The limited acceptance of an electronic prescription system by general practitioners: reasons and practical implications

Transcription

1 New Technology, Work and Employment 19:2 ISSN The limited acceptance of an electronic prescription system by general practitioners: reasons and practical implications Albert Boonstra, David Boddy and Moira Fischbacher To control the cost of drugs prescribed by general practitioners (GPs), the Netherlands Ministry of Health decided to implement an electronic prescription system. This paper uses an interpretive perspective to analyse the reasons for limited acceptance of the system. While the promotion campaign focused on the system, GPs based their decision on wider contextual factors. This article examines the limited success of an attempt by a national healthcare agency to implement an electronic prescription system (EPS). The promoters wanted to reduce the cost of drugs prescribed by general practitioners (GPs), and invested heavily in developing the system and promoting it to the intended users. GPs are autonomous, self-employed professionals and they reacted to the system in different ways some used it in full, some partially and some not at all. The analysis relates these reactions to theories about the acceptance and use of information systems. Trying to understand why an information system is used (or not) becomes interesting especially when the users have a high degree of autonomy. Promoters cannot then rely on hierarchical authority to ensure acceptance, instead they need a better understanding of the users attitudes to the system. If these attitudes relate to features of the system, then designing a system that will, for example, be easy to use will encourage acceptance. However, if they reflect a wider set of beliefs, such as personal views on the tension between evidence-based medicine and the exercise Albert Boonstra is Associate professor at the Faculty of Management and Organisation, University of Groningen, The Netherlands. David Boddy is Research Fellow in the School of Business and Management, University of Glasgow. Moira Fischbacher is Lecturer in Strategic Management at the School of Business and Management, University of Glasgow. Blackwell Publishing Ltd 2004, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. 128 New Technology, Work and Employment

2 of clinical judgement by independent professionals (Armstrong, 2002), then ensuring ease of use will be necessary but not sufficient. The paper first describes the background to the EPS, and how the Netherlands Ministry of Health designed and promoted the project. It then sets out an interpretive perspective on the acceptance and use of information systems, followed by the methods used to gather and analyse data. The results show that five factors (and how GPs interpreted them) influenced acceptance. Further analysis suggests that cultural differences between practices shaped these interpretations. This will have some implications for those implementing optional information systems. An electronic prescription system for GPs In the Netherlands, as in other western countries, the costs of health care rise each year, and those who finance the system insurance companies and the central government have taken several measures to contain costs. These include more restrictive insurance conditions, limiting hospital budgets and, the focus of this study, attempts to contain the costs of drugs. General practitioners, also called family doctors, are an important link in the chain of health care providers. Nearly every citizen has a family doctor of their choice whom they consult when they need non-urgent medical assistance. GPs run their medical practice as independent businesses and have complete autonomy in their work, including how they conduct a consultation. A typical consultation takes about 10 minutes and involves: (i) an introduction with some informal interaction between GP and patient; (ii) the subjective explanation of the problem by the patient; (iii) the diagnosis in objective medical terms, sometimes coded in the International Classification System of Primary Care (ICSPC) coding system; (iv) deciding the course of treatment, including a prescription for drugs, where appropriate. A study by Wolters et al. (2001) showed that, for similar cases, prescription costs varied by up to 40%, depending on the quantity and brand of drugs prescribed. The study calculated that if all GPs made more consistent and cost-efficient prescriptions, drug costs would fall by 150 million Euros, representing 20% of the cost of drugs prescribed by GPs. The insurance companies, the Ministry of Healthcare and the National Association of General Practitioners, therefore, developed an EPS, which advises doctors on suitable treatments during consultations (Hunt et al., 1998; Schiff and Rucker, 1998; Mellin, 2002). The main input is the GP s diagnosis, a list of available drugs and the patient s medical records, which include details regarding age, sex, weight, allergies, problems, laboratory data and current use of drugs. The database on medications includes current drugs, past medications, drug allergies, interactions (drug drug) and costs. By using this data the system takes account of the specific situation of the patient. The doctor types in the patient number and the ICSPC code representing the diagnosis. The EPS then recommends a treatment and either prints the prescription or s it to the pharmacist, if the patient so desires. Figure 1 shows the input and output of EPS. The system requires the GP to have a computer in the consulting room, a database of patients and to be able to use the ICSPC coding system. About 50% of GPs use a computer in their consulting room to record and retrieve patients medical records, and a vast majority of this group uses the ICSPC codes. Most of the others have a computer for administrative and archival purposes, usually in the practice office. Ninetyfive per cent of all doctors have a computer either in the consulting room or in the practice office. The objective of those promoting the EPS was that it would advise GPs on the best treatment for a given diagnosis. This would include whether the patient needed a particular drug and, if so, the appropriate quantity and the most cost-effective brand. The targeted savings of 150 million Euros would be feasible if all doctors used the system and followed its recommendations. Specific targets were that: the EPS would be installed on the computers of computer-using GPs (95 per cent of all GPs); Blackwell Publishing Ltd 2004 Limited acceptance of an electronic prescription system 129

