the hospital
they worked at. The questionnaire was finally ready for pilot test after being translated to
Farsi.

3.7 Pilot Study

Mitchell (1996) suggests that a researcher should run a pilot study asking an
expert or a group of experts to comment on the representativeness and suitability of the
questionnaire, as well as allowing suggestions to be made to the structure of the
questionnaire. The pilot study was conducted after translating the questionnaire to Farsi.
The number of people a researcher chooses for the pilot test should be sufficient to
include any major variations in his/her population that the researcher feels is likely to
affect responses (Fink, 1995). For most questionnaires, this means that the minimum
number for a pilot is 10 (ibid). In this research the number of experts in the pilot test, was
15. The pilot study of this research was run in two stages. The first stage of the pilot
study was conducted in order to identify and eliminate potential problems of the
questionnaire. Fifteen experts among healthcare providers, who were nonusers of EPR,
were asked to answer the questions and report anything in the questionnaire which caused
misunderstanding or was not clear or relevant. As a result, the vocabulary problems
which caused misunderstandings were solved by making slight changes in wording. Also,
one of the performance expectancy questions was eliminated, as it was reported irrelevant
to the case of healthcare providers in Iran. In the second stage of the pilot study the
revised questionnaire was given to another fifteen experts in order to make sure there
were no more problems with it. In this stage the questionnaire was approved by the
respondents and therefore it was accepted as the final questionnaire (shown in appendix
B) in order to be distributed among the sample respondents.

68
3.8 Data Collection

Most research questions are answered using some combination of secondary and
primary data (Saunders et al., 2000); it is the same for this research. Data collection
process consisted of four stages in this study.

The first stage included using literature as secondary data to propose the research
model, which was explained in previous chapters.

In the second stage, primary data was gathered through interviews with experts, to
find out their point of view and refine the research model in order to be more relevant to
the especial characteristics of the healthcare industry. In this stage, 25 experts among
healthcare providers who were nonusers of EPR but familiar with the system were
interviewed, being asked openended questions.

During the third stage, primary data was collected through distributing
questionnaires to test the developed hypotheses statistically. In this stage questionnaires
were distributed from mid October 2007 to the end of December 2007, in 6 hospitals in
Tehran which had implemented HIS supporting EPR but did not force the clinical staff to
use the system. This was done as mentioned before to be able to investigate the factors
influencing the intention to adopt EPR among healthcare providers who could use the
system and yet they did not. As the number of staff is considerably larger in public
hospitals than the private ones in Iran, following the advice of hospital managers, two of
the selected hospitals were public hospitals: Dr. Shariati Hospital and Shahid Rajaee
hospitals and four of them were private ones: Toos, Day, Kasra, and Laleh hospitals. Out
of the 248 distributed questionnaires, 123 questionnaires were collected from the public
hospitals and 109 questionnaires from private ones, which make an overall of 232
questionnaires which were all complete and considered valid. Thereby, the response rate
was 93%. According to Barclay et al., (1995), in Partial Least Squares (PLS), which was
the data analysis technique used in this study and is to be discussed later in chapter 4, the
sample should have at least ten times more datapoints than the number of items in the
most complex construct in the model. Since the most complex constructs in the proposed

69
research model in this study had 4 items, the minimum size of the sample needed was 40.
Consequently, 232 was a very satisfying sample size in order to analyze the data. It is to
be noted that, questionnaires were completely anonymous and none of the material sent
to the hospitals staff was personalized.

Finally, in the fourth stage primary data that was gathered through interviews with
fifteen healthcare providers as experts was used to find out the reason why some of the
hypotheses were rejected in their opinion and also to obtain practical suggestions
regarding the final research model.

3.9 Summary

In this research a descriptive purpose was followed through a quantitative

approach by running a survey using nonprobability sampling. The target population was
defined as:

Elements: Inexperienced users of EPR

Sampling units: Physicians and nurses working at hospitals which had
implemented HIS supporting EPR
Extent: Hospitals located in Tehran
Time: Mid October 2007 to the end of December 2007

A questionnaire was created using the items validated in prior technology

acceptance researches and arranged in three sections. Performance expectancy, effort
expectancy, social influence, facilitating conditions and behavioral intention scales were
adapted from Venkatesh et al. (2003); perceived time risk scales were adapted from
Featherman and Pavlou (2003); and personal innovativeness in IT scales were adapted
from Limayem et al. (2000). In order to test the moderating influences, gender was coded
as a dummy variable and age was coded as a continuous variable, consistent with prior
research of Venkatesh et al. (2003). Five point likert scales were used for construct
measurements, consistent with prior study of Limayem et al. (2000).

70
 With the help of a twostage pilot study the questionnaire was refined and some
corrections were made to finalize it according to the experts opinion and healthcare
industry characteristics in Iran.

Data collection process consisted of four stages. The first stage included using
literature as secondary data to propose the research model. In the second stage, primary
data was gathered through interviews with experts, to find out their point of view and
refine the research model in order to be more relevant to the healthcare industry especial
characteristics. During the third stage, primary data was collected through distributing
questionnaires to test the developed hypotheses statistically. In this stage questionnaires
were distributed in 6 hospitals located in Tehran which had implemented HIS supporting
EPR but did not force the clinical staff to use the system, and as a result 232
questionnaires were collected. Finally, in the fourth stage primary data that was gathered
through interviews with healthcare providers as experts were used to find out the reason
why some of the hypotheses were rejected in their opinion and also to obtain practical
suggestions regarding the final research model.

71
Chapter 4
Data Analysis

4. Data Analysis

This chapter presents the statistical analysis method used to analyze the collected
data and then introduces the reader to the evaluation of the proposed research model in
terms of reliability and validity. Finally the results of hypotheses tests are reported.

72
4.1 Statistical Analysis Method

Regarding the complex nature of the proposed research model, the Structural
Equation Modeling (SEM) method was used to evaluate the model and analyze the
sample data. SEM techniques such as LISREL and Partial Least Squares (PLS) are
second generation data analysis techniques that can be used to test the extent to which IS
research meets recognized standards for high quality statistical analysis (Bagozzi and
Fornell, 1982). That is to say, they test for statistical conclusion validity (Cook and
Campbell, 1979).

