HSU, SU-CHEN MBA, RN; LIU, CHUNG-FENG PhD; WENG, RHAY-HUNG PhD; CHEN, CHIA-JUNG MBA
Recently, while the Taiwan government and healthcare organizations have made great efforts to facilitate the adoption of innovative technology in healthcare, the development of mobile nursing information systems has increased in nursing settings. Since 2000, several hospitals in Taiwan have implemented specific types of mobile nursing information systems, including laptops or PDAs. Nurses can administer medication to patients or treat them by using mobile nursing carts. The introduction of mobile electronic medical records (MEMRs) by hospitals enables medical and nursing personnel to access electronic medical records (EMRs) at any time and place, improving how medical records are documented and conveyed and enabling greater point-of-care services. However, most of the cases were evaluated through academic studies or experimental trials and were rarely empirically tested using large-scale clinical implementation.
Among healthcare professionals, nurses are usually deficient in computer literacy.1 The introduction of a large number of information technologies has already directly and profoundly affected nurses. They may worry that computerization will deprive nursing of humanized and individualized care and even replace the role of nurses. Consequently, nurses may become “technophobic”2 and have a negative attitude toward information systems or have used information systems passively.3 Mobile electronic medical records are designed to help nurses complete their nursing recording at the bedside to enhance point of care for patients. However, MEMR integrating complicated hardware and software may also raise uncertain pressure for nurses to use MEMR smoothly. Adopting MEMR is a high-cost investment, and thus knowing the factors influencing nurses’ intention to use MEMR is crucial for hospitals for optimizing the consequent strategies. However, many MEMR-related studies have focused on system design features or adoption experience4–6; relatively rare studies have empirically examined the factors influencing nurses’ use intention. Hence, the purpose of the study was to empirically test the factors affecting nurses’ use intention of MEMR based on the Theory of Diffusion of Innovations (DOI) proposed by Rogers.7
Mobile Electronic Medical Records
Various definitions for computer-based patient records have been advanced.8,9 A consentaneous definition of EMR provided in the US National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology10 states, “EMR is an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.”
Over the last decade, the Department of Health (DOH) in Taiwan has taken various measures to accelerate the development of EMR and increase medical institutions’ willingness to actively use EMR. In practice, a medical record is a type of legal document; therefore, the use of medical records must comply with applicable regulations. The measures taken by the DOH include amending applicable regulations, establishing EMR standards, providing technical support, strengthening information safety, providing a budget subsidy, and adopting computerized media to declare medical expenses to National Health Insurance. With the development of healthcare information management (HIM), many types of medical records can be kept in computers.
Moreover, the rapid development of wireless networks and the rapid revolution of mobile or handheld electronic devices have urged the development of EMR. This encourages many researchers to start investigating MEMR-related issues.4,11–13 However, these studies mainly focused on the development of MEMR and its advantages and disadvantages, but did not define MEMR clearly.
In clinical nursing practice, MEMR (also known as the MEMR system) can be used by the mobile computer on a nursing cart (so-called mobile nursing carts), such as a tablet or laptop, for keeping and accessing nursing records. Figure 1 shows a picture of a mobile nursing cart with MEMR functions used in a hospital in Taiwan. Therefore, we operationally define MEMR as “an EMR that can be accessed and managed through the wireless or mobile computers on nursing carts to help nurses deliver nursing care anywhere and anytime.”
Diffusion of Innovations
The DOI theory was first proposed by Everett M. Rogers7 in 1962, who suggested that innovation is a concept, and any approach or idea deemed “new” by people or groups is innovation. Diffusion is a process whereby members of a social system communicate with one another through specific channels within a period. Rogers7 further indicated that the adoption of a certain innovation by people or decision-making units is triggered not by a temporal behavior but by a series of activities and a decision-making model. These activities and decision-making models are factors affecting the attitude toward adopting innovation. Thus, measuring potential adopters’ perceptions of innovations has been a critical research issue. Rogers7 reviewed thousands of innovation-related studies and identified five perceptual characteristics of an innovation that affect its rate of diffusion: relative advantage, compatibility, complexity, trialability, and observability.
