This study was conducted to empirically validate the generalizability of the D&M model by assessing the psychometric properties of the model in the context of low-resource setting hospitals. Additionally, insights were provided into HIS implementation success research by assessing the mediating effect of computer literacy on the relationship between service quality and EMR use as well as user satisfaction.
Our findings support all D&M constructs, except of the effect of EMR use on user satisfaction. The relationships of system quality, information quality, service quality, EMR use, user satisfaction and perceived net-benefit were proven to possess adequate psychometric properties and thus can be used as effective measures of EMR success in low resource settings. Individual relationships and their implication for practice are explained below.
System quality directly affects EMR use and user satisfaction (H1 and H2), thus implying that an increase in the quality of the system leads to an increase in EMR use and user satisfaction and hence, EMR success. System quality incorporates system ease of use, user friendliness, user interface and responsiveness. Thus, a net positive effect from these factors will result in a positive effect on EMR success. This result is consistent with different studies [7, 13, 16, 20] but different from e-government success [14] which might be attributed to the difference in user type and setting.
Information quality also positively affects EMR use and user satisfaction (H3 and H4), indicating that an increase in the quality of the information leads to an increase in user satisfaction and EMR use. The result is in line with previous studies [4, 20, 13, 14]. When the user’s attitude towards the information quality is more positive, the perceived usefulness of information will be higher. Therefore, while implementing EMR, managers should emphasize the following aspects: making sufficient information available, having good accuracy and ensuring on-time updating of information on the system and making sure that reports are in a format and layout health professionals routinely use and understand.
This study also shows that service quality of EMR implementation strongly influences EMR use and user satisfaction (H5 and H6). When users feel more satisfied with the service quality of the EMR, e.g. receiving good internal and external support, their satisfaction and probability of using the system will be higher. The result is consistent with other studies [7, 13, 16, 20]. Creating a supportive environment that is responsive to user concerns can increase the service quality. Additionally, it is necessary to provide more computers within the wards to allow clinicians entering patient data without having to wait for a free computer. Ensuring a sustainable power supply and giving immediate system support are also important factors to improve service quality. Given most implementations in those settings are donor supported, it is necessary for these organizations to provide satisfactory support to increase service quality and hence, user satisfaction and EMR use.
The findings of this study also indicate that the total effects of service quality on use and user satisfaction are substantially greater than those of system quality and information quality. This means that EMR implementation managers should pay much more attention to promoting the service quality of EMR systems. This result is not in line with other similar studies [7, 13, 16, 20] which is attributed to the setting differences. In low resource settings, there is a lack of computer access and sustainable power supply, which might make service quality a more determinant factor than the others.
The relationship between use and user satisfaction is a rarely researched factor in IS success literature [40]. In this study, we found that user satisfaction positively affects EMR use (H8) but our data does not support the hypothesis that EMR use positively affects user satisfaction (H7). This result might be attributed to the relatively small number of participants who currently use the system in the study hospitals.
EMR use and user satisfaction also positively affect net-benefit. This relationship is shown by many empirical studies and our result is consistent with them [11, 12, 40, 41]. Additionally, user satisfaction was found to be a stronger predicator of perceived net-benefit than EMR use. This result is also similar with other studies [14, 15, 42]. Assuming that user satisfaction is the user’s best estimate of the system capabilities, a stronger relationship between user satisfaction and perceived net-benefit is quite understandable.
The mediating effect of the computer literacy between service quality and EMR use as well as between service quality and user satisfaction was found to be significant. This result is consistent with Nunes et al. [20]. When we compare the two hypotheses, a stronger mediation effect was observed in the relationship between service quality and EMR use than with user satisfaction. This is a strong indicator that basic computer literacy is necessary for health professionals to increase their motivation of using the system. Therefore, during or before system implementation, in addition to specific user training, it is advisable to give additional basic computer courses to increase the success of the system.
Strengths, weaknesses and generalizability of the study
Although we believe this study will make significant contributions to future EMR implementations in low-resource settings, some of the limitations must be noticed. First, the discussed findings were obtained from one single study from one EMR system in one country. Therefore it should be generalized to other populations with caution. However, with the context of the study, the survey result exhibited adequate validity and reliability. Second, our study is based on only self-reported questionnaires, which might have some response bias that, however, is almost unavoidable in cross sectional studies.
Implications
To the level of our knowledge, this study is the first comprehensive validation of the D&M model to be applicable for EMR success evaluations in low resource settings. This study advances previous research by validating the model and testing the mediating effect of computer literacy in the service quality satisfaction relationship. The model provides not only an overall assessment of factors influencing EMR success but also the capability to identify the most problematic aspects of EMR implementation efforts. The magnitude of path coefficients provides useful insights into the relative importance of each subscale of the D&M model.
The validation of the D&M model under voluntary use and in low resource settings, is an input for and contribution to the IS scientific community, especially for the under-researched domain of healthcare ICT.
Practitioners should note that service quality was found to be the strongest determinant for EMR use and user satisfaction and user satisfaction was found to be the most important determinant factor for perceived net-benefit, hence EMR success. Therefore, managers should strive to improve hospital service quality and health professionals’ satisfaction. Additionally, the assessment of the computer literacy component in this study recognizes that the ability to use computers is an important aspect that influences an individual’s use of the implemented system in the hospital. Hence, this result implies that specific training to EMR is not enough for its success but the management should provide general basic computer courses to increase the system adoption.
Future work
The instrument we used measures only perceived net-benefit but not actual net-benefit. Thus, future studies should carefully define the context in which net-benefit is measured and they should measure at user, hospital or governmental level (for example time savings in the clinical practice or return on investment). We also agree with D&M [12] that it is necessary to continuously challenge, validate and extend the proposed model under different user and implementation settings.