Contrary to first generation statistical tools such as regression, SEM enables

researchers to answer a set of interrelated research questions in a (a) single, (b)
systematic, and (c) comprehensive analysis, by modeling the relationships among
multiple independent and dependent constructs simultaneously (Gerbing and Anderson,
1988). This capability for simultaneous analysis differs greatly from most first generation
regression models such as linear regression, LOGIT, ANOVA, and MANOVA, which
can analyze only one layer of linkages between independent and dependent variables at a
time (Gefen et al., 2000).

According to Gefen et al. (2000), unlike first generation regression tools, SEM
not only assesses: (a) the structural model the assumed causation among a set of
dependent and independent constructs but, in the same analysis, also evaluates (b) the
measurement model loadings of observed items (measurements) on their expected
latent variables (constructs). The combined analysis of the measurement and the
structural model enables: (a) measurement errors of the observed variables to be analyzed
as an integral part of the model, and (b) factor analysis to be combined in one operation
with the hypotheses testing (ibid). Consequently, the result is a more rigorous analysis of
the proposed research model and, very often, a better methodological assessment tool
(Bollen, 1989; Bullock et al., 1994; Jreskog and Srbom, 1989).

SEM techniques also provide fuller information about the extent to which the
research model is supported by the data than in regression techniques (Gefen et al.,

73
2000). The complex causal networks enabled by SEM characterize realworld processes
better than simple correlationbased models (ibid). Therefore, SEM is more suited for the
mathematical modeling of complex processes to serve both theory (Bollen, 1989) and
practice (Dubin, 1976). As a result, SEM tools are increasingly being used in behavioral
science research for the causal modeling of complex, multivariate data sets in which the
researcher gathers multiple measures of proposed constructs (Hair et al., 1998). The
holistic analysis that SEM is capable of performing is carried out via one of the following
two distinct statistical techniques (Gefen et al., 2000):

1. Covariance analysis such as LISREL

2. Partial least squares such as PLS

4.1.1 Covariance Analysis versus Partial Least Squares

The two distinct types of SEM differ in the objectives of their analyses, the
statistical assumptions they are based on, and the nature of the fit statistics they produce
(Gefen et al., 2000). The statistical objective of PLS is, overall, the same as that of linear
regression, i.e., to show high R2 and significant tvalues, thus rejecting the null
hypothesis of noeffect (Thompson et al., 1995). Consequently, PLS is more suited for
predictive applications and theory building, in contrast to covariancebased SEM (Gefen
et al., 2000). The objective of covariance based SEM, on the other hand, is to show that
the null hypotheses is insignificant. Moreover, its goodness of fit tests, test the
restrictions implied by a model. In other words, the objective of covariancebased SEM
is to show that the operationalization of the theory being examined is not disconfirmed by
the data (Bollen, 1989; Hair et al., 1998; Jreskog and Srbom, 1989).

Some researchers suggest that PLS should be regarded as a complimentary

technique to covariancebased SEM techniques (Chin, 1998b; Thompson et al., 1995)
possibly even a forerunner to the more rigorous covariancebased SEM (Thompson et
al., 1995). PLS, applies an iterative sequence of OLS and multiple linear regressions,
analyzing one construct at a time (Thompson et al., 1995), rather than estimating the
variance of all the observed variables, as in covariancebased SEM. PLS estimates the
parameters in such a way that will minimize the residual variance of all the dependent
74
variables in the model (Chin, 1998b). Consequently, PLS is less affected by small sample
sizes (Thompson et al., 1995). PLS, like linear regression models (Neter et al., 1990), is
also less influenced by deviations from multivariate normal distribution (Chin, 1998b;
Thompson et al., 1995), although, sample size considerations influence the strength of the
statistical test (Cohen, 1977, 1988). According to Barclay et al., (1995), in PLS the
sample should have at least ten times more datapoints than the number of items in the
most complex construct in the model.

In this study, among SEM statistical techniques, PLS was chosen to statistically
analyze the sample data. This was done using the bootstrap method in Visual PLS version
1.04 consistent with prior research of Venkatesh et al. (2003).

4.2 Quality Standard: Reliability and Validity

In order to reduce the possibility of getting wrong answers, attention need to be

paid to: Reliability and Validity (Saunders and Thornhill, 2003). The questionnaire used
to conduct this research was developed replicating the questions used in Venkatesh et al.
(2003), Featherman and Pavlou (2003), and Limayem et al. (2000) studies and therefore
validated previously. Also to ensure the validity of the questionnaire for the Iranian
healthcare industry domain, a twostage pilot test was run. Still, due to the complex
nature of the proposed research model, the SEM approach was used to assess the
proposed research models reliability and validity.

4.2.1 Reliability

Reliability can be defined as the degree to which measurements are free from
error and therefore, yield consistent results (Mitchell, 1996). In other words, reliability
concerns the extent to which an experiment, test, or any measuring procedure yields the
same results on repeated trials (Carmines and Zeller, 1979).

The reliability (internal consistency) of the collected data in this study was
assessed by calculating the Cronbachs Alpha coefficient. Although several measures of
reliability can be ascertained in order to establish the internal consistency of an
75
instrument, this method is considered to be the most general form of reliability estimation
(Nunnally, 1988). In this method reliability is operationalized as internal consistency,
which is the degree of intercorrelations among the items that constitute a scale (ibid).
An alpha value of 0.60 and 0.70 or above is considered to be the criteria for
demonstrating internal consistency of new scales and established scales respectively
(ibid). Table 4-1 shows each main constructs related Cronbach Alpha and accordingly
internal consistencies of main constructs of the model were considered acceptable since
the Cronbachs Alpha related to each of them exceeded 0.86, confirming satisfactory
reliability.

Table 4-1 Cronbach Alphas

Construct Cronbach Alpha

PE 0.869153

EE 0.927455

SI 0.868445

FC 0.876574

PTR 0.959152

PIIT 0.882405

BI 0.983100

4.2.2 Validity

Validity is defined as the extent to which data collection method or methods

accurately measure what they were intended to measure (Saunders and Thornhill, 2003).
In other words, validity concerns whether the measured concept represents the
intended concept (Swanborn, 1987).