3 ICPSC diagnosis code Medical record of patients Electronic Prescription System (EPS) Therapy, including drug prescription List of drugs Figure 1: Input and output of an EPS for GPs 90 per cent of the computer-using GPs would be able to use the EPS; in 90 per cent of consultations, GPs would use the EPS to recommend a therapy; and in 90 per cent of these cases GPs would follow that recommendation. The EPS implementation campaign To promote the EPS the Health Ministry conducted a large implementation program that included: providing information about the system by an instruction CD-ROM, a booklet, posters, a video tape with instructions and presentations at relevant meetings of GPs; distributing a CD-ROM containing a free copy of the EPS system, with instruction programs, to all GPs; holding afternoon or evening instruction meetings in every region of the country; creating a national help desk to answer questions. These programs aimed to show GPs that the EPS was easy to use and the benefits they would gain if they used it such as saving time and improving the quality and consistency of treatments. The campaign started at the end of 1999 and continued until mid Actual use of EPS in 2001 Research by Wolters et al. (2001) showed that approximately 50 per cent of GPs have installed the EPS on their computers and that 50 per cent of this group consults the system at least once a day. However, using the system does not mean that the GP follows what it recommends: users follow its recommendation in approximately 60 per cent of the cases. Thus, only 12 per cent of all GPs use the system and follow the recommendations in all possible cases. So, by mid-2002, the cost of prescription drugs had not fallen to any worthwhile extent and this continued to be the case until the end of Table 1 summarises the objectives of EPS and the degree of realisation after 18 months of implementation. Representatives of the Health Ministry accept that they have not met the objectives of the project, especially with regard to prescription costs. However, they do not speak of failure. They refer to intangible quality improvements in medical practices; that the 130 New Technology, Work and Employment Blackwell Publishing Ltd 2004

4 Table 1: Project objectives and realisation System installed on computer Daily system use Recommendation of system normally followed System used as intended Source: Based on Lagendijk et al., 2001; Wolters et al., Objective Realisation mid-2001 (%) (%) EPS is helping to change the attitude of GPs towards IT and that they need more time to realise tangible results. This study was conducted to gain some insight into GPs attitudes to the system. Interpretive perspectives on acceptance of information systems Walsham (1993) proposed using an interpretive approach when researching the organisational issues associated with information systems, including variability among users in their acceptance of innovation. Interpretive methods focus on the context of information systems, and on the processes whereby the information system influences, and is influenced by, the context (p. 5). The approach is consistent with Czarniawska s emphasis on the need to understand human intentions when considering how people react to a new system. She also points out that it is impossible to understand human intentions by ignoring the settings in which they make sense (Czarniawska, 1998: 4). Those settings can include institutions and practices that people have created through an accumulation of decisions and events. People work within this context and bring to it their unique experiences and interests. They select and interpret events in a personal and subjective way, and attach different meanings to them. An event or artefact (such as a paper setting out the purposes and design of an information system) is not an objective phenomenon. People consciously created the proposal what Walsham (1993: 5) refers to as a social construction by human actors to reflect their interests, experiences and responsibilities. Those with different interests, experiences and responsibilities will attach different meanings to the proposal do they recognise the stated problem?; do they agree that this proposal is the right way to solve it? and to the system will it be a help, a threat, a source of ideas? As these interpretations form attitudes to a system it is not surprising to observe different degrees of acceptance among users. Interpretive approaches emphasise the subjective nature of the acceptance decision. They try to identify the range of interpretations that people make of a system and to understand their sources. Some studies focus on interpretations of the features of the system itself. Davis et al. (1989) developed the Technology Acceptance Model (TAM; Figure 2), which suggests that use depends on a prospective user s attitude to the system. This reflects their perceptions about usefulness and ease of use, emphasising the role of system design in acceptance. Later work by Davis (1993) and others (Igbaria, 1993; Sheppard et al., 1998) found significant correlation among the components of the model. Davis also argued that researchers may identify more variables which influence attitudes and hence acceptance. A noteworthy feature of this case is that the Health Ministry offered all GPs the same system, yet they differed substantially in their willingness to use it. Others have focused more on how people see and interpret the wider context within which a system is designed and used. Some (see, e.g., Markus, 1983; Walsham, 1993; Knights and Murray, 1994; Currie and Brown, 1997) focus on immediate organisational Blackwell Publishing Ltd 2004 Limited acceptance of an electronic prescription system 131

