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Examining a Model of InformationTechnology Acceptance by IndividualProfessionals: An Exploratory StudyPA T RICK Y .K . CH A U A N D PA U L J. HUPATRICK Y.K. CHAU is Associate Professor of Information Systems at the School ofBusiness, Faculty of Business and Economics, The University of Hong Kong. Hereceived his Ph.D. in business administration from the Richard Ivey School of Busi-ness (formerly Western Bu siness Schoo l), The University of Western O ntario, Can ada.His research interests include issues related to IS/IT adoption and implementation,information presentation and model visualization, and electronic commerce. He haspapers published in major infonnation systems journ als including MISQuarterly,Communications of the ACM, Joumal ofManagement Information Systeins. Deci-sion Sciences, International Joumal of Hum an Comp uter Studies, Decision Su pportSystems. Information and Management, Joumal ofOrganizational Computing andElectronic Commerce, European Joumal of Information S ystems, and others. He serveson the editorial board of a number of IS journals including MIS Quarterly, Informa-tion and Management, and European Joumal of Information Systems.PAUL J. Hu is Assistant Professor and George S. Eccles Emerging Scholar at the DavidEccles School of Business, University of Utah . He received his Ph.D . in ManagementInformation Systems from the University of Arizona. He has papers published (in-cluding forthcoming) iti Joumal of Management Information Systems. Decision Sci-ences, Decision Support Systems, IEEE Transactions on Engineering Management,IEEE Transactions on Information Technology in Biomedicine, IEEE Intelligent Sys-tems and Their Applications, Infonnation and Managem ent, and Journal of Organiza-tional Computing and Electronic Commerce. His current research interests include ITapplications and managem ent in health care, electronic commerce, human-computerinteraction, data mining and warehousing, and IS project management.ABSTRACT: The recent proliferation of information technology designed to supportor enhance an individual professional's task performance has made the investigationof technology acceptance increasingly challenging and significant. This study inves-tigates technology acceptance by individual professionals by examining p hysicians'decisions to accept telemedicine technology. Synthesized from relevant prior research ,a generic research framework was built to provide a necessary foundation upon w hicha research model for telemedicine technology acceptance by physicians could bedeveloped. The research model was then empirically examined, using data collectedfrom more than 400 physicians practicing in public tertiary hospitals in Hong Kong.Results of the study suggest several areas where individual "professionals" mightsubtly differ in their technology acceptance decision-making, as compared with endusers and business managers in ordinary business settings. Specifically, physicians

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accept a technology, physicians expressed considerable concerns about the compat-ibility of the technology with their practices, placed less importance on controllingtechnology operations, and attached limited weight to pe ers' op inions about using thetechnology. Based on results obtained from this study, the initially proposed frame-work for technology acceptance by individual professionals was revised to a "h ierar-chical, three-layer" structure with the individual context at the inner core, theimplementation context on the outermost layer, and the technological context resid-ing in the middle. Implications for information systems research and telemedicineman agemen t practice that have emerged from the study's findings are also discussed .KEY WORDS AND PHRASES: acceptance of information technology, adoption of infor-mation technology, professional users, telemedicine technology management.

TH E USE OF INFORMATION TECHNOLOGY (IT) has expanded into many a reas that canbe broadly categorized by applications and target users. Driven by service improve-ment, market competitiveness enhancement, or bottom-line survival, business orga-nizations have invested heavily in IT and are likely to continue doing so in the nearfuture. Examples of prevalent or highly publicized IT applications for business in-clude technology-enabled process reengineering, open systems, electronic data inter-change, and more recently, Internet-based electronic commerce. In the meantime,various IT applications designed to support or enhance individual task performanceand services within for-profit and not-for-profit professional organizations have alsoproliferated rapidly. This phenomenonthe fast-growing acquisition and implemen-tation of innovative IT applications for individual professionals' has dem anded ef-fective technology management from ado pting organizations with which professionalindividuals are affiliated. A case in point is telemedicine technology, which supportspatient care from a distance and distributed service collaboration of individual phy si-cians from different health-care organizations.

Broadly speaking, telemedicine is an IT-based innovation that sup ports, facilitates,and potentially improves health-care professionals' care and services to clients, inmost cases, their patients. Understandably, physicians are the principal users and sta ke-holders of telemedicine technology. Com pared with end users and man agers in ordi-nary business settings, these professionals may exhibit subtle differences in theirtechnology accep tance decision-m aking. For instance, the extent to which attitude orpeer influences affect physicians' technology acceptance decisions may differ fromthat common to their end user or business manager counterparts, in part because ofspecialized training, autonomous practices, and professional work arrangem ents. Priortechnology acceptance/adoption research has concentrated on IT applications prima-rily designed or intended for "common" user groups that typically include end users,

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EXAMINING A MODEL OF INFORMATION TECHNOLOGY ACCEPTANCE 193

by individual professionals. As the development of IT applications specifically de-signed to support individual task performance and services within a professional con-text continues to grow at a rapid pace, the need for identifying essential factorspotentially affecting individual professionals' technology acceptance decisions hasbecome increasingly important.

This paper reports on an exploratory study that investigated the technology accep-tance decisions of individual physicians in a health-care context. Synthesizing rel-evant prior research, we proposed a generic framework for technology acceptance byindividual professionals. Based on the framework, a research model was developedto explain telemedicine technology acceptance by physicians.^ The research modelconsisted of important technology acceptance decision factors and specified theirplausible causal relationships. Because of its behavioral intention orientation and tech-nology control consideration, the model had its theoretical premise established aroundthe Technology Acceptance Model (TAM) and the Theory of Planned Behavior (TPB ).Furthermore, the research model was supplemented by factors drawn or modifiedfrom other relevant theories or models, m aking it increasingly adequate for the target"professional" context. The model was then empirically examined, using data col-lected from a survey that involved more than 400 physicians practicing in publictertiary hospitals in Hong Kong.

The current work contributes to information systems (IS) research by supplem ent-ing the existing literature with insights into potential areas w here professional usergroups might differ from common user groups in their respective technology accep-tance decision-making. Such differences in technology acceptance have become anincreasingly important technology management issue that has not yet received ad-equate research attention. At a minim um, findings from this study provide theoreticalgroundings for and empirical evidence of probable directions for continued investi-gations of technology acceptance by individual professionals. Seeking a systematicconceptualization of technology acceptance by individual professionals, we proposedand then revised a generic framework upon which particular research m odels can bedeveloped for different technologies, professional categories or user groups, or theircombinations. From a managerial perspective, findings from this study may also ad-vance our understanding and practice of the organizational management of tele-medicine technology. Specifically, the study identified several factors essential tophy sicians' technology acceptance decisions and discussed their implications for for-mulating organizational strategies that encourage and foster technology acceptanceamong member physicians.

In the next section, we examine the background of the current research by describ-ing the health-care system in Hong Kong. This background description is followedby a review of prior telemedicine research and the relevant technology acceptanceliterature, together with a discussion of our research motivations. A generic frame-work of technology acceptance by professionals is proposed and discussed next. The

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and its implications for both TS research and telemedicine management by health-care organizations.

I

The Health-Care System inHong KongTHE HEALTH-CARE SYSTEM IN HONG KONG is largely dominated by public health-care establishmen ts, which, to a large extent, are centrally planned and controlled andhierarchically organized for resource allocation efficiency and service effectivenesspurposes. Central to the system is the Hospital Authority (H A), the suprem e statutorybody responsible for delivering a comprehen sive range of secondary and tertiary spe-cialist care and rehabilitation services through a network of health-care facilities. TheHA is accountable to the Hong Kong government through the Secretary for Healthand W elfare, w ho charts health policies and m onitors the services and performance ofthe public health-care system. At the time of the study, the HA managed 44 publichospitals and health-care institutions (including eight tertiary hospitals) and 49 spe-cialist outpatient centers. M anaging m ore than 26,400 hospital beds, which trans latesto an average of 4.06 public hospital beds per 1,000 people, the HA employed ap-proximately 48,500 full-time staff and operated under a recurrent budget of HK$26billion in 1998-1999 (HK$7.8 equals US$1).