The two elements, convergent validity and discriminant validity, are components
of a larger scientific measurement concept known as construct validity (Straub et al.,

76
2004). These two validities capture some of the aspects of the goodness of fit of the
measurement model (Gefen and Straub, 2005).

Convergent validity is shown when each measurement item correlates strongly

with its assumed theoretical construct (ibid). To assess convergent validity, every
measurement item loading should be examined (ibid). A measurement item loads highly
if its loading coefficient is above 0.60 and does not load highly if the coefficient is below
0.40 (Hair et al., 1998). Table 4-2 shows each main measurement items loading and
accordingly convergent validity of main constructs of the model were considered
acceptable since the loadings exceeded 0.80, confirming satisfactory convergent validity.

Table 4-2 Factor Loadings

Construct Indicator Loading

PE1 0.914700

PE PE2 0.895600

PE3 0.866200

EE1 0.890700

EE2 0.918400
EE
EE3 0.907500

EE4 0.911400

SI1 0.850900

SI2 0.800200
SI
SI3 0.849000

SI4 0.885500

FC1 0.872500

FC FC2 0.887400

FC3 0.824100

77
 Table 4-2 Factor Loadings (Continued)

Construct Indicator Loading

FC FC4 0.835500

PTR1 0.937500

PTR2 0.962000
PTR
PTR3 0.966300

PTR4 0.909500

PIIT1 0.848700

PIIT2 0.872800
PIIT
PIIT3 0.892600

PIIT4 0.826000

BI1 0.985600

BI BI2 0.991700

BI3 0.973200

Discriminant validity is shown when each measurement item correlates weakly

with all other constructs except for the one to which it is theoretically associated (Gefen
and Straub, 2005). Two procedures are used for assessing discriminant validity (ibid).

The first procedure is to examine item loadings to construct correlations. All the
loadings of the measurement items on their assigned latent variables should be an order
of magnitude larger than any other loading (ibid). Table 4-3 presents factor structure
matrix of loadings and crossloadings of main constructs of the model and accordingly
all loadings of the main measurement items on their assigned latent variables were larger
than any other loading, confirming satisfactory discrimnant validity.

78
 Table 4-3 Factor Structure Matrix of Loadings and CrossLoadings

Scale PE EE SI FC PTR PIIT BI

Items
PE1 0.9186 0.7218 0.6527 0.6259 -0.6330 0.6003 0.6333
PE2 0.8995 0.6670 0.5912 0.5862 -0.6390 0.5497 0.5761
PE3 0.8699 0.6600 0.6213 0.5829 -0.5230 0.5337 0.6178
EE1 0.6995 0.8945 0.7122 0.7356 -0.5871 0.6792 0.7132
EE2 0.7142 0.9224 0.6920 0.7132 -0.5990 0.6489 0.6781
EE3 0.6688 0.9114 0.6746 0.7294 -0.5807 0.6433 0.6786
EE4 0.6963 0.9153 0.7184 0.7399 -0.6097 0.6570 0.7141
SI1 0.5715 0.6798 0.8546 0.6353 -0.4621 0.4804 0.6615
SI2 0.6086 0.6455 0.8036 0.6495 -0.5251 0.5251 0.5751
SI3 0.5318 0.5932 0.8527 0.6061 -0.4891 0.4858 0.5564
SI4 0.6498 0.6879 0.8893 0.6619 -0.5848 0.5731 0.6190
FC1 0.6011 0.7147 0.6834 0.8763 -0.5106 0.5755 0.6323
FC2 0.6037 0.7460 0.6596 0.8912 -0.5230 0.5844 0.6866
FC3 0.5368 0.6830 0.5989 0.8276 -0.4869 0.5900 0.6031
FC4 0.5511 0.5994 0.6365 0.8391 -0.4847 0.4844 0.5733
PTR1 -0.6316 -0.5709 -0.5228 -0.5092 0.9415 -0.5291 -0.5086
PTR2 -0.6429 -0.6358 -0.6044 -0.5626 0.9662 -0.5685 -0.5169
PTR3 -0.6459 -0.6403 -0.6069 -0.5872 0.9705 -0.5708 -0.5321
PTR4 -0.6086 -0.6279 -0.5589 -0.5555 0.9134 -0.5618 -0.4871
PIIT1 0.4903 0.5523 0.4959 0.5355 -0.5291 0.8523 0.5501
PIIT2 0.5862 0.6482 0.5305 0.5667 -0.4960 0.8766 0.5822
PIIT3 0.6208 0.7165 0.6137 0.6601 -0.5683 0.8965 0.6553

79
 Table 4-3 Factor Structure Matrix of Loading and CrossLoadings (Continued)

Scale PE EE SI FC PTR PIIT BI

Items
PIIT4 0.4562 0.5631 0.4428 0.4757 -0.4317 0.8295 0.5574
BI1 0.6761 0.7558 0.6966 0.7182 -0.5425 0.6741 0.9898
BI2 0.6731 0.7584 0.7054 0.7213 -0.5312 0.6842 0.9960
BI3 0.6679 0.7518 0.7074 0.7193 -0.5248 0.6594 0.9774

The second procedure is to examine the ratio of the square root of the AVE of
each construct to the correlations of this construct to all the other constructs (Gefen and
Straub, 2005). The square root of the AVE of each construct should be larger than the
correlation of the specific construct with any of the other constructs in the model (Chin,
1998a) and should be at least 0.50 (Fornell and Larcker, 1981). For this research Table 4-
4 shows AVE and square root of AVE for main constructs and Table 4-5 presents the
correlation of latent variables.