5 Perceived usefulness System design features Attitude towards using Actual system use Perceived ease of use External Cognitive Affective Behavioral stimulus response response response Figure 2: Technology Acceptance Model (Davis et al., 1989) factors, while others examine how influential players interpret and react to external changes (Boddy, 2000; Dawson and Gunson, 2002). As players interpret and respond to their context (e.g. by implementing a system or changing some aspect of structure), they simultaneously reshape that context. Others then interpret and respond to the (new) context as they defend or promote their beliefs and interests. In this case, major contextual factors were drug costs, GP autonomy and cultural differences between practices. Taking an interpretive perspective encourages us to consider how the main players (i.e. promoters and users) vary in their attention to such factors and in the meanings they attach to them. In this case, the promoters were the Health Ministry, insurance companies and medical associations, while the users were autonomous medical practitioners. This autonomy opens up the possibility of variations in use, but would not in itself explain the variations that were observed between GPs. One possibility suggested by organisation theorists is that the culture of a GP s practice affects his/her attitude to the system and willingness to use it. By culture we mean the shared values, ideals and beliefs that members of an organisation develop it expresses shared assumptions about the world and the tasks they perform (Martin, 1992; Hatch, 1997). One practical expression of this is how GPs view information: what they regard as useful, how they wish to obtain it and who they believe should have access to it. This affects how satisfied they are with a given information system, and how they will view a new one. They will welcome a system that fits their culture and resist or ignore one that is in conflict with it. In this paper we will use Quinn s Competing Values Model (Quinn et al., 1996) to examine whether GPs perceptions of the culture of their practices affected their willingness to use the EPS. Pinch and Bijker (1987) propose that as people design a system they do not interact with their context in a linear way, moving systematically from idea to working model. A better description would be multi-directional, in which many possible forms of the artefact exist in the early stages of development, but only some survive. Why some survive and others fail depends on the actions of the social groups that have an interest in the project. The social groups concerned with the artifact, and the meanings that those groups give to the artifact, play a crucial role: a problem is defined as such only when there is a social group for which it constitutes a problem (Pinch and Bijker, 1987: 30). The most influential of these groups will ensure that the system deals with their problem. McLoughlin (1999: 92) defined these relevant social groups as: those who share a particular set of understandings and meanings concerning the development of a given technology....each group will be identifiable through the different views they have (about) the artefact, or even whether it is a desirable technology at all. They will thus each perceive different problems and potential solutions to them. 132 New Technology, Work and Employment Blackwell Publishing Ltd 2004

6 Crucially, McLoughlin argues that these cannot be sensibly defined by prior assumptions about the likely interests of pre-defined groups, but by the empirical device of asking the actors themselves (p. 93). In this case, the promoters vision of the system was one in which all GPs used the system in the intended way and, in doing so, resolved the promoters problem of high drug costs. However, realisation of this vision depended on the autonomous GPs sharing that vision, which may not be the case. A successful innovation depends on achieving consensus among the relevant social groups that stabilise the form (sometimes called closure ) of an acceptable system. This is not one that is technically superior, but one that the groups, which take part in the social process of design, agree is superior. Until the players achieve closure, the new system is not stable and is unlikely to meet promoters expectations. This paper will examine how the initial form of a system favoured by one group (comprehensive adoption) changed during implementation into a more limited form (partial adoption). In that sense, the system has not stabilised, as the promoters are dissatisfied with the rate of acceptance, yet they hope to increase it. These issues have been discussed typically in relation to computer-based information systems within hierarchical organisations. This case is about implementing a relatively optional information system, in the sense that the intended users had a relatively high degree of choice over whether they used the system and how they used it. An example of a low option system is the script that a call centre agent must follow to conduct a call. An example of a high option system is a knowledge management system in a consultancy that enables, but does not require, staff to exchange ideas and issues arising from current projects. In low option systems, managers may be able to rely on hierarchical power relations to ensure at least an appearance of use. In high option systems, they will need to spend more time to promote ready acceptance and use. This paper offers some practical suggestions to those implementing optional systems. The questions that arise from the discussion are: what factors affected the use of the EPS the most (e.g. the system itself or wider contextual factors)? how did social groups differ in their attention to and interpretation of these factors? did GP practices display different cultures and did these affect their attitudes to the EPS? what practical implications does the research suggest when implementing optional systems? The next section of the paper outlines the EPS, the circumstances that encouraged the ministry to introduce it and the outcomes after 18 months of implementation. Method We used a qualitative, case study approach since the questions are exploratory (Yin, 1999) and intended to identify why GPs accepted or rejected the system. The reasons for this are unclear, as there are few studies directly focused on the acceptance of optional information systems. The unit of analysis is the EPS and its acceptance by users. The study was undertaken on the academic initiative of one of the authors after the media in the Netherlands drew attention to the limited success of the EPS. The researchers first observed physical artefacts like the screen layouts and how GPs used the system, and collected documentary evidence including user manuals. They interviewed two designers and four representatives from the Ministry of Health and health insurance companies. This provided information about government policies and expectations with respect to health care, drugs and GPs. The main source of information was semi-structured interviews, conducted during 2001, with 36 general practitioners about their reasons for accepting or rejecting the EPS. The interviews usually lasted about one hour (minimum 45 minutes, maximum two hours) and were Blackwell Publishing Ltd 2004 Limited acceptance of an electronic prescription system 133

