Beyond Individual Adoption Models

Multidimensional Approaches to Healthcare IT Implementation

Scott Warren, University of North Texas

Stephanie L. Robinson, University of North Texas

Brent Tincher, Lockheed Martin

Annette Fog, Globe Life

Janetta Boone, NASA

Technology Acceptance Model (TAM)

Predicts technology adoption based on two key beliefs: perceived usefulness and perceived ease of use, which influence behavioral intention to use.

Davis (1989); Venkatesh & Davis (2000)

Core Constructs

  • Perceived usefulness
  • Perceived ease of use
  • Behavioral intention
Davis (1989); Venkatesh & Bala (2008)

Key Limitation

  • Overly simplistic approach
  • Individual-level focus
  • Ignores organizational context
Holden & Karsh (2010); Bagozzi (2007)

Unified Theory of Acceptance and Use of Technology (UTAUT)

Integrates eight theories to predict user intention and technology use behavior through four key constructs.

Venkatesh, Morris, Davis, & Davis (2003)

Core Constructs

  • Performance expectancy
  • Effort expectancy
  • Social influence
  • Facilitating conditions
Venkatesh et al. (2003); Dwivedi et al. (2019)

Key Limitation

  • Still individual-focused
  • Perception and belief based
  • Narrow causal assumptions
Bagozzi (2007); Benbasat & Barki (2007)

The Problem in Healthcare Settings

Both adopt a narrow perspective that primarily focuses on individual users' beliefs, perceptions, and usage intentions, narrowing the complexity of the socio-technical system to just individual users' perceptions or expectations.

Holden & Karsh (2010); Cresswell et al. (2013)

What Gets Missed

  • Teamwork and collaboration dynamics
  • Multitasking and time constraints
  • Workflow integration and exceptions
  • Organizational culture and governance
  • Real-world interruptions and disruptions
Berg (1999); Ash et al. (2004); Greenhalgh et al. (2017)

What Healthcare Really Needs

Healthcare processes occur within complex socio-technical systems comprising people, processes, and technology, where workflow issues are defined by exceptions.

Berg et al. (2003); Sittig & Singh (2010); Greenhalgh et al. (2017)

Multidimensional approaches needed to capture this complexity

Actor-Network Theory (ANT)

Views the world as networks where objects like software have an active role in shaping social relations, not as passive equipment but as agents that actively transform established practices.

Latour (2005); Callon (1986); Law (1992)

Key Concepts

  • Human and non-human actors
  • Technology as active agent
  • Networks and relationships
  • "Zooming in" on network formation
Latour (2005); Cresswell et al. (2010)

Benefits

  • Appreciates complexity and fluidity
  • Multiple realities coexist
  • Context-dependent performance
  • Reveals active role of technology
Law & Mol (2001); Greenhalgh & Stones (2010)

Normalization Process Theory (NPT)

Identifies, characterizes, and explains the mechanisms that promote and inhibit implementation, embedding, and integration by focusing on the "work" people do to implement new practices into their routines.

May & Finch (2009); Murray et al. (2010)

Four Constructs

  • Coherence (sense-making)
  • Cognitive participation
  • Collective action
  • Reflexive monitoring
May et al. (2009); Rapley et al. (2018)

Application

  • Flexible across settings
  • Multiple professional groups
  • Explains success and failure
  • Dynamic implementation contexts
McEvoy et al. (2014); May et al. (2016)

Institutional Theory

Considers the influence of external forces such as the organizational environment, regulations, professionalism, and network externalities on individual behavior and decision-making.

DiMaggio & Powell (1983); Scott (2008); Meyer & Rowan (1977)

Key External Factors

Organizational Environment

Regulations

Professionalism

Network Externalities

Zucker (1987); Tolbert & Zucker (1996)

Adaptive Structuration Theory (AST)

Recognizes that interventions are configured and co-constructed over time and can be adapted, with implementation as a dynamic process rather than a discrete event.

