To comply with Meaningful Use (MU), Millcreek Primary Care (MCPC), a primary care clinic affiliated with St. Mark’s Hospital in Utah, initiated eClinicalWorks Patient Health Portal (eCW). Stage 2 of MU mandates 5% of patients adopt the electronic health record (EHR) through engagement by secure messaging with providers and viewing their personal health information through the portal (Dalrymple, Rogers, Zach, & Luberti, 2016; Irizarry, De Vito Dabbs, & Curran, 2015; Neuner, Fedders, Caravella, Bradford & Schapira, 2015). MCPC met Stage 2 MU goals, however the providers had concern patients were not experiencing the benefits of portal engagement based on portal use data. Our research question is: What motivating factors influence the patients’ behaviors to use health information technology (HIT)?
Purpose
The purpose of this study was to identify motivating factors influencing patients’ behaviors to engage with eCW for strategic planning to enhance communication between patients and providers.
Methods
We used the Health Information Technology Acceptance Model (HITAM) as a framework to determine what factors played an influential role in HIT use. We conducted a survey developed based on HITAM with the author’s agreement, to assess the motivating factors, demographic data and eCW registration status. The survey was disseminated through REDCap, an online research electronic data capture system, which was active from November 17, 2017 to December 31, 2017 (Harris, 2009). A survey link was sent by mass email to all MCPC patients with a valid email address. In the clinic, participants were offered a paper-based survey or the option of a desktop computer through the REDCap survey link. All data collected was voluntary, anonymous, and confidential. Descriptive statistics was used to describe participant characteristics. Independent t-tests were used to examine different motivating factors between participants who registered for the eCW and those who did not. Pearson’s r was used to assess the correlation between each motivating factor from the HITAM. The statistical analysis was conducted in SPSS 24.0.
Results
In total, there were 103 responses (102 via REDCap, 1 paper-based), with 98 completed surveys. The demographic characteristics of equality between participants registered (n = 64) or not registered (n = 29) for the eCW, revealed no statistical difference (age: p = .06, gender: p = .32, race: p = .32, employment: p = .90, and educational background: p = .08). The independent t-tests for equality of means showed no statistical difference between participants who registered for the eCW and those who did not regarding all the 11 motivating factors from the HITAM (p values ranged from .263. to .886). Reliability to estimate the internal consistency of question items from the HITAM motivating factors/subscales showed Cronbach’s alpha values between .57 and .96. We validated each question item within the subscales for reliability which were comparable with the original HITAM instrument (a= .85) (Kim & Park, 2012). Secondary analysis showed “intention to use” had a significantly strong correlation with attitude, perceived usefulness, HIT reliability, and HIT self-efficacy. All participants’ data were used to assess correlations between “intention to use” and other motivating factors from the HITAM. The results revealed moderate to strong positive correlations between “intention to use” and these factors (p < .001): “attitude” (r = .81), “perceived usefulness” (r = .77), “HIT reliability” (r = .73), “HIT self-efficacy” (r = .71), “perceived ease of use” (r = .65), “subjective norm” (r = .52), and “health beliefs/concerns” (r = .43). Yet the strongest correlation was between perceived usefulness and attitude.
Discussion
To solve MCPC’s dilemma of less than stellar patient engagement with eCW, we sought to understand the motivating factors that influence patients to engage with the portal. The HITAM is an effective model that provides insight into patients behavioral intent to engage with HIT (Kim & Park, 2012). Initially we thought, patients who register for eCW would likely be more engaged technology than patients who do not. Our project focused on MCPC patients classified as registered or not registered for the eCW portal. Despite assumptions that demographics or the HITAM subscales would explain the differences in motivating factors, our analysis proved there are no statistical differences between the two groups. Like a ripple effect, having a positive attitude about HIT builds a patient's confidence in their ability to seek health information online, which we understand increases intention to use (Kim & Park, 2012; Tavares & Oliveira, 2016). As online health resources are perceived to be useful and reliable, patients’ may be inclined to use HIT. According to Kim and Park, perceived usefulness shifts attitudes, which is a direct consequence of the behavioral intention (Kim & Park, 2012). According to the HITAM, patients’ behavior to use HIT is influenced by “intention to use” (Kim & Park, 2012). Interestingly, the original HITAM describes behavioral intention and attitude as consequential outcome drivers of HIT motivating factors, influenced by perceived ease of use, perceived usefulness, HIT self-efficacy, and HIT reliability. Similar to our findings, subjective feelings of ones’ competency levels using HIT is significant to the perceived effort to gain access online for health information and health management, therefore empirically supporting the reliability and usefulness of HIT (Kim & Park, 2012).
According to the HITAM, patients’ behavior to use HIT is influenced by “intention to use” (Kim & Park, 2012). Interestingly, the original HITAM describes behavioral intention and attitude as consequential outcome drivers of HIT motivating factors, influenced by perceived ease of use, perceived usefulness, HIT self-efficacy, and HIT reliability. Similar to our findings, subjective feelings of ones’ competency levels using HIT is significant to the perceived effort to gain access online for health information and health management, therefore empirically supporting the reliability and usefulness of HIT (Kim & Park, 2012). Intention to use is the initial step prior to the activation of the behavior. Patients appropriation of information technology, is confirmation of the perceived usability, ease of use and positive attitude for HIT acceptance (Kim & Park, 2012; Tavares & Oliveira, 2016). Perceived usefulness is inversely connected to attitude. For this reason, MCPC should investigate how to change patients’ perception of the usefulness of the eCW Patient Health Portal. To improve patients’ perception of usefulness, daily opportunities of portal integration during patient appointments must be utilized by all staff and providers. For example, providers can engage patients during the visit by instructing them to log onto the portal to review lab results. Medical Assistants can also engage the patient with the portal by uploading educational materials directly into the portal and reviewing them with patients. As patients leave the clinic, the receptionist can have the patient schedule their follow-up appointment through the portal with conveniently located portable electronic devices (e.g. smartphone, laptop, desktop or tablet). The HITAM results demonstrate patients’ behavior to use HIT is guided by positive attitudes that support the perceived belief that HIT is useful (Kim & Park, 2012).
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