Behaviour & Information Technology

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Obstacles to continued use of personal health

records

Michele Heath , Tracy H. Porter & Kenneth Dunegan

To cite this article: Michele Heath , Tracy H. Porter & Kenneth Dunegan (2020): Obstacles
to continued use of personal health records, Behaviour & Information Technology, DOI:
10.1080/0144929X.2020.1829051

To link to this article: https://doi.org/10.1080/0144929X.2020.1829051

Published online: 05 Oct 2020.

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BEHAVIOUR & INFORMATION TECHNOLOGY
https://doi.org/10.1080/0144929X.2020.1829051

Obstacles to continued use of personal health records

Michele Heath, Tracy H. Porter and Kenneth Dunegan
Cleveland State University, Cleveland, OH, USA

ABSTRACT ARTICLE HISTORY

The purpose of this paper was to examine organisational change in a hospital setting. Specifically, Received 11 September 2019
the paper examines how patients responded to the introduction of personal health records (PHR). Accepted 21 September
This research was an empirical investigation based on surveys completed by 136 patients in the 2020
United States. The paper draws on Lewin’s Force Field Analysis Model to explain patient
KEYWORDS
responses to new PHR technology. The results indicate that affective and cognitive resistance Health information system;
factors exist, but the presence of change information can mitigate the resistance. While both government policy; user
resistance factors were relevant, the study found that reducing cognitive resistance had a participation; information
stronger influence than reducing affective resistance. This research will contribute to the health management
care literature by offering insight into the factors associated with resistance and the continued
use of PHR systems. The research also contributes to the individual IT literature by examining
attitudes and beliefs that lead to continued use of IT systems.

1. Introduction is important in successful management of change

initiatives.
A personal health record (PHR) is an electronic docu- With respect to PHRs, most patients are introduced
ment which allows patients to access, manage, and to these systems during an initial visit to the doctor’s
share their health information in a private, secure, and office. However, oftentimes the introduction occurs
confidential environment (Kaelber and Pan 2008). without patients receiving convincing information
Such tools are intended to get patients more involved related to why the new system is important or how
in their health care and subsequently improve health lit- the patient might benefit. Broadly speaking, research
eracy, allow patients to communicate directly with their has shown that approximately two-thirds of change
physicians, and promote preventative self-care (Detmer initiatives fail because of ineffective direction and infor-
et al. 2008). Previous research has demonstrated a num- mation (Roeleven 2010; Choi and Ruona 2011; Dacey
ber of benefits to PHRs including reducing health care 2017). The current study examines change information
costs, improving personal health outcomes, and as a force that can help reduce resistances to PHR use.
improving the experience of care for patients and their An example of change information would include
families (Jilka et al. 2015; Kruse, Bolton, and Freriks pamphlets, brochures, or instructional videos that pro-
2015). These benefits can best be achieved when both vide pertinent details about the new system. Sutton
patients and providers consistently and continuously and Kahn (1987) argued that individuals need this
utilise the PHR portal. kind of information to help establish expectations and
This paper draws upon Lewin’s Force Field Analysis an understanding why a change is necessary. The
Model (Lewin 1951) as an operational framework to assumption is that if a patient receives convincing infor-
analyze the process of change and assist in identifying mation about the PHR they will be more inclined to
forces which propel initiatives forward or create bar- accept and use the system going forward.
riers. Lewin’s approach has been widely recognised as Accomplishing this, however, has been a challenge.
an effective framework to plan and manage change While previous PHR research has focused on the initial
(Burnes 2004; Cummings and Worley 2001; Cummings, registration for such systems (Ozok et al. 2014) few
Bridgman, and Brown 2016; Muldoon 2019) and studies have looked at the issue of continued use. This
describes change as a process shaped by the balance of is relevant because the promotion and ongoing use of
the driving and restraining forces. Driving forces are PHRs is a central component of government meaningful
catalysts promoting a change; restraining forces are use guidelines and incentive programmes. Meaningful
inhibitors. Identifying and understanding these forces use (MU) is the set of standards defined by the Centers

CONTACT Michele Heath m.heath@csuohio.edu Cleveland State University, 1860 E. 18th Street, BU 430, Cleveland, OH 44114, USA
© 2020 Informa UK Limited, trading as Taylor & Francis Group
2 M. HEATH ET AL.