Table 4-4 AVE and Square Root of AVE

Construct AVE Square Root of AVE

PE 0.796339 0.892378

EE 0.822750 0.907055

SI 0.717322 0.846948

FC 0.731496 0.855240

PTR 0.891347 0.944111

PIIT 0.740237 0.860370

BI 0.967301 0.983514

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 Table 4-5 Correlation of Latent Variables

PE EE SI FC PTR PIIT BI
PE 1.000
EE 0.763 1.000
SI 0.695 0.768 1.000
FC 0.668 0.801 0.751 1.000
PTR -0.667 -0.652 -0.605 -0.584 1.000
PIIT 0.627 0.722 0.606 0.652 -0.588 0.681

BI 0.681 0.681 0.681 0.681 -0.588 0.681 0.681

Comparing Tables 4-4 and 4-5, it was seen that the square root of the AVE of
each main construct was larger than the correlation of the specific construct with any of
the other constructs in the model and was at least 0.84. Thereby once again satisfactory
discrimnant validity of the main constructs of the research model was confirmed.

4.3 Demographic and Descriptive Statistics

All the 232 respondents of the questionnaire were inexperienced users of EPR
among physicians and nurses working at hospitals which had implemented HIS
supporting EPR. Table 4-6 represents the demographic characteristics of the respondents.

Table 4-6 Demographic Characteristics of the Respondents

Classification of
Variable Frequency Percentage
Variables

Gender Female 93 40%

Male 139 60%

Marital Status Single 81 35%

Married 151 65%

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 Table 4-6 Demographic Characteristics of the Respondents (Continued)

Classification of
Variable Frequency Percentage
Variables

Age 20 30 77 33%

31 40 101 43%

41 50 35 15%

51 60 6 3%

Over 60 13 6%

Occupation Doctor 133 57%

Nurse 99 43%

The result showed that more males than females participated in the study.
According to these descriptive statistics most of the respondents were married and
between 31 and 40 years old. Also, 57 percent of the participants in the research were
doctors.

4.4 Results of Hypotheses Tests

Table 4-7 represents the results of testing the hypotheses related to the proposed
research model using PLS analysis. The estimated path coefficients are given along with
the associated tvalues. Using a twotailed test, hypotheses H1a, H2a, H3a, H3b, H4a,
and H6 were strongly supported. These results showed a confirmation of the
appropriateness of the main constructs represented in UTAUT, for explaining
individuals voluntary behavioral intention to accept new technology. The results also
provided strong support for two of the newly added links to UTAUT, representing the
effects of Facilitating Conditions and Personal Innovativeness in IT on Behavioral
Intention toward EPR acceptance.

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 Table 4-7 Results of Hypotheses Tests

Hypothesis Effects Path Coefficient TStatistics Remarks

H1a PE >BI 0.193 3.1824 Supported *

H1b PE*GDR >BI -0.050 -1.2733 Not Supported

H1c PE*AGE >BI 0.142 1.8367 Not Supported

H2a EE >BI 0.247 3.0167 Supported *

H2b EE*GDR >BI -0.122 -1.7410 Not Supported

H2c EE*AGE >BI -0.063 -1.0671 Not Supported

H3a SI >BI 0.182 2.3688 Supported **

H3b SI*GDR >BI 0.160 2.7603 Supported *

H3c SI*AGE >BI -0.004 -0.0817 Not Supported

H4a FC >BI 0.176 2.4937 Supported **

H4b FC*AGE >BI -0.079 -1.3484 Not Supported

H5 PTR >BI 0.046 1.1488 Not Supported

H6 PIIT >BI 0.203 3.5084 Supported *

* P<0.01
** P<0.05

4.4.1 Antecedents of Behavioral Intention toward EPR Adoption

The results showed that the behavioral intention to use EPR was predicted by
Performance Expectancy (=0.193, p<0.01), Effort Expectancy (=0.247, p<0.01),
Social Influence (=0.182, p<0.05), Facilitating Conditions (=0.176, p<0.05) and
Personal Innovativeness in IT (=0.203, p<0.01) and that the relationship between
social influence and behavioral intention toward the use of EPR was particularly stronger
for women (=0.160, p<0.01). The effects of the mentioned antecedents of BI totally
explained 70.3% of the variance in behavioral intention to use EPR (R2=0.703,
coefficient of determination). This was an indication of the good explanatory power of

83
the model for behavioral intention, which was much higher comparing to other UTAUT
based IT acceptance studies such as AlGahtani et al. (2007) with an R2 equal to 0.391
for intention to use and Chang et al. (2007) whose proposed model explained only 28%
of the variance in behavioral intention.

4.4.2 Explaining Performance Expectancy

Performance expectancy had a significant effect on behavioral intention, with

99% significance level and thereby H1a Performance expectancy positively influences
hospitals staff behavioral intention to use EPR was strongly supported. This was
consistent with the findings of Venkatesh et al. (2003), who reported the existence of a
significant relationship between performance expectancy and behavioral intention in the
domain of IT acceptance. Regarding the related path coefficient value (=0.193), PE had
the third strongest effect on BI, confirming the important role of performance expectancy
in healthcare professionals intention to adopt EPR.

4.4.3 Explaining Effort Expectancy

The path between effort expectancy and behavioral intention was found to be
significant, with 99% significance level, and consequently H2a Effort expectancy
positively influences hospitals staff behavioral intention to use EPR was accepted .
This finding supported the results reported by Venkatesh et al. (2003), who claimed that
there was a strong relationship between effort expectancy and behavioral intention in the
domain of IT acceptance. Considering the related path coefficient value (=0.247), EE
had the strongest effect on BI, emphasizing the important influence of effort expectancy
on healthcare professionals intention to adopt EPR.

4.4.4 Explaining Social Influence

H3a Social influence positively influences hospitals staff behavioral intention

to use EPR was accepted with 95% significance level, showing that social influence
had a significant effect on behavioral intention. This result was consistent with the
findings of Venkatesh et al. (2003), who reported the existence of a significant
84
relationship between social influence and behavioral intention in the domain of IT
acceptance. Regarding the hypotheses tests, social influence was very important in
forming the healthcare professionals intention to use EPR in their workflow. According
to the related path coefficient value (=0.182), SI had the fourth strongest effect on BI. It
is to be mentioned that the effect of social influence on behavioral intention was shown to
be even stronger for women which was again consistent with the results of Vankatesh et
al. (2003). The tstatistics related to the effect of the product term of social influence and
gender on behavioral intention to accept and use EPR, was 2.7603, showing a
significance level of 99%, and therefore H3b The influence of social influence on
hospitals staff behavioral intention to use EPR will be moderated by gender, such that
the effect will be stronger for women was strongly supported. Regarding the experts
point of view, this could be because of a general characteristic of women that they are
very sensitive to what other people, who are important to them or influence them, think.
This effect was also referred to as the psychological gender by Vankatesh et al. (2003).