7 tape-recorded and transcribed. The interviews were conducted in Dutch, relevant excerpts of which have been translated for use in this paper by the second author. Appendix 1 lists the questions grouped by the characteristics of the practice, reasons for use or non-use and perceptions of the meaning of the system. The questions were deliberately open, allowing the respondents maximum freedom to offer reasons for acceptance or otherwise. The interviewees were randomly chosen from a list of doctors who were willing to participate in academic research. Initially, 42 doctors were approached, of whom 36 agreed to participate in this study. It is important to emphasise that this is not a quantitative study: the findings reveal reasons and perceptions, but not the relative importance of each. For that reason, 36 interviews seemed an acceptable number. After approximately 20 interviews, the respondents offered few new reasons or perceptions. Of those interviewed, 15 used the system daily (users), 10 were familiar with the system but did not use it daily (partial users), and 11 did not use it (non-users), but many of these non-users nevertheless expressed clear and sometimes strong views about the EPS. The research team reviewed the transcribed interviews and paraphrased quotations from interviewees about the perceived advantages and disadvantages of EPS, as shown in Appendix 2. Several interviewees offered the same comments, and in those cases the appendix gives only one typical quotation. The team then reviewed these quotations to identify common factors in GPs decisions to use the EPS. They observed five such factors and placed each quotation under what they judged to be the most appropriate heading, shown in Appendix 2. Results The first factor, consistent with the TAM, was the system itself, its features, usability, etc., and was labelled system. A small number of GPs also referred to aspects of the system that had to do with finance. Many spoke not about the system itself, but as part of the complete doctor patient consultation process, which was labelled system in consultation process. A fourth set of factors related to the values that GPs held towards their profession, and how they saw their role in relation to their patients, was labelled culture. A final set related to their views on the wider political drivers behind the EPS was labelled policy environment. This analysis also revealed that, except for finance, GPs expressed contrasting views on each factor: for example, while at least 16 respondents saw advantages in the system in consultation process, at least 10 saw disadvantages. Nearly all interviewees mentioned both perceived advantages and disadvantages of the EPS, though users mentioned more of the former and non-users more of the latter. System An important reason to accept or reject a system is the system itself. Perceived usefulness and ease of use were key variables in the TAM and many EPS users found it easy to use, useful, produces good quality output (Wolters, 2001). However, partial users and non-users did not share these perceptions. Table 2 shows illustrative quotations in each category, while the text expands these with examples of comments in full from the GPs. Examples of positive comments on the system were: The system is very user-friendly in terms of installation, use and maintenance. During a consultation it s just a matter of entering the relevant diagnosis code and the system provides a therapy advice given certain constraints. EPS is easy to use and is integrated with our medical records, which is very efficient. It is also very useful in communications with pharmacies, hospitals and laboratories. Examples of negative comments were: 134 New Technology, Work and Employment Blackwell Publishing Ltd 2004

8 Table 2: Perceived advantages and disadvantages of system factors Perceived advantages Perceived disadvantages 3. Easy to use, easy to install 24. System is inflexible and cannot be adapted to personal preferences of users 25. Wireless and portable version is not yet available 48. No computer in consulting room 49. Not able to use ICSPC codes 53. I am not familiar with this system Source: Appendix 2. Table 3: Examples of perceived advantages and disadvantages of finance factors Perceived advantages Perceived disadvantages 54. We received EPS free 37. EPS does not deliver economic benefits for family doctors 44. Implementation of EPS results in high costs, including patient recording system 46. Does not lead to financial benefits Source: Appendix 2. I am not very familiar with the ICSPC diagnosis system, which makes the system quite impracticable. The system doesn t help me to find the relevant code. I would appreciate more flexibility of the system. One can enter only one code and the output is only one therapy; that s quite rigid. Financial factors Representatives of the Ministry of Health and the health care insurers believed that providing the EPS free would encourage GPs to accept it. They would be able to experiment with the system and to implement it when they felt confident. However, doctors without a computer in the consulting room (50% of the total) needed to buy and implement a patient record system. Moreover the EPS brings no direct financial benefit to the GP, and several mentioned this as a reason for non-use (Table 3). There were few comments on finance, but one positive comment was: The financial issue is not a very big deal. We received the system free. Examples of negative comments: The insurers and the government have a clear financial benefit if we use the system. But we have all the hassle of implementation, maintenance and use. Why don t we share the financial benefits? I feel that the costs of the system are only on our side. We have to become familiar with the system, to implement and maintain it and keep our system knowledge up to date. For all those hidden costs, we are not compensated at all. System in consultation process Users are likely to assess a system not in isolation, but for its contribution to a complete process. Some non-users and partial users stated that the EPS consumed rather than saved time during a consultation. Others observed that the system disrupts the short contacts with patients because doctors start communicating with the system, not the patient. It imposes more structure on the consultation process. Blackwell Publishing Ltd 2004 Limited acceptance of an electronic prescription system 135