for Medicare and Medicaid Services (CMS) (2015) Replacing previous hardcopy versions, PHRs are
Incentive Programmes that governs the adoption and changing the health care context in unprecedented
extended use of personal health records. Ozok et al. ways and consequently generating great interest
(2014) found that health care providers encourage among all stakeholders. However, understanding how
patients to sign-up for PHRs during an early appoint- to effectively manage the shift from hardcopy to elec-
ment in order to adhere to the Meaningful Use compli- tronic records has proven to be challenging (Heath
ance rule, but pay far less attention to what happens and Porter 2017; Kahn, Aulakh, and Bosworth
after signing up. Hence, there is a general lack of under- 2009). Key to the success of this shift is the acceptance
standing about factors that might be associated with of the new system by patients. Although PHRs can
decisions to use or resist the use of PHRs. This leads provide opportunities for patients to actively engage
to our two research questions: in their own medical care and medical self-manage-
ment, the change from a traditionally passive relation-
RQ1: To what extent does education, in the form of
change information, impact continued use of the PHR ship to a more participative one can be intimidating.
system? While PHRs have the potential to promote desirable
levels of patient engagement, the voluntary nature of
RQ2: To what extent do resistance behaviours nega- these systems presents a challenge: how do we get
tively influence the continued use of a PHR system?
patients to accept and utilise PHRs long term. We
This research has important implications for health know from previous research that PHRs get patients
care leaders who are investing significant resources in more involved in their health care, improve their
PHR systems hoping to realise their health-related health literacy, allow them to communicate directly
benefits, but also hoping to capitalise on the monetary with health care providers, and promote greater pre-
incentives from the federal government. ventative self-care (Detmer et al. 2008). Studies also
What follows is a review of relevant literature on show that getting patients more engaged and active
PHRs and organisational change in health care. We in their own medical programme improves patient
then introduce the research model, outline our satisfaction, quality of care, and ultimately clinical
hypotheses and methodology, followed by a discussion outcomes (Nazi et al. 2013).
of our findings. Finally, we consider the theoretical Despite these apparent benefits, there have been a
and practical implications of our findings and provide number of obstacles related to patient satisfaction with
a discussion of broader issues related to patient PHRs, and consequently the continued use of the sys-
engagement. tems. For example, patient-provider conversations
have proven to be uncomfortable because PHRs chal-
lenge the traditional roles for patients and physicians
2. Background (Rathert et al. 2019; Woods et al. 2013). Many end
users have reported that PHRs are too complicated
2.1. Patient health record (PHR)
(Rathert et al. 2019; Liu, Shih, and Hayes 2011). Patients
The introduction of PHRs has resulted in significant also experienced usability issues, which led them to
changes to the traditional manner in which patients believe they may not actually save time (Baird, North,
and their health care providers interact. A PHR is an and Raghu 2011; Rathert et al. 2019). To date, however,
electronic record of a patient’s health-related infor- little research has focused on identifying factors which
mation stored in a health care provider’s IT system affect this relationship. Recognising the importance of
(Kahn, Aulakh, and Bosworth 2009). There are two patient acceptance and adoption of PHRs, the Centers
different types of PHR systems: standalone and con- for Medicare and Medicaid Services (CMS) (2015)
nected (ONC 2019). The standalone model involves implemented a programme to incentivise health care
information completed by a patient and the information providers to be more attentive to maintaining patient
is stored on the patient’s computer (ONC 2019). In a involvement. These guidelines have been articulated in
standalone system a patient can make the decision on the Meaningful Use (MU) Legislation.
whether to share information with providers, family
members, or someone involved in their care. The con-
2.2. Meaningful use legislation
nected PHR however, is linked to a hospital’s electronic
health record (EHR) system or to a health plan’s infor- The Health Information Technology for Economic and
mation system (ONC 2019). Therefore, it is important Clinical Health (HITECH) Act, enacted as part of the
to note a connected system asks patients to ‘share’ American Recovery and Reinvestment Act of 2009,
their health information with others. was signed into law on February 17, 2009, to encourage
 BEHAVIOUR & INFORMATION TECHNOLOGY 3

the adoption and meaningful use of health information opportunities to health care providers to capitalise on
technology (ONC 2019). The enacting of the HITECH government incentives.
ACT and the MU programme has had a significant
impact on the direction that PHRs have taken in recent
years. PHRs allow patients to access their test results, 3. Conceptual lens
make doctor appointments, and exchange emails with
3.1. Force field analysis model
providers (Hoffman 2017). Beginning in 2011, the Med-
icare and Medicaid Electronic Health Record Incentive There is a considerable body of research on organis-
Programmes were established to encourage medical ational change, but the majority focuses on the for-
providers to adopt, implement, and demonstrate mean- profit private sector (Aslam et al. 2018; Heward, Hutch-
ingful use of EHR technology (CMS 2015). Meaningful ins, and Keleher 2007; Husmann 2020). Few studies
use outlines criteria defined by the Centers for Medicare specifically examine patient change management within
and Medicaid Services (CMS) Incentive Programmes health care (Woollen et al. 2016; Mohd Yaacob et al.
which oversees the use of electronic health records 2019). This absence is noteworthy given the increasing
and personal health records and allows eligible provi- significance of the health care industry, and justifies
ders and hospitals to earn incentive payments by meet- efforts, like the current study, which examines change
ing specific criteria (Krishnaraj, Siddiqui, and Goldszal with a more sector-specific perspective. Among the pro-
2014). fusion of general models on change, one of the more
Meaningful Use includes three stages. Stage 1 time-tested was proposed by Kurt Lewin over 50 years
focuses on computerised health information data col- ago (Lewin 1951). The model is very simple but,
lection (ONC 2019). Stage 2 focuses on clinical pro- sufficiently elegant to capture the essence of change pro-
cedure advancement and encourages the use of cesses. Although some suggest Lewin’s model may be
health information technology (IT) for continuous overly simplistic, as noted by Burnes (2004) and Mul-
quality improvement at the point of care (CMS doon (2019), few would argue the significance of his
2015). This stage of the MU programme requires contribution to the field of change management (Cum-
the active engagement of patients and their families, mings, Bridgman, and Brown 2016). Indeed, many feel
which is demonstrated through the percentage of con- Lewin’s three-step model continues to be a relevant fra-
sumers who must utilise their PHR and communicate mework within which to understand the dynamics of
electronically with their provider. The threshold of change initiatives (Bakari, Hunjra, and Niazi 2017).
compliance in this stage should be five percent For example, Seyfried and Ansmann (2018) recently
(ONC 2019). used the model to examine change in higher education.
Meaningful use stage 3 involves promoting intero- Akingbola, Rogers, and Baluch (2019) applied the three-
perability through the incentive programme and setting step model in a study of non-profit organisations. In
up metrics to evaluate provider performance (CMS fact, Lewin’s approach to understanding change con-
2015). Stage 3 meaningful use recommends that patients tinues to be an accepted framework in a host of organ-
should be able to communicate electronically using isational settings, nursing (Wojciechowski et al. 2016),
secure messaging, access patient education materials, schools (Buttazzoni, Coen, and Gilliland 2018), health
generate health data into their providers’ EHRs, and and human services (Batras, Duff, and Smith 2016;
view, download, and transmit information. The percen- Heward, Hutchins, and Keleher 2007), public health
tage of patients who must communicate electronically initiatives (Rütten and Gelius 2014), software develop-
with their provider is 10 percent under stage 3 and ment (Capatina et al. 2017), and law enforcement (Car-
fifty percent of patients should have access to their ter and Phillips 2015; Duxbury et al. 2018), to name a
entire record. few. While acknowledging significant advances in
Clearly, patient engagement is a central feature of research on change management, Lewin’s model con-
Meaningful Use guidelines (Buck 2011). Embedded in tinues to demonstrate its versatility, in part because it
these guidelines are financial incentives rewarding pro- is practical and easy to understand (Shirey 2013).
viders who demonstrate success securing patient adop- Lewin’s force field analysis model describes three
tion of PHRs, but also who demonstrate ongoing patient stages of change: unfreezing, introducing changes, and
use of the systems. Therefore, a more comprehensive refreezing. Unfreezing refers to a relaxation of current
understanding of the change processes involved in procedures and habits such that change can be intro-
PHR introduction and adoption is beneficial for at duced. However, there are competing forces that can
least two reasons: greater involvement by patients in either facilitate or prevent unfreezing from occurring.
their own personal medical care and increasing According to Lewin, driving forces facilitate an
4 M. HEATH ET AL.

