Health Care Provider Adoption of Ehealth: Systematic Literature Review

INTERACTIVE JOURNAL OF MEDICAL RESEARCH Li et al
Original Paper
Health Care Provider Adoption of eHealth: Systematic Literature

Review
Junhua Li1,2, PhD; Amir Talaei-Khoei3, PhD; Holly Seale2, PhD; Pradeep Ray1, PhD; C Raina MacIntyre2,4, PhD
1
Asia-Pacific ubiquitous Healthcare research Centre (APuHC), The University of New South Wales, Sydney, Australia
2
School of Public Health and Community Medicine, Faculty of Medicine, The University of New South Wales, Sydney, Australia
3
Discipline of Informatics, Faculty of Arts and Business, University of the Sunshine Coast, Sunshine Coast, Australia
4
National Centre for Immunization Research and Surveillance of Vaccine Preventable Diseases (NCIRS), Sydney, Australia
Corresponding Author:
Junhua Li, PhD
Asia-Pacific ubiquitous Healthcare research Centre (APuHC)
The University of New South Wales
Room 1039, Quadrangle Building, University of New South Wales
Sydney, 2052
Australia
Phone: 61 (2) 9931 9308
Fax: 61 (2) 9662 4061
Email: junhua.li.syd@gmail.com
Abstract
Background: eHealth is an application of information and communication technologies across the whole range of functions
that affect health. The benefits of eHealth (eg, improvement of health care operational efficiency and quality of patient care) have
previously been documented in the literature. Health care providers (eg, medical doctors) are the key driving force in pushing
eHealth initiatives. Without their acceptance and actual use, those eHealth benefits would be unlikely to be reaped.
Objective: To identify and synthesize influential factors to health care providers’ acceptance of various eHealth systems.
Methods: This systematic literature review was conducted in four steps. The first two steps facilitated the location and
identification of relevant articles. The third step extracted key information from those articles including the studies’ characteristics
and results. In the last step, identified factors were analyzed and grouped in accordance with the Unified Theory of Acceptance
and Use of Technology (UTAUT).
Results: This study included 93 papers that have studied health care providers’ acceptance of eHealth. From these papers, 40
factors were identified and grouped into 7 clusters: (1) health care provider characteristics, (2) medical practice characteristics,
(3) voluntariness of use, (4) performance expectancy, (5) effort expectancy, (6) social influence, and (7) facilitating or inhibiting
conditions.
Conclusions: The grouping results demonstrated that the UTAUT model is useful for organizing the literature but has its
limitations. Due to the complex contextual dynamics of health care settings, our work suggested that there would be potential to
extend theories on information technology adoption, which is of great benefit to readers interested in learning more on the topic.
Practically, these findings may help health care decision makers proactively introduce interventions to encourage acceptance of
eHealth and may also assist health policy makers refine relevant policies to promote the eHealth innovation.
(Interact J Med Res 2013;2(1):e7) doi: 10.2196/ijmr.2468
KEYWORDS
technology acceptance; eHealth; health care provider; adoption
and communication technologies (ICT) across health-related

Introduction functions [3]. The benefits of eHealth, such as improved
Poor health care outcomes lead to increased levels of morbidity operational efficiency, higher quality of care, and positive return
and mortality, and obstruct countries’ prosperity and business on investments have been well documented in the literature
profitability (eg, [1,2]). eHealth is an application of information [4-6].
http://www.i-jmr.org/2013/1/e7/ Interact J Med Res 2013 | vol. 2 | iss. 1 | e7 | p. 1

(page number not for citation purposes)
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eHealth is an emerging field at the intersection of medical

