DO GERMAN PHYSICIANS WANT ELECTRONIC

HEALTH SERVICES?

A Characterization of Potential Adopters and Rejecters in German

Ambulatory Care

Sebastian Dünnebeil, Ali Sunyaev, Ivo Blohm

Department of Informatics, Technische Universität München, Germany

Jan Marco Leimeister

Department of Economics,Universität Kassel, Germany

Helmut Krcmar

Department of Informatics, Technische Universität München, Germany

Keywords: Ambulatory care, Electronic health services, Health telematics infrastructure, Technology adoption,

Standardization, Data security, Practice equipment, Clustering.

Abstract: Germany is introducing a nation-wide health telematics infrastructure that enables various electronic health

services (EHS). Little is known about the burdens and drivers for potential adoption of these innovations.

Based on a quantitative study among German physicians participating in pilot test regions for health

telematics, this paper clusters potential adopters and rejecters of EHS, based on their usage intention as

determined with the UTAUT model. The study furthermore depicts opinions, attitudes, as well as equipment

of physicians in ambulatory care to find similarities in terms of IT diffusion, process and security

standardization, patient involvement, communication, documentation and general working patterns. The

clustering shows that “Supporters” and “Rejecters” of EHS differ significantly in many aspects investigated.

Based on these empirical findings, implications for design and introduction of e-health services can be

derived, ranging from a different way of approaching physicians in ambulatory care to incentive structures

for EHS usage.

1 INTRODUCTION

As health information systems have the potential to

improve Healthcare quality (Shekelle et al., 2006),

German health authorities are currently building a

nationwide telematics infrastructure (TI) in order to

harmonize transactions and data storage of e-health

applications in the German public health system.

Universal accessibility of data without institutional

boundaries, via web services or common portable

data carriers, aims at reducing healthcare costs by

avoiding redundant examination of patients and

administration (Bundesministerium für Gesundheit,

2005). Unified telematics specifications can ensure

high data security standards, a standardized access

process and common data formats throughout the

national health system (Sunyaev et al., 2008).

Misuse can be avoided by mandatory encryption of

health data and role based access rules for health

care providers (gematik, 2008b, German Federal

Office for Information Security, 2008).

A major goal of the efforts is the enforcement of

patient centered treatment (Marschollek and

Demirbilek, 2006), standardization and transparency

of medical treatment. In Germany the telematics

infrastructure is used as the backbone for the

mandatory electronic health card (eHC) system. The

infrastructure is specified by a government

controlled institution, and connects existing

information systems of care providers via a common

202

Dünnebeil S., Sunyaev A., Blohm I., Marco Leimeister J. and Krcmar H. (2010).

DO GERMAN PHYSICIANS WANT ELECTRONIC HEALTH SERVICES? - A Characterization of Potential Adopters and Rejecters in German

Ambulatory Care.

In Proceedings of the Third International Conference on Health Informatics, pages 202-209

DOI: 10.5220/0002695602020209

 SciTePress

network with shared data storage locations

(Fraunhofer Institut, 2005). This service oriented

architecture (SOA) provides services: the primary

systems (e.g., clinical information systems or

practice information system) of medical institutions

can invoke them to communicate with other care

providers and maintain, review or share medical data

objects. A local component, called “Connector,”

encapsulates all local services, as encryption or card

access and establishes a secure virtual private

network (VPN) connection to the central services if

needed (gematik, 2008a).

So far a number of different basic offline health

services, such as electronic prescription, emergency

data, and insurance basic data service, have been

tested in seven regions to verify the functions of the

technical infrastructure deployed. In the long term,

further services like electronic health records,

electronic physician letters, and electronic drug

documentation should be offered online via the

infrastructure. The infrastructure will be kept open

for the development of commercial value-added

services (Bernnat, 2006). Evaluation of the online

functionality of electronic health services will be

started with around 200 care providers in the test

region, involving about 100,000 citizens with health

insurance.