4.4.5 Explaining Facilitating Conditions

Facilitating conditions had a significant effect on behavioral intention, with 95%

significance level and thereby H4a Facilitating conditions positively influences
hospitals staff behavioral intention to use EPR was accepted. This result did not
support Venkatesh et al. (2003) contention regarding the influence of FC on BI
Facilitating conditions does not affect behavioral intention to adopt the new
technology. In this study according to the related path coefficient value (=0.176), FC
had a very strong effect on BI, emphasizing on the important role of facilitating
conditions in the healthcare professionals intention to adopt EPR. This was consistent
with the findings of both Boots and Treloar (2000), who found that facilitating conditions
was one of the predictors of intention and Wu et al. (2007b) who empirically tested the
direct effect of facilitating conditions on behavioral intention in a study of 3G mobile
communication acceptance and found reasonable support for it.

85
4.4.6 Explaining Perceived Time Risk

The path between perceived time risk and behavioral intention was found to be
nonsignificant with a tstatistics equal to 1.1488, and therefore H5 Perceived time
risk negatively influences hospitals staff behavioral intention to use EPR was rejected.
This was inconsistent with the findings of Featherman and Pavlou (2003), who verified
the existence of a significant relationship between perceived time risk (as a facet of
perceived risk) and behavioral intention to adopt new technology. When experts among
the healthcare professionals were interviewed and asked about this, they claimed that
using the EPR itself, indeed helped them to augment their documentation speed and
thereby would not result in any waste of time. They added that unfortunately due to the
lack of technological facilities in hospitals they could not always enter their observations
and recommendations to a computer system at the time of visiting the patient and
therefore they had to provide a paper based version of the patient record first and then
transfer it to the EPR which was very time consuming. Consequently, the reason why H5
was not accepted was that most of the healthcare professionals did not believe working
with EPR itself, would concern any time risks for them.

4.4.7 Explaining Personal Innovativeness in IT

Personal innovativeness in IT had a significant effect on behavioral intention,

with 99% significance level and thereby H6 Personal innovativeness in IT positively
influences hospitals staff behavioral intention to use EPR was accepted. This result
strongly supported both Limayem et al. (2000) and Boyle and Ruppel (2004) contentions
indicating that there was a significant relationship between personal innovativeness in IT
and behavioral intention in the domain of IT acceptance. Regarding the related path
coefficient value (=0.203), PIIT had the second strongest effect on BI, confirming the
strong influence of personal innovativeness in IT on healthcare professionals intention to
adopt EPR.

86
4.4.8 Explaining Moderating Effects

Following Venkatesh et al. (2003), H1b, H1c, H2b, H2c, H3b and H3c were
proposed in this research to test the moderating effects of gender and age on the paths
that linked performance expectancy, effort expectancy and social influence to behavioral
intention and H4b was proposed to verify the moderating effect of gender on the
relationship between facilitating conditions and behavioral intention to accept the usage
of EPR. Except for H3b The influence of social influence on hospitals staff
behavioral intention to use EPR will be moderated by gender, such that the effect will be
stronger for women unlike the results of Venkatesh et al. (2003), other hypotheses on
the moderating effects of gender and age, were found nonsignificant and therefore H1b,
H1c, H2b, H2c, H3c and H4b were all rejected with tstatistics equal to -1.2733, 1.8367,
-1.7410, -1.0671, -0.0817 and -1.3484, respectively. This could be explained by the fact
that EPR was a different technology than the ones examined in the study of Venkatesh et
al. (2003). In addition, the target population of this study was the healthcare providers
which differed from the one studied by Venkatesh et al. (2003). According to Gagnon et
al. (2003), the decision to use EPR implies not only a personal evaluation of its benefits
by physicians and nurses, but highly depends upon the context in which they are working.
Moreover, the feeling of professional responsibility is central to physicians and nurses
decisionmaking and influences their acceptance of EPR (Tanriverdi and Venkatraman,
1999). Therefore, their professional responsibility towards patients does not let factors
such as age or gender, affect such decisions.

When experts among the healthcare professionals were interviewed and asked
about the rejection of the effects of moderators, they claimed that they did not believe
differences in gender or age would result in any changes in intention to use a new
technology such as EPR among them, since (a) their profession was in fact very IT
intensive and according to their job requirements they always had to stay up to date, no
matter how old they were or what their gender was, (b) all they cared about, was the
comfort and wellbeing of the patients and the improvement of healthcare quality,
therefore they did their best to ensure that and their age or gender did not make any
difference.
87
4.5 Summary

Regarding the complex nature of the proposed research model, the SEM method
was used to evaluate the model and analyze the sample data. Among SEM statistical
techniques, PLS was selected in order to perform the statistical analyses. This was done
using the bootstrap method in Visual PLS version 1.04 consistent with prior research of
Venkatesh et al. (2003).

Internal consistencies of main constructs were considered acceptable showing the

reliability of the measurement model. Convergent validity and dicriminant validity of the
main constructs were also assessed and considered satisfactory.

Using a twotailed test, hypotheses H1a, H2a, H3a, H3b, H4a, and H6 were all
accepted. The results showed a confirmation of the appropriateness of the main
constructs represented in UTAUT, for explaining individuals voluntary behavioral
intention to accept new technology. The results also provided strong support for two of
the newly added links to UTAUT, representing the effects of facilitating conditions and
personal innovativeness in IT on behavioral intention toward EPR acceptance. As for the
moderators, only the moderating influence of gender on the relationship between social
influence and behavioral intention was accepted.

88
Chapter 5
Conclusion

5. Conclusion

Based on the results obtained in the study, final discussion and conclusion,
theoretical and empirical contributions and also practical implications of the research
are presented in this chapter. Furthermore, the reader is introduced to the limitations of
the study and recommendations for further research.

