Use and acceptance of an electronic health record: factors affecting

170 Pages·2008·0.55 MB·English

by  Morton, Mary Elizabeth

Use and Acceptance of an Electronic Health Record:
Factors Affecting Physician Attitudes

A Thesis
Submitted to the Faculty
of
Drexel University
by
Mary Elizabeth Morton
in partial fulfillment of the
requirements for the degree
of
Doctor of Philosophy
August 2008
© Copyright 2008
Mary Elizabeth Morton. All Rights Reserved.
ii
DEDICATIONS

In loving memory of my parents, Walter and Elizabeth Krueger.
iii
ACKNOWLEDGMENTS

I had no idea how many people would become involved in completing this
dissertation. My committee members were a wonderful team and all gave willingly of
their time and expertise. My chairs, Dr. Susan Wiedenbeck and Dr. Kate McCain
patiently helped solve more issues than they probably ever thought possible. Dr. Scot
Silverstein, Dr. Lisl Zach and Dr. Valerie Watzlaf provided thoughtful feedback and
encouragement.
Dr. Laurie Bonnici served as an outside reader and Dr. Xiaohu Xu assisted with
the statistical analysis. Dr. James Gill and his colleagues in the Family Medicine
Residency Program at Christiana Care Health Services willingly served as a pilot testing
site.
This research would not have been possible without the help of many people at
the University of Mississippi Medical Center. I’d like to thank Dr. Scott Stringer,
Dr. Tom Moore, Dr. Jessica Bailey and Ann Peden. I am indebted to Christa Vutera, all
of the residency program coordinators and the subjects who participated in the study.
A number of friends provided support throughout the entire process: Laurinda
Harman, Maggie Foley, Cathy Flite, Karen McBride, Cindy Marselis, Drew Procaccino,
Jodi Williams, Yolanda Jones, Connie Phelps, Angela Morey and my fellow dissertation
support group members. I couldn’t have done it without your prayers and the Lord’s
help. I’d also like to acknowledge the American Health Information Management
Association (AHIMA) for awarding me two graduate scholarships toward my studies.
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Finally, I never could have succeeded without the constant encouragement and
support of my husband Vince. He never gave up, though I sometimes wanted to. He
willingly cooked, cleaned, shopped and babysat so I could get my work done. My
daughter Elisabeth has kept me focused on the fun things in life. This has definitely been
a family effort; we finally made it!
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Table of Contents