2 DISPUTE OVER THE EHC

Previous surveys have shown that a vast majority of

physicians rejects electronic services offered by the

National TI (Techniker Krankenkasse, 2009, Oliver

Kalthoff et al., 2008). Numerous campaigns have

been started by medical associations and politicians,

calling for a moratorium of the eHC project (Tuffs,

2008). The main reasons for rejection, as indicated

by the objectors, are safety concerns about central

storage of patients’ medical data as well as the

unsatisfactory performance during the offline testing

of services and infrastructure (Oliver Kalthoff et al.,

2008). Moreover, testing and introduction of the

eHC have been delayed many times: although the

initial introduction date was set for 2006, the testing

has still not been completed in 2009. The date of the

final introduction is not yet clear.

In order to get a clear picture of the

characteristics of physicians in the ambulant sectors,

we analyzed the characteristics in depth of

physicians who, in contrast to care providers in

hospitals, decide independent of management on the

adoption of the TI and its services. Important fields

of medical work, intended to be improved by the

telematics, were the focus of the research. The goal

was to conclude whether rejection and support of the

telematics correlate with other aspects that are

important in daily work in ambulatory practices.

Therefore, the usage intention was measured directly

to get a clear picture of the general adoption

preferences. To scrutinize the publicly dispersed

criteria leading to rejection, we grouped physicians

according to their behavioral intention. The resulting

clusters were then analyzed in terms of the

remaining criteria to find out which characteristics

were common for the different adopter groups.

Consolidated findings, of the survey thus enabled

predictions about general attitude, working

characteristics, and equipment of physicians,

derivable from the usage intentions.

3 METHODOLOGY

3.1 Survey Design

The survey was developed based on the Unified

Theory of Acceptance and Use of Technology

(UTAUT) to determine the usage intention for

electronic health services deployed via the national

TI for the support of ambulatory care (Venkatesh et

al., 2003). Based on medical goals documented by

leading institutions of the healthcare system and the

German government (Bundesrepublik Deutschland,

1988), we further asked for certain important

healthcare aspects, such as security concerns

(Sunyaev et al., 2009), treatment and administration

standards, patient involvement, and inter-

institutional communication (Hoppe and Richter-

Reichhelm, 2000, Haux, 2005), before posing the

questions about telematics and EHS. The question

sequence was designed to ensure minimum

influence of the public opinion on the answer

patterns not directly related to the telematics.

The questionnaire was named “Survey on IT

diffusion in ambulatory health care.” We

investigated the state of conventional Information

Technology in ambulatory practices and its usage by

physicians as well. The goal was to gain information

on the status quo of the testing region concerning the

aspects mentioned. Further, we were keen to find the

medical domain-related characteristics of medical

personnel and practices to be predictable when

measuring usage intention based on the UTAUT

model.

DO GERMAN PHYSICIANS WANT ELECTRONIC HEALTH SERVICES? - A Characterization of Potential Adopters

and Rejecters in German Ambulatory Care

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3.2 Sample Description

We distributed 500 questionnaires to all physicians

in ambulatory care of the Bavarian testing region

for healthcare telematics by mail, but also provided

the questionnaire on the Internet. The test region

has 452,000 inhabitants on 2,847 square kilometers.

The region is geographically well definable because

of its heterogeneous structure, which makes the

region suitable for field testing since it represents

the structure of Germany very well (ZTG Zentrum

für Telematik im Gesundheitswesen GmbH, 2009).

We received 117 responses, representing a response

rate of 23.2%.

Only 4 physicians used the online option to

submit their results, the remaining 113 returned it by

mail.

3.3 Clustering of the Respondents

The respondents were cluster analyzed according to

their usage intention. For this purpose a hierarchical

cluster analysis was performed, using ward’s

clustering algorithm and the squared Euclidean

distance as distance metric (Backhaus et al., 2006).

Usage intention was measured by the behavioral

intention scale as used in UTAUT by Venkatesh et

al. (Venkatesh et al., 2003). The rating scales were

Figure 1: Detailed Usage Intention.

slightly adapted to the given context (Table 1). They

ranged from 1 (intended adoption in less than 1 year)

to five (no intended adoption at all). As all variables

were measured on the same rating scales, there was

no need for normalization of the cluster variables.