9 Table 4: Examples of perceived advantages and disadvantages of system in consultation factors Perceived advantages Perceived disadvantages 1. Increases quality of data and 26. Interrupts the short contacts with therapies patients 2. Improves accuracy 28. Does not offer alternative therapies 4. Saves time 5. Improves knowledge and skills of 31. Leads to more activities during a doctors short consultation 7. Already use the ICSPC coding 32. Recommendations of EPS differ system, which suits EPS sometimes from my insights 10. A tool for obtaining a second opinion 33. Time consuming Source: Appendix 2. In contrast, users said that the EPS saves time and gives more focus to the consultation. They believed the system makes consultations more efficient and that patients feel that the consultation is nearly finished when the doctor starts to key in codes and print prescriptions. They also found that treatments became more consistent with those of colleagues in practice (Table 4). Examples of positive comments: We have a relatively large practice with five GPs and we agreed to work as much as possible according to the available protocols. This means that the patient records have to be perfect. This is very useful, especially when we consult each other s patients (for example at weekends). The system is also effective for communicating with colleagues. Different therapies become visible so that we can discuss such differences. The system records therapies and treatments and that helps me to work in a systematic way. Examples of negative comments: The system hinders and interrupts the very short consultation process because we have to spend more time dealing with the system. Sometimes patients continue talking while I use the system, which distracts my attention. It would take time to type in a diagnosis code, you have to look for a code and then you may hope that the suggested therapy will make sense. That seems very complicated to me. I don t want to spend more time than necessary using a computer, certainly during a consultation. Cultural factors Acceptance of the EPS may also be related to cultural factors differences between GPs values and beliefs about their work (Table 5). They are likely to accept a system that supports their beliefs, and reject one that they perceive is contrary to them. The EPS embodies the values of rationality and its promoters intended it to promote consistency, efficiency, quality, protocols and other forms of formalisation. There is cultural validity between the EPS and rationally driven practices and cultural invalidity with the more informal practices (Markus and Robey, 1983). An example of a positive comment was: The system is consistent with the image of our practice: modern, efficient and meeting the highest professional standards. We have a long tradition of computer use and our patients expect this from us. Examples of negative comments: I studied medicine to help patients as well as I can. I feel that systems like these invade my relation with patients; so I want to determine effective therapies on my own. 136 New Technology, Work and Employment Blackwell Publishing Ltd 2004

10 Table 5: Examples of perceived advantages and disadvantages of cultural factors Perceived advantages Perceived disadvantages 5. Improves knowledge and skills 35. I prefer to rely on own knowledge of doctors 38. Doctors who use EPS become 8. Improves image of quality and more impersonal to patients, use being up to date reduces involvement, computer 19. Leads to more attention to becomes a barrier to effective patients communication 23. It strengthens the reputation of 39. Focus on cost-effectiveness (of our practice EPS) can conflict with expectations and interests of patients 42. EPS demystifies physician s knowledge 52. Patients and colleagues are not interested in my possible use of EPS Source: Appendix 2. Table 6: Relation between cultural values of practice and EPS use Characterisation of practice Number of Extent of EPS use practices Non-users Partial users Full users Human relations (traditional, personal) Internal process (efficiency, stability) Open systems (innovative, experimental) Rational goal (professional, quality) I feel that the system leads to impersonal contacts, it reduces involvement. I have a lot of experience with different therapies and I want to use that. To test the possible effects of cultural differences between practices on acceptance we used Quinn et al. s (1996) Competing Values Model. Question 1 invited GPs to characterise their practice using several words representing Quinn s four cultural types, shown in the left-hand column of Table 6. If culture is an influential factor, GPs who see their practices as efficient and professional will welcome the chance to implement a system like the EPS, while those who follow a more personal approach will see its cost-focused nature as a threat. Table 6 shows the number of GPs who described their practices as corresponding to each type, and the number of those who used the EPS. Within this very small sample we found that full users of the system typically characterised their practice by the words efficiency and quality. Partial users of the system characterised their practice by the words professional, experimental and innovative. Non-users of the system characterised their practice mostly by the words personal, traditional and stable. Thus, culture does appear to affect acceptance of information systems. Blackwell Publishing Ltd 2004 Limited acceptance of an electronic prescription system 137

11 Table 7: Examples of perceived advantages and disadvantages of policy environment factors Perceived advantages Perceived disadvantages 22. It will help new doctors to 34. For GPs there are no financial benefits of become more cost conscious. using EPS. All cost savings are for the benefit of the health care insurers 36. EPS is only directed to cost reductions 40. Will lead to more control on costs by insurers and less autonomy for GPs 50. Disagree with objectives of EPS Source: Appendix 2. Policy environment Many non-users and partial users perceived the EPS as a threat to their social status and an attempt by powerful politicians and insurers to guide and control GPs treatments (Table 7). They see it as a threat to their medical autonomy and so rejected it. Some feared that the EPS would weaken the therapeutic mystique associated with physicians (McCauly and Ala, 1992), and that this would lower their esteem among those patients for whom a prescription works as a placebo. Some doctors also said that the EPS would lead away from a culture of innovation, initiative, experimentation and judgment to a culture of compliance and conformity with general standards imposed by administrators. This is an example of users interpreting the objectives of a system and using that interpretation to shape their acceptance decision. An examples of a positive comments was: I think that the system promotes cost reduction and consistency of health care services by suggesting effective therapies against the lowest prices. I believe that s an interest of the society as a whole. Examples of negative comments: The system has a one sided cost focus which is not always in the interest of patients. Sometimes a more expensive drug makes the life of patients much more comfortable. In other cases it is more safe to prescribe a more expensive drug to prevent for misuse. The system is an attempt of the government, together with insurers, to control our work. I don t like that. Discussion and conclusions This paper has shown that the initial intention of the Health Ministry was to implement the EPS so that 95% of GPs in the Netherlands would use it (comprehensive adoption). If the process had corresponded to the rational, linear view of system design, then they would have substantially reached that target. However, many GPs have not adopted the system to the extent the Ministry had hoped (it is only a partial adoption). Significant groups of partial users and non-users have engaged (or are engaging) in an implicit negotiation with the Ministry. The system has not achieved closure, as relevant social groups have substantially different views regarding the system. To move towards an acceptable form, the Health Ministry needs to understand the underlying reasons for non-acceptance and construct a process through which the relevant social groups could agree on an acceptable system. We posed four questions, which we hoped the empirical results would answer, and use these now to summarise the paper. What factors affected the use of the EPS the most (e.g. the system itself or wider contextual factors)? 138 New Technology, Work and Employment Blackwell Publishing Ltd 2004