informatics, public health, and business, and refers to health
Methods
services and information delivered or enhanced through the Overview
Internet and other related technologies [7,8]. Different eHealth
applications have been used across countries, corresponding to In light of the guidelines originally proposed by [17,18] and
their health needs and priorities. The World Health Organization already applied in several systematic reviews (eg, [19]), we
(WHO) eHealth for Health Care Delivery (eHCD) program, for conducted a systematic literature review on eHealth adoption.
example, targeted primary health care in a number of countries For the specific objective of this study, the guidelines have been
in the Asia-Pacific region. Some of these countries have modified and 4 steps were taken: (1) identification of resources,
instigated telemedicine as a means of bringing specialist health (2) selection of relevant papers, (3) data extraction, and (4) data
care to rural communities, whereas some others have analysis and validation.
endeavoured to improve the safety and continuity of patient Identification of Resources
care through the use of electronic health records (EHR).
A literature search was conducted between October and
While there has been high interest in eHealth, the adoption and November 2011 using 8 online databases: Medline, Cinahl,
acceptance rates have not been high enough for health care Web of Science, PubMed, PsychInfo, ERIC, ProQuest Science
systems to experience the maximal benefits eHealth has to offer Journals, and EMBASE. These databases were thought to be
[8]. Past experience of eHealth adoption in the United States, the most likely to publish eHealth adoption related work [20].
for example, informed us that the low adoption rate could be All search fields available from each search service were used.
attributed to both macro-level factors (eg, supportive policies) In each database, the search was repeated 3 times using the
from the perspective of the public, health care organization, and following phrases (operators came before keywords):
system, and micro-level barriers from the perspective of health [“e-Health” AND “Adoption” OR “User Acceptance”] or
care providers (eg, physicians’ perception about technological [“eHealth” AND “Adoption” OR “User Acceptance”] or
complexity, [9]). [“EMR” AND “Adoption” OR “User Acceptance”] or [“EHR"
AND “Adoption” OR “User Acceptance”].
A broad spectrum of research methodologies have been used
to study eHealth adoption and acceptance factors based on The terms “electronic medical records” (EMR) and EHR were
information provided in published studies [9]. The separately used to search papers. This is because the EMR/EHR
methodologies include quantitative surveys [10], observations consists of patient health related information and forms the core
[11], qualitative focus groups [12], ethnographic studies [13], of eHealth systems [8]. The inclusion of those papers increased
and personal intuition and experience [14]. According to the the validity of the findings. Table 1 lists the number of papers
results of these studies, different eHealth adoption factors may found in each database using the search phrases. In summary,
have led to difficulty for decision makers to explicitly a total of 3315 papers were found, of which 420 papers were
understand, measure, and decrease inhibiting factors or enhance duplicated. The selection process excluded the repeated papers
facilitating forces [9]. Hence, there is a need to synthesize those from the archive and produced a list of 2895 papers.
insights and provide decision makers with a holistic view of
eHealth adoption. Selection of Relevant Articles
The full texts of the selected papers were reviewed for relevance.
Health care providers are the key driving force in pushing Papers with the following criteria were filtered out:
eHealth initiatives [14]. eHealth implementation represents a
disruptive change in the health care workplace. The change does 1. articles not written in English
not occur simply from the introduction of ICT infrastructure 2. articles that did not directly use the terms “adoption” and
but may also require remodelling of the job design of “eHealth” or related terms in the title, abstract, or entire
interconnected health professionals to effectively and efficiently text, with casual referencing of eHealth adoption related
incorporate technology [15]. Without the presence of issues.
motivational forces (eg, health care providers’ dissatisfaction 3. articles without empirical evidence
with the status quo), it is unlikely that the innovation process 4. articles which discussed adoption or user acceptance of
would be initiated. If health care providers resist change or do eHealth but not from the health care provider’s perspective
not possess attributes necessary for change (eg, adaptability and This examination process had two iterations. Finally, 93 relevant
growth-orientation), the change process is less likely to proceed papers were selected.
[16]. The objective of this paper was to identify and synthesize
the factors influential to health care providers’ acceptance of Data Extraction
various eHealth applications. The key information was extracted from the 93 papers. The
extracted data included: (1) characteristics of the study (eg, year
of publication and health care settings where the studies were
conducted), (2) the study results and output—eHealth adoption
factors. Relevant text was extracted or retyped verbatim and
was added to a database.

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Table 1. Identification of papers for review from 8 online databases.

Keywords Medline Cinahl Web of PubMed PsycInfo ERIC ProQuest EM- Total Duplicated
Science Science BASE results
Journals (1980+)
User acceptance 2 3 15 2 2 1 73 2 100 -
AND eHealth
User acceptance 6 0 7 8 3 0 45 2 71 20
AND eHealth
User acceptance 9 5 8 9 2 0 93 10 136 17
AND EMR
User acceptance 13 2 15 12 3 0 57 10 112 20
AND EHR
Adoption 31 15 47 34 24 1 244 36 432 39
AND eHealth
Adoption 29 9 29 44 28 1 155 30 325 74
AND eHealth
Adoption 89 30 67 97 12 3 395 101 794 87
AND EMR
Adoption 165 83 106 187 17 1 607 179 1345 163
AND EHR
Total unrepeated articles retrieved 2895 -
moderators (ie, gender, age, voluntariness of use, and