Relative advantage means the degree to which an innovation is perceived as being better than its precursor; compatibility measures the degree to which an innovation is perceived as being consistent with the existing values, needs, and past experiences of potential adopters; complexity refers to the degree to which an innovation is perceived as being difficult to use; observability reflects the degree to which the results of an innovation are observable to others, and trialability considers the degree to which an innovation is experimented with before adoption.7
The DOI theory is used to explain and predict users’ acceptance of diffusion behavior.14 In recent years, DOI has been more comprehensively applied to studies of users’ attitudes toward adopting new technology.15,16 Many DOI-based studies assessing healthcare information technology17–20 have suggested that DOI is also applicable to the healthcare field. Thus, the following hypotheses were made:
* Hypothesis 1 (H1): Relative advantage has a significant effect on nurses’ intention to use MEMR.
* Hypothesis 2 (H2): Compatibility has a significant effect on nurses’ intention to use MEMR.
* Hypothesis 3 (H3): Complexity has a significant effect on nurses’ intention to use MEMR.
* Hypothesis 4 (H4): Trialability has a significant effect on nurses’ intention to use MEMR.
* Hypothesis 5 (H5): Observability has a significant effect on nurses’ intention to use MEMR.
Previous Relevant Studies Using the Diffusion of Innovations Theory
In healthcare, the DOI theory is also often used in the research of innovative technology adoption. Schubart and Einbinder21 conducted interviews to understand factors affecting the adoption of a clinical data repository and found that compatibility with an individual’s skills and work style was associated significantly with satisfaction and continued use. Chew and colleagues17 identified relative advantage, compatibility, complexity, trialability, and observability as affecting the intention of family doctors to use the Internet. In a study of smartphone acceptance for nurses, Putzer and Park19 indicated that compatibility and observability were critical factors for adoption intention. Lee20 also discovered that relative advantage, compatibility, complexity, trialability, and observability had significant impact on nurses’ acceptance for nursing care plan systems. These studies showed that the DOI theory could be used to help understand factors contributing to the successful adoption of innovative technology such as MEMR in a nursing setting.
The study site, a large-scale hospital located in southern Taiwan, was founded in 1969. At present, there are approximately 1300 beds and 800 clinical nurses at the study site. More than 4000 patients are hospitalized at the study site every month.
The planning of a nursing information system at the hospital was initiated in 2000, and a mobile nursing cart (self-assembled prototype) has been continuously developed and tested since 2002. In 2009, with the maturity of the environment, technology, and organizational climate, the hospital formally established an ad hoc committee to fully reinspect and strongly promote the development of a nursing information system and to assess the introduction of professional mobile nursing carts. The hospital started to establish a wireless network in October 2009 and began introducing and testing a mobile medical cart in December 2009. In May 2010, the mobile medical cart was formally implemented at the hospital. It was subsidized by the EMR Promotion Program of the DOH to develop the e-signature system of hospitalization medication records. In October and November 2010, the site initiated the use of the e-signature system for keeping hospitalization treatment and nursing records, and other nursing information-related e-signature systems were continuously introduced into the hospital as well. Thereafter, nurses could use the computer on the mobile medical carts or the computers at their nursing stations to keep nursing-related records by applying e-signatures.
Research Framework and Instrument Development
Based on the literature review, we developed a research framework for exploring nurses’ intentions on MEMR usage, which includes five perceptual concepts: relative advantage, compatibility, complexity, observability, and trialability. Conceivably, MEMR usage intention can be affected by a number of contextual variables other than innovation characteristics. Therefore, considering previous studies in nursing information technology adoption,22–24 we chose nursing seniority and nursing unit to be controlled variables in our research framework (see the research framework depicted in Figure 2).
Moore and Benbasat25 developed an instrument for easily measuring the perceptual characteristics of an innovation as derived by Rogers26 in 1983. The instrument was tested for acceptable reliability and validity in previous studies.21,27,28 Our expert panel, including two researchers in HIM and two practitioners in nursing management, revised the instrument as the basis for measuring the independent variables (relative advantage, compatibility, complexity, trialability, and observability) of perceptual characteristics of MEMR. Behavioral intention, as the dependent variable, was measured with three items commonly used in Technology Acceptance Model (TAM) studies.29 Table 1 demonstrates the operational definitions and measurement items of the variables.
The questionnaire draft used in this study consists of a cover page and a list of items that were measured using a 5-point Likert scale, from 1 (strongly disagree) to 5 (strongly agree). The cover page briefly introduced the purpose of the study and clearly defined EMR and MEMR and indicated how MEMR has been implemented for nurses in the hospital. The draft was then reviewed by an expert panel. An in-depth interview and a pretest were then conducted on five experienced nurses, whose opinions were compiled as the modification reference for the final version of the questionnaire. The questionnaire had 14 questions designed to cover the five concepts of DOI and three questions for behavioral intention.