89
5.1 Discussion and Conclusion

In order to investigate the factors influencing the intention to adopt EPR among
Iranian hospitals staff, the present research set out to propose an extension of the
UTAUT model specifically adapted to the particular characteristics of the health care
sector in Iran, which captured the essential elements of previously established theories
and researches on individuals intention to accept IT.

First, different intention based technology adoption theories were discussed.

Among these theories, the UTAUT model proposed by Venkatesh et al. (2003) appeared
to encompass many of the determinants found in other models such as IDT, TPB and
TAM. Since UTAUT considered all the cultural, social, and moral factors that are not
accounted for in other theories and was one of the latest IT adoption models, it was
chosen as the basis of the proposed research model. Therefore the paper by Venkatesh et
al. (2003) was selected as the supportive article for this study. Among the moderators
mentioned in UTAUT, only gender and age were chosen to be included in the proposed
research model, because the study was cross sectional and conducted under voluntary
setting only, thus the effects of experience and volutariness could not be measured.

Second, regarding the characteristics of healthcare professionals in Iran and

reviewing the literature on individuals behavioral intention, three determinants of
intention that were not included in UTAUT were used to formulate the final proposed
research model. These three constructs were: facilitating conditions, perceived time risk,
and personal innovativeness in IT (Boyle and Ruppel, 2004; Featherman and Pavlou,
2003; Gagnon et al., 2003; Limayem et al., 2000; Lu et al., 2005; Rosen, 2004; Wu et al.,
2007b).

Third, based on the proposed research model, a questionnaire was developed

replicating the questions used in Venkatesh et al. (2003), Featherman and Pavlou (2003),
and Limayem et al. (2000) studies. After translating the questionnaire into Farsi, in order
to assess the questions in terms of their meaning and vocabularies and make sure that the
questionnaire was valid for the Iranian healthcare industry, a twostage pilot test was run.

90
 Fourth, a cross sectional data collection was conducted through a large sample
survey from six hospitals. Data was gathered by distributing questionnaires among
physicians and nurses who were inexperienced users of EPR and worked at hospitals
which were located in Tehran and had implemented HIS supporting EPR. As a result, out
of the 248 distributed questionnaires, 232 complete ones were collected, which showed a
93% response rate.

Fifth, the proposed research model was statistically tested using the sample data.
A SEM approach was performed using the bootstrap method in Visual PLS version 1.04
consistent with prior research of Venkatesh et al. (2003). Analyses were performed in two
major steps. The first step was conducted to assess the measurement model in terms of
reliability and validity. Thus, Cronbachs Alpha of each construct, every measurement
item loading, every item loading to construct correlations, and the ratio of the square root
of the AVE of each construct to the correlations of this construct with all the other
constructs were examined and ensured satisfactory reliability and validity of the model
and measurement items. In the second step, the adequacy of the proposed research model
in explaining behavioral intention to use EPR by hospitals staff was tested. Figure 5-1
shows the results of these tests, providing strong empirical support for most of the main
constructs mentioned in the model, which posited five direct determinants of intention to
use EPR as follow: performance expectancy, effort expectancy, social influence,
facilitating conditions and personal innovativeness in IT. As for the moderators, only the
moderating influence of gender on the relationship between social influence and
behavioral intention was accepted.

While each of the existing theories in the domain of IT adoption was quite
successful in predicting behavioral intention, the presented model in this research
considered the particular characteristics of the medical profession and was especially
developed and tested for the context of Iranian hospitals staff. The results showed that
recognizing both technological and personality traits were important in increasing
hospitals staff behavioral intention to use EPR, each contributing their significant
influence on behavioral intention.

91
Figure 5-1 Results

92
 The final theoretical model, shown in Figure 5-2, was able to account for 70.3
percent of the variance in Iranian hospitals staff behavioral intention to adopt EPR,
which was a substantial improvement over the other UTAUTbased models such as Al
Gahtani et al. (2007) with an R2 equal to 0.391 for intention to use and Chang et al.
(2007) whose proposed model explained only 28% of the variance in behavioral
intention. Given such a high proportion of explanatory power for behavioral intention, it
is possible that the practical limits of the ability to explain healthcare professionals
intention to accept and use EPR systems in hospitals are approached.

Figure 5-2 Final Theoretical Model

As shown in Figure 5-2, antecedents of behavioral intention mentioned in the

UTAUT model were all significant determinants of Iranian healthcare providers
behavioral intention to adopt EPR. This means that the degree to which physicians or
nurses believed that using EPR helped them to improve their job performance, their
perception of how easy and understandable using the system was, and the degree to
93
which they perceived that people who were important to them and influenced them
thought they should use EPR, directly and positively affected their readiness and
intention to adopt EPR systems.

The results revealed that facilitating conditions was also one of determinants of
Iranian healthcare professionals intention to accept the usage of EPR. This shows that
the existence of sufficient organizational and technical infrastructure supporting the use
of EPR, was of great importance to them. In addition, the findings showed that the
personal innovativeness of doctors and nurses in the domain of IT and how willing they
were to try out the EPR system was one the most important antecedents of their
behavioral intention to adopt EPR.

The influence of perceived time risk on behavioral intention was not supported.
This was also confirmed by the healthcare providing experts point of view, indicating
that using the EPR itself, indeed helped them to augment their documentation speed and
thereby would not result in any waste of time. They added that unfortunately due to the
lack of technological facilities in hospitals they could not always enter their observations
and recommendations to a computer system at the time of visiting the patient and
therefore they had to provide a paperbased version of the patient record first and then
transfer it to the EPR which was very time consuming. Thereby, they suggested that
using IT tools such as PDAs which enabled them to directly enter everything into the
computerized system at once, would very much help in order to save time as it was the
purpose of using EPR in the first place.