Data Analysis and Validation experience) have also been incorporated in the UTAUT. Apart
Figure 1 illustrates the analysis process of the data collected in from the 4 core constructs and 4 moderators, another cluster of
Step 3. Based on the terminologies or terms utilized in the eHealth adoption factors, which could not be mapped against
papers, 49 eHealth adoption/acceptance factors were initially the UTAUT, was identified. Accordingly, the factors were
extracted. All citations used to identify the results were noted. initially grouped into 9 clusters (Figure 1).
The next activity was to study the definitions used in the papers.
Factors with close relevance were combined, generating a list To search for convergence among multiple sources of
of 40 factors. For example, “time required to select, purchase, information and methods of data collection and analysis, a
and install the eHealth system”, “time involved in learning to validity procedure was applied [22,23]. First, the eHealth
use the eHealth system and additionally required to become adoption factors were reanalyzed within and across the clusters
familiar with the system operation”, and “the degree to which to ensure consistency and independence. The factors were
use of the innovation is perceived as being time consuming” regrouped into 7 clusters:
were all grouped to “time cost”. 1. health care provider characteristics (eg, IT experience and
Based on the perceived commonality of the themes, the 40 knowledge, gender, age, and years in practice)
2. medical practice characteristics (eg, practice size and
factors were analyzed and organized according to the Unified
Theory of Acceptance and Use of Technology (UTAUT) by teaching status)
3. voluntariness of use
Venkatesh et al [21]. The UTAUT set out to integrate the
4. performance expectancy (eg, perceived usefulness and
fragmented theory and research on individual acceptance of
information technology into a unified theoretical model, which needs)
5. effort expectancy (eg, perceived ease of use)
highlights the importance of contextual analysis in developing
6. social influence (eg, subjective norm)
strategies for technology implementation within organizations.
7. facilitating or inhibiting conditions (eg, legal concerns)
This model accounts for 70% of the variance in usage
intention—a substantial improvement over any of the original The clusters were then given labels and reviewed once more
8 models and their extensions. Within the UTAUT, 3 core for consistency. Reassessment and relabelling were performed
constructs that impact on behavioral intention, and consequently for some papers. This step was repeated until a consensus was
use behavior, are performance expectancy, effort expectancy, reached on the labels for clusters. In the final analysis, papers
and social influence, whereas the other core construct facilitating were reassigned to appropriate clusters. The resulting clusters
conditions has a direct impact upon use behavior. Four represented another level of abstraction.

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Figure 1. Data analysis process. f=number of factors; c=number of clusters.
persons at some distance from a health care provider [25]. The

Results remnant studies examined the acceptance of other eHealth
Characteristics of Selected Studies applications such as Intensive Care Information System (ICIS)
[26], e-discharge which helps inpatient physicians to track
This section presents the results of statistical analyzes on the pending tests at hospital discharge [27], Anesthesia Information
characteristic data extracted from the 93 papers, including: (1) Management System (AIMS) [28], and electronic logistics
the growth of publications by years, (2) distribution by information system [29].
geographical areas, (3) types of research methodologies
employed, (4) eHealth applications studied, (5) health care Health Care Settings
settings selected, and (6) study participants. The majority of the studies were conducted in hospitals and
Growth of Publications office-based clinics (primary care). In some studies, multiple
health care settings of different types were chosen to examine
Figure 2 shows the growth in the publications. The growth the eHealth acceptance issue. For example, Jha et al used survey
represented by the curve was not linear, with a dramatic rise in data from stratified random sample of all medical practices in
the number of papers published after 2005. Massachusetts in 2005 to determine rates of EHR adoption and
Geographical Areas perceived barriers to adoption [30].
The majority of the studies (72/93, 77%) were conducted in Study Participants
North America, followed by Europe (9/93, 10%), and Asia The majority of the studies (ie, 68/93) focused on physicians.
(7/93, 8%). Nurses and other health workers were recruited in 25 research
Research Methodologies projects on eHealth adoption and acceptance.
Quantitative methodology was predominately used by 57/93 eHealth Acceptance Factors
studies. The number was nearly twice as large as that of Through the data analysis and validation process, 40 factors
qualitative studies. were identified to be influential to the health care providers’
eHealth Applications acceptance of eHealth and grouped into 7 clusters (Figure 3 and
Table 2). A brief description of each cluster is provided below.
The 93 papers addressed a wide range of eHealth applications.
57 targeted the EHR/EMR, which was defined as computerized A health care provider’s characteristics included his/her
medical information systems that collect, store, and display information technology (IT) experience and knowledge, years
patient information [24]. Telemedicine/Telehealth was the in medical practice, professional role, age, gender, and race.
second most popular application studied (addressed by 7/93 Characteristics in relation to a health care provider’s medical
studies). Telemedicine frequently referred to the use of a wide practice included the practice size, teaching status, location,
array of technologies to deliver a range of medical services to single or multi-specialty, practice level, types of third party

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payers, and patient age range. Voluntariness of use was defined included the subjective norm, competition, supportive
as “the degree to which use of the innovation is perceived as organizational culture for change, and friendship network.
being voluntary or of free will” [21]. Performance expectancy Facilitating or inhibiting conditions were defined as the degree
was defined as the degree to which a health care provider to which a health care provider believes that an organizational
believes that using the eHealth system will help him or her to and technical infrastructure exists to support use of the eHealth
attain gains in job performance [21]. It included the perceived system [21]. It included the computer self-efficacy, computer
usefulness and needs, relative advantage, job-fit, and anxiety, legal concerns, financial constraints, availability of
reimbursement and financial incentive. Effort expectancy was ICT infrastructure, time cost, eHealth interoperability, IT
defined as the degree of ease associated with the use of the support, eHealth and business process alignment, end user
eHealth system [21]. It included perceived ease of use, ease of involvement, management commitment and support to change,
use, and complexity. Social influence was defined as the degree uncertainty about IT vendor, professional autonomy, interference
to which a health care provider perceives that important others with the health care provider and patient relationship, and patient
believe he or she should use the new eHealth system [21]. It privacy concerns.
Figure 2. Growth of publications (based on our selected articles).