Individual physicians areemployed by the HA and assigned to different hospitalsand care centers. Typically, the position of a physician is based on rank, ranging fromclinical administrator to junior medical officer. In spite of the formal rank-based hier-archy, physicians in a hospital or care center usually have high control over issuesconcerning their practices and services. Th us, physicians p ractice in a fairly indepen-dent manner and typically have high autonomy in patient care/management and ser-vice decision-making. To a great extent, physicians consider that the patient 'swell-being is their top priority and they would do w hatever is medically nece ssary orappropriate for patients. Com pared w ith their counterparts in the United States, phy-sicians at tertiary hospitals or specialized care centers in Hong K ong are burdened byrelatively heavy clinical loads andmay need to work long hours on a routine basis.In general. Hong Kong lacks health-care professionals in several subspecialty ar-eas, including neurosurgery. Demand exceeding supply is common in these areaswhere service queues or backlogs are considerable; thus, resource allocation/utiliza-tion efficiency and service effectiveness are challenging management issues. For ter-tiary hospitals or specialized care centers, telemedicine represents an attractivealternative mode for service delivery or collaboration and may eventually help ph ysi-cians become more effective in responding to patient care and service demands.

L iterature Review and R esearch M otivations

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order to improve service effectiveness or resource allocation/utilization efficiency^[5]. Rapid technology advancements and continual increases in the performance-priceindex have significantly expanded the role of telemedicine technology in physicians'clinical decision-making and patient care and management. At the same time, persis-tent problems in health care that include service accessibility, quality, costs, and re-source allocation, have also significantly contributed to telemedicine's economicalattractiveness, social desirability, and political appeal. As a result, a fast-growing num-ber of telemedicine projects and programs have been implemented or are under de-velopment around the globe [29].

The development of telemedicine in Hong K ong has significantly proliferated sincethe mid-1990s [32]. Several programs were initiated and ultimately established byproactive physicians who were in part motivated by factors interestingly differentfrom those common to most rural-based telemedicine programs in the United States[32]. Driven mostly by urgent patient care demands and the needs for improved utili-zation efficiency (particularly in highly specialized facilities of limited service c apac-ity), existing telemedicine programs in Hong Kong are largely urban-based and havea prominent tertiary care focus.

In their fairly comprehensive review of previous telemedicine research, Peredniaand Allen [39] commented that, because of a predominant focus on technologicaldevelopments and clinical applications, most prior research has offered limited dis-cussion on important issues pertaining to organizational and managerial consider-ation (for exam ple [3]). As the authors concluded, the ultimate success of telemedicineas a viable service collaboration and delivery alternative or as a routine means forphysicians to manage patient care requires health-care organizations to address bothtechnological and managerial challenges. One fundamental managerial challenge isuser technology acceptance.

Investigations of user technology acceptance have been abundant in the IS literature.A review of relevant prior research has suggested that a fairly rich stream of tech nol-ogy acceptance/adoption studies is anchored in behavioral intention. Acco rding to thebehavioral-intention approach, an individual's decision to accept/adopt a technologyis a conscious act that can be sufficiently explained and therefore predicted by theirbehavioral intention. Following this reasoning, researchers are challenged to identifycrucial determinants of an individual's intention toward accepting/adopting the tech-nology, Several intention-based theories and models have been developed and em piri-cally examined, including the Theory of Reasoned Action (TRA), TAM, and TPB.

Proposed by Fishbein and Ajzen [20] , TRA postulates that beliefs influence atti-tude, which in turn shapes a behavioral intention guiding or even dictating anindividual's behavior. TAM [17] shares with TRA the common thread that connectsattitude to behavioral intention, but it differs considerably in the conceptualization ofattitude and behavioral intention. According to TAM, behavioral intention is jointlydetermined by attitude and perceived usefulness, which together with perceived ease

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and user groups [18]. Because of its technology focus. TAM is appropriate for exam -ining technology acceptance by individual professionals, but may need to be supple-mented by other theories or models due to its intended generality and parsimony.TPB extends from TRA by incorporating an additional construct (that is, perceivedbehavioral co ntrol) to account for situations w here an individual lacks the control orresources necessary for carrying out the targeted behavior freely [1]. Because of thebehavioral control consideration, TPB is considered to be more general than TRAand, together with TAM, was selected to provide a necessary theoretical prem ise forthe research m odel examined in this study.

A Generic Framework for Technology Acceptance byIndividual ProfessionalsBASED ON HNDINGS FROM RELEVANT PRIOR RESEARCH, we propose here a genericframework for systematic analysis of technology acceptance by individual profes-sionals. In tum , the framework provides a foundation upon which particular researchmodels can be developed to account for different technology accep tance s cena rios, asdefined by distinct characteristics pertaining to technology, professional category oruser group, professional setting, or their combinations. Specifically, the proposedframework suggests that an individual profess ional's decision to accept a technologycan be explained or predicted by factors pertaining to the individual context, the tech-nological context, and the implementation context.

The individual context comprises essential characteristics of individual users; inour case, health-care professionals. C onceivably, p hysicians, as a grou p, may exh ibitcharacteristics subtly different from those of end users and managers in ordinarybusiness organizations. W ithin the individual context, the investigative focuses are toidentify essential individual characteristics and to assess their plausible effects ontechnology acceptance. The technological context concentrates on important charac-teristics of the technology under investigation. From both cognitive and behavioralperspectives, perceived characteristics may be more important or relevant than "ob-jective" characteristics. Understandably, various user groups may view a technologydifferently and are likely to concentrate their technology evaluation using differentcriteria. In this connection, the analysis focus of the technological con text is to iden-tify important perceived technology attributes, together with assessments of theirpotential effects on individual technology acceptance. The implementation contextrefers to the specific professional environment where the investigated technologyacceptance takes place. A common telemedicine implementation context is the clini-cal setting w here individual ph ysicians provide care and services to patients and co l-laborate with their peers in service delivery and patient manag ement. H ence, a nalysisof the implementation context needs to concentrate on important characteristics ofthe underlying organizational and task-performance setting that may affect physi-

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ered by several prior studies [28 ,30 ] to be fundamental in individual technology a ccep-tance/adoption. The rationale for not including the managem ent context is theoreticallyjustifiable and pragmatically adequate. AsMintzberg [36, p. 192] comments, the powerof a professional office is to emp hasize authority of a professional nature that is , thepower of expe rtise. Individual physicians not only control their own work but also seekcollective control of the adm inistrative and m anagerial decisions that may affect them ,particularly in their practices and services. Consequently, adm inistrators and m anagersare likely to exert some, but limited, influences on physicians' technology acceptancedecisions. The described expertise-oriented control or power, in tum, contributes toprofessional dominance of physicians over managers, which has been examined andsupported empirically (such as [32]). Second, the framework departs from conclusionsoffered by Goodhue and Thompson [21], who advocate the importance of the taskcontext. As we define it here, the implementation context in effect partially subsumesthe task context as discussed by Good hue and Thomp son [21]. The nonroutinenesscom ponent, which they found to be the most significant issue, can be viewed as part ofthe compatibility factor included in our implemen tation framework, which, at the sametime, embraces other factors (such as, peer influence) that may have considerable ef-fects on individual technology acceptance in a professional setting.

Within the framework, plausible causal relationships may exist between or amongthe described constituent contexts. The implementation context conceivably encom-passes both the individual and the technological contexts and thus might exert influ-ences on them. Similarly, the individual context may affect or be affected by thetechnological context. Although effects at the broad-context level might be fairly in-variant, the particular factors characterizing the respective contexts and their prob-able causal relationships and effects on technology acceptance may be specific withrespect to the technology and the professional category. Hence, the proposed frame-work can provide a useful departure point toward a systematic examination of tech-nology acceptance by individual professionals. Nevertheless, investigations of thetechnology acceptance of interest should proceed in light of a particular technology,a particular professional (user) category, or both.

The current study examines the acceptance of telemedicine technology by indi-vidual physicians. Based on the discussed framework as well as findings from rel-evant prior research and o ur field observations, a research m odel specifically tailoredto the technology acceptance u nder investigation is developed. As shown in Figure 1,our research model includes six factors that denote characteristics essential to theconstituent contexts included in the framework. The following section describes ourresearch model in detail.

