Discussion
The results show that the perceived usefulness of computerized CPGs, attitude toward using computerized CPGs, social influence, and organizational support are critical factors influencing physicians’ intention to use computerized CPGs. Consistent with Wu et al. [
56], our study revealed that attitude is the most critical factor affecting physicians’ intention to use computerized CPGs. Cabana et al. [
21] reported that identification with CPGs is the primary cause that hinders the promotion of computerized CPGs. Previous studies have suggested that a lack of knowledge, familiarity, and recognition indicates a negative physician attitude toward computerized CPGs [
21,
74]. To improve physicians’ attitude toward computerized CPGs, hospital managers should expend substantial effort in computerized CPG training and education.
Perceived usefulness refers to users’ subjective beliefs about the benefits of using HIT to achieve job goals in medical practice [
64,
65]. Stoddard et al. [
89] found that when clinical guidelines are flexible and can be adjusted according to the situation to improve the quality of medical decisions, physicians are more willing to use the guidelines. Consistent with previous studies investigating health care professionals’ acceptance of HIT [
58‐
61,
65,
67], our study demonstrated that perceived usefulness is a significant factor influencing physicians’ intention to use computerized CPGs. This finding implies that when physicians consider that actual benefits can be obtained through computerized CPG use, they have a higher intention to use such systems. We suggest that hospital managers establish a dedicated EBM team for promoting and educating physicians about the benefits of computerized CPGs to improve the quality of medical decisions, job performance, and cost effectiveness.
Our study showed that support from colleagues and supervisors positively affects physicians’ intentions to use computerized CPGs; this is consistent with the findings of Davis and Taylor-Vaisey [
79] and Kortteisto et al. [
41]. Thus, support from colleagues and supervisors is encouraged for facilitating the widespread use of computerized CPGs in a health care institute. Organizational support refers to resources (time, money, and human resources) provided by health care institutions to physicians to alleviate stress during computerized CPG use. Cabana et al. [
21] and Simpson et al. [
76] have reported that deficiency in organizational resources (e.g., personnel and time) increases workloads and personal work stress, leading to poor results of clinical guideline implementation. This finding is consistent with our results. Therefore, hospitals managers can alleviate physicians’ stress during computerized CPG use by providing sufficient personnel, time, and equipment, thereby increasing physicians’ intention to use computerized CPGs.
Although several critical factors influencing physicians’ intention to use computerized CPGs were identified, complexity, compatibility, perceived ease of use, and task uncertainty had no significant effect on physicians’ intention to CPG use. Simpson et al. found that higher patient disease complexity may lower the rate of computerized CPG adoption. A computerized CPG that accounts for various clinical conditions simultaneously has not been developed. In a follow-up interview with physicians, the experts expressed that physicians consider various conditions when making clinical decisions and cannot completely accept every suggestion provided by computerized CPGs. Thus, computerized CPGs may provide insufficient support when physicians are faced with complex decision-making situations. In addition, when clinical guidelines become increasingly comprehensive and interdisciplinary, their complexity inevitably increases.
Our study derived a result inconsistent with those of previous studies, in that compatibility was a critical factor affecting users’ willingness to adopt innovative technology [
68,
69]. In 2009, the Ministry of Health and Welfare added EBM to the evaluation criteria for the Evaluation Standards and Measurement Criteria for Teaching Hospitals. EBM practices and the writing of medical records were included in the training of teachers, medical interns, and resident physicians. EBM learning and application were also incorporated into training for general medical skills. Thus, to manage and improve the quality of medical care, EBM standards should be used to determine whether the quality meets the required standards. In addition, regular reviews should be conducted. Therefore, knowledge regarding EBM is now included in the basic training for medical interns and general medical education; hence, the number of physicians who have read and understood the clinical guidelines has gradually increased. Moreover, several developed clinical guidelines have been combined with EMR and HIS to assist physicians in clinical decision-making processes. This can provide a possible explanation for why compatibility does not significantly affect physicians’ intention to use computerized CPGs.