unfreezing of existing conditions while restraining thereby increasing the likelihood that change initiatives
forces push to maintain the status quo (Muldoon will succeed (Bartunek et al. 1999; Saksvik et al. 2007).
2019; Rosch 2002). This ‘force field’ perspective predicts For example, Nielsen and Randall (2012) found that
opposing forces simultaneously pushing for and against change information was positively related to stake-
change. Unless or until driving forces become stronger holder adjustments in terms of well-being, job satisfac-
or more compelling than restraining forces, no change tion, and engagement. Similarly, change information
occurs (Burnes 2004; Lewin 1951; Rickards 1999). If has been found to be predictive of higher openness to
the driving forces are successful and unfreezing occurs, change (Sawesi et al. 2016; Langer 2017) and less resist-
changes to the status quo can be initiated. After changes ance to change (Oreg 2018). Organisational scholars
are introduced, Lewin suggests a new equilibrium have supported the assertion that the functional, sym-
should be established and ‘refrozen’, because without bolic, and linguistic roles of communication efforts
the refreezing stage, former procedures and old habits help to frame and explain organisational change initiat-
are likely to re-emerge. ives (Torppa and Smith 2011; Werner and Cornelissen
Lewin’s framework is employed in this study to 2014). In turn, communication affects the level of
examine how patients are responding to changes in motivation and rationality towards the change, which
the way they interact with health care providers; specifi- can then decrease resistance.
cally, how patients are responding to the introduction of With respect to the current study, without adequate
personal health record (PHRs) systems. As mentioned, or convincing information about PHRs, patients may
change requires strengthening driving forces or redu- be uncertain about what specific changes will occur,
cing some of the restraining forces (Carter 2008). As how a given change will affect their health care or
the process unfolds, stakeholders try to understand doctor-patient relationship or even how they will have
how the change will affect them personally, evaluating to adapt. If clear, comprehensive, and believable change
it cognitively (i.e. thoughts about the change) and affec- information is not well received by the patient, resist-
tively (i.e. feelings about the change) (Burnes 2004; Oreg ance could potentially come into play (Heath and Porter
2006; Piderit 2000). If the cognitive and affective reac- 2017; Hong et al. 2016). With that in mind, we use
tions are positive restraining forces are reduced. If change information (i.e. information about the PHR)
they are not positive, restraining forces increase. Apply- as a form of education/communication such that
ing this to the current study, if a new PHR system does patients will be more likely to understand the reasons
not meet a patient’s expectations, or if they are having a for and the potential benefits of a transition to PHR.
hard time using the new system, efforts to maintain the We know that patients are being introduced to PHR
status quo increase (Carr and Hancock 2006) and the as a new technology because of the government man-
PHR is resisted. Conversely, if cognitive and affective date, but there appears to be a lack of information on
reactions are favourable, resistance decreases and why they should adopt and continued to use it (Irizarry,
patients are more likely to accept the PHR and incor- Dabbs, and Curran 2015; Kruse, Bolton, and Freriks
porate it into their health care regimen. If the PHR 2015). Therefore, to the extent Kotter and Schlesinger
has been accepted and refreezing occurs, from the per- (2008), and others referenced above, are correct, when
spective of the health care provider, the process is relevant change information is provided to patients
successful. about the PHR we would expect there to be less resist-
As stated earlier, change can only occur if/when the ance; that is, unfreezing can occur because a patient’s
driving forces are stronger than the restraining forces. cognitive and affective reactions to the PHR would be
If the restraining forces remain stronger, the status more accepting.
quo is likely to be maintained (Batras, Duff, and Smith
2016). Kotter and Schlesinger (2008) suggest several
3.2. Refreezing – continued use
mechanisms to reduce resistance. Education and com-
munication, for example, are tools organisations can In the Information Systems (IS) literature, continuance
use to increase acceptance and combat resistance. Edu- refers to the sustained use of a technology (Bhattacher-
cation and communication are needed most when there jee 2001). The essential argument is that continuing to
is a lack of information or when the available infor- use a technology is fundamentally an intentional behav-
mation is perceived to be misleading or inaccurate (Bar- iour driven by conscious decisions (Bhattacherjee 2001).
rett 2017; Kotter and Schlesinger 2008). In these These decisions are the result of an evaluative process
situations, education and communication efforts can involving expectations and reflections on experiences,
reduce the anxiety/uncertainty surrounding pending as well as emotions and cognition (De Guinea and Mar-
changes (Ashford 1988; Miller and Monge 1985), kus 2009).
 BEHAVIOUR & INFORMATION TECHNOLOGY 5