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Figure 3. eHealth acceptance factors and clusters.

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Table 2. eHealth acceptance factors under 7 clusters.

Cluster and factors Definitions and citations
Health care provider characteristics
IT experience and Generic IT skills (eg, typing skills) and experience [24,30-47]
knowledge Those who had little experience with computers were challenged by the process of learning how to use the computer
in addition to learning the software [43]

Previous experience of computer use in medical practice or training in using particular eHealth systems [48-56]
Respondents with an electronic health record (EHR) were more likely to e-prescribe than those who did not have
an EHR, and to have patients take a computer-generated prescription to the pharmacy [55]

Years in practice Total years in practice since medical school graduation [32,48,57-61]
Based on the comments offered by those in practice for longer than 25 years in our study, it did not make sense to
invest time or money at this point in their careers [32]

Role Variation between physicians and other health professionals [53]

Physicians use most of the advanced features more than nonphysicians [53]

Variation between specialists and others [59,62,63]
high-end specialists, such as obstetrician-gynecologists, are less likely to be using EHR in their practice [63]

Age Physical age [36,39,46,59,61,64-67]

EMR use was inversely associated with physician age [65]

Gender Biological sex [39]

Females were less likely to use PDAs [39]

Race A group of people of common ancestry, distinguished from others by physical characteristics [39]
African American and Hispanic physicians were more likely than Caucasian to indicate routine PDA use; Asian
physicians reported using email with patients significantly less frequently than their Caucasian counterparts [39]

Medical practice characteristics

Practice size Number of physicians in the medical practice [36,39,48,57,58,60,61,65,67-72]
Physicians in practices with 11 or more physicians were most likely to use any EMR system, whereas physicians
in solo practice were least likely to use EMRs [65]

Number of patient visits [24,32,61,72,73]
who saw fewer than ten patients per day, reviewed fewer than 20 medical records per day and handled fewer than
ten calls daily, were statistically less likely to want to use a computer during a consultation; Those seeing fewer
than ten patients daily were the most receptive to the use of handwriting [32]

Teaching status Practices affiliated with academic institutions [58,70-72]

There was a statistically significant association between presence of students and residents in a practice and the
practice’s use of an her [71]

Location The medical practice in a rural setting or urban setting [40,61,68,72-74]

urban settings were significantly more likely to have adopted AIMS [72]


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Single/Multi-specialty Difference between those in a single-specialty practice and in a multi-specialty practice [39,65,66,68,75]
those in a multi-specialty group were more likely than those in a single specialty practice to routinely use EHRs
[39]

Practice level Distinctions between Primary, Secondary and Tertiary health care [36,58,60]
physicians whose practice consisted of a specialty other than primary care were more likely to use an EHR [60]

Types of third-party Proportion of patients who are privately insured, Medicaid, Medicare, or uninsured [48,66,73,76]
payers Physicians with the highest percentage of Medicaid patients in their practices were significantly less likely to indicate
using an EHR system when compared with those in the low-volume Medicaid group [76]

Patient Age Range The age range of served patients’ [67]

doctors who treat HVEawere significantly less likely to adopt EHR [67]

Voluntariness of use
Perceived voluntariness The degree to which use of the innovation is perceived as being voluntary, or of free will [77]
Perceived voluntariness had a negative causality on behavioral intention to use telemedicine. These findings con-
tradict those from prior IS literature that found a positive relation between voluntariness of use and intention to
adopt [77]

Performance expectancy
Perceived usefulness The degree to which a health care provider believes that using the eHealth system would enhance his or her clinical
and needs or non-clinical job performance [24,25,28,29,33,35,36,38,41,43,46,50,56,75,77-91]

Perceived needs of adopting the eHealth system [42,79,92-94]
Participants from private hospitals or who owns a private practice reported that most of their patients are one-
time customers and they do not expect them to come back. For private hospitals, about 30% of their patients are
from out of the state (mostly from near towns and villages). Therefore, they do not keep their past medical records
[93]

Relative advantage The degree to which using an innovation is perceived as being better than using its precursor of practices
[5,45,59-61,72,93,95,96]
physicians who used electronic prescribing were significantly more likely to view it as saving time than those who
have not adopted the technology [5]

Job-fit How the capabilities of the eHealth system enhance a health care provider’s clinical job performance [24,40,97]
no mechanism of alerting inpatient physicians that finalized test results were available for viewing (eg, by email
or by an alert in the inpatient computer system [97]

Reimbursement and fi- The degree of a health care provider’s perception of uncertainty over return on monetary investment
nancial incentive [5,24,26,31,40,73,86,90,91,95,98]

Availability of financial reward for a health care provider’s time investment in learning and using the eHealth
system [36,54,70,86,92,99]
the availability of incentives for adoption of HIT were more likely to have EHRs than practices without such incen-
tives [70]