12 System in consultation process System design features Finance Environment Perception and interpretation Acceptance Culture Figure 3: Factors affecting acceptance of optional information systems We have shown that the factors in the TAM (Davis et al., 1989; Davis, 1993) are relevant, in the sense that some GPs mentioned disadvantageous features of the system. However, they were few and this factor does not appear to have had a significant influence on acceptance or otherwise. Finance also played a part: although few respondents mentioned this, some who did regarded the costs as considerable. Other factors must explain this variation. The theoretical interest here is that the results are consistent with those of earlier writers (such as Markus, 1983; Walsham, 1993; Knights and Murray, 1994; Currie and Brown, 1997) who stressed the influence of the wider context of an innovation. One unexpected factor was the way the system affected the consultation process. The study has also identified the significant influence that culture and the policy environment had on GPs decisions to accept or reject the system. Figure 3 summarises the factors identified in the research. How did social groups differ in their attention to and interpretation of these factors? The research clearly supports the idea that social groups attend to different aspects of the context, and interpret them in unique and subjective ways. The promoters stressed the cost-saving pressures in the context of health care and the potential of the system to contain costs. They also acknowledged the autonomous position of GPs, by mounting an expensive promotion campaign to support acceptance. However, they did not address the possibility that cultural differences between practices would affect how GPs responded to standard promotional material. They appear to have relied heavily on the view that the technical innovation would in itself cause a major change in the (diverse) culture of GPs practices towards a (so-called) rational, efficient form. The users did not interpret the system and its context in a unified way, even on the apparently objective issue of whether it was easy to use. They held strongly contrasting views on whether the system helped or hindered the consultation process and on the financial effects. This is consistent with Pinch and Bijker s (1987) view that problems are not universally recognised or objective phenomena. People are likely to accept a solution only if they have already developed a common set of shared meanings and understandings about the situation. Did GP practices display different cultures and did these affect their attitudes to the EPS? The study has shown that the prevailing culture within GPs practices influenced their willingness to accept the EPS. Those with a traditional, personal culture tended to reject the system, whereas those who saw themselves as professional and efficient welcomed what they perceived was the ability of the EPS to support that culture. This suggests that members of autonomous professional organisations have different cultures that affect their attitude to a specific innovation. Blackwell Publishing Ltd 2004 Limited acceptance of an electronic prescription system 139

13 This is an example of a wider issue within health care where tensions exist between evidence-based practice and the exercise of professional autonomy. Some GPs interpret managerially guided reforms as a challenge to the ideals (and enjoyment) of professional practice (Marjoribanks and Lewis, 2003), and this will affect their attitudes to systems such as the EPS. Lawton and Parker (1999) examined similar issues in a study of professional attitudes to the introduction of standard clinical protocols for patient care. Many professionals perceived universal guidelines as being rigid, and feared that they would discourage clinicians from using their professional judgement in a way best suited to the specific case. Armstrong (2002) examined the search for balance between standardising practice and professional judgement, suggesting that wider use of evidence-based medicine might help doctors to defend their collective autonomy from external constraints. However, that would depend on individual practitioners being more willing, than those in the study reported here, to accept external decision support mechanisms (such as the EPS) in their clinical practice. Attitudes of professional staff can also, as this study shows, be exacerbated by distrust of the management s motives in making the change. What practical implications does the research suggest when implementing optional systems? The study also has practical implications, notably that mere introduction of new technologies will not ensure universal acceptance by professionals. Those promoting the EPS took a highly optimistic view about the power of an information system to change the behaviour of autonomous professionals. They (i) made the system easy to use; (ii) offered it free; (iii) informed users; (iv) offered training when necessary. The strategy was directed at system factors, but ignored issues about finance, system in consultation process, culture and the policy environment. These were the underlying reasons for the low acceptance of the EPS. More fundamentally, the promotion campaign paid no attention to the importance of subjective interpretation that GPs differ in the way they see a system and the meanings they attach to it. Suggestions that may have increased acceptance include: helping those GPs who do not have computers in their consulting room or do not use ICSPC codes to acquire these pre-requisites (finance); sharing the financial savings of lower drug costs among the different parties (GPs, insurers and taxpayers) (finance); designing the system to suit the consultation process, for example, turning the monitor to the patient and/or using it to enhance doctor patient communication (system in process); designing the system so that it suggests alternative treatments. This would recognise and strengthen the self esteem of GPs as medical professionals (culture and system in process); designing the system so that users could add new treatments or local agreements (culture and system in process); informing patients about the features and advantages of the system (culture). Suggestions such as these imply considering the EPS more as a tool for GPs and less as a means to reduce costs. Paradoxically, this may have been more successful in reducing costs in the longer term. By late 2003, the promoters had an unstable system (in the sense that usage was far below their expectations) that was not achieving their cost targets. Designing a system that met the diverse needs of users more satisfactorily, in being more compatible with their diverse cultures, may have encouraged wider and more creative use, and thus achieved more savings than the present arrangements have achieved. Finally, the evidence in the paper supports Walsham s (1993) suggestion regarding the benefits of an interpretive approach to information systems. It has enabled us to show the range of factors that people use to form their attitudes to a system and the different ways in which they interpret them. The evidence that culture is an important source of these perspectives adds to our theoretical understanding of attitudes 140 New Technology, Work and Employment Blackwell Publishing Ltd 2004