LIST OF TABLES..............................................................................................................x
LIST OF FIGURES..........................................................................................................xii
ABSTRACT.....................................................................................................................xiii
CHAPTER 1: INTRODUCTION.......................................................................................1
CHAPTER 2: THE PROBLEM..........................................................................................3
2.1 Rationale for Study..................................................................................................3
2.2 Current Electronic Health Record (EHR) Environment..........................................3
2.3 Theoretical Framework............................................................................................5
2.3.1 Diffusion of Innovations (DOI).........................................................................6
2.3.2 Technology Acceptance Model.........................................................................7
2.3.3 Theoretical Framework: Unifying Concepts...................................................7
2.4 Problem Statement...................................................................................................9
2.5 Research Questions..................................................................................................9
2.6 Delimitations and Limitations of the Study...........................................................14
2.7 Definition of Terms...............................................................................................15
2.8 Summary................................................................................................................17
CHAPTER 3: REVIEW OF THE LITERATURE...........................................................18
3.1 Introduction............................................................................................................18
3.2 Theoretical Framework: Diffusion of Innovations (DOI)....................................18
3.2.1 Diffusion, Innovations and Rate of Adoption..................................................19
3.2.2 Types of Innovation-Decisions........................................................................19
3.2.3 Attributes of Innovations.................................................................................20
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3.2.4 Social Networks and Communication.............................................................22
3.2.5 Concerns Based Adoption Model....................................................................23
3.2.6 Adopter Categories.........................................................................................23
3.3 Theoretical Framework: Technology Acceptance Model (TAM)........................24
3.3.1 Introduction.....................................................................................................24
3.3.2 Application in Clinical Information Systems Research..................................27
3.4 Factors Influencing EHR Adoption.......................................................................28
3.4.1 Organizational Leadership, Commitment and Vision....................................29
3.4.2 Physician Involvement and Participation.......................................................30
3.4.3 Autonomy........................................................................................................30
3.4.4 Impact on Workflow, Practice Patterns and Professional Relationships.......31
3.4.5 Physician-Patient Relationship.......................................................................32
3.4.6 Perceived Value and Benefits.........................................................................32
3.4.7 Ease of Use and Information Technology Support.........................................33
3.4.8 Discretionary Use...........................................................................................33
3.4.9 Computer Skills and Training.........................................................................33
3.4.10 Motivation and Peer Influence......................................................................34
3.5 Related User Studies of Clinical Information Systems.........................................34
3.5.1 Physician Attitudes Toward Technology and Computers...............................35
3.5.2 User Satisfaction Studies Post-implementation..............................................36
3.5.3 Adoption Attitudes Pre-Implementation.........................................................37
3.6 Contribution of Current Study...............................................................................37
CHAPTER 4: RESEARCH METHODS..........................................................................39
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4.1 Research Design....................................................................................................39
4.2 Case Setting...........................................................................................................40
4.3 Research Population..............................................................................................41
4.4 Instrumentation......................................................................................................42
4.5 Pilot Study..............................................................................................................43
4.6 Survey Administration...........................................................................................46
4.7 Data Collection......................................................................................................48
4.8 Sample Size and Response Rate............................................................................48
4.9 Treatment of the Data............................................................................................48
4.9.1 Analysis of Incomplete Responses...................................................................48
4.9.2 Recoding And Initial Processing Of Data........................................................50
4.10 Summary..............................................................................................................55
CHAPTER 5: RESULTS..................................................................................................56
5.1 Research Questions and Model Variables.............................................................56
5.2 Description of Respondents...................................................................................64
5.3 Descriptive Statistics for Scale Variables..............................................................69
5.4 Structural Equation Modeling (SEM) Analyses....................................................72
5.4.1 Model Specification........................................................................................75
5.4.2 Reliability and Validity of Research Constructs.............................................76
5.4.3 Model Identification........................................................................................77
5.4.4 Model Estimation, Evaluation of Model Fit, Model Modification..................78
5.4.5 Interpretation of Model Statistics...................................................................79
5.5 Qualitative Comments...........................................................................................89
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5.6 Summary................................................................................................................92
CHAPTER 6: DISCUSSION............................................................................................94
6.1 The Need for Health Information Systems Research............................................94
6.2 Development of an Integrated Research Model....................................................95
6.3 Effects of Individual Physician Characteristics on Attitudes................................97
6.4 Effects of Organizational and Behavioral Contextual Factors on Attitudes........100
6.4.1 Organizational Leadership and Management Support.................................101
6.4.2 Physician Involvement and Participation.....................................................102
6.4.3 Perceptions of Training................................................................................104
6.4.4 Physician Autonomy......................................................................................105
6.4.5 Doctor-Patient Relationship.........................................................................106
6.4.6 Concerns Related to Workflow and Efficiency.............................................107
6.5 Effects of Technical Antecedents on Attitudes....................................................109
6.5.1 Perceived Ease of Use..................................................................................109
6.5.2 Perceived Usefulness....................................................................................110
6.6 Attitudes About EHR Use....................................................................................110
CHAPTER 7: CONCLUSIONS.....................................................................................112
7.1 Limitations of the Study......................................................................................112
7.2 Limitations of Structural Equation Modeling......................................................113
7.3 Summary of Findings...........................................................................................114
7.4 Implications for Professional Practice and Contribution to the Literature..........116
7.5 Recommendations for Future Research...............................................................117
7.6 Recommendations for Practitioners.....................................................................119
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LIST OF REFERENCES................................................................................................122
APPENDIX A: SURVEY INSTRUMENT...................................................................132
APPENDIX B: LETTER OF SUPPORT......................................................................140
APPENDIX C: EMAIL INTRODUCTION AND INFORMED CONSENT...............141
APPENDIX D: ANALYSIS OF OMITTED SURVEY RESPONSES.........................142
APPENDIX E: CORRELATIONS BETWEEN INDEPENDENT VARIABLES.......144
APPENDIX F: CORRELATIONS BETWEEN INDIVIDUAL PHYSICIAN
CHARACTERISTICS AND DEPENDENT (TAM) VARIABLES..............................144
APPENDIX F: CORRELATIONS BETWEEN INDIVIDUAL PHYSICIAN
CHARACTERISTICS AND DEPENDENT (TAM) VARIABLES..............................145
APPENDIX G: CORRELATIONS BETWEEN CONTEXTUAL FACTORS AND
DEPENDENT (TAM) VARIABLES.............................................................................146
APPENDIX H: MEASUREMENT MODEL: CONSTRUCT PATH DIAGRAMS...147
APPENDIX I: FULL PATH DIAGRAM (STRUCTURAL MODEL).........................151
VITA...............................................................................................................................153