As mentioned previously, only the moderating influence of gender on the

relationship between social influence and behavioral intention was accepted, meaning
that the effect of SI on BI was shown to be even stronger for women, which was
consistent with the results of Vankatesh et al. (2003). Regarding the experts point of
view, this could be because of a general characteristic of women that they are very
sensitive to what other people, who are important to them or influence them, think. This
effect was also referred to as the psychological gender by Vankatesh et al. (2003). Unlike
the results of Venkatesh et al. (2003), other moderating effects of gender and age, were

94
found nonsignificant. This could be explained by the fact that EPR was a different
technology than the ones examined in the study of Venkatesh et al. (2003). In addition,
the target population of this study was the healthcare providers which differed from the
one studied by Venkatesh et al. (2003). According to Gagnon et al. (2003), the decision
to use EPR implies not only a personal evaluation of its benefits by physicians and
nurses, but highly depends upon the context in which they are working. Moreover, the
feeling of professional responsibility is central to physicians and nurses decisionmaking
and influences their acceptance of EPR (Tanriverdi and Venkatraman, 1999). Therefore,
their professional responsibility towards patients does not let factors such as age or
gender, affect such decisions. When experts among the healthcare professionals were
interviewed and asked about the rejection of the effects of moderators, they claimed that
they did not believe differences in gender or age would result in any changes in intention
to use a new technology such as EPR among them, since (a) their profession was in fact
very ITintensive and according to their job requirements they always had to stay up to
date, no matter how old they were or what their gender was, (b) all they cared about, was
the comfort and wellbeing of the patients and the improvement of healthcare quality,
therefore they did their best to ensure that and their age or gender did not make any
difference.

To conclude, the present study advanced the individual acceptance research by

enriching the UTAUT model unifying the theoretical perspectives common in the
literature and concerning the characteristics of Iranian healthcare providers in order to
identify the factors influencing Iranian hospitals staff intention to adopt EPR systems.

5.2 Contributions of the Study

The contribution to knowledge of any academic study can be classified into three
categories: theoretical contribution, empirical contribution and methodological
contribution. The contributions of this study occurred within the first and second areas
which are discussed in the following two sections.

95
5.2.1 Theoretical Contribution

Existing IT adoption models were mostly developed without the consideration of

the characteristics of healthcare industry. Many researches have been conducted testing
the existing adoption theories in the healthcare context (previously mentioned in Tables
1-1, 1-2 and 2-1), but none had focused on studying the intention to adopt EPR using the
UTAUT model. As a theoretical contribution this research enriched the UTAUT model
by adding two other constructs as direct antecedents of behavioral intention (Facilitating
Conditions and Personal Innovativeness in IT) and exclusively focused on Iranian
healthcare providers and their intention to adopt EPR.

The results showed that the main constructs of UTAUT along with facilitating
conditions and personal innovativeness in IT were all appropriate to predict physicians
and nurses intention to use EPR in their workflow. The explained variance in behavioral
intention by the final theoretical model was 70.3%. This high proportion of models
explanatory power for behavioral intention was noteworthy comparing to other studies
that have explored the technology acceptance intention in healthcare industry (Chismar
and WileyPatton, 2002; Croteau and Vieru, 2002; Hu et al., 1999a, 1999b; Yi et al.,
2006) and also previously conducted UTAUTbased researches (AlGahtani et al.,2007;
Chang et al., 2007). Thereby, from a theoretical perspective, the inclusion of facilitating
conditions and personal innovativeness in IT expanded the explanatory power of the
research model and furthered the understanding of the roles of technological and
personality traits in innovation adoption in healthcare industry.

5.2.2 Empirical Contribution

This research resulted in an empirical contribution to the knowledge, as it

examined whether a certain extension of the UTAUT model, was valid for a new
empirical object which was the Iranian hospitals staff. As an empirical contribution, this
study provided a useful tool for hospital managers needing to assess the likelihood of
success for the new technology introductions and helped them understand the drivers of

96
acceptance in order to focus on different aspects of them and proactively design
interventions targeted at users that have not adopted and used EPR systems.

5.3 Practical Implications

There were several new findings regarding the UTAUT model and the roles of
facilitating conditions and personal innovativeness in IT in the Iranian hospitals staff
EPR acceptance context, as discussed previously. These findings have different
implications at the practical level and bring up a number of considerations to hospital
managers in order to try to prompt the EPR adoption by manipulating the aspects that are
within their control and support the diffusion of this new technology in the health care
system.

Firstly, the results showed that the more doctors and nurses perceived EPR to be
easy to learn, the more they intended to use it and thereby the design of the EPR system
needs to be carefully paid attention to, so that it would be as easy as possible to interact
with.

Secondly, as it was seen that the degree to which hospitals staff believed that the
healthcare organization and their colleagues thought they should use the system
positively motivated them to accept EPR usage, it is very important for the authorities
and managers to try to encourage the clinical staff (especially women) to use the system
and convince them that EPR usage adds to their professional and social image. In
addition, from the personal innovativeness in IT point of view it might be helpful to
identify doctors and nurses who are more likely to adopt EPR usage and set them as
examples in order to motivate other clinical staff.

Thirdly, since there was a direct relationship between the degree to which the
clinical staff perceived the system to improve their performance and speed up their
workflow and the degree that they intended to use the system, it is suggested to equip the
healthcare providers with mobile IT facilities such as PDAs so that they could
immediately enter the data into the system instead of using papers to document their
visits. This can help them to perceive EPR as a useful tool to their daily job which
97
quickens their documentation and research process and consequently motivate them to
use the system.

Fourthly, the findings pointed out the fact that the level of facilitating conditions
existing within the hospital influenced physicians and nurses intention to utilize EPR in
a positive way. Accordingly it is of great importance to offer extensive training to clinical
staff, provide them with sufficient technological resources, and arrange for IT technicians
to be present at the hospital at all times.

5.4 Limitations of the Study

This study had some limitations. Fist, due to the fact that EPR was a new
phenomenon and was at its infancy in Iran, the number of hospitals which had implanted
HIS supporting EPR were limited and they were mostly located in the capital city of Iran,
thus the target population of this research were the clinical staff of a limited number of
hospitals in Tehran.

Second, there were a few hospital managers who agreed to cooperate and
permitted the distribution of questionnaires in the hospitals under their supervision.
Consequently the questionnaires were only given to the physicians and nurses working at
six hospitals which had implemented HIS supporting EPR but did not force their clinical
staff to use it.