Effort expectancy

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Perceived Ease of use The degree to which a health care provider believes that using the eHealth system would be free of effort
[5,25,28,29,38,40,46,47,52,54,56,68,74,75,81,84,87,88,90]
co-existence of paper and electronic records at the transition period, as an important barrier to EMR adoption
[74]

Ease of use The degree to which using the eHealth system is perceived as being difficult to use
[5,27,28,35,41,45,46,52-54,64,77,84-86,89,91,97,100-103]
a perception that technical system deficiencies reduce the quality of clinical routines can result users’ resistance
[103]

Location of ICT equipment for convenient use of the eHealth system [41,45,49,96,101,102]
Sometimes the physician practice does not have appropriate equipment to facilitate use of the e-Prescribing system
as part of the existing workflow. For example, if they do not have a handheld device or computer in the examination
room, the busy clinician needs to use a PC outside the examination room, adding an extra step to the workflow
[49]

Complexity The degree to which the eHealth system is perceived as relatively difficult to understand and use
[24,26,35,37,45,46,54,79,84,86,89,93,96,100,101]
this study indicated that the EMR systems are very complex and difficult to learn, and this affects their attitude
towards using the EMR systems [93]

Social influence
Subjective norm The health care provider’s perception that most people who are important to him or her thinks he or she should or
should not adopt the eHealth system in question [40,59,77,91]
Patient resistance or not wanting their physicians to use EHR [40]

Competition Perceived competitive advantage with eHealth [48,86,94]

adopt mobile technologies to gain a competitive advantage; adopting IS creates a competitive advantage by giving
businesses new ways in which to outperform their rivals [94]

Supportive organization- Leadership and presence of champions for the eHealth system adoption within a health care setting
al culture for change [24,35,38,43-45,74,79,86,96,104]
Health care professionals were likely to accept and participate in the process of eHealth adoption when the programs
were introduced and promoted by a peer with considerable authority and influence and familiarity with the practices
[79]

The degree of a health care provider’s perception of organizational culture (eg, learning culture) supportive to
eHealth adoption [33,105]
The culture of the organization, including its supportive elements, influences both implementation and persistence
of the work innovation [33]

Friendship network Personal intimacy and interactions with personal friends [47]
Social influence affecting physician adoption of EHR was predominantly conveyed through interactions with per-
sonal friends rather than interactions in professional settings [47]

Facilitating or inhibiting conditions

Computer self-efficacy A health care provider’s self-judgment of his or her ability to use the eHealth system to accomplish clinical jobs
or tasks [46,48,67,77,86]


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Computer anxiety Evoking anxious or emotional reactions when it comes to adopting the eHealth system [24,33,40,77,80,92,106]
They are concerned that under certain circumstances, or as time passes, the systems will reach their limitations,
become obsolete and will no longer be useful [24]

Legal concerns The availability of the policy, regulation, and protocol supportive to using the eHealth system
[31,54,74,78,79,82,93,95]
Regulation regarding sharing of clinical information between the various EMR users across settings of care could
represent a complex issue. During interviews, some respondents expressed concern with respect to the application
of the law related to patients’ consent in the context of EMR implementation [74]

Financial constraints The degree of a health care provider’s perception of high monetary cost for adopting the eHealth system (ie, start-
up costs and ongoing maintenance costs) and of the availability of financial resources to cover the cost
[5,25,27,28,30-33,35,37,39,41,50,52,53,58,60,62,69,71-75,79,80,85-87,91,93,94,107-110]
respondents noted the lack of capital to invest in EHRs as an important or very important barrier to adoption [73]

Availability of ICT in- The degree of a health care provider’s perception of the availability of ICT infrastructure required for using the
frastructure eHealth system [24,35,38,49,51,79,81,91,107]

Time cost Time required to select, purchase, and install the eHealth system [5,24,37,40,59,61,86,90]
Implementing an EMR means switching from paper-based to electronic based systems, and this involves transferring
records between the two systems [24]

Time involved in learning to use the eHealth system and additionally required to become familiar with the system
operation [25,28,31,32,37-39,41,44,46,50,53,55,57,60,62,71,72,74,85,87,91,92,109,110]
the time and effort involved in learning to use these technologies as a significant barrier [31]

The degree to which use of the innovation is perceived as being time consuming [24,35,84,86,90,93,97,99-101]
takes too much time to enter data in real time [93]

Interoperability The degree of a health care provider’s perception of the ability of the eHealth system to exchange and use relevant
clinical data within and across the health care setting [24,26,31,32,38,49,72,73,86,91,92,103,104]
Lack of ability to exchange clinical data with laboratories and hospitals is a major barrier for smaller physician
practices [31]

IT support The degree of a health care provider’s perception of the availability of experienced IT personnel for technical
support (eg, troubleshooting emergent problems during actual usage of the eHealth system, and providing instruc-
tional and/or hand-on support to users before and during usage)
[24,26,28,30,31,34-38,54,57,72,74,79,81,84,91,94,100]
the provision of good maintenance and user support systems greatly increases user acceptance of a new system
[84]