14 towards computer-based information systems and leads to empirically based suggestions for practice. References Armstrong, D. (2002), Clinical Autonomy, Individual and Collective: The Problem of Changing Doctors Behaviour, Social Science and Medicine 55, 10, Boddy, D. (2000), Implementing Inter-organisational IT Systems: Lessons from a Call Centre Project, Journal of Information Technology 15, 1, Currie, G. and A.D. Brown (1997), Implementation of an IT system in a Hospital Trust, Public Money and Management 7, 4, Czarniawska, B. (1998), A Narrative Approach to Organizational Studies (Thousand Oaks, CA: Sage). Davis, F.D., R.P. Bagozzi and P.R. Warshaw (1989), User Acceptance of Computer Technology: A Comparison of Two Theoretical Models, Management Science 35, Davis, F.D. (1993), User Acceptance of Information Technology: System Characteristics, User Perceptions and Behavioral Impacts, International Journal of Man-Machine Studies 38, Dawson, P. and N. Gunson (2002), Technology and the Politics of Change at Work: The Case of Dalebake Bakeries, New Technology, Work and Employment 17, 1, Hatch, M.J. (1997), Organisation Theory: Modern, Symbolic and Postmodern Perspectives (Oxford: Oxford University Press). Hunt, D.L., R.B. Haynes, S.E. Hanna and K. Smith (1998), Effects of Computer-Based Clinical Decision Support Systems on Physician Performance and Patient Outcomes, A Systematic Review, Journal of the American Medical Association 280, 15, Igbaria, M. (1993), User Acceptance of Microcomputer Technology: An Empirical Test, OMEGA International Journal of Management Science 21, 3, Knights, D. and F. Murray (1994), Managers Divided: Organizational Politics and Information Technology Management (Chichester: Wiley). Lagendijk, P.J.B., R.W. Schuring and T.A.M. Spil (2001), Het Elektronisch Voorschrijf Systeem, Van kwaal tot medicijn (Enschede: Dinkel Instituut). Lawton, R. and D. Parker (1999), Procedures and the Professional: The Case of the British NHS, Social Science and Medicine 48, 3, Marjoribanks, T. and J.M. Lewis (2003), Reform and Autonomy: Perceptions of the Australian General Practice Community, Social Science and Medicine 56, 10, Markus, M.L. (1983), Power, Politics and MIS Implementation, Communications of the ACM 26, 6, Markus, M.L. and D. Robey (1983), The Organizational Validity of Management Information Systems, Human Relations 36, 3, Martin, J. (1992), Cultures in Three Organizations: Three Perspectives (London: Oxford University Press). McCauly, N. and M. Ala (1992), The Use of Expert Systems in the Healthcare Industry, Information & Management 22, McLoughlin, I. (1999), Creative Technological Change (London: Routledge). Mellin, A. (2002), E-prescribing: An Opportunity for Process-Re-engineering, Health Management Technology 43, 1, Quinn, R.E., S.R. Faerman, M.P. Thompson and M.R. McGrath (1996), Becoming a Master Manager, 2nd edn (New York: Wiley). Pinch, T.J. and W.E. Bijker (1987), The Social Construction of Facts and Artifacts: Or How the Sociology of Science and the Sociology of Technology Might Benefit Each Other, in W.E. Bijker, T.P. Hughes and T.J. Pinch (eds), The Social Construction of Technological Systems (Cambridge, MA: The MIT Press), Schiff, G.D. and T.D. Rucker (1998), Computerized Prescribing: Building the Electronic Infrastructure for Better Medicine Usage, Journal of the American Medical Association 279, 13, Sheppard, B.H., J. Hartwick and P. Warshaw (1998), A Theory of Reasoned Action: A Meta Analysis of Past Research with Recommendations for Modification and Future Research, Journal of Consumer Research 15, Walsham, G. (1993), Interpreting Information Systems in Organizations (Chichester: Wiley). Wolters, I., H. van den Hoogen and D. de Bakker (2001), Evaluatie invoering Elektronisch Voorschrijf Systeem (Utrecht: Nivel). Yin, R.K. (1999), Case Study Research: Design and Methods, (Thousand Oaks, CA: Sage). Blackwell Publishing Ltd 2004 Limited acceptance of an electronic prescription system 141