Research Model

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Technological Context

ImplementationContextBehavioralIntention

Figure L The Research Model

in their practice. In many cases, administrative managers have only limited influ-ences on a physician's decision to include a technology in their practice. The de-scribed autonomy increases the likelihood or importance of voluntary technologyuse, making technology acceptance increasingly dependent on individual perceptionand evaluation. In this connection, individual attitude and perceived control of theuse of a technology may become essential determinants of the individual context.

In this study, attitude refers to a physician's positive or negative evaluative affectabout using telemedicine technology. Through professional ne twork s, medical litera-ture and other sources, physicians have become aware of telemedicine technologyand have accumulated varying levels of knowledge about the technology's clinicalvalues/utilities and potential risks, which jointly form individuals' salient beliefs about

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HI: A physician's attitude toward using telemedicine technology will positivelyaffect the intensity of their behavioral intention to accept the technology.

The level of technology acceptance exhibited by a physician may also be influ-enced by their perceived technology control, which broadly refers to a physician'sperceived ability to use telemedicine technology. Prevalent dimensions of perceivedtechnology control include acquisition of the procedural knowledge and resourcesnecessary for mastering the technology under discussion. Perceived technology con-trol is closely related but does not precisely correspond with the perceived behavioralcontrol (in TPB), which refers to an individual's perceptions of the presence or ab-sence of requisite reso urceso roppo rtunitiesnec essary for performing a behavior [2].In general, perceived behavioral control encom passes various facilitating cond itionspertaining to both the organization and the technology and thus has a broader scopethan perceived technology control. The discussed professional dominance of physi-cians observed in many health-care organizations is likely to enhance their control offacilitating conditions not directly related to technology. As a result, the notion ofperceived technology control arguably is more relevant and specific than perceivedbehavioral control in investigations of physicians' technology acceptance decisions.Accordingly, we tested the following hypo thesis:

H2: The level of technology control as perceived by a physician will positivelyaffect the intensity of their behavioral intention to accept the technology.

The Technological C ontextInvestigations of important technology characteristics and their influences on indi-vidual acceptance/adoption have been fairly extensive. Instead of examining key tech-nology characteristics from a primary or objectively technical perspective, we evaluatedthe technolog y's usefulness and ease of use perceived by the physicians. Mo ore andBenbasat [37] have suggested that perceived rather than objective technology attributesare more relevant to an individual's technology acceptance decision-making. To beaccepted, telemedicine technology, at a minimum , needs to be seen by a physician asencompassing sufficient utilities for supporting or facilitating their core patient careservices. Perceived usefulness is important to a physician's technology acceptancedecision-making and may influence the ultimate decision directly as well as indi-rectly (such as, via the strengthening of a positive attitude toward accepting the tech-nology). Both the direct and indirect effects are included in the model, which postu latesthat perceived usefulness has positive influences on attitude and behav ioral intention.Accordingly, the following hypotheses were tested:

H3: The level of usefulness of telemedicine techn ology as perceived b y a physi-cian w ill positively affect their attitude toward accepting the techno logy.

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200 C H A U A N D H U

At the same time, physicians, as a group, are not particularly known for technologycompetence, perhaps in part because of the historically nondominant role of IT inphysicians' medical education and clinical training. Despite their relatively high intel-lectual/mental capacities and leaming capabilities, some physicians m ay not be highlyfamiliar w ith IT, which , coupled with their busy schedule s, is likely to result in consid-erably diminished acceptance of technologies that are complicated or difficult to use.As Mintzberg comments [36], the knowledge base of a health-care organization issophisticated but its technical system, the set of technologies and instruments used toapply the knowledge base, is not (nor can be) complicated. In this vein, having apositive perception of a technology's ease of use may contribute to the developmentand solidification of a positive attitude toward using the technology, which, in tum,can strengthen the intention for accepting the technology. Similarly, favorable per-ceived ease of use may contribute to an increased level of perceived technology con-trol. Moreover, perceived ease of use may positively affect perceived usefulness. Asreported by several previous studies [8, 26, 27, 28], individual users have exhibited atendency toward considering a technology to be more useful when it is perceived aseasy to use. Based on the above discussion, the following hypotheses w ere tested:

H5: T he level of ease of use of telemedicine techn ology as perceived by a physi-cian w ill positively affect their attitude toward accepting the technology.H6: T he level of ease of use of telemedicine technology as perceived by a physi-cian w ill positively affect their perceived technology control,H7: The level of ease of use of telemedicine techn ology a s perceived by a physi-cian will positively affect their perceived usefulness of the technology.

The Implementation ContextThe implementation context refers to the particular professional setting where thetarget technology is to be implemented. Results from prior research suggest that theimplementation environment for a particular technology may be assessed from twoperspectives: compatibility of the adopting technology with respect to current workpractices and peer influences.

In this study, compatibility refers to the degree to which the use of telemedicinetechnology is perceived by a physician to be consistent with their practice style orpreference.** Broadly, the practice of a physician follows a pigeonhole process, con-sisting of contingency categorization and standard program selection and executionphases (with probable iterations). When providing care or services to a patient, aphysician first categorizes the patient's need (such as, contingency or diagn osis), thenselects appropriate standard program s (such as, treatments or protocols) from a reper-toire, and subsequently executes them. Over time, a physician becomes increasingly

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technology is perceived by a physician to be compatible with their current wo rk prac-tice, the higher the likelihood the physician would accept the technology. The de-scribed effect is supported by previous research findings that conclude that physiciansresist changing their traditional long-standing practice pattems when their organiza-tions implement infonnation systems that interfere with their routines [4]. Accord -ingly, we tested the following hypo thesis:

H8: The degree of compatibility of telemedicine technology as perceived by aphysician will positively affect the intensity of their behavioral intention to ac-cept the technology.

Compatibility may also influence behavioral intention indirectly, such as, throughits effects on perceived usefulness or perceived ease of use. Physicians are likely to"recognize" the usefulness of a technology when it is considered to be compatiblewith their work practices. At the same tim e, physicians are likely to cons ider a tech-nology as easy to use when its inclusion in their practices does not require majorchanges in care procedures or service processes. Significant incompatibility necessi-tates major process/service changes, which often require considerable leaming andunleamin g on the part of physicians who con sequently are likely to find the technol-ogy not easy to use. Accordingly, we tested the following hypotheses:

H9: The degree of compatibility of telemedicine technology as perceived by aphysician will positively affect their perceived usefulness of the technology.HIO: The degree of compatibility of telemedicine technology as perceived by aphysician will positively affect their perceived ease of use of the technology.

Peer influence, on the other hand, refers to a physician's perception of relevantcolleag ues' opinions on their use of telemedicine technology. Peer influence is closelyrelated to subjective norms but has an explicitly defined focus; that is, the relevantothers are professional peers. Results from prior research suggest that physicianshave exhibited considerable dom inance over managers and patients, making the op in-ions of their professional peers alone increasingly relevant and important. Such opin-ions may in part become the basis for normative beliefs to which a physician maywant or is willing to conform to varying degrees. In a nutshell, the specialization andprofessionalism in the practice of medicine may partially explain the respect or valuethat a physician places on the opinions or suggestions of their peers. Consciously orunconsciously, a physician may align or adjust their behavior or behavioral intention,including that for using telemedicine technology, to such opinions and suggestions.Therefore, we hypothesized the following:

HH : The level ofpeer influence as perceived by a physician will positively affectthe intensity of their behavioral intention to accept the technology.

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knowledge and professional opinions, which m ay make peer influences increasinglypotent and relevant in patient care and service decision-m aking. F urtherm ore, opin-ions of peers may become normative beliefs of varying intensity levels, which, intum, can exert considerable conformance pressure on a physician. As a result, thephysician may include peers' opinions when forming their attitude toward usingtelemedicine technology. Accordingly, the following hyp othesis was tested:

H12: The level ofpeer influence as perceived by a physician will positively affecttheir attitude toward accepting the technology.