The degree of a health care provider’s perception of the adequacy of training for the usage of the eHealth system
[24,27,35,38,41,43,44,50,53,71,75,78,79,92,100,103,108]
This study found that inadequate training limits EMR utilization [108]

eHealth and business The degree of a health care provider’s perception of the fitness of the eHealth system into the clinical workflow
process alignment [29,32,77,96,97,99,103]

End user involvement The involvement of end users in the planning and implementation process of the eHealth system
[24,38,75,83,84,86-88,103,104]
Clinicians’ resistance was also related to whether or not they had been involved in the design and implementation
process [103]


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Management commit- The presence of management commitment and availability of management support for adoption of the eHealth
ment and support to system [24,33,45,75,79,81,82,87,88,91,92,103,109]
change the implementers’ responses were supportive and addressed the issues related to the real object of resistance; the
severity of resistance decreased [109]

Uncertainty about IT The degree of a health care provider’s perception of the availability of reputable and trustworthy external IT service
vendor providers in the market [24,29,49,52,106]

Professional autonomy The degree to which using the eHealth system is perceived by a health care provider as losing professional control
over the conditions, processes, procedures, or content of his or her work according to the individual judgment in
the application of his or her profession's body of knowledge and expertise [24,42,75,86-89,91,110,111]
With the implementation of EMRs, physicians are concerned about the loss of their control of patient information
and working processes since these data will be shared with and assessed by others. Physicians’ perceptions of the
threat to their professional autonomy are very important in their reaction to EMR adoption [24]

Interference with health The degree to which using the eHealth system is perceived as interfering the health care provider-patient relationship
care provider-patient during their encounter [24,33,36,46,50,75,86-88,91,92,112]
relationship physicians who value a close patient relationship have less positive attitudes about the EMR [33]

Patient privacy con- The degree of a health care provider’s perception of the security of patient information and protection of patient
cerns privacy [24,30,31,40,79,89,111,112]
a
high volume of elderly
[25,29,41,42,75,77,79,81,83-85,87,88,102], the factors

Discussion influential to health care providers’ acceptance of eHealth
Comparative and Gap Analysis included their perceived usefulness and needs, perceived ease
of use, and all of the facilitating or inhibiting conditions.
Of the 93 papers, 57 examined the adoption/acceptance issue
of EHR/EMR. EHR/EMR is a repository of health information Few studies (eg, [41]) have successfully tested the applicability
in relation to a subject of care (ie, patient) in a computer of the UTAUT model by Venkatesh et al [21]. Using the
processable form [113]. Li et al explained that electronic patient definition of the UTAUT constructs, we analyzed and organized
records form the core of any other eHealth applications and thus the eHealth acceptance factors that we found. The mapping
the success of these is very much dependent on the EHR/EMR work demonstrated that the UTAUT model is a useful
adoption [114]. Although EHR/EMR can be utilized by all framework for applying and organizing literature, which is of
groups of health care providers (eg, physicians, nurses, and great benefit to readers interested in learning more on the topic
pharmacists), physicians were study participants among an [119]. Nevertheless, it was found that half of the health care
overwhelmingly large number of publications. provider characteristics (years in practice, role, and race) as
well as medical practice characteristics identified from this
After 2002-2004, there was a sharp increase in the number of literature review have not yet been covered in the UTAUT.
publications. A majority of these studies were conducted in the Further, some studies also showed significant correlations
United States. According to Burt et al [115], EHR adoption in among the identified factors. Perceived usefulness had the
the United States was significantly low until 2005, with less strongest impact on health care providers’ behavior intention
than 18% of physicians used EHR at their office. After 2005, [88], whereas their perceived usefulness was influenced by the
there was a great increase in EHR adoption levels across the perceived ease of use, eHealth and business process alignment,
United States [115], making more health care settings available end user involvement, management commitment and support
for eHealth acceptance research. to change, health care provider-patient relationship, and IT
Most of the 93 studies used a quantitative research methodology experience and knowledge [25,28,33,56,77,83,86-88]. The
to measure eHealth adoption/acceptance variables and test variance of the perceived ease of use was associated with the
hypotheses. A small percentage applied models or theories on computer self-efficacy, end user involvement, management
individual acceptance of information technology (eg, commitment and support to change, as well as health care
Technology Acceptance Model, TAM [116-118]). The results provider-patient relationship [77,88]. These correlations have
supported the models in predicting the adoption behavior in the not been incorporated in the UTAUT. Our efforts to map eHealth
health care context. The most applied model was the TAM, acceptance research results against the UTAUT model suggested
which proposed a method of evaluating user acceptance through that health care settings could potentially extend theories on
his/her beliefs, attitudes, intentions, and actual technology information technology adoption due to their complex contextual
adoption behavior. Within these studies dynamics.