DeSanctis & Poole (1994); Orlikowski (2000)

Key Insights

  • Dynamic temporal processes
  • Configuration over time
  • Co-construction by users
  • Continuous adaptation
Giddens (1984); DeSanctis & Poole (1994)

Application

  • Learning Health Systems
  • Continuous study of HIT
  • User-technology interaction develops
  • Evolving implementation
Friedman et al. (2015); Psek & Greenhalgh (2001)

Supporting Implementation Frameworks

PARIHS

Promoting Action on Research Implementation in Health Services

Encompasses broader contextual factors impacting across wider settings or services

Sources: Kitson et al. (1998); Rycroft-Malone (2004)

CFIR

Consolidated Framework for Implementation Research

Comprehensive framework addressing implementation factors across multiple contexts

Sources: Damschroder et al. (2009)

Why These Theories Matter

Socio-technical complexity: Recognize healthcare as dynamic systems of people, processes, and technology

Berg et al. (2003); Sittig & Singh (2010)

Networks and relationships: Focus on pivotal role of actors (human and non-human), relationships, and networks in mobilizing knowledge

Latour (2005); Cresswell et al. (2010)

Embedding and integration: Understanding the work required to implement and integrate new practices into routines

May & Finch (2009); Greenhalgh et al. (2004)

Structural context: Consider external forces, regulations, organizational environment, and professionalism

Scott (2008); DiMaggio & Powell (1983)

Dynamic processes: Implementation evolves over time, not a discrete event; acknowledging fluidity and multiple realities

Rogers (2003); Greenhalgh et al. (2017)

Moving Forward

By drawing on these multidimensional and systemic theories, researchers and practitioners can gain a more sophisticated and comprehensive understanding of why implementation succeeds or fails in complex healthcare settings.

Greenhalgh et al. (2017); May et al. (2016); Cresswell & Sheikh (2013)

Move beyond simply measuring individual acceptance

Key Takeaways

  1. TAM and UTAUT are criticized for oversimplifying complex socio-technical systems
  2. Healthcare requires recognition of people, processes, and technology interactions
  3. ANT, NPT, Institutional Theory, and AST offer richer, multidimensional perspectives
  4. Implementation is dynamic and evolves over time, not a discrete event
  5. Context, relationships, networks, and structures matter as much as individual perceptions

References

Thank You

Questions and Discussion Welcome

Theoretical Framework Citations:

Ash, J. S., Berg, M., & Coiera, E. (2004). Some unintended consequences of information technology in health care. Journal of the American Medical Informatics Association, 11(2), 104-112.

Bagozzi, R. P. (2007). The legacy of the technology acceptance model. Journal of the Association for Information Systems, 8(4), 244-254.

Benbasat, I., & Barki, H. (2007). Quo vadis TAM? Journal of the Association for Information Systems, 8(4), 211-218.

Berg, M. (1999). Patient care information systems and health care work. Social Science & Medicine, 48(11), 1505-1518.

Berg, M., Aarts, J., & van der Lei, J. (2003). ICT in health care: sociotechnical approaches. Methods of Information in Medicine, 42(4), 297-301.

Callon, M. (1986). Some elements of a sociology of translation. In J. Law (Ed.), Power, action and belief (pp. 196-223). Routledge.

Cresswell, K. M., Worth, A., & Sheikh, A. (2010). Actor-Network Theory and its role in understanding implementation. BMC Health Services Research, 10(1), 67.

Cresswell, K., & Sheikh, A. (2013). Organizational issues in the implementation and adoption of health information technology. International Journal of Medical Informatics, 82(5), e73-e86.

Damschroder, L. J., et al. (2009). Fostering implementation of health services research findings into practice: a consolidated framework. Implementation Science, 4(1), 50.

Davis, F. D. (1989). Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly, 13(3), 319-340.

DeSanctis, G., & Poole, M. S. (1994). Capturing the complexity in advanced technology use: Adaptive structuration theory. Organization Science, 5(2), 121-147.