Research ApproachTH E FOCU S O F T>IIS STUDY IS INDIVIDUAL PH YSICIA NS' INTENTIONS to use telemedicinetechnology. Similar tomany other behaviors, technology acceptance can be mea-sured by actual technology use as well as by intention to use [37, 41]. In this study,intention was chosen over actual usage to measure technology acceptance. The deci-sion was practical and theoretically justifiable. At the time of the study, actual use oftelemedicine technology inHong Kong, our study site, was not widespread. How-ever, many organizations had shown considerable interest in lelemedicine-assistedservices and some had committed to or actually implemented the technology. Theconstraint of primitive (but growing) technology use prohibited us from using actualtechnology use to generate results with statistical significance. Nevertheless, use ofbehavioral intention to approximate or project actual beh avior is justifiable from bothresearch and managerial perspectives. On the research side, use of intention to ex-plain or predict actual behavior has anestablished theoretical foundation and hasaccum ulated sufficiently strong empirical support [44, 54 ]. Mathieson [34] has ex-amined and supported the use of behavioral intention as a viable dependent variable,commenting that, given the strong causal link between intention and actual behavior,the fact that behavior was not directly assessed isnot a serious limitation (p. 186).Several recent technology acceptance/adoption studies have also used intention touse as their dependent variable (such as [30, 54]). From the technology managementperspective, measuring and analyzing the target intention of physicians allow an es-sential and timely examination of their technology acceptance decision-making at atime when a fast-growing number of health-care organizations are seriously contem-plating adopting and implementing telemedicine technology.

Research Design and Data Collection ProceduresMeasuresThe question items used tooperationalze the constmcts included in the research

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[17]; items on compatibility, peer influence, perceived technology control, and atti-tude came from Taylor and Todd [49]; and items on behavioral intention originatedfrom Davis [17] and Taylor and Todd [49] . All items w ere measured using a seven-point Likert-type scale, with "strongly ag ree" at one end and "strongly disagree " atthe other. To ensure desired balance and rand omn ess in the questionnaire, one-half ofthe included items were negated and all of the questions were randomly arranged soas to reduce a potential ceiling (or floor) effect that may induce m onotonous respon sesto multiple question items designed to measure a particular construct.

SubjectsThe study targeted physicians practicing at public tertiary hospitals in Hong Kongand included ten different medical specialty areas, namely, internal medicine, geriat-rics, pediatrics, obstetrics and gynecology, surgery, emergency care, intensive care,psychiatry, pathology, and radiology. Choice of the these specialties was made pri-marily on the basis of accessibility and the likelihood of the respective specialists'involvement with telemedicine-enabled services as well as becoming technology adopt-ers in the near future. As a group, physicians at these hospitals have considerableinterorganizational service needs, including rendering second or specialist's opin-ions, assessing patient transfer or admission requests, participating in and often tak-ing the lead in team-based patient management, and responding to medical emergenciesthat require special care [31, 32]. These service needs and others may be effectivelysupported by telemedicine technology. The specific medical specialty areas includedin the study were selected based on their frequent appearances in prior telemedicineresearch/practice and the satisfactory results documented in these studies [39],

PretestsUse of question items developed or validated in previous studies does not automati-cally guarantee satisfactory validity and reliability. As Straub [45] comments, thevalidity of an instrument may not be persistent acros s different techno logies and usergroups. A series of pretests were therefore conducted to examine and validate thesurvey instrument, ensuring that it encompassed content validity and reliability at anaccep table level. First, three physicians from different specialty areas and public ter-tiary hospitals were asked to evaluate the content validity of the instrument. Using acard sorting method discussed by Moore and Benbasat [37], question items includedin the instrument were printed on 6 cm x 8 cm index cards. The cards were shuffledrandomly and presented to the physicians who were asked to sort them into appropri-ate categories (that is, theoretical constructs) individually. The card sorting evalua-tion results were satisfactory, as the physicians were able to categorize the presentedquestion items with an accuracy rate of 85 percent or higher.

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hospitals were conducted to solicit input and suggestions on the wording and sequen ceof the question items in the instrument. Based on the feedback, some modificationswere made, including the removal of several question items. For instance, an itemadapted from Davis [17], "using telemedicine technology can enable me to completepatient care more quickly," was subsequently removed because many physicians, inspite of their heavy clinical duties and busy schedules, contend that the primary pur-pose of using telemedicine technology was patient care and service improvement.They considered service efficiency enhancement (measured by service turnaroundtime) to be secondary. The resulting instrument was considered more communicativeand appropriate for telemedicine technology and the targeted health-care context.

Another 35 physicians were asked to evaluate the survey instrument in a subse-quent pretest study. Based on responses from this pretest group , the instru ment's re li-ability was evaluated using Cronbach's alpha. Judged by the resulting alpha values(ranging from 0.62 to 0.85), the instrument app eared to exhibit an acceptab le level ofreliability. The question items used to measure the respective constructs of the re-search model are listed in Appendix A, together with their original sources. Physi-cians w ho participated in the card sorting evaluation, instmment assessment interviews,or the pretest study were excluded from the subsequent formal study.

Study AdministrationBefore sending out the questionnaires, an encounter letter, which explained the re-search purpose and ensured the necessary confidentiality, was sent to the chiefs ofservice of the targeted clinical departments or divisions at eight public tertiary hospi-tals in Hong Kong. Personal visits and telephone calls were then made to these chiefsof service to provide detailed study information and solicit their support. Out of the70 clinical departments or divisions contacted, 41 agreed to take part in the study,showing a 59 percent participation rate.

With the assistance of these chiefs of service, questionnaire packets were deliveredto individual physicians who practiced in the participating clinical departments ordivisions. Fach packet contained a cover letter stating the study purpose and the in-tended data usage and management, endorsement letters from the Hong KongTelemedicine Association and the HA, the questionnaire, and selected representativetelemedicine references that included pictorial illustrations and technology overviewsappropriate for the respective medical specialty areas under investigation. The par-ticular references and technology overview materials had been reviewed and recom-mended by many physicians participating in the pretests. In addition, the instrumentincluded a working defmition of telemedicine to anchor responses from individualphysicians. Immediately after the questionnaire distribution, a letter soliciting intem-al promotion of the study was faxed to the participating chiefs of service. Physicianswere asked to retum the completed questionnaire to their department secretar ies, from

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tive respondents totaled 408, showing a 23.6 percent response rate. Among the re-spondents, 75 percent were male and approximately 80 percent had received theirmedical education in Hong Kong. On average, the responding physicians were 35years old and had 9.5 years of post-intemship clinical experience in their respectivespecialty areas. Approximately 44 percent of the responding physicians (that is, 178)specialized in services that required considerable (direct) patient contact (such as,intemal medicine, obstetrics and gynecology, and pediatrics), 32 percent (that is , 130)specialized in services primarily based on medical/radiological imaging (such as,radiology and pathology), and the remaining were from specialty areas that usuallyinvolved patient contact and medical/radiological imaging (such as, accident andemergency, intensive care and surgery).

Data A nalysis and R esultsReliabilityUsing the collected responses, the reliability and convergent and discriminant valid-ity of the factors contained in the research model were evaluated. Reliability wasassessed using Cronbach's alpha. As summarized in Table 1, most of the investigatedfactors exhibited an alpha value close to or greater than 0.70, suggesting a reliabilityexceeding the common acceptable level [38]. Adapted from Taylor and Todd [4 9], thescale of perceived technology control showed an alpha value of 0.55, which is lower(but not by much) than 0.60, a reliability threshold commonly considered as satisfac-tory in exploratory investigations.

Convergent and Discriminant ValidityFactor analysis was conducted to examine the measurement's convergent and dis-criminant validity. Specifically, we used iterated principal axis analysis w ith a prom axrotation rather than principal components factor analysis with a varimax rotation,primarily because of the likelihood that the factors would be correlated [22, 33].Generally, convergent validity is considered to be satisfactorily established w hen mea-surement items load highly on their respective constructs. Table 2 summarizes thefactor analysis results. As shown, seven factors were obtained with eigenvalues greaterthan 1.0 and m ost item loadings were satisfactorily high (that is , greater than 0.50) onthe respective construc ts. The only exception was the item loading for perceived tech-nology control, which was below but close to 0.50. The convergent validity is there-fore con sidered reasonably satisfactory. A primary criterion for discriminant validityevaluation is each item's loading being higher on its respective construct than that onany other construc ts. As shown in Table 2, the results also suggested that the includedmeasures exhibited satisfactory discriminant validity.