Third, the previous two limitations resulted in a choice of non-probability

sampling which may affect the generalization of the findings to the entire Iranian
hospitals staff population.

Fourth, regarding the fact that the unit of analysis of this study was doctors and
nurses who were professionally very busy and faced time constraints during their daily
job, convincing them to fill out questionnaires was very difficult.

Fifth, as the research had to be completed by a certain time, conducting a

longitudinal study was not feasible. Thereby verifying the moderating influence of

98
experience on EPR adoption and investigating the factors affecting hospitals staff actual
use of EPR were not possible.

Sixth, the study was conducted under voluntary setting only. Thus, testing the
moderating effect of volutariness on EPR adoption was not feasible.

Despite these limitations, this research contributed considerably to the

understanding of EPR acceptance by physicians and nurses and provided a foundation to
guide further researches in this area.

5.5 Recommendations for Further Research

Regarding the limitations of this study and the numerous research opportunities
existing within the area of EPR acceptance, this study provided a foundation for further
researches. The followings are recommended for future work:

To use probability sampling to collect data, so that the results could be

generalized to the entire population.
To conduct a longitudinal research to investigate the factors affecting the
healthcare professionals actual use of EPR and also to verify the moderating
influence of experience on EPR adoption.
To identify causal antecedents of the constructs presented in this research
model to provide more precise practical implications.
To conduct the study under both voluntary and mandatory settings, so that the
moderating effect of voluntariness on EPR adoption could be examined.
To analyze the data gathered from doctors and nurses separately in order to be
able to differentiate the results and provide more precise practical
implications.

99
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Appendices

Appendix A. Abbreviations

The abbreviations used in this study are as follow:

AMR: Automated Medical Record

AVE: Average Variance Extracted
CTAMTPB: Combined Technology Acceptance Model and Theory of
Planned Behavior
CDR: Clinical Data Repository
CMR: Computerized Medical Record
CPR: Computerbased Patient Record
CPR: Computerized Patient Record
CPRS: Computerbased Patient Record System
DTPB: Decomposed Theory of Planned Behavior
EE: Effort Expectancy
EHR: Electronic Health Record
EMR: Electronic Medical Record
EPR: Electronic Patient Record
FC: Facilitating Conditions
GDR: Gender
HIS: Hospital Information System
HIT: Healthcare Information Technology
ICT: Information and Communication Technology
IDT: Innovation Diffusion Theory
IS: Information System
IT: Information Technology
LDR: Lifetime Data Repository
MM: Motivational Model
MPCU: Model of PC Utilization
PE: Performance Expectancy
PI: Personal Innovativeness
PIIT: Personal Innovativeness in Information Technology
PLS: Partial Least Squares
PR: Perceived Risk
PTR: Perceived Time Risk
SCT: Social Cognitive Theory
SEM: Structural Equation Modeling
SI: Social Influence
TAM: Technology Acceptance Model

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 TAM2: Extended Technology Acceptance Model
TPB: Theory of Planned Behavior
TRA: Theory of Reasoned Action
UTAUT: Unified Theory of Acceptance and Use of Technology
VHR: Virtual Health Record
VPR: Virtual Patient Record

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Appendix B. Questionnaire

1. Respondents Personal Information:

No. Question Answer

1 Gender Female

Male

2 Age

3 Marital Status Single

Married

4 Occupation Doctor

Nurse

2. Respondents Perception about EPR:

(1 = Strongly disagree 5 = Strongly agree)

Performance Expectancy

Indicator Question 1 2 3 4 5

PE1 I would find the system useful in my job.

PE2 Using the system enables me to accomplish tasks

more quickly.

PE3 Using the system increases my productivity.

Effort Expectancy

Indicator Question 1 2 3 4 5

EE1 My interaction with the system would be clear and

understandable.

EE2 It would be easy for me to become skillful at using

the system.

EE3 I would find the system easy to use.

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2. Respondents Perception about EPR (Continued):

Indicator Question 1 2 3 4 5

EE4 Learning to operate the system is easy for me.

Social Influence

Indicator Question 1 2 3 4 5

SI1 People who influence my behavior think that I

should use the system.

SI2 People who are important to me think that I

should use the system.

SI3 The hospital manager has been helpful in the

use of the system.

SI4 In general, the healthcare organization has

supported the use of the system.

Facilitating Conditions

Indicator Question 1 2 3 4 5

FC1 I have the resources necessary to use the system.

FC2 I have the knowledge necessary to use the

system.

FC3 The system is not compatible with other systems

I use.

FC4 A specific person (or group) is available for

assistance with system difficulties.

Perceived Time Risk

Indicator Question 1 2 3 4 5

PTR1 If I begin to use EPR, the chances that I will

lose time due to having to switch to a different
filing method are high.

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2. Respondents Perception about EPR (Continued):

Indicator Question 1 2 3 4 5

PTR2 It is probable that my signing up for and using

EPR would lead to a loss of convenience of me

because I would have to waste a lot of time
entering the data.

PTR3 Considering the investment of my time involved

to switch to EPR makes it very risky.

PTR4 The possible time loss from having to setup

and learn how to use EPR makes it very risky.

Personal Innovativeness in Information Technology

Indicator Question 1 2 3 4 5

PIIT1 I am generally cautious about accepting new

ideas.

PIIT2 I find it stimulating to be original in my

thinking and behavior.

PIIT3 I am challenged by ambiguities and unsolved

problems.

PIIT4 I must see other people using innovations before

I will consider them.

Behavioral Intention

Indicator Question 1 2 3 4 5

BI1 I intend to use the system in the next 3 months.

BI2 I predict I would use the system in the next 3

months.

BI3 I plan to use the system in the next 3 months.

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3. Status of EPR usage in the hospital the respondent is working at:

No. Question Answer

1 Does the Hospital Information System support EPR in this Yes

hospital?
No

2 Is it mandatory to use EPR in this hospital? Yes

No

3 If your answer to the previous question is no, have you ever Yes
tried using EPR voluntarily?
No

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