Survey Procedure and Ethics Consideration
A survey consisting of a paper questionnaire was conducted at the study site. Targeted respondents were all RNs at nursing stations of the site. An appropriate ethical approval for the study was obtained from the institutional review board of the hospital before the questionnaires were officially distributed to all of the nursing stations to protect the rights and privacy of the participants.
A total of 878 copies were sent, and 720 valid responses were collected from December 1, 2010, to December 16, 2010, yielding a response rate of 82.0% (surgery: 201 cases, 27.9%; ICU: 220 cases, 30.6%; internal medicine: 217 cases, 30.1%; obstetrics, gynecology, and pediatrics: 82 cases, 11.4%).
Reliability and Validity Assessment
Before data analysis, the completed questionnaires were examined for reliability and validity. In this study, the Cronbach’s α values for the variables ranged from .622 to .930, and composite reliability ranged from 0.650 to 0.930, indicating that the questionnaire is of acceptable reliability.30 The value of average variance extracted (AVE) of each variable was greater than or equal to 0.59, better than the 0.5 benchmark for convergent validity suggested by Fornell and Larcker.31 The standardized factor loading of each variable exceeded 0.5. These two measures demonstrated acceptable levels of convergent validity.31 Regarding assessing discriminant validity, the square root of AVE value of each variable is greater than the cross-correlation values of all other variables, implying that the variables have high discriminant validity.31 In confirmatory factor analysis, seven model-fit measures were used to assess the overall goodness-of-fit of the proposed model32,33 and showed a good overall fit between the measurement model and the data (2.678 for the ratio of the χ2 to its degrees of freedom, 0.015 for the root mean square residual, 0.964 for the goodness-of-fit index, 0.944 for the adjusted goodness-of-fit index, 0.977 for the normed fit index comparative fit index, 0.986 for the comparative fit index, and 0.048 for the root mean square error of approximation).
Descriptive Statistical Analysis
Table 2 shows a summary of descriptive statistics for the constructs of innovation of diffusion. Among these five variables, observability had the highest mean score (4.26), indicating that nurses generally had known or seen medical institution personnel using MEMR. Complexity had the lowest mean score (2.04), showing that nurses tended to disagree that the MEMR is difficult to use; that is, nurses did not consider MEMR complicated. Nurses’ responses suggested that MEMR is characterized by high relative advantage, high compatibility, high trialability, high observability, and low complexity, which complies with Rogers’ view on innovation characteristics.
Nurses generally reported a high intention to use the MEMR system (mean, 4.32) and were willing to recommend that other people (either within a hospital or elsewhere) use it.
To investigate the influence of DOI variables and controlled variables with respect to the intention to use MEMR, this study performed regression analysis on two models (named model 1 and model 2). The first model (model 1) consists of the five variables of DOI, and the second model (model 2) consists of the five DOI variables along with the two controlled variables, nursing seniority and nursing unit. The authors first confirmed that a bell-shaped curve was observed in the frequency distribution diagram of the standardized residual, suggesting that the sample observation values of this study are close to normal distribution. The variance inflation factor values of the independent variables in the model of this study were all lower than 10, indicating that the multicolinearity of the regression model was not severe.30 When these two controlled variables were added in regression analysis, the R2 value increased from 0.492 to 0.499, suggesting that model 2 can better explain nurses’ intention to use MEMR (Table 3). Nursing seniority had a significant effect on the intention to use MEMR, whereas nursing unit did not. Of the five aspects of DOI, compatibility, complexity, and observability all had a significant effect on the intention to use MEMR. Among them, observability had the most significant effect (β = .311), followed by compatibility (β = .280) and complexity (β = −.174). Relative advantage and trialability did not have a significant effect on the intention to use MEMR. The research results therefore supported H2, H3, and H5, whereas they did not support H1 and H4.
DISCUSSION AND CONCLUSION
Current Status of Development of Mobile Electronic Medical Record at the Study Site
Approximately 170 mobile nursing carts were introduced at the study site and connected to the wireless network in May 2010. As of May 2011, the number of mobile nursing carts had increased to 230. At present, the nurses have kept approximately 40% of nursing records using the mobile medical cart computers and have completed e-signatures simultaneously, with the remaining completed using relevant systems on desktop PCs at the nursing stations.