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206 CHAU AND HU

Table 1. Summary of Measurement Scales

Construct Mean Standarddeviation ReliabilityAttitude (ATT)A mATT2ATT3

Perceived technology control (PTC)PTC1PTC2PTC3PTC4Perceived usefulness (PU)PU1PU2PU3PU4

Perceived ease of use (PEOU)PE0U1PE0U2PE0U3PE0U4

Compatibility (COM)C0M1COM2COM3

Peer influence (PIN)PINlPIN2PIN3

Behavioral intention (Bl)BI1BI2BI3

2.832.962.592.853.942.883.852.803.043.302.933.023.463.113.213.463.233.283.663.303.363.472.983.23

i

1.391.31

t

1.30USX

1iJ7

0.69

0.55

0.86

0.77

0.83

0.75

0.86

of a single factor is observed, these items areconsidered to be related because of theuse of a common method, in our case, the self-report ing method. Our analysis resultshows that the single most dominant factor accounted for only 14 percent of the totalvariance, suggesting that the underlying comm on method v ariance may nothave beensignificant.

Nonresponse B iases

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207

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2 P P P P R P P P P o c o O ' - c y c M c o o c o c o c v j c n oi n o o o o o o o o o i - o i ^o O Oo o o o o o oII II O O O CO CO

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.2 o C O C v J 5 > 3 I D - . . . I ^ C O C N J C O ) c v j T c o ^ ^ ^ O O O O g ^ ^ c o - ^ t N F h P ' - ^ " * ^ ' - * o i "Q . C L a . Q - O O O Q - C L Q - D - E E Q l m m m < < < Q - D - D - C L L i J C L

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characteristics and responses to question items for the respective constructs includedin the research model. Early respondents were physicians who completed and re-tumed the questionnaire within the initial two-week response window, whereas laterespondents were those who retumed the questionnaire in the subsequent extendedresponse periods. The distribution of early and late respondents in the study is fairybalanced, showing a ratio of 203 to 205.

No significant differences in both age and post-intemship clinical experience wereobserved between these two groups, which were also largely comparable in theirrespective distribution in such areas as medical specialty, gender, and country of medi-cal training. Findings from the comparative analysis of the responses (to questionitems for the respective constructs) from early and late respondents also suggestedinsignificant differences between these gro ups (Table 3). Together, the pro minen tcompatibility in important demographic characteristics and the high similarity in re-sponses to the respective question items suggested that the threat of nonresponse biasmay have been reduced.

Model Testing ResultsThe research m odel was evaluated using LISR EL. Using the sample covariance m a-trix (see Appendix B), the overall fit and the explana tory power of the research modelwere examined. In addition, we also evaluated the significance and the relative strengthof the individual paths specified by the model.

The overall goodness-of-fit was examined using the following six common modelfit measures: chi-square/degree of freedom, goodness-of-fit index (GFI), adjustedgoodness-of-fit index (AGFT), non-norm fit index (NNFI), comparative fit index (CFI),and standardized root mean square residual (SRMSR). The chi-square statistic wasnot included b ecause of its inherent problem with sample size [23]. As summarized inTable 4, the research model exhibited a fairly good fit with the data collected from theresponding physicians, as suggested by the investigated goodness-of-fit indices ex-ceeding or approaching their respective acceptance levels commonly suggested byprevious research [9].The explanatory power of the research m odel was evaluated by examining the por-tion of variance explained. The analysis results suggested that the model was able toexplain 43 percent of the variance in physicians' intention to use telemedicine tech-nology (Figure 2). Furthermore, 37 percent of the observed variance in attitude ap-peared to have been explained by perceived usefulness, of which 57 percent of thevariance was accounted for by compatibility.

The significance and the relative strength of individual links specified by the re-search model were also evaluated. As summarized in Table 5, six out of th e 12 postu-lated paths were of statistical significance: one at the 0.05 significance level, two atthe 0.01 level, another at the 0.001 level, and the remaining two at the 0.0001 level.

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Table 3. Analysis of Nonresponse Biases

ConstructEarly

respondents(N = 203)

Laterespondents

(N = 205) SignificanceAttitude (ATT)Perceived technology

control (PTC)Perceived usefulness (PU)Perceived ease ofuse (PEOU)Compatibility (COM)Peer influence (PIN)Behavioral intention (Bl)

2.783.443.123.243.363.383.16

2.793.323.0S3.183.293.283.07

/= 0.093, p= 0.926f = 1 .4 3 6 ,p -0 .1 5 2(=0.695, p = 0.488(= 0.6 53 ,p = 0.515( = 0.590, p = 0.555(=1.190, p = 0.234(=0.904, p = 0.366

Table 4. Overall Fits of the Research Model

Fit indexRecommended

valueObservedvalue

Chi-square/degree of freedomGFIAGFINNFICFISRMSR

0.90>0.80>0.90>0.90

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210 CHAU AND HU


ImplementationContextPath coefFicteni(/-value) p.value < 0.05 " p value< 0 001"p-valuc< 0 .0001

BehavioralIntentionR' = 0.43

Figure 2. Results of the Model Test (only significant paths are shown)

DiscussionTHIS STUDY EXAMINED TELEMEDICINE TECHNOLOGY acceptance by physicians in ahealth-care context. Based on a proposed generic framework for technology accep-tance by individual professionals, a research model for the investigated technologyacceptance was developed and empirically examined, using responses from morethan 400 physicians practicing in public tertiary hospitals in Hong Kong. Resultsobtained from the structural equation modeling analysis suggested that the researchmodel exhibited a satisfactory overall fit to the collected data and was capable ofproviding a reasonable explanation of individual physicians" acceptance of tele-medicine technology (that is, 43 percent). One-half of the causal links (that is, hy-

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ATT -> BlPTC -> BlPU -> BlCOM -> BlPIN->BIPU -> ATTPEOU -> ATTPIN -> ATTPEOU -> PTCCOM -> PUPEOU -> PUCOM -> PEOU

0.330.280.400.03

-0.090.450.070.080.110.720.020.08

(3.13)"(3.06)"(3.74)"*(0.34)

(-0.94)(9.08)""(1.57)(0.99)(2.09)*

(13.07)""(0.51)(1.41)

EXAMINING AMODEL OF INFORMATION TECHNOLOGY A CCEPTANCE 211

Table 5. Significance of Individual PathsPath coefficient

Path (f-value) Hyp othesisH1H2H4HBH11H3H5H12H6H9H7H10

Nole.s: ^ p-value < 0.05; ** p-va lue < 0 . 0 1 ; *** p-va lue < O.OQl; **** p-value < 0 .0001 .

Table 6. Strengths of Individual FactorsEffect on behavioral intention Effect sizeDirect effectATT 0.33

PTC 0.28PU 0.40COM 0.03PIN -0.09

Indirect effectPU 0.15PEOU 0.05COM 0.39PIN 0.02

Total effectATT 0.33PTC 0.28PU 0.55PEOU 0.05COM 0.40PIN -0.07

Signiftcance of Perceived UsefulnessResults ofthe study showed that perceived usefulness may be the single most signifi-cant determinant of physicians' acceptance of telemedicine technology. In addition to

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212 CHAU AND HU

physician's tendency of taking a tool-oriented view of technology. Several implica-tions can be derived from this finding. First, physicians, as a group , appear to be fairlypragm atic in their technology evaluation and selection by focusing on practical utilityrather than on technological novelty. Thus, physicians are likely to accept a technol-ogy when it provides considerable or desirable utilities to their practice s. In this light,telemedicine technology, to be accepted, needs to dem onstrate satisfactorily suffi-cient utilities for supporting or enabling patient care and other services offered byphysicians. Second, the observed considerable indirect effects of perceived useful-ness on technology acceptance suggest the importance of attitude man agement throughcommunication and articulation of favorable perceived usefulness. Hence, health-care organizations may need to consider formulating strategies that foster technologyacceptance through favorable attitude cultivation and solidification. Communicatingthe technology's usefulness is important, particularly in situations where perceivedusefulness alone cannot (directly) bring about a desired level of technology accep-tance. Third, the observed strong dependence o fthe acceptance decision on perceivedusefulness represents an interesting area where individual professionals may subtlydiffer from common users in technology acceptance decision-making.