Although perceived ease of use was found to be a critical factor influencing the user acceptance of systems among various health care professionals [
58,
65,
67], perceived ease of use had no significant influence in our study. Moreover, Bhattacherjee and Hikmet ([
85], p. 734) found that perceived ease of use nonsignificantly influenced physicians’ intention to use HIT. They argued that the effect of perceived ease of use can be mediated by other factors such as perceived usefulness [
55] and perceived technology control [
90]. Therefore, perceived ease of use may not be influential at the postimplementation stage of CPG use.
Task uncertainty refers to the frequency at which physicians encounter uncertainties and disorganization-related problems. Raymond and Bergeron [
91] indicated that when encountering task uncertainty, system users exhibited increased satisfaction toward personalized decision-making systems. Although much attention has been paid to clinical guidelines in assisting physicians’ decision-making processes, task uncertainty was not a critical factor significantly influencing physician’ intention to use computerized CPGs. In practice, this finding may be attributed to three reasons: (1) When providing clinical care, physicians frequently encounter sudden, unexpected problems; (2) not all hospital departments have guidelines that can be followed to manage such problems; and (3) clinical care work can involve unprecedented diseases or complications, and treating patients generally requires that physicians from other disciplines participate and share their expertise. Although comprehensive and fully integrated cross-department clinical guidelines facilitate addressing aforementioned problems, few effective complex cross-departmental clinical guidelines have been developed. In addition, ANOVA analysis was conducted to investigate the effects of age and computerized CPG experience on physicians’ intention to use computerized CPGs. The results demonstrated that age and computerized CPG experience were significant demographic factors influencing physicians’ intention to use computerized CPGs. Although age and user experience were found to be significant to user intention in this study, future research can focus on exploring the moderate effect between the investigated factors and user intention.
The findings of this study are subject to five major limitations. First, we examined three hospitals with EBM centers belonging to one medical group in Southern Taiwan, to investigate organizational concerns (culture differences and the establishment of EBM centers), thus potentially restricting the generalization of the findings to other medical institutions. Second, data were collected from experienced users of EBM databases and computerized CPGs. The results from the respondents were based on users’ perceptions, experiences, and understanding. Thus, the data collected may not be adequately objective. Third, we analyzed only cross-sectional data collected by physicians during one period. The data should be carefully interpreted regarding the effect of time. Fourth, multimorbidity is one of the major causes inhibiting the development of CPGs. Because the 17 developed CPGs in Taiwan focus on a single disease rather than multiple conditions of patients, the findings might be not adequately applied in computerized CPGs for addressing multimorbidity problems. Finally, computerized CPG use in the three investigated hospitals is voluntary; thus, tracing individual physicians is difficult. This study investigated physicians’ intention to use computerized CPGs rather than actual use, because we could not directly identify the actual users of computerized CPGs. Two conditions may have caused this problem: (1) Some medical specialists (departments) do not have access to developed computerized CPGs, and (2) some physicians are computerized CPG users but do not consider themselves actual computerized CPG users because they may violate or neglect the suggestions from computerized CPGs. Future studies should pay particular attention to the mentioned problems.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
JLH is the first author of this paper. She took the responsibilities for the conception and design of the study and collection, analysis and interpretation of data. She also helped to compile the submitted paper and made required modifications of the paper. RFC is the corresponding author of this paper. He helped to propose adequate research concepts and strategies of this study. He also provided useful suggestions in research design and the collection, analysis and interpretation of data. Both authors read and approved the final manuscript.
Ju-Ling Hsiao is an associate professor of department of Hospital and Health Care Administration at the Chia-Nan University of Pharmacy and Science. Her research interests include nursing informatics, electronic medical record, and hospital information systems. Her published works have appeared in BMC medical informatics and decision making, CIN-Computers, Informatics, Nursing, International Journal of Medical Informatics, Journal of Nursing Research, Telemedicine and e-Health, and Total Quality Management & Business Excellence.
Rai-Fu Chen is an associate professor of department of Information Management at the Chia-Nan University of Pharmacy and Science. His research interests include medical informatics, electronic medical record, and healthcare information systems. His published works have appeared in BMC medical informatics and decision making, CIN-Computers, Informatics, Nursing, International Journal of Medical Informatics, Journal of Nursing Research, Telemedicine and e-Health, and Total Quality Management & Business Excellence.