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In some of the papers, significant correlations were not providers may lack the adequate computer skills to use eHealth
necessarily found between acceptance factors on the list systems or had previous negative technology experiences
(particularly those of individual characteristics and medical [49,121]. IT support before, during, and after initial eHealth
practice characteristics) and health care providers’ usage implementation can provide a smooth transition to their
intention or actual use of eHealth. Chavis’s study [105], for reengineered job routine and overcome their technology phobia,
example, did not demonstrate a significant positive correlation hence facilitating eHealth acceptance and use (eg, [27,78,81]).
between individual characteristics (ie, job role and age) and IT support includes, but is not limited to training, provision of
technology adoption. This result can be explained with the guideline documents, and troubleshooting [50,123,124].
UTAUT model: the age acts as a moderator rather than a factor
Training can take various forms such as group training or
directly impacting upon the behavioral intention or use behavior.
one-on-one training, which is ideal in all circumstances [122].
Russell et al found that health care providers in large practices
One-on-one training needs to set expectations, teach health care
were not more likely to use an EMR [112]. Others
providers about the eHealth system features, customize the
[24,40,57,69,120] argued against that, suggesting that larger
technology for each particular specialty, and help them to
practices tended to “have access to the potentially greater
integrate the system (eg, e-Prescribing) into their medical
resources” (financial and human resources) required for the
practice workflow [49].
eHealth system delivery and adoption, and have extensive
internal IT assistance and training. Guideline documents as a knowledge source promote authentic
translation of domain knowledge and reduce the overall
Apart from the contradicting findings among these studies, some
complexity of the implementation task [123]. Each care provider
acceptance factors can also be context sensitive. Given that most
should be provided with a manual containing step-by-step
of the 93 studies were conducted in the United States, the types
instructions for the system’s use [124].
of third-party payers (which is by definition the proportion of
patients who are privately insured, Medicaid, Medicare, or Real time troubleshooting (especially through internal resources)
uninsured), for example, reflects the health insurance scheme facilitates the effective use of the eHealth system and becomes
specifically in the United States context. In the future, further essential to the system success in terms of actual usage [49,124].
studies particularly in health care settings of other countries, Health care providers need to know how to access it when
are required in order to improve the understanding of eHealth required [124]. A feedback mechanism (eg, online help) allows
adoption phenomenon in a global context, as well as to extend health care providers to document a problem that they are having
the theory and research on individual acceptance of information with the system and then to receive prompt feedback [13,125].
technology. Compared with external support services from the IT vendor,
internal IT staff is more familiar with the work environment
Limitations and related needs, and may respond more quickly to an urgent
Here are a few major limitations of this literature review. request [124].
Although efforts were made to include all research papers on
health care providers’ acceptance of various eHealth Another example is eHealth/business process alignment.
applications, some may not have been identified due to selected Workflow is associated with routine processes, characterized
search phrases. In order to at least include those papers, which by a fixed definition of tasks and an order of execution [126].
can help us increase the validity of the findings, the The eHealth system needs to be designed in close collaboration
supplementary search keywords “EHR” and “EMR” were both with health care providers so that it truly assists their medical
used as previously discussed. practice [122,127,128]. The collaboration between IT vendors
and clinical sites is to understand the site's workflow and
The review was limited also due to the selection of the determine the most suitable IT solution [124,129]. After the
databases. Although they are the outlets that were deemed most workflow is analyzed thoroughly with health care providers’
likely to publish eHealth acceptance-related work, some papers involvement, their participatory process is also essential to
may have been missed. We tried to compensate for this potential fine-tune the system’s capabilities [128]. Extensive software
loss by ensuring that all selected databases were searched to testing of the vendor's claims for the baseline functionality and
their full extent. system adaptability to local needs is critical before the
Mapping the identified eHealth adoption factors against the implementation, as health care providers' frustration from
UTAUT model can be subjective. We attempted to maximize software problems can promptly escalate and result in resistance
the accuracy and appropriateness of our mapping work by to continue using the system [128].
applying the validity procedure. To Policy Makers at the Health Sector
Practical Implications By synthesizing the evidence from the literature, our study may
also assist policy makers at the health sector in refining or
To Decision Makers at Health Care Settings developing relevant policies to push eHealth innovation. eHealth
The study results could help decision makers at the health care adoption and ongoing maintenance requires a large capital
setting systematically understand facilitating forces and investment [131-133]. While the government in some cases
inhibiting factors influential to the health care providers’ funds the start-up cost of an eHealth project (eg, the EMRX
acceptance of eHealth, and thus proactively introduce system in Singapore), health care providers may still need to
interventions for the adoption success. For example, health care undertake the operation and enhancement cost of their system