Insignificance of Perceived Ease of UsePerceived ease of use. In the investigated professional context, appeared to have lim-ited effects on attitude. This fmding differs from results reported in several prior tech-nology acceptance/adoption studies that had focused on common user groups (suchas [30]). The observed limited effects may be partially explained by tbe workingenvironment of individual health-care professionals. By and large, physicians haveaccess to reasonably strong staff support from nurses and technologists in servicerendering and equipment/technology operations. The described staff support might,in tum, make ease of use an issue of less importance as perceived by physicians.Another plausible explanation may be the higher-than-average leaming capability orintellectual capacity of physicians who often have developed effective leaming heu-ristics or methods that may enable them to master a new technology with less exten-sive training than is necessary for other user groups, thus reducing the effect ofperceived ease of use on attitude. Furthermore, perceived ease of use appeared tohave no significant effects on perceived usefulness, suggesting that physicians are notlikely to conside r a technology to be useful simply because it is easy to use.

Davidson and Chismar 115, 16] examined technology adoption in hospitals andsuggested that physicians had exhibited reluctance or resistance when the inclusionof a technology would reduce their professional authority. In this connection, a phy-sician may feel halfliearted about, or even develop a negative attitude tow ard, accep t-ing a technology when the physician needs to depend significantly on the nursing orother staff to use the technology. Our observations in various clinical settings in

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EXAMINING AMODEL OF INFORMATION TECHNOLOGY ACCEPTANCE 213

in telemedicine-enabled service encounters. From the perspective of professionalauthority as discussed by Davidson and Ch ismar [15 ,16 ], perceived ease of use mayhave limited impacts on both positive and negative attitudes.Perceived ease of use, on the other hand, appeared to have a significant effect onperceived technology control. This fmding suggests that a physician's perceived con-trol in the use of telemedicine technology may improve when the technology is con-sidered to be easy to use. Understandably, the perceived level of technology controlin operating a technology decreases wben the technology is considered to not bedifficult or complicated to use.

Significance of CompatibilityCompatibility was found to be a significant determinant of perceived usefulness butnot of perceived ease of use. Judged by its 0.72 path coefficient at a 0.001 signifi-cance level, the link from compatibility to perceived usefulness is the most significantamong all the causal paths investigated. As summ arized in Table 6, the indirect effectof compatibility on intention is comparable to the direct effect of perceived useful-ness on intention and is greater than the direct effect of attitude on intention. Thisfinding may imply another interesting characteristic of technology acceptance byindividual professionals. The compatibility of a technology with an individualprofessional's current work practice may be a critical antecedent to perceived useful-ness, which may play an important, although indirect, role in developing a positiveattitude toward using the technology. The observed significance of compatibility onperceived usefulness is consistent with and therefore reinforces the fmdings from arecent study by Davidson and Chism ar [ 15,16], who concluded that technology ad op-tion in hospitals was heavily influenced by doctors' perceptions about their profes-sional role and status in the provision of services. A physician's use of a technologyhighly compatible to their current practice style/preference is not likely to introduceunfavorable changes in their perceived role in the provision of services and, at thesame time, may contribute to increased usefulness ofthe technology as perceived bythe physician. On the other hand, significant changes in long-standing practice pat-tems necessitated by the inclusion of an incompatible technology may diminish thetechnology's usefulness as perceived by individual physicians. As noted by Chircuand Kauffman [10], required changes in existing routines and norms might redu cethe potential value of a newly introduced infonnation technology.

Compatibility appeared to have no significant direct influences on intention but ilexhibited a significant indirect effect on intention via perceived usefulness, alone orin conjunction with attitude. This fmding suggests that com patibility may represe nt anecessary but insufficient condition for technology acceptance by individual profes-sionals. In our case, a physician is not likely to exhibit a strong intention to use tele-medicine technology simply because of its fit with their practice pattem or style. The

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resources to technology acquisition and imp lementation. Tn situations where an orga-nization has to implement a technology not highly comp atible with the existing prac-tices of its mem ber professionals, the management needs to evaluate primary so urcesor areas of incompatibility and develop strategies to bring about a gradual and smo oth-ing transition toward the necessary changes.

Significance of AttitudeAttitude showed a significant direct effect on intention and, in effect, appeared to bethe second m ost important determinant of intention, next to perceived usefulness.This finding is largely consistent with results from many previous studies (such as[30]) that have examined the relationship between attitude and behavioral intention.Thus , forming a positive attitude toward accepting the technology u nder discussion iscrucial for both professional and common users. In the case of telemedicine technol-ogy, the observed effects of attitude on intention suggests tbat health-care organiza-tions should be attentive to individual attitudes and should proactively cultivate andsolidify favorable individual attitudes toward technology acceptance.

Insignificance of Peer InfluencePeer influence appeared to have no significant effects on either attitude or in tention, afinding inco nsistent w ith the conclusions by Taylor and Todd 149] and Harrison et al.[22], respectively. Several factors might have been at the root of tbe observed insig-nificance of peer influence, including professional autonomy and the characteristicsof urban-based medical practice as well as the early telemedicine development inHong K ong. Typically, physicians provide specialized services in a professional man -ner and often have relatively high autonomy over their practices, including the u se ofa technology. Administrative management or even peers may affect a physician'stechnology acceptance decision but perhaps not to an extent of profound significance.The described autonomy, in tum, increases the importance of voluntary technologyuse that may largely be detemiined by individual attitude and technology evaluationrather than by influences from managers and peers alike. Specialized training andhigh autonomy encourage independent thinking and decision-making, which mayjointly contribute to a physician's tendency to respect but place relatively less weigh ton peers' opinions in attitude development or making a technology acceptance deci-sion. Together, the described specialization and autonomy and the resulting indepen -dence may partially explain the observed insignificant peer influence on attitude andintention.

The urban characteristics of Hong Kong and its early telemedicine developmentmight also have explained the observed insignificance of peer influence on attitudeand intention. Hong Kong is highly dense in population, making geograpbic disper-

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dispersion in Hong Kong may, to some degree, have diminished the perceived valueof telemedicine by some physicians who subsequently may not be easily be con-vinced by their peers' opinions or recommendations on the technology use. More-over, judging from the established programs and the provided services, the overalltelemedicine development in Hong Kong was largely in an early stage at the time ofthe study. Conceivably, some physicians may not bave interacted with or had conve-nient access to peers sufficiently experienced in the evaluation and use of telemed icinetechnology. The described lack of experts in the field might, in tum, have causedsome physicians to place less weight on peer opinions when making their tecbnoiogyacceptance decisions. Regardless of its sources, the observed limited effects of peerinfluence on technology acceptance single out another potential area where profes-sionals and common users might subtly differ in their respective technology accep-tance decision-making.

Significance of Perceived Technology ControlPerceived technology control appeared to have a significant effect on intention, but toa lesser extent than attitude and perceived usefulness did. A plausible explanation forthis observed modest effect is that, as supported by our observations of various clinicalsettings, the technology operations in general may not be particularly complicated,especially when considering physicians' leaming capability and staff support from nursesand technologists alike. This finding is consistent with results obtained fTom severalprevious technology acceptance/adoption studies involving common user groups, in-cluding Mathieson [34] and Taylor and Todd [48, 49]. As explained by Taylor andTodd [48], "inexperienced users tend to discount control information in the formationof intentions, relying instead primarily on PU (perceived usefulness)" (p. 566). To-gether, the relatively uncomplicated technology operations, reasonable staff support,and relatively high intellectual/leaming capacity may have decreased the effects ofperceived technology control on technology acceptance by individual physicians.