In the current study, acceptance and adoption of should try to better address an individual’s subjective
PHRs would be reflected in a patient’s intentions to con- experiences in order to construct a more comprehensive
tinue to use the system as a routine part of their ongoing understanding of the basis for resistance.
health care programme. In Lewin’s terminology, such a
decision would be part of the refreezing stage of his
model. Given the aforementioned legislation on Mean- 3.4. Model for examining continued use
ingful Use (CMS 2015) and given that patients must As previously stated, this study was undertaken to
choose to use a PHR, both government agencies and examine how patients respond to the introduction of
health care providers will be interested in, and motiv- electronic PHR systems and the extent to which they
ated to find, ways to encourage acceptance, adoption will be inclined to continue to use the system going for-
and refreezing. This study is an effort to contribute to ward. Since this process involves a change from tra-
that understanding. ditional interactions between patients and health care
providers, we designed the study utilising Lewin’s
3.3. Resistance to change (1951) force field framework. Specifically, we wanted
to determine the how information about the change
Oreg (2006) defines resistance as a negative attitude correlated with a patient’s affective and cognitive
towards change and most models of attitudes recognise response, and then how these attitudinal components
three components: affective, cognitive, and behavioural correlated with a patient’s behavioural response; that
(Breckler 1984; Ostrom 1969). The affective component is, their intentions to continue to use the PHR.
deals with how one feels about the change (e.g. angry, We will use the following model which will simply
anxious). The cognitive component involves what one posit main effects of both affective and cognitive resist-
thinks about the change (e.g. is it necessary and ben- ance. The model suggests that meaningful use, which set
eficial), and the behavioural component involves actions guidelines for PHR use, and incentive programmes are
or intention to act in response to the change (e.g. com- driving forces. The unfreezing agent is change infor-
plaining about the change, trying to convince others mation. Affective and cognitive resistance are restrain-
that the change is bad). This framework is interrelated ing forces. Figure 1 provides a graphic representation
because what people feel about a change will often cor- of our study.
respond with what they think about it and, eventually, Change research indicates how a change may be
with their subsequent behavioural intentions (Oreg characterised depending on the perspective of the obser-
2006). While the three factors are distinct of one ver or recipient (Lines 2005). Adequate information
another, each could reflect different aspects of the resist- regarding the change is a tool that organisations can
ance phenomenon (McGuire 1985; Oreg 2006; Piderit use to control that perspective and create a more uni-
2000). form understanding/acceptance of the change (Huh,
Organisational change involves the unsettling con- Kim, and Law 2009). Information can introduce a
dition of moving from the known to the unknown. level of understanding that helps avoid potential uncer-
Because the future is uncertain and may adversely tainty that could be raised in a change recipient’s mind.
affect people’s competencies or value and relevance to In order to mitigate such challenges, project managers
a company, organisational members are generally hesi- will often provide educational materials or communi-
tant to support change unless compelling reasons con- cations on why the system change is important.
vince them to do so (Agboola and Salawu 2011).
However, the reasons for resistance may not be straight-
forward. For example, Piderit (2000) suggests that
resistance may actually result from a sense of ambiva-
lence whereby an individual’s feelings, behaviours, and
thoughts about the change may not coincide, resulting
in equivocation or indecision. Nord and Jermier
(1994) argue resistance is often used as part of an agenda
that may overshadow an individual’s legitimate reasons
for objecting to the change. However, regardless of the
catalyst, resistance in whatever form, could represent a
major obstacle to the adoption and continued use of a
PHR system. Given that change can increase uncer-
tainty, Nord and Jermier (1994) suggest researchers Figure 1. Continued use research model.
6 M. HEATH ET AL.

