Viewpoint PaperEHR acceptance among Austrian resident doctors
Introduction
Steadily rising healthcare costs and the fact that quality and efficiency of care can still be improved challenge healthcare policymakers in most industrialized countries. Currently, there is a movement among many countries to engage in public initiatives and reforms in order to reduce healthcare costs while improving quality and safety of care [28], [31], [38]. Various countries (e.g., Denmark, New Zealand, Australia, Canada, USA, UK) have started remarkable projects using Health Information Technology (HIT), especially nationwide electronic health records (EHR), to improve the quality and safety of care while sustainably reducing healthcare costs [9]. Even though the intention of implementing EHR systems (enabling data storage, usage, and exchange) is almost the same in all of these countries, there are remarkable differences within the specific implementations [39], [41].
The Austrian implementation of a nationwide EHR system is part of a series of major reforms and modernization projects in the health sector. These initiatives are aimed at improving quality and safety of diagnoses and therapies, increasing health data security and cutting healthcare costs by enabling health data exchange and reducing administrative efforts. The Austrian EHR system, called ELektronische GesundheitsAkte (ELGA; German for “electronic health record”) is currently implemented and will allow healthcare providers across the country to access a patients’ medical data regardless of its origin. The efforts to establish a nationwide EHR system started in 2005 with the Austrian health reformation law declaring the EHR system as explicit goal within upcoming healthcare reforms. In the same year, every Austrian citizen was provided with a smart card (“eCard”) that has been used for patient identification since then and can be upgraded for e-government applications. After publishing the results of an ELGA feasibility study [26], different stakeholders (e.g., physicians, health associations, patients’ organizations) became aware of the specific plans and started a heated debate. Although health professionals had serious concerns regarding the ELGA implementation [19], in late 2012 the Austrian National Council passed the law prescribing the implementation of a nationwide decentralized EHR system based on centralized indices for patients, providers, and medical documents [4]. The Austrian Resident Doctors’ Association criticized the lack of physicians’ involvement during the planning phase. Several doctors responded with strikes and protests since they claimed their fears of loss of privacy, additional workload and costs, increased medical liability, and bad usability of the ELGA system were not taken seriously by policymakers. In 2008, a regional interview study among a small sample of physicians in one Austrian state investigated the opinions, needs, and barriers related to ELGA [19]. The aim of the study was to identify ELGA-related themes that had caused uncertainty and concerns among Austrian doctors (e.g., missing information, data protection and privacy, workload and cost) and subsequently had led to a negative attitude toward the EHR system.
In an attempt to further investigate these aspects and identify mechanisms that may lead to higher acceptance levels of ELGA among Austrian physicians, a quantitative survey was conducted. Using a nationwide, quantitative research approach can help gaining a more holistic view on determinants of physicians’ intention to accept and use ELGA. Thus, the goals of the presented study were (a) to identify and analyze factors that influence the ELGA acceptance among doctors and (b) to examine the mechanisms that lead to a higher intention to use the ELGA system after its implementation. Determining factors that are relevant to the physicians’ intention to use ELGA can allow Austrian policymakers to set target-oriented measures in order to increase acceptance. Higher acceptance levels and a greater extent of integration of ELGA in the healthcare processes increase the likelihood that the expected improvements in the Austrian healthcare sector will occur.
Section snippets
TAM and EHR research
Prior health IT (HIT) acceptance research has shown that the Technology Acceptance Model (TAM) [14] is suitable to predict and explain physicians’ acceptance of EHR systems [23], [25], which is why TAM instead of other IT acceptance models was chosen as a basis for the presented study. Additional aspects reflecting Austrian characteristics of the ELGA implementation were derived from other acceptance theories, e.g. the Unified Theory of Acceptance and Use of Technology (UTAUT) [47]. Derived
Participants and procedure
Between June and August 2010, a nationwide survey was conducted using a paper-based questionnaire. Out of the 2000 randomly chosen Austrian doctors in private practices, 307 responded. Two-hundred and four participants (24% female) provided a sufficient amount of questionnaire data (less than 5% of missing values [33]) and were therefore included in the analyses.
Research instrument and measures
The research instrument was developed with HIT experts from the eHealth Management Austria and the Austrian Resident Doctors’
Results
Table 2 presents the goodness-of-fit statistics of the five models (M0–M4). Model fit improved significantly when direct effects were added (M0 vs. M1), as well as indirect effects via acceptance (M0/M1 vs. M2) and perceived usefulness were added (M0/M1/M2 vs. M3): all the χ2 difference tests were significant (p<0.001), and the fit indices improved (e.g., CFI and TLI were low for Models 0 and 1, but high for Models 3 and 4).
The external variables explained 38% of variance in intention to use
Conclusions and limitations
As to the constructs already considered in the generic version of TAM, the results of the present study were in line with expectations derived from prior research: Attitude toward ELGA was a significant predictor of intention to use ELGA (H1). Similarly, perceived usefulness had a significant positive effect on intention to use ELGA (H2a), as well as on the attitude toward ELGA (H2b), which partially explained (mediated) the direct effect of perceived usefulness on intention to use ELGA (H2c).
Ethical approval
None required.
Funding
None.
Competing interests
None declared.
Acknowledgments
The authors thank Bernd Baumgartner and Bernhard Engleder for their assistance in data collection.
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