A Revised Framew ork for Technology Acceptance byIndividual ProfessionalsRESULTS FROM THIS STUDY HAVE SHED LIGHT on the potential areas w here the initiallyproposed framework can be modified. In particular, a hierarchical structure appears tohave emerged. As shown in Figure 3, the framework may be considered to be of a"three-layer" structure, in which the individual context and the implementation con-text are situated in the inner and outer layers, respectively, with the technological con-text in the middle. The "core" of the hierarchy is the individual professional's technologyacceptance, the exact level or intensity of which is determined jointly by these three

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Implementation Context


Individual C ontext

TechnologyAcceptance

Eigure 3, A Revised Pramework for Technology Acceptance by Individual Professionals

Acco rding to this revised framework, the main thm sts of an individual profe ssional'sdecision to accept or not to accept a technology w ould be their attitudinal assessm entof accepting the technology and the evaluation of their control over the technologyuse. Together these factors characterize the individual context and directly affect in-dividual technology acceptance. At the same time, these factors, to a great extent, aredirectly influenced by other sets of factors that define the technological context andthe implementation context. Specifically, essential characteristics of the technologi-cal context that may include perceived usefulness and perceived ease of use, whichdirectly affect the individual context in terms of attitudinal assessment and perceivedtechnology control. Meanwhile, perceived usefulness and perceived ease of use ofthe technology may be directly affected by such factors as compatibility and peerinfluence, which together characterize the implementation co ntext. Broadly, comp at-ibiiity (or technology-practice fit) may be conceived as a technology's complianceand congruence with the underlying service rendering process or procedure and thuscan be measured accordingly.

Through the described layered structure that depicts plausible sources and direc-

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tion of important technology acceptance factors atan adequate abstraction level and,at the same tim e, provides a systematic analysis of the general influence structure (orpattems) among the constituent contexts that are fundamental to the technology ac-ceptance of interest. Tbe resultant conceptualization of technology acceptance is es-tablished at tbe context level and thus the specific factors essential to each context andtheir effects may be specific to the technology, the professional (user), or both. Com-pared with prior studies, which generally follow a (nonstructural) factor-modelingapproach, the revised layered-structure framework arguably may provide additionalinsights about tecbnoiogy acceptance by individual professionals.

LimitationsTHIS EXPLORATORY STUDY HAS SEVERAL LIMITATIONS. Our research results suggestpotential areas wbere professional and common users might subtly differ in theirrespective tecbnoiogy acceptance d ecision-mak ing. However, discussed findings andimplications nevertheless are based on a single-study design tbat examined a particu-lar technology and involved a specific user group, professionally and geographically.Therefore, caution needs to be taken when extrapolating or generalizing tbese re-search results to other technologies, professional groups, or environmen ts. Sim ilarly,this study did not address tbe potential individu al diversity w ithin a professional group .Physicians are not homogenous in their technology acceptance decision-making, whichmay vary with specialty areas, the service sector (such as, public or private), coreservices, and clinical experience levels. Although singling out the potential differ-ences between professional and common users, this study did not investigate tbe de-scribed individual variations in the targeted specialty areas, which understandablyencompass some shared characteristics.

The revised framework has the potential toprovide additional insights about tech-nology acceptance by individual professionals but it is limited in its stmctural delin-eation and general impact pattems. For instance, the individual context may affect tbetechnological content. Several previous studies (such as [12, 13]) bave reported thatself-efficacy, an individual-level factor, has significant effects on technology accep-tance in a variety of ways, including indirect influences on perceived usefulness (inthe technological context). Similarly, our research results did not support the directimpact of the implementation context on individual technology acceptance (as sug-gested by the revised framework). Nevertheless, the revised framework represents areason able starting point for contin ued investigation s required for further frameworkrefinement.

The working definition of telemedicine tecbnoiogy used in this study admittedly israther broad in scope and thus conceivably supports anarray of health-care servicesor applications. The definition was chosen because of the exploratory nature of th e

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desirable than a definition highly specific to a particular technology or medical spe-cialty. This broad definition allowed tbe establishment of a fundamental understan d-ing of the tecbnoiogy acceptance of interest and, at the same time, enabled thegeneration of preliminary findings from whicb continued researcb may proceed. Toreduce potentially adverse variations in physic ians' arbitrary characterization of tech-nology, we provided a working definition of telemedicine technology in the instru-ment and included in each survey packet selected references and brochures oncommonly available telemedicine technologies adequate for tbe respective specialtyareas under investigation. Both the working definition and the selected referenceswere intended to anchor responses from the individual physicians. At the time of thestudy, most physicians at Hong Kong's tertiary hospitals by and large had possessedconsiderable knowledge about telemedicine technology and its common or promis-ing applications in their respective areas, mainly through medical literature, technol-ogy vendors, professional contacts, and various workshops and seminars. On anexperimental or trial basis, many physicians in effect had accumulated hands-on ex-periences with the technology made available by vendors or research groups fromuniversities [31, 32].

The operationalization ofthe constructs included in the research model is anothersource of limitation. Measures were primarily adapted from relevant prior researchand therefore might introduce limitations in investigating the probable tecbnoiogyacceptance differences between professional and common users. The relatively lowreliability values of some scales, perceived technology control in particular, mightsuggest the potential limitation of tbe measure's applicability in situations that in-volve different user groups or contexts. Tbis limitation reinforces the importance ofinstrument reevaluation discussed by Straub [45] and highlights the need for newinstrument dev elopmen t, or at least modifications to existing ones , to ensure a d esiredfit witb tbe targeted context, the user group, or both.

Another limitation is the research model's explanatory utility, whicb is reasonablebut not satisfactory. Compared with those reported by prior studies on IT acceptance/adoption, the R-square obtained in our study is relatively low. Specifically, in tbestudies conducted by Mathieson [341 and Taylor and Todd [49], R-squares were re-ported in the range of 0.5 and 0.7 for the respective researcb mod els (tbat is, TAM andTPB). In our case, tbe R-square for behavioral intention was 0.43, suggesting thatthere was a plausible omission of factors important to acceptance of telemedicinetechnology by individual physicians.

Last but not least, tbe current study is also limited in the timing of and method fordata collection. Our data were cross-sectionalthat is, the responses were collectedfrom physicians at a particular point in time. Tbe acceptance or assessment oftelemedicine technology by a physician understandably may be time-v ariant, adjusted,or modified as the physician gains additional kno wledge about or experien ce witb thetechnology. In effect, results from prior researcb (such as [25, 47]) bave suggested

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and tbeir generalization requires cautious interpretation. Furthermore, the responseswere collected from the physicians using the self-report technique, a technique aboutwhich IS researchers still have con cem s of varying degrees [1 1,4 6] , in spite of its usein many previous technology acceptance/adoption studies. For examp le, Thompsonet al. [51] suggest that botb objective and subjective measures should be employedand tbat the correspondence (or the lack of it) between them should be examinedregardless of which factor is used as tbe dependent variable. Similarly, Szajna [47]suggests tbat additional bebavior-oriented measures (such as, choice bebavior) shouldbe used. Melone [35], on the other hand, has examined the use of the user-reported,self-assessment data collection technique and has suggested that tbis approach is ap-propriate in situations where p erceptual measures can cop e with real-world co nstraintsmore effectively than objective measures can. Although the intention focus of ourstudy inherently made the self-report approach natural and appealing, choice of thisdata collection method nevertheless represents a limitation ofthe study.

ConclusionsAs VARIOUS IT APPLICATIONS THAT SUPPORT THE WORKand services of professionalscontinue to be rapidly developed, adopted, and implemented, examinations of factorscritical to technology acceptance by individual professionals become increasinglyimportant. Of pa rticular interest and importance to IS researcb is whether or not thesefactors might differ from those reported by prior IT acceptance/adoption studies thathave focused on end users, knowledge workers, and business managers. Drawn froma theoretical premise established through a synthesis of relevant literature, a genericframework for technology acceptance by professionals was proposed to provide afoundation upon which a research model for explaining or predicting physicians'acceptance of telemedicine technology was developed. Using responses collectedfrom more than 400 physicians practicing in public tertiary hospitals in Hong Kong,the research model was empirically examined in terms of its overall fit and explana-tory power as well as the individual causal relationships it specified. Several imp lica-tions for both research and practice bave emerged and are discussed as follows.