Education materials can be considered unfreezing H4: A patient’s cognitive resistance is negatively related
agents that notify the patient why the change is needed to the continued use of the PHR system.
and highlight the associated benefits. It is possible these
communications may trigger attitudinal changes that 4. Research methodology
will encourage patients to adopt and use the PHR.
Research by van den Heuvel et al. (2013) supports this This research employed a cross-sectional design in 2019
expectation. Their findings suggest change information to survey patients in the United States. The survey gath-
can facilitate adaptive attitudes (willingness to change) ered self-reported data from a sample of patients with
as well as behavioural change (adaptive behaviour). PHR experience. Existing measures were adapted to col-
The importance of adequate information is further lect information to allow the assessment of four con-
demonstrated by research noting the frequency of structs: change information, affective and cognitive
change information can generate energy towards a resistance, and continue use.
change, which in turn clarifies the objective and interna-
lises the change within individuals (Lewis 2007). There-
4.1. Measures
fore, we hypothesise the following:
Change information. Four items from Wanberg and
H1: Positive patient perception of the change infor- Banas (2000) were used to measure Change Information
mation is positively related to patient continued use. (CR = .94). Items asked about the usefulness and value
H2a: Positive patient perception of the change infor-
of the information. For example, ‘Patient feels the infor-
mation is negatively related to affective resistance. mation I have received has adequately answered my
questions about the changes’. Responses were collected
H2b: Positive patient perception of the change infor- using a five-point Likert scale ranging from 1 (strongly
mation is negatively related to cognitive resistance.
disagree) to 5 (strongly agree).
Affective resistance refers to the feelings associated Resistance to change. Four items from Oreg’s (2006)
with the change (Oreg 2006). The affective component affective resistance (CR = .93) and cognitive resistance
could potentially manifest in various types of feelings (CR = .92) scale items were used to assess the change
such as anger, being anxious, or being positively inter- attitude. Affective resistance refers to the feelings associ-
ested (Oreg 2006). These reactions have specific refer- ated with the change initiative. For example, ‘Patient
ents and arise in response to the appraisal of an event feels angry about the change’. Cognitive resistance refers
perceived as relevant and important to an individual to the way the individual thinks about a change and the
(Bagozzi, Gopinath, and Nyer 1999; Lazarus 1991). A beliefs surrounding the change. For example, ‘Patient
PHR can trigger emotional reactions from individuals believes the change will not benefit them’. Responses
when they interrupt the customary sequence of events were collected using a five-point Likert scale ranging
in one’s routine (Rafaeli and Vilnai-Yavetz 2004). In from 1 (strongly disagree) to 5 (strongly agree).
addition, patients who exhibit negative emotions Continued use. Four items from Bhattacherjee’s
about a PHR have been shown to be less satisfied with (2001) continue use (CR = .90) scale items were used
their experience with a PHR overall (Heath and Porter to assess intentions to continue to use the PHR. For
2017). Therefore, we hypothesise the following: example, ‘Patient intends to continue using PHR system
in the future’. Intentions were collected using a five-
H3: A patient’s affective resistance is negatively related
point Likert scale with responses ranging from 1
to the continued use of the PHR system.
(strongly disagree) to 5 (strongly agree). The full survey
Cognitive resistance refers to the beliefs surrounding is available in Table 1.
the change (Oreg 2006) such as, ‘I believe the change
will not benefit me’. This belief in turn might create a
level of resistance within the individual (Chung, Su, 4.2. Instrument development
and Su 2012). For example, a person may ignore the To develop the survey for this study, we began with
nurse when PHRs are mentioned and they may assume Oreg’s cognitive behaviour model survey (Oreg 2006).
the system to be useless (Armenakis, Harris, and Mos- The survey items were adapted, and terminology was
sholder 1993). Hence, patient’s may create their own changed to better fit the hospital context and focus on
interpretations of what is going to happen, how others PHR use. For example, one survey item was changed
perceive the change, and what others are thinking or to ‘I believed that the change would harm the inter-
intending to do about the change (Bowling 2014). action between me and my physician’. We also used
Therefore, we hypothesise the following: Wanberg and Banas (2000) change information survey
 BEHAVIOUR & INFORMATION TECHNOLOGY 7

Table 1. Survey instrument.

Construct Survey items Citation
Information about the change . The information I have received about the changes has been timely. Wanberg and Banas (2000)
. The information I have received about the changes has been useful.
. The information I have received has adequately answered my questions about the changes.
. I have received adequate information about the forthcoming changes.

Affective resistance . I was afraid of the change. Oreg (2006)

. I had a bad feeling about the change.
. I was quite excited about the change.a
. The change made me upset.
. I was stressed by the change.

Cognitive resistance . I believed that the change would harm the interaction between me and my physician. Oreg (2006)
. I believed the change is a positive thing for me.
. I believed that the change would make me more involved in managing my health.
. I believed that the change would benefit the physician.
. I believed that I could personally benefit from the change.

Behavioural resistance . I looked for ways to avoid participating in the change. Oreg (2006)
. I protested against the change.
. I complained about the change to my colleagues.
. I presented my objections regarding the change.to management.
. I spoke rather highly of the change to others.

Continue use . I intend to continue using PHR system in the future. Bhattacherjee (2001)
. I will continue using PHR system in the future.
. I will strongly recommend PHR system for others to use it.
. I will keep using PHR system as regularly as I do now.

a
Reverse.

items and Bhattacherjee’s (2001) continue use survey distributed. This survey included first a consent form
items. Change information survey items did not require which was IRB compliant and then four screener ques-
modification. The continue use survey items were chan- tions to assure participants fit the researcher’s criteria.
ged to mentioned PHR. For example, one survey item The screener questions included asking respondents
was changed to state ‘I intend to continue using PHR what a patient portal was, the level of functionality
system in the future’. used (e.g. scheduling, appointments, reviewing labora-
To assess the face and content validity of the adapted tory results), and how often they used a PHR (e.g.
survey, we interviewed three individuals that have experi- weekly, monthly, yearly). Finally, to ensure validity
ence with PHR use. There were no proposed changes two attention checks were included in the actual survey
after the interview. The full survey was then pilot tested (e.g. please select extremely unhappy).
with 50 patients and factor analysis was conducted to ver- We received 182 survey responses. After eliminating
ify the loading of the items. All items loaded appropri- 46 respondents for missing data or failing the attention
ately with regards to the existing literature. checks, 136 respondents were available for the study.
Within this sample there were more women (71.30 per-
cent) than men. The smallest percentage of respondents
4.3. Sample and procedures came from the 18 to 24-year age group. One-third of the
respondents had a high school education or less. Almost
The sample for the study was obtained through Qual- all respondents were non-hispanic Caucasian. Most of
trics. The researchers asked Qualtrics to locate roughly the respondents had been using PHRs for an average
200 potential respondents living in the United States, of four to 12 months and had used it more than four
were at least 18 years old and had experience working times during the five-month period before the survey
with a PHR. To locate respondents Qualtrics e-mailed was conducted.
an invitation to potential individuals and in the survey
noted the general survey intent, the duration (20 min-
utes), and the incentive they would receive. To avoid
5. Data analysis
self-selection bias, the survey invitation did not include
specific details about the contents of the survey. All analyses were carried out utilising SMART PLS 2.0.
Once the full sample was chosen by Qualtrics the SmartPLS is a component-based path modeling soft-
researcher’s previously prepared online survey was ware application based on the partial least squares
8 M. HEATH ET AL.

