Introduction
Effective utilization of Information Technology (IT) in the health sector can lead to cost cutting and restructuring [1] which can help citizens avail medical services at an affordable price. The main challenges for any technology are the users’ acceptance and regular use of technology in day-to-day operations [2] and successful integration with the entire clinical workspace [3]. The mere provision of technology does not guarantee adoption and usage of clinical IT systems [4]. Investments in clinical IT systems can be beneficial only when the systems are used by the physicians for accurate diagnosis and prescriptions [5]. If the usage rate is low, the technology can no longer be effective for organizations [6]. According to Lowenhaupt [7], physicians’ adoption of clinical IT systems is not encouraging. Many studies have corroborated this point [8], [9], [10], [11], [12]. What is (are) the factor(s) that contribute to this negative behavior?
We argue that professional autonomy (or the lack of it) plays a central role in deciding whether clinical IT systems will be adopted or not by the physicians. Professional autonomy is defined as “professionals having control over the conditions, processes, procedures, or content of their work according to their own collective and, ultimately, individual judgment in the application of their profession's body of knowledge and expertise” (: p. 207). The professional autonomy is granted by the State through the necessary legislation and can vary from one country to another country. The professional bodies ensure that this autonomy is not invalidated. In general, professional autonomy addresses the control over the profession's scientific knowledge–production, conveyance, application and evaluation in practice [13]. Walter and Lopez [12] have introduced a new construct called perceived threat to professional autonomy to study the adoption behavior of physicians and we use the same construct in this research. Esmaeilzadeh et al. [14] have explained some of the challenges and issues regarding adoption of health information technology and have emphasized the importance of perceived threat to professional autonomy in IT adoption in the health care sector.
Clinical IT applications are of two types [15], [16]: (1) Electronic Medical Records (EMR) systems–computer systems that allow users to create, store, and retrieve patient charts on a computer and (2) Clinical Decision Support Systems (CDSS)–computer systems that use patient data to generate case-specific advice. The data for CDSSs predominantly come from the EMR systems. In this research, we address issues related to adoption of CDSS by physicians in hospitals in a developing country. More physicians are comfortable in adopting EMR than CDSS. A study among the outpatient physicians in USA indicates that 17% use CDSS and 30% use EMR systems [17]. Why is there a need for a different framework to study the behavior of CDSS adoption by physicians when there are general frameworks available?
Many theories and frameworks have been developed from different perspectives to study user acceptance of IT systems and this single factor is critical to determine if the adoption has been successful or not [18], [19], [20], [21]. A unified model called UTAUT [22] and DeLone and McLean model [23] are popular among researchers to study the adoption and effectiveness of IT systems. We agree with other researchers that these frameworks are for general users and are not completely suitable for studying the adoption behavior of professionals such as physicians. Each profession has special contextual characteristics that may affect IT adoption behavior. The physicians are different because of their specialized training, autonomous practices and professional work arrangements [24].
Our study differs from earlier studies in the following ways. First, we study the antecedents and outcomes of perceived threat to professional autonomy. Previous studies have studied this construct with a few other constructs. For example, Walter and Lopez [12] have studied this construct with perceived ease of use and perceived usefulness on intention to adopt clinical IT systems. Sambasivan et al. [25] have studied this construct with performance expectancy, effort expectancy and physicians’ involvement in decision making on intention to adopt CDSS. In this study, we have developed an integrated framework that includes the antecedents and outcomes of physicians’ perceived threat to professional autonomy. An integrated framework can help us comprehend the entire mechanism of CDSS adoption. Second, the study has been conducted in a fast developing country of South-east Asia, Malaysia. Developing countries face more challenges than developed countries in implementing IT systems. The usage rate of CDSS in developing countries is very low [26] and some of the pertinent reasons are: (1) problem in implementing and using EMR (EMR provides input to CDSS), (2) poor design of human interface, (3) difficulties in fitting CDSS as a part of routine care process, (4) computer illiteracy of physicians and (5) cost of purchasing and implementing CDSS.