Implications for R esearchFindings of the study shed light on several areas wbere professional and commonusers might subtly differ in tbeir respective technology acceptance decision-making.Specifically, professionals appear to be fairly pragmatic, focusing on tbe usefulnessof a technology ratber tban on its ease of use. Individual professionals appear to bavestrong concem s about technology-practice com patibility, tend to place less empb asison their control of technology use, and appear to attach a limited weight to sugges-

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220 CHAU AND HU

experienced increasing IT investment and penetration 141 ] and has the merits of gen-erating research results applicable to real-world technology management practices.

Results from the study also provide evidence of the usefulness or appropriatenessof the proposed (and revised) framework for tecbnoiogy acceptance by individualprofessionals. Based on a multidimensional approach, the framework may provide aholistic view of technology acceptance that takes place in a professional organizationas well as a foundation upon which particular research models can be developed ormodified. Additional empirical support is needed to validate the resulting frameworkthat broadly depicts a layered structure and general impact pattems at the constituentcontext level.

In addition, this study brings an intemational perspective to IT acceptance/adop-tion research. Rosenzweig [43] challenges tbe presumption of conceptual equiva-lence across language and cultural barriers in management research. To be useful,researcb results must be validated in a larger context, providing additional empiricalsupport of researcb findings that subsequently can be generalized or considered ap-plicable in different cultural settings. In this connection, this study represents aneffort toward validating previous researcb results in a different context by ex am iningtbe acceptance of telemedicine technology by physicians in Hong Kong. Conceiv-ably, physicians from a different culture may exhibit interesting differences in tech-nology acceptance decision-making. For exam ple, physicians practicing in a culturetypically characterized by relatively bigb uncertainty avoidance [24] might considercom patibility or perceived ease of use of telem edicine tecbnoiogy differently fromthose operating in a culture exhibiting more uncertainty tolerance. Similarly, theparticular technology acceptance decision factors essential to physicians and theirexact effects might subtly vary with such cultural dimensions as power distance andindividualism.

The discussed limitations and imp lications suggest several important future researchdirec tions. First, continued effort is needed to validate and improve the research mo del,regarding both its theoretical b asis and em pirical applicability. For instan ce, identifi-cation of additional variables to explain the observed behavioral intention variationsnot accounted for by tbe current model is essential. Plausible theoretical premisesmight include co mputer self-efficacy [12, 13, 53 ], participation and involvement inthe design process [50], prior usage and experience [48, 50], and user characteristics[28]. Analysis of important task characteristics may be interesting, particularly whenanchored on the notion of task-technology fit that focuses on the efficacy of technol-ogy with respect to an individual's task performance [15, 19]. In addition, the per-ceived net value of a transition as described in tbe Technology Transition Model byBriggs et al. [7] might shed additional light on potential model enhancement direc-tions. When properly combined with those already included in the researcb model,these factors may provide a fuller explanation of the technology acceptance of inter-est. Inclusion of new variables into the research model may result in additional rela-

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portant, given the constraints or limited empirical support of the revised frameworkin structural delineation and general impact pa ttem s. Along tbis vein, identifying thefactors of concem in the literature and examining their plausible effects are a logicalstarting point, allowing a broad assessment ofthe framework's layered structure andits general impact pattems. Longitudinal investigations that involve different contextsdefined by technology or professional (user) groups may further augment the frame-work's empirical validity and generalizability. At the same time, investigating tech-nology acceptance longitudinally also allows an examination of potential change s inthe relative importance and influence pattem of key acceptance factors over time.Together, results anticipated from tbese promising research directions would con-ceivably advance our understanding of the underlying causality between or amongthe important decision variables and, at the same time, extend and validate comp ara-tive technology accep tance differences between individual professionals and en d us-ers and business managers commonly found in tbe business world.

Implications for Telemedicine Management PracticeFrom a managerial standpoint, the findings of tbis study reveal tbe importance of atti-tude cultivation and solidification in managing technology acceptance by individualprofessionals. In this light, dissemination and communication of positive perceptionsofth e technology 's usefulness are crucial. The technolo gy's ease of use may be impor-tant to individual professionals' technology acceptance decisions but perhaps to a re-duced extent. Along with the decision to adopt a particular technology, the managem entshould consider placing a high priority on demonstrating the usefulness of the technol-ogy and com mu nicating to the affiliated professionals its support of and utility in ren-dering individual services and work performance. In tbe case of telemedicine, initialinfonnation sessions and hands-on training programs should concentrate on demon-strations of tbe tecbnology's support, facilitation, and improvement of an individualphysicians' patient care and services ratber than detailed operational procedures orsequences. A fundamental objective of tbe initial information and training sessions isto cultivate positive attitudes among physicians who subsequently may develop orexhibit increasing intention to include the tecbnoiogy routinely in their services.

Tbe ob served effects of compatibility on perceived usefulness also have impo rtantimplications for telemedicine technology development, selection, and implementa-tion. The prevalent systems approach in contemp orary med icine, together w ith rigor-ous and demanding clinical training, inevitably calls for and subsequently results inthe developm ent of specific practice routines to which individual physicians becom eaccustomed over time. Major changes to these routines are difficult and are rarelywell received by physicians. To promote the acceptance of telemedicine technology,management needs to devise strategies that establisb and communicate assurance ofthe tecbnology's compatibility with the physicians* current practices rather tban re-

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222 CHAU AND HU

of a characteristic natural to their underlying professionalism. However, the limitedeffects of peer influence should be duly considered by taking account of tbe earlystage of telemedicine development in Hong Kong, where few health-care profes-sionals bave sufficiently strong experiences with and expertise in telemedicine toexert convincing influence to disseminate and foster desirable technology accep-tance among their peers. Nevertheless, when promoting telemedicine tecbnoiogy,management may need to focus on highlighting and demonstrating the tecbnology'susefulness rather than heavily depend on persuasion by those witb limited experi-ences with the technology.

Acknowledgments: The authors thank the anonymous reviewers for their constructive commentsand suggestions that were valuable to the revisions ofthe manuscript. The work described in thispaper was substantially supported by a grant from the Research Grants Council of the HongKong Special Administrative Region, China (Project No. HKUST/HKU 6195/98H).

NOT E S1. Although acknowledging the differentiation between "professionals" and "common us-ers" is largely coarse rather than dichotomous, we took a fairly conventional and selective viewof "professionals." By professionals, we mean those who have received highly specializedediication/iraining in the traditionally recognized professional categories (such as, medicine

and law), obtained commonly and legally required professional qualifications (such as, M.D.and J.D.), and are currently practicing their profession in a professional manner and setting.The authors thank an anonymous reviewer for providing valuable comments on differentiatingprofessional and common user groups.2. Loosely, physicians in this study refer to all certified and licensed medical doctors, whichinclude general practitioners, specialists, and subspecialists. Thus, we did not distinguish pri-mary care physicians and specialists (or subspecialists), the latter ofwhich, in effect, were thetargeted physicians in the study.3. Although greatly congruent with those commonly referenced as defined by the WorldHealth Organization, the American Medical Association, the European Commission, Bashshur[5 , 6] and Darkins and Cary [14], this defmition admittedly is broad and embraces serviceapplications of interest or relevance to physicians from different special areas. Our choice of a

broad rather than a focused defmition is supported by the existing telemedicine literature and,at the same time, allows an examination of technology acceptance by physicians across anarray of medical specialty areas. To anchor the subjects' responses, our survey packet includedreferences on representative or common types of telemedicine technology applicable or rel-evant to the services of target physicians from each special area examined. Exemplar technolo-gies included two-way real-time teleconferencing systems and medical image transmission/display systems with multimedia capability, about which thephysicians were knowledgeableor experienced. Hence, results of the study are probably more generalizable as well as morerelevant to the management of telemedicine technology by health-care organizations than wouldbe otherwise.4. The compatibility literature suggests that compatibility may consist of two components:congruence with existing practices and consistency with the values or norms of potential adopters[52]. In our research model, we decided torepresent these two components using two distinctconstructs that jointly depict the implementation context. Specifically, we used compatibilityto denote the level of congruence with the existing work practices. On the other hand, peer

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EXAMINING A MODEL O F INFORMATION TECHNOLOGY ACCEPTANCE 223

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