Table 2. Inter-construct correlations: consistency and reliability tests.

Composite reliability AVE Change information Affective Cognitive Continued use
Change information 0.950 .801 .895
Affective resistance 0.930 .780 −.370 .883
Cognitive resistance 0.930 .765 −.378 .401 .874
Continued use 0.900 .702 .492 −.451 −.567 .838
Notes: Diagonal elements are the square roots of the AVE of each construct.

(PLS) method. PLS identifies two models: the measure- evidence that a measure is not unduly related to other
ment model and the structural model. The measure- similar, yet distinct, constructs (Messick 1989). Discri-
ment model consists of relationships among the minant validity was assessed by comparing the square
conceptual factors and the measures underlying each root of average variance extracted of one construct
construct (Halawi, McCarthy, and Aronson 2008). It with correlations between this construct and another
is assessed by examining individual internal consist- construct. In Table 2, diagonal elements are square
ency, factor loadings, and discriminant validity. It is root of the variance shared between the constructs
necessary to test that the measurement model has a sat- and their measurements. The off-diagonal elements
isfactory level of validity and reliability before testing for are the correlations among constructs. For discriminant
a significant relationship in the structural model (For- validity, diagonal elements should be larger than off-
nell and Larcker 1981). The structural model gives diagonal elements. The recommended threshold is
information as to how well the theoretical model pre- greater than .50 (Fornell and Larcker 1981), which is
dicts the hypothesised paths or relationships (Chin the case as shown in Table 2 (bold). Lastly, we analyze
1998). It is estimated by the path coefficients and the the AVE index. The average variance extracted (AVE)
size of the R-squared values. Smart PLS provides the measures convergent validity. Fornell and Larcker
squared multiple correlations (R-squared) for the (1981) recommended values higher than 0.50 to indicate
endogenous construct in the model and the path coeffi- convergent validity. Each AVE exceeds the 0.5 guideline
cients. R-squared indicates the percentage of the var- as suggested (Table 2) (Fornell and Larcker 1981). Con-
iance of the constructs in the model. The path vergent validity measures the items on a scale to deter-
coefficients indicate the strengths of relationships mine if the items are linked. Fornell and Larcker (1981)
between constructs (Chin 1998). recommended values higher than 0.50 to indicate con-
vergent validity. In this instance, the items loaded on
their constructs from .660 to .930 indicating convergent
5.1. Assessment of measurement model validity. Cross-loadings of items are given in Table 3.
The acceptability of the measurement model was
assessed by the reliability of individual items, internal
5.2. Assessment of structural model
consistency between items, and the model’s discrimi-
nant and convergent validity. Our first step in the analy- The bootstrap resampling method to assess the level of
sis was to measure the reliability. Reliability measures significance of the paths was computed by PLS. Results
accuracy and refers to the extent to which a scale pro- from PLS, including path coefficients and their
duces consistent results, if the measurements are
repeated several times (Kline 1994). Reliability measures
Table 3. Factor loadings italicised and cross loadings.
the degree to which the set of indicators of a latent vari- Affective Cognitive Continue use Change information
able is internally consistent in their measurements AF1 0.882 0.428 −0.425 −0.346
(Kline 1994). Internal consistency reliability was AF2 0.878 0.322 −0.406 −0.356
assessed using composite reliability. As shown in AF4 0.878 0.357 −0.399 −0.296
AF5 0.894 0.300 −0.346 −0.305
Table 2, the value of the composite reliability of the CO2_REV 0.399 0.899 −0.544 −0.367
different latent variables ranged from 0.900 to 0.950. CO3_REV 0.327 0.878 −0.491 −0.281
CO4_REV 0.199 0.662 −0.227 −0.187
These values exceeded the recommended acceptable CO5_REV 0.368 0.889 −0.551 −0.380
limit of 0.70, indicating reliability (Chin 1998). CU1 −0.461 −0.497 0.928 0.414
CU2 −0.458 −0.528 0.914 0.425
Validity is the extent to which a scale or set of CU3 −0.291 −0.545 0.808 0.552
measures accurately represents the concept. Straub CU4 −0.355 −0.402 0.842 0.323
IC1 −0.339 −0.260 0.401 0.855
(1989) indicated that the two main dimensions for test- IC2 −0.325 −0.362 0.434 0.902
ing the measurement model were discriminant validity IC3 −0.335 −0.342 0.476 0.914
and convergent validity. Discriminant validity is IC4 −0.329 −0.380 0.470 0.906
 BEHAVIOUR & INFORMATION TECHNOLOGY 9

Table 4. Summary of hypothesis testing.