Nurses’ Intention to Use Mobile Electronic Medical Record
The results revealed that respondents generally had a high intention to use mobile nursing EMR, irrespective of which clinical departments they belonged to. This finding is similar to several recent works on healthcare.4,34,35 A possible reason is that the study site has been developing and adopting various computer applications for supporting daily healthcare and administrative tasks for over 20 years. Employees, including nurses, are already familiar with computer support, indicating positive encouragement for adopting innovative technologies in nursing today.
Effects of Factors of Diffusion of Innovations on the Use of Mobile Electronic Medical Record
EFFECT OF RELATIVE ADVANTAGE
Relative advantage did not have a significant effect on nurses’ intention to use MEMR in this study, which is inconsistent with the research results obtained from the studies of other industries.15,16 However, this finding was consistent with that of some previous studies. For example, Lee’s20 work of investigating computerized nursing care plan systems implementation indicated that the introduction of a system characterized not only by advantages such as paper-saving, increased readability, and structured list printing but also by disadvantages such as slowed response time of computers or hardware (resulting from paper jams, the need to change ink cartridges, and system crashing) may lead to delayed chart processing and may affect changing shifts in a timely manner. In addition, Lee and colleagues36 indicated that work performance does not have a significant effect on nurses’ use of a nursing planning system. Nurses in these studies showed a skeptical attitude toward whether using these nursing systems can increase their relative advantages. These studies give a rational support for our finding.
Informational support for daily work to facilitate the completeness of nursing care (eg, instantaneous and easy recordkeeping and inquiry) is mainly provided to nurses by the MEMR. The main responsibility of nurses is still to comply with the standard regulations of the nursing profession to provide patients with adequate face-to-face care. Adopting MEMR is believed to reduce a burden of data management. However, approximately 60% of nursing records at the site are kept and e-signed by desktop PCs at the nursing stations rather than at the bedside. This implies that nurses still break their work into segments and have not improved effectiveness and efficiency, as expected. Furthermore, the use of innovative technology may be associated with problems caused by unstable system devices, such as a nurse ID card malfunctioning or being misplaced, the card reader malfunctioning, or a wireless network disconnection or instability. These may lead to work delays and further reduce nurses’ intention to use MEMR. That is, the need to reinvestigate why such a finding occurred calls for advanced exploration.
EFFECT OF COMPATIBILITY
This study found that compatibility had a significant effect on nurses’ intention to use MEMR, which is consistent with the findings of past healthcare-related studies.35–37 Mobile nursing carts resemble a portable nursing station. Physicians can provide their medical advice from any location, and nurses can then immediately provide patients with required drugs and treatment through automatic screening as long as they can access the patients’ medication administration system. In addition, nurses can input the data of patients’ blood pressure, breathing, and temperature, as well as data on medication administration and treatment into the information system, and also complete the e-signature immediately. In addition, they can even present the EMR to patients to explain medical conditions or to provide patients with nursing health education. All patient records can be obtained, irrespective of the time and location of patients, enabling the medical and nursing team to rapidly obtain the patients’ most accurate, up-to-date disease condition information. In other words, more highly integrated information is more compatible with nursing work, whereas the hospital information system of lower integrated information is less compatible with nursing work.20
The integrated medical information systems can simplify nurses’ operations (eg, reducing the need to switch between different information systems and repeated information input), provide warnings and information on abnormalities, instantaneously obtain patients’ information to tally with normal clinical operation, and further reduce nurses’ time spent on work irrelevant to patient care. Nurses’ work satisfaction and service quality can be significantly improved by MEMRs, leading to increasing intention and commitment to use MEMRs.
EFFECT OF COMPLEXITY
The study results suggest that complexity is negatively associated with nurses’ intention to use MEMR. That is, the higher the complexity of the system, the lower the intention to use it will be. This finding is consistent with that found by a past study in healthcare.38 Moore and Benbasat,25 however, suggested that the “complexity” in the DOI theory proposed by Rogers26 shares the same concept with the “ease of use” in TAM (but in reversed view) proposed by Davis.29 According to such a perspective, several studies39,40 found that “ease of use” had a significant effect on nurses’ “attitude toward use” and “intention to use” an innovative technology. These reports provide a rational explanation for our finding.
