What drives E-Health usage? Integrated institutional forces and top management perspectives

Highlights

• Top management support includes top management beliefs and E-Health championing.

• Top management beliefs foster E-Health championing and E-Health usage.

• Institutional forces are conceptualized as mimetic, coercive and normative pressures.

• Institutional forces affect both top management beliefs and E-Health championing.

• Top management support mediates the relationship between Institutional forces and E-Health usage.

Abstract

As hospitals increase their reliance on healthcare information technology to deliver services, there is a growing need to understand how to promote E-Health innovation usage within a hospital. Drawing on institutional theory and top management perspectives, we develop a theoretical model that explains how E-Health usage is influenced by external institutional forces and top management support. Three types of institutional forces: mimetic, coercive and normative pressures and two actions: top management beliefs and E-Health championing by which top management champions E-Health usage are identified and examined. Our empirical results show: 1) mimetic and coercive pressures positively affect top management beliefs and mimetic pressure also positively affects E-Health championing, 2) the effect of mimetic pressure on top management beliefs and E-Health championing is significantly stronger than other pressures, 3) both top management beliefs and E-Health championing promote E-Health usage, and 4) institutional forces' influence on E-Health usage is mediated by top management support. These findings highlight the important role of top management support in mediating the effect of institutional forces on E-Health usage and provide insight into how hospitals govern the institutional forces that drive top management support for E-Health innovations, thereby leading to actual E-Health usage.

Introduction

Today's healthcare industry is undergoing significant transformation. Most hospitals (e.g., medical centers and hospitals) are challenged to lower costs, enhance the quality of care and innovate administrative and clinical processes by exploiting advanced information technology (IT) (Garg et al., 2005). IT use in healthcare is referred to as electronic health (E-Health), defined as the cost-effective and secure use of IT in support of health and health-related activities (WHO, 2005). To the extent that IT can help alleviate persistent problems, such as inadequate patient safety, medical errors and escalating costs, accelerating IT utilization in healthcare is a crucial public policy issue (Salge, Kohli, & Barrett, 2015).

A variety of E-Health innovations (e.g., electronic health record [EHR], electronic medical records [EMR], health information exchange [HIE], computerized provider order entry [CPOE], picture archiving and communication systems [PACSs], and health clouds) have been introduced in the healthcare industry in recent years. The healthcare IT market continues to see rapid entrepreneurial growth and E-Health innovations as well as huge increases in venture capital funding (Meier, Fitzgerald, & Smith, 2013). Therefore, it is important for us to understand how hospitals that represent the consumption side of these E-Health innovations can utilize them effectively to improve healthcare services and then achieve better performance.

Using E-Health in hospitals is becoming increasingly important for effectively executing clinical/administrative processes and connecting internal processes to other entities (e.g., patients, insurance providers, other hospitals) (Devaraj & Kohli, 2003). For instance, HIE systems are an E-Health innovation being pushed by the US federal government. The aim of HIE systems is to digitalize health records to create a central data repository that will ensure EHRs are shared across organizations within a region, community, or hospital system to prevent errors and enhance patient care. However, relatively few primary physicians participate in HIE due to the resources required for a hospital to establish connectivity with an HIE as well as inefficient system integration within primary clinics (Fontaine, Ross, Zink, & Schilling, 2010). As this example demonstrates, the actual use of E-Health is often problematic, with many hospitals reporting implementation failures and problems achieving anticipated benefits (Kellermann and Jones, 2013, Murray et al., 2011).

Evidence suggests that organizations in the healthcare sector have been remarkably slow to adopt IT despite its promise for business value (DesRoches et al., 2008, Jha et al., 2009). Uncertainties as well as deficiencies in the understanding, reengineering, deployment and use of complex E-Health innovations have contributed to a lack of widespread success (Gagnon et al., 2012, Kellermann and Jones, 2013). Many hospitals consequently remain acquiescent to external environment pressures arising from external stakeholders and institutions, including suppliers, patients, competitors, industry associations and government agencies (Ahmadi, Nilashi, Shahmoradi, & Ibrahim, 2017). Coping with this plight requires an in-depth understanding of institutional environments and how institutional forces can institutionally influence top management to advocate E-Health usage (Salge et al., 2015).

While there is a rich body of literature on healthcare IT developments and clinical applications in the healthcare environment (e.g., Leidner et al., 2010, Salge et al., 2015, Vest et al., 2011), little attention has been paid to understanding how hospitals can successfully use E-Health innovations (Meier et al., 2013). Existing studies focus mainly on investigating the organizational impact of E-Health and consequently its value (e.g. Kohli, Devaraj, & Ow, 2012) or the challenges associated with the meaningful use of EHR or EMR (e.g. Newell and David, 2012, Vest and Jasperson, 2010). Therefore, utilizing a theory-focused approach to better understand the role of institutional forces and top management in influencing and E-Health usage is needed (Vest et al., 2011). Our research objectives examine 1) how external institutional forces drive top management to championing E-Health toward actual E-Health usage, 2) what the top management role plays in influencing E-Health usage, and 3) why top management support is critical to affecting and motiving organizational E-Health usage.