Statistical
Results of hypotheses significance Path coefficient Results
H1: Positive patient perception of the change information is positively related to patient continued Significant .282** Supported
use.
H2a: Positive patient perception of the change information is negatively related to affective resistance. Significant −.378** Supported
H2b: Positive patient perception of the change information is negatively related to cognitive Significant −.371** Supported
resistance.
H3: A patient’s affective resistance is negatively related to the continued use of the PHR system. Significant −.188* Supported
H4: A patient’s cognitive resistance is negatively related to the continued use of the PHR system. Significant −.389** Supported
*p < .05; **p < .01.

statistical significance are displayed in Table 3. The R 2 6.4. Hypothesis 3

for the model was .448, which reflect the amount of var-
H3 proposed that affective resistance would be nega-
iance explained by continued use.
tively related to the continued use of the PHR system.
Analyses were consistent with this hypothesis; that is,
affective resistance negatively affected continued use
6. Results (β = −.188, p < .05). This suggests patients who develop
The results of the hypotheses testing are summarised in affective resistance, even when they receive information
Table 4. As the table indicates, all of the hypothesised about the change, are less likely to continue to use the
relationships were supported. PHR system. Therefore, hypothesis 3 is supported.

6.5. Hypothesis 4
6.1. Hypothesis 1
Finally, H4 predicted cognitive resistance would nega-
The first hypothesis tested the relationship between tively affect continued use. Our analysis found support
change information and intentions about continued for this hypothesis (β = −.389, p < .01). This suggests
use. As hypothesised, information about changing to a patients who develop cognitive resistance will be less
PHR system was positively related to intentions to con- likely to continue to use the PHR system. Taken
tinued using the system in the future. Our analysis together, analyses of the proposed model (including
found that change information significantly predicted change information, affective resistance and cognitive
continued use (β = .282, p < .01), suggesting that when resistance) explained almost half the variability in con-
a patient receives what they consider adequate infor- tinued use intentions (R-square = 0.448).
mation they will be more likely to use the PHR system
going forward. Therefore, hypothesis 1 is supported.
7. Discussion
The central focus of this research was to examine organ-
6.2. Hypothesis 2a isational change in a hospital setting, specifically review-
Analysis found change information was significantly ing how change information is related to intentions to
and negatively related to affective resistance (β = continue to use PHR systems. Lewin’s force field analy-
−.378, p < .01). This suggests that patients who receive sis model (1951) provided the theoretical framework to
adequate change information will potentially develop examine the relationships between the study variables
fewer negative feelings about the change. Therefore, and their impact on a patient’s intentions. Previous
hypothesis 2a is supported. research suggests that information about forthcoming
changes could be key to understanding and overcoming
resistance by those impacted by a change (Kotter and
Schlesinger 2008). Results from the current study sup-
6.3. Hypothesis 2b port this position.
Analysis found change information was significantly
and negatively related to cognitive resistance (β =
7.1. Change information
−.371, p < .01). This suggests that patients who receive
inadequate change information will potentially develop Information about the change refers to information cre-
stronger negative thoughts or beliefs about the change. ated and shared with patients regarding the introduc-
Therefore, hypothesis 2b is supported. tion off a PHR system. Change information could
10 M. HEATH ET AL.

potentially include flyers, brochures, or videos to edu- up stage and continued to provide them with messages
cate patients on the benefits of the new system and touting the benefits of using the PHR.
through these communications, influence them to con-
tinue using it in the future. Conversely, patients who
7.3. Cognitive resistance
receive inadequate or unconvincing change information
will potentially develop negative feelings, thoughts or In this study, cognitive resistance refers to beliefs or
beliefs about the change and be less inclined to use thoughts of an individual concerning the PHR system;
the system. These findings are supported by the work in other words, the patients’ thoughts and beliefs sur-
of Kotter and Schlesinger (2008) who stress the impor- rounding the rationale for changing how they interact
tance of communication and education surrounding a with their health care team. The study found that
change. Individuals need to develop supportive expec- change information could potentially reduce negative
tations around the change and understand ‘why’ the thoughts and beliefs regarding the PHR system and its
change is necessary (Sutton and Kahn 1987). Without continued use. These findings support previous
a well-constructed change information process the research, which demonstrated the impact of cognitive
change itself would likely fail (Beer and Nohria 2000). beliefs on one’s level of cognitive resistance (Chung,
Although these communicative steps might appear tri- Su, and Su 2012). In other words, of the three measures,
vial or time consuming, results from this study suggest cognition, a patient’s thoughts and beliefs about the new
they might be extremely relevant in encouraging system, play a more substantial role in her/his intentions
patients to accept and use the PHRs. This result would about continued use. This finding is supported by pre-
contribute to successfully satisfying the government’s vious research noting the relationship between an indi-
PHR mandate of continued use. vidual’s affective and cognitive processes (Fredrickson
2001) and the importance of understanding the cogni-
tive influence (Chung, Su, and Su 2012). Assuming
7.2. Affective resistance
these results are correct, health care providers should
In the current study, affective resistance refers to the pay particular attention to creating information deliver-
emotional reaction of an individual toward the PHR ables designed to help patients understand and believe
system; in other words, how the patient feels about the that the new system makes sense. If accomplished, the
introduction of a new way of interacting with her/his logical decision would then be to embrace and contin-
health care team. Our findings indicate that the presence ued to use the system going forward. These communi-
of sufficient information can reduce a patient’s negative cations should continue well beyond the initial sign-
feelings about the system. In turn, this decreases one of up. Health care groups must not only pass out bro-
the restraining forces that would otherwise keep the chures or flyers, a passive strategy, but also strive to
PHR from being accepted and used. These findings sup- make sure patients cognitively comprehend the need
port previous research, which notes how a change (e.g. for change. This is an important finding and offers
EHR) might act as a trigger to emotions (Rafaeli and health care leaders insight into how best to target their
Vilnai-Yavetz 2004) and the importance of the individ- educational materials.
ual’s appraisal of such events on affective resistance
(Bagozzi, Gopinath, and Nyer 1999; Lazarus 1991). In
7.4. Continued use
addition, these findings are in line with other previous
research, which demonstrates a relationship between This study draws upon Kurt Lewin’s force field model
positive affect and decision-making (Fredrickson 2001; (1951) as a framework for understanding acceptance
Isen 2001). Therefore, the information created by health of PHR systems. The force field can be depicted as
care providers about the PHR should focus on how this two opposite forces working for and against change.
information can be structured or framed to affect a Driving forces push for changes to the status quo.
patient’s affective responses in a desirable way. How- Restraining forces resist those forces. In this study,
ever, if the information is not adequate or not convin- meaningful use legislation and financial incentives rep-
cing, a patient will develop affective resistance. resents the driving forces for the change. Conversely,
Affective resistance will then become a barrier for a affective and cognitive resistance represents the
patient to continue the use of the PHR system. Again, restraining forces. Information about the changes are
this finding is in alignment with previous research introduced as instruments to reduce the strength of
(Greifeneder, Bless, and Pham 2011). From a prescrip- the restraining forces. According to Lewin, changes to
tive standpoint, health care providers should maintain the status quo will only happen when the driving forces
communications with patients beyond the initial sign can overcome the restraining forces or if the strength of
 BEHAVIOUR & INFORMATION TECHNOLOGY 11