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[8]. In small or independent medical practices, there is lack or of a viable and sustainable product from hundreds of IT vendors
absence of internal capacity for system maintenance; eHealth in the market [68,106].
vendors alternatively provide all these services but often charge
Legal and regulatory changes can be required to address eHealth
high fees. Due to financial constraints, system maintenance
adoption related issues [130,132]. For example, the Medicines
represents a vulnerable spot for the entire effort of eHealth and
Regulations (1984) and the Misuse of Drugs Regulations (1977)
many practices underperform [130]. To address this challenge,
in New Zealand, which governs respectively the form of
the development of programs such as zero-interest or revolving
medication prescriptions and controlled substances, stated that
loans that make capital available to health care provider groups
indelible text and practitioners’ handwritten signature was
at low interest rates is essential, particularly in small or
required for a legitimate prescription. To facilitate the adoption
independent practices [48,106,130].
of electronic prescribing and dispensing of medicines, the Health
Another important issue is interoperability. Bates commented Department of Commonwealth has amended the National Health
that the interoperability between eHealth applications and (Pharmaceutical Benefits) Regulations [8]. These amendments
seamless and reliable clinical information exchange is a key to came into effect from March 1, 2007 and the electronic
making EHR use a cornerstone of practice [130]. Even if prescribing and dispensing process has been additional and
physicians started to use an EHR system, they might still be separate to the already existing paper-based process. The states
unable to seamlessly share some other patient information (such and territories have continuously been taking steps to remove
as laboratory and radiology results stored in Laboratory any legal barriers to the adoption of the electronic process in
Information Systems, LIS, and Picture Archiving and each jurisdiction.
Communication Systems, PACS) for clinical decisions [130].
According to a recent analysis, $77.8 billion USD could be
Concluding Remarks
saved annually by interoperable clinical information exchange In this 4-step literature review, 40 factors were identified to be
among key stakeholders in the health care delivery system [131]. influential to health care providers’ acceptance of eHealth and
The government should take stronger position to create a organized in accordance with the UTAUT model. The findings
database of eHealth vendors whose products meet certain may help decision makers at health care settings and policy
standards and enable clinical information exchange and to certify makers at the health sector to better understand eHealth adoption
these products [31,82]. The certification effort would also issues and take action to facilitate the eHealth innovation
minimize health care providers’ uncertainty over the selection process. Our work also suggests further studies to extend
theories on information technology adoption.
Conflicts of Interest
None declared.
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Abbreviations
AIMS: Anesthesia Information Management System
eHCD: eHealth for Health Care Delivery
EHR: electronic health records
EMR: electronic medical records
HVE: high volume of elderly
ICIS: Intensive Care Information System
ICT: information and communication technologies
IT: information technology
LIS: Laboratory Information Systems

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PACS: Picture Archiving and Communication systems

TAM: Technology Acceptance Model
UTAUT: Unified Theory of Acceptance and Use of Technology
WHO: World Health Organization
Edited by G Eysenbach; submitted 09.12.12; peer-reviewed by H Siadat, T Solvoll, D Keeling; comments to author 22.01.13; revised
version received 04.02.13; accepted 09.03.13; published 16.04.13
Please cite as:
Li J, Talaei-Khoei A, Seale H, Ray P, MacIntyre CR
Health Care Provider Adoption of eHealth: Systematic Literature Review
Interact J Med Res 2013;2(1):e7
URL: http://www.i-jmr.org/2013/1/e7/
doi: 10.2196/ijmr.2468
PMID: 23608679
©Junhua Li, Amir Talaei-Khoei, Holly Seale, Pradeep Ray, C.Raina MacIntyre. Originally published in the Interactive Journal
of Medical Research (http://www.i-jmr.org/), 16.04.2013. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work, first published in the Interactive Journal of Medical Research, is properly
cited. The complete bibliographic information, a link to the original publication on http://www.i-jmr.org/, as well as this copyright
and license information must be included.

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INTERACTIVE JOURNAL OF MEDICAL RESEARCH Li et al

Health Care Provider Adoption of eHealth: Systematic Literature

(Interact J Med Res 2013;2(1):e7) doi: 10.2196/ijmr.2468

and communication technologies (ICT) across health-related

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eHealth is an emerging field at the intersection of medical

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Table 1. Identification of papers for review from 8 online databases.

moderators (ie, gender, age, voluntariness of use, and

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Figure 1. Data analysis process. f=number of factors; c=number of clusters.

persons at some distance from a health care provider [25]. The

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Figure 3. eHealth acceptance factors and clusters.

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Table 2. eHealth acceptance factors under 7 clusters.

Role Variation between physicians and other health professionals [53]

Age Physical age [36,39,46,59,61,64-67]

Gender Biological sex [39]

Medical practice characteristics

Teaching status Practices affiliated with academic institutions [58,70-72]

Location The medical practice in a rural setting or urban setting [40,61,68,72-74]

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Cluster and factors Definitions and citations

Patient Age Range The age range of served patients’ [67]

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Cluster and factors Definitions and citations

Competition Perceived competitive advantage with eHealth [48,86,94]

Facilitating or inhibiting conditions

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Cluster and factors Definitions and citations

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Cluster and factors Definitions and citations

[25,29,41,42,75,77,79,81,83-85,87,88,102], the factors

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and urban analysis URL: http://free-doc-lib.com/book/application-of-the-diffusion-of-innovations-theory-among-alabama.

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PACS: Picture Archiving and Communication systems

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