To fully support nurses in completing their recordkeeping at the bedside, MEMR should use equipment such as a tablet PC, wireless bar-code reader, and miniprinter, as well as applications for nursing assessment, nursing care plans, medication administration records, treatment records, vital sign records, and discharge preparation on a nursing cart. A MEMR is a complex integrated system with a burden to operate smoothly and efficiently. As a result, nurses consider returning to nursing stations to complete the data management using desktop PCs. It is crucial to provide nurses with simple and standardized operational interfaces for MEMR to increase nurses’ use intention, especially when it is generally accepted that nurses may be deficient in computer literacy.1
EFFECT OF TRIALABILITY
Trialability did not have a significant effect on nurses’ intention to use MEMR, which is inconsistent with findings of past studies.17,38 Trialability focuses the relevant trials in advance to understand the function of a new information system. Users will be more familiar with the system and intend to use it if they have a sufficient trial period.
However, at the study site, nurses were not required to use MEMR to complete records of the related nursing care at the bedside. We found that approximately 60% of care records were not completed on the MEMR nursing carts and that nurses were still accustomed to returning to the nursing stations to record as before. Therefore, nurses might neither have the motivation to fully understand the functions of the system in time nor want to spend too much time to try out the system. In the meantime, nurses might feel the need to pretest the MEMR system. This may explain why trialability did not directly affect nurses’ intention to use MEMR.
EFFECT OF OBSERVABILITY
Observability had a significant effect on nurses’ intention to use MEMR, which is consistent with the results obtained from past studies.17,19 High observability is believed to increase a user’s intention toward a new system because he/she can gain rich experience and knowledge from those who have used or are using the new system.
Generally, nurses’ computer literacy is relatively low, and they may have a greater fear of innovative technology. Thus, observability is relatively critical for them. If nurses can observe the MEMR use of colleagues inside or outside their hospital, understand the operating procedures and precautions, and know how to consult with experienced colleagues while encountering trouble during MEMR use, they will reduce their fear of and resistance to MEMR, thereby increasing their willingness to use it.
EFFECTS OF CONTROLLED VARIABLES
The research results discovered that nursing seniority was positively associated with MEMR use intention, whereas nursing unit did not have a significant effect. Many daily operation systems were practically integrated into mobile nursing carts by the MEMRs, and senior nurses could better perceive the systems’ convenience and speed for patient care and were therefore more willing to accept MEMR (the mean nursing seniority of the respondents is 6.35 years). This implies that such experienced nurses may help the MEMR diffuse from expert training in more advanced usage and should be included in the system design phase.41 A nurse’s unit was not associated with the intention to use MEMR, and in general, top managers have designed MEMR-promoting nursing activities without considering nursing unit difference. More research is required for further exploration of the unit factor based on our finding.
Limitations and Future Study Directions
A limitation of this study is that all participants recruited from a single hospital would affect the sample representativeness of this study. In addition, the replies from the self-report questionnaires used in this study may be influenced by each respondent’s different perception of the questionnaire items (common method bias).
With many uncertain factors and issues to be clarified, investigated, and overcome, MEMR is still in the beginning stages. Other theoretical models, such as the Information System Success Model,42 TAM,29,43 and Technology-Task Fit Model,44 could be used to enhance the studies.
Finally, in addition to the nurses, other MEMR users, such as physicians, are also potential study targets, and the results obtained may be compared with those of nurses.
As nursing staff are the largest group of users of healthcare information technology, improving nurses’ information management capabilities could have a significant impact on daily care service. How to increase nurses’ intention to use innovative technology has been a research issue of academic importance. This study can help accumulate abundant research achievements on such an issue. Researchers may follow up with further investigation into more aspects of this subject.
This study found, however, that the compatibility, complexity, and observability aspects of DOI have a positive effect on nurses’ intention to use MEMR. Therefore, hospitals are advised to note the compatibility of EMR introduction with the existing nursing operating procedures. Moreover, to reduce learning barriers, the design style of operation steps and interface layouts of an MEMR system should be as consistent as possible with those of the existing applications. Simplifying and standardizing the system functions of MEMRs and adding auxiliary functions such as online help and online video tutorials can be considered by their developers. In addition, encouraging peer experience sharing to increase observability of MEMR is a constructive approach for improving nurses’ intention to use MEMR. On the other hand, the study showed that the relative advantage and trialability aspects of DOI are not nurses’ major or direct concerns for using MEMR. This merits further in-depth studies.
This study not only provides a valuable reference for hospitals and HIM providers while developing and promoting MEMR, but also encourages other relevant stakeholders to discover the factors influencing nurses’ decisions to adopt MEMR based on DOI in a systematical approach.
Sincere thanks and recognition are given to Chi Mei Medical Center for funding this study (CMFHR9957).
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