the restraining forces is sufficiently reduced. That being than men. Lastly, the study did not control for different
the case, the goal for health care providers is to reduce usage time frames. Time could play a factor into where
the restraining forces, in this study the affective and cog- the patient is currently in the technology life cycle. Each
nitive resistances, so that they can introduce changes to of these issues could be addressed in future research.
the status quo.
Our results suggest that if a hospital is able to disse-
10. Future research
minate adequate change information to reduce affective
and cognitive resistance, a patient will be more likely to This study offers a number of potential avenues for sub-
continue to use the PHR system. In line with previous sequent future research. For example, it would be inter-
research, high quality communication is a critical ingre- esting to collect data from younger respondents to
dient in any organisational change initiative (Barrett assess their understanding of PHRs and how they
2017). With continued reinforcement, the patient is might be more likely to use such technology. It would
more likely to establish a new norm of using the PHR be of interest to compare the younger and older
system instead of the former paper-based reporting sys- samples. Future research might also assess respondent
tem. If successful, the new system will replace the old perspectives from both the pre-and post-adoption of
and become the new means of seeking medical advice, an individual’s PHR. Studying the two stages will give
reviewing tests results, and scheduling appointments. researchers the ability to understand and investigate
Such changes would also capitalise on the documented more dynamics regarding the resistance to the PHR sys-
benefits associated with PHRs within the literature (Det- tem. Future research might also explore antecedents to
mer et al. 2008; Jilka et al. 2015). resistance to change in the context of PHRs, as well as
the sequential ordering effects of the antecedents. Such
information would help hospital leaders to better
8. Implication for research and practice
focus training, education, and marketing efforts for var-
In this paper we focused on several factors associated ious groups, thereby encouraging the likelihood of con-
with decisions about continued use of a PHR. Specifi- tinued PHR use.
cally, we looked at information about the change and
how it influences affective and cognitive resistance. As
11. Conclusion
reported, each type of resistance had a statistically sig-
nificant impact on a patient’s intentions to continued Healthcare facilities continue to grapple with govern-
using the PHR. That being the case, our results hold a ment mandates requiring the migration from paper to
number of theoretical and practical implications. For electronic health records. While many of the early tech-
example, previous research has examined barriers nological challenges of designing and implementing
associated with PHR use. However, most studies are PHR systems are being resolved, getting patients to
limited in scope because they do not address the ulti- accept and use PHRs continues to be a challenge. This
mate goal of Meaningful Use legislation, which is con- study suggests that providing convincing change infor-
tinued use of the PHR system (Tang et al. 2006). mation and reducing affective and cognitive resistance
Within this study we incorporated continued use, could potentially increase patient decisions about con-
thereby offering health care leaders insight into areas tinued use. While both types of resistance are found to
they might want to focus upon during the change infor- be important restraining factors in the decision process,
mation stage (i.e. to focus on cognition or affect). This our data suggest that, of the two, cognitive resistance is
research also contributes to the individual IT continu- the most significant.
ance literature by examining the behaviours that Although our study focused on the impact of change
might lead to a patient’s continued use of the PHR information to unfreeze the status quo, healthcare facili-
system. ties should employ a variety of initiatives to encourage
patient acceptance and use of PHRs. For example, the
introduction and training of PHRs should not be a
9. Limitations
‘one and done’ exercise limited to a single patient
The study has several limitations. First, results were sign-up session. Follow-up exchanges through email,
drawn from responses to a cross-sectional survey. It is text messages, provider web sites, and other social
also possible that common method variance had some media could provide links to additional training
impact on the results (Conway and Lance 2010). materials, FAQs about PHRs, and contact information
Further, the panel data utilised in the sample was com- to support people/department, should patients feel
prised of mostly older respondents, with more women they need more personalise assistance. FAQ topics
12 M. HEATH ET AL.

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