15 Appendix 1 Interview questions (translated from Dutch) Section 1: Characteristics of practices Can you outline the main features of your practice (number of patients, number of doctors, some history)? Can you characterise your practice by placing the following words in order of importance: efficient, quality, personal, innovative, traditional, stable, professional, experimental? Do you use computers in this practice? Where are these computers located (in the office and/or in the consulting room)? What kinds of computer applications are being used in this practice (e.g. finance, invoicing, patients data)? What do you think about computer use during consultations? Are there any major advantages or disadvantages? Section 2: Perceptions about EPS Do you know about EPS? Have you installed EPS on your computer? Do you use EPS when it is possible or appropriate? In case of use: What are your specific reasons for using EPS? Do you use EPS during or after the consultation? In case of non-use: What are your specific reasons for not using EPS? Would you use EPS under certain conditions? Which conditions? Section 3: Questions on reasons for use or non-use, in addition to points raised in Section 2 What are main advantages and/or disadvantages of using EPS? What do you think about the ease of use of EPS? What do you think about the usefulness of EPS? In how many cases (estimated %) do you think that EPS use is possible or appropriate? Is it easy or difficult to use EPS during a consultation? Does EPS influence the interaction with patients? How? Does EPS use affect job satisfaction? Does EPS use affect the quality of your work? Does EPS use affect your time-efficiency? Appendix 2 Perceived advantages and disadvantages of EPS identified in the interviews, by factor. Perceived advantages Perceived disadvantages (a) System factors 3. Easy to use, easy to install 24. System is inflexible and cannot be adapted to personal preferences of users 25. Wireless and portable version is not yet available 142 New Technology, Work and Employment Blackwell Publishing Ltd 2004

16 48. No computer in consulting room 49. Not able to use ICSPC codes 53. I am not familiar with this system (b) Finance factors 54. We received EPS free 37. EPS does not deliver economic benefits for family doctors 44. Implementation of EPS results in high costs, including patient recording system 46. Does not lead to financial benefits (c) System in consultation factors 1. Increases quality of data and 26. Interrupts the short contacts with therapies patients 2. Improves accuracy 28. Does not offer alternative therapies 4. Saves time 6. Improves communications with 29. I do not always agree with therapy colleagues and other providers suggestion of the EPS of health care 31. Leads to more activities during a 7. Already use the ICSPC-coding short consultation system, which suits EPS 32. Recommendations of EPS differ 9. Reduces doctor patient sometimes from my insights interactions 33. Time consuming 10. A tool for obtaining a second 38. Doctors who use EPS become more opinion impersonal to patients, use reduces 11. Promotes consistency of therapies involvement, computer becomes a 12. Provides quality check on barrier to effective communication therapies 41. ICSPC system is not always 13. Leads to improvements in unambiguous medications by helping doctors 45. Implementation takes time. to determine whether drugs 47. No time to attend instruction meetings can or cannot be combined with other drugs 14. Promotes effective communication 15. Reduces risk of errors 16. Automatic data retrieval is efficient 17. Helps to convince patients about the choice of a certain therapy 18. Sometimes makes unexpected suggestions 19. Leads to more attention to patients (d) Cultural factors 5. Improves knowledge and skills 30. I don t feel a need for an EPS of doctors 35. I prefer to rely on own knowledge 8. Improves image of quality and 38. Doctors who use EPS become more being up to date impersonal to patients, use reduces 19. Leads to more attention to patients involvement, computer becomes a 20. When more colleagues use EPS, I barrier to effective communication may follow 39. Focus on cost-effectiveness (of EPS) 21. When many patients expect EPS can conflict with expectations and use, I may start using it but now interests of patients they are unaware of these issues 42. EPS demystifies physician s 23. It strengthens the reputation of knowledge our practice 43. System formalises and standardises the doctor patient contacts Blackwell Publishing Ltd 2004 Limited acceptance of an electronic prescription system 143

17 51. Reduces variety and fun 52. Patients and colleagues are not interested in my possible use of EPS (e) Policy environment factors 22. It will help new doctors to become 27. System has a one-sided cost focus more cost-conscious 34. For GPs there are no financial benefits of using EPS. All cost savings are for the benefit of the health care insurers 36. EPS is only directed to cost reductions 40. Will lead to more control on costs by insurers and less autonomy for GPs 50. Disagree with objectives of EPS 144 New Technology, Work and Employment Blackwell Publishing Ltd 2004