DiMaggio, P., & Powell, W. W. (1983). The iron cage revisited: Institutional isomorphism and collective rationality. American Sociological Review, 48(2), 147-160.

Dwivedi, Y. K., et al. (2019). Re-examining the unified theory of acceptance and use of technology. International Journal of Information Management, 45, 202-217.

Friedman, C. P., et al. (2015). Toward a science of learning systems: A research agenda. Journal of the American Medical Informatics Association, 22(1), 43-50.

Giddens, A. (1984). The constitution of society. University of California Press.

Greenhalgh, T., & Stones, R. (2010). Theorising big IT programmes in healthcare: Strong structuration theory meets actor-network theory. Social Science & Medicine, 70(9), 1285-1294.

Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations. Milbank Quarterly, 82(4), 581-629.

Greenhalgh, T., et al. (2017). Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to scale-up. Journal of Medical Internet Research, 19(11), e367.

Holden, R. J., & Karsh, B. T. (2010). The technology acceptance model: Its past and its future in health care. Journal of Biomedical Informatics, 43(1), 159-172.

Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice. Quality in Health Care, 7(3), 149-158.

Latour, B. (2005). Reassembling the social: An introduction to actor-network-theory. Oxford University Press.

Law, J. (1992). Notes on the theory of the actor-network: Ordering, strategy, and heterogeneity. Systems Practice, 5(4), 379-393.

Law, J., & Mol, A. (2001). Situating technoscience: An inquiry into spatialities. Environment and Planning D: Society and Space, 19(5), 609-621.

May, C., & Finch, T. (2009). Implementing, embedding, and integrating practices: An outline of normalization process theory. Sociology, 43(3), 535-554.

May, C. R., et al. (2009). Development of a theory of implementation and integration. Implementation Science, 4, 29.

May, C. R., et al. (2016). Using Normalization Process Theory in feasibility studies. Implementation Science, 11(1), 80.

McEvoy, R., et al. (2014). A qualitative systematic review of studies using the normalization process theory. Implementation Science, 9(1), 2.

Meyer, J. W., & Rowan, B. (1977). Institutionalized organizations: Formal structure as myth and ceremony. American Journal of Sociology, 83(2), 340-363.

Murray, E., et al. (2010). Normalisation process theory: A framework for developing, evaluating and implementing complex interventions. BMC Medicine, 8, 63.

Orlikowski, W. J. (2000). Using technology and constituting structures. Organization Science, 11(4), 404-428.

Psek, W. A., & Greenhalgh, T. (2001). Viewing organizations as complex adaptive systems. Quality and Safety in Health Care, 10(4), 248-251.

Rapley, T., et al. (2018). Improving the normalization of complex interventions. BMJ Quality & Safety, 27(4), 289-298.

Rogers, E. M. (2003). Diffusion of innovations (5th ed.). Free Press.

Rycroft-Malone, J. (2004). The PARIHS framework. Journal of Nursing Scholarship, 36(2), 152-156.

Scott, W. R. (2008). Institutions and organizations: Ideas and interests (3rd ed.). Sage Publications.

Sittig, D. F., & Singh, H. (2010). A new sociotechnical model for studying health information technology. International Journal of Medical Informatics, 79(4), e81-e90.

Tolbert, P. S., & Zucker, L. G. (1996). The institutionalization of institutional theory. In S. Clegg, C. Hardy, & W. Nord (Eds.), Handbook of organization studies (pp. 175-190). Sage.

Venkatesh, V., & Bala, H. (2008). Technology acceptance model 3 and a research agenda on interventions. Decision Sciences, 39(2), 273-315.

Venkatesh, V., & Davis, F. D. (2000). A theoretical extension of the technology acceptance model. Management Science, 46(2), 186-204.

Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User acceptance of information technology. MIS Quarterly, 27(3), 425-478.

Zucker, L. G. (1987). Institutional theories of organization. Annual Review of Sociology, 13, 443-464.

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