Respondents that did not completely answer all three

items were excluded from the analysis. The total

mean reflects the combined opinion of all 117

respondents.

4 RESULTS

4.1 Description of Clusters

The cluster analysis revealed two different clusters

that can unambiguously be interpreted as

“Supporters” (Cluster 1) (also referred to as

adopters/potential adopters) and “Rejecters” (Cluster

2) of telematics services. 49 physicians were

grouped into the supporters cluster and 29 into the

rejecters cluster. The remaining respondents were

excluded. This categorization is surprising; we

expected the group of supporters to be smaller, as

their opinion is merely perceived in the public

discussion of telematics services. The supporters

embrace the new technology and show a

significantly (p<0.001) higher intention, plan and

prediction of usage than the rejecters

(table 1).

Table 1: Usage Intention from electronic healthcare

services deployed by via the TI.

Description Supporters Rejecters

Behavioral

Intention:

From 1 (In less than

1 year) to 5 (Never)

Do see the

benefits the TI

and are willing to

use the services

in the short term

Do not see the

benefits of the TI

and are not

willing to use the

services

I intend to use the

system ***

1.94 4.83

I plan to use the

system. ***

2.17 4.90

I predict I would

use the system ***

2.55

3.86

*p < .05; **p < .01; ***p < .001

No significant distinction could be observed in terms

of age, experience, or size of the practice (number of

physicians, number of patients). However,

significantly (p<0.05) more medical specialists are

grouped into the supporters’ cluster than general

practitioners.

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Table 2: Characteristics of physicians and practices.

Total

Mean

Adopter

Mean

Rejecter

Age

49.7 48.9 50.9

Gender

(1=Female, 2=Male)

1.70 1.67 1.73

Specialization *

(1=Family Doctor,

2=Medical

Specialist)

1.59 1.62 1.44

Number of

physicians working

in the practice

2.1 1.7 2.3

Patient

consultations per

day ***

46.5 40.3 61.7

Average time spent

on patient contact

per day

7.4 6.3 7.0

Patients visiting the

practice per day

86.1 79.9 99.5

Number of

employees in the

practice

4.5 4.8 4.0

*p < .05; **p < .01; ***p < .001

Moreover, physicians with a significantly lower

frequency of patient consultations are more often

(p<0.001) supporters of the new TI services, as they

are likely to have more time to treat every single

patient, thus using the services. When interpreting

this data, it has to be taken into account that the field

of medical specialists is very diverse in Germany,

and can only be compared with caution.

Dermatologists and orthopedists declared to

medicate regularly more than 80 patients per

working day, whereas specialists, such as

anesthetists or pediatricians, covered only a range of

20 to 40 patients.

4.2 Current use of Information

Technology in Ambulatory

Healthcare

The results seen in Figure 2 show widespread use of

conventional IT Technology in ambulatory care. For

more than 84% of all physicians, the Internet is

currently a source for medical information. While

Internet consultations for medical content is a

commodity for both groups, the practice of Internet

access is only a commodity for adopters,

significantly less (p<0.001) so for the cluster of the

rejecters, where only about half are connected to the

Internet. Internet access is apparently used

significantly more (p<0.05) by the supporters for

email communication within the health system with

colleagues, other institutions and patients.

Further, medical data are already distributed

among medical institutions, mainly by the adopter

cluster, even though a common and secure electronic

communication platform is not yet in place. Hence,

the inter-institutional communication differs

significantly, while very few differences can be seen

concerning the electronic documentation within the

practices. Physician-patient contacts are documented

electronically by 78% of the physicians, and for

73%, even with electronic medical records (EMR).

All respondents reported having an information

system in their practice. Most supporters already use

electronic utilities to represent their practice on the

Internet, to exchange patients’ medical data and to

communicate within the public health system. We

conclude thus that the supporters see the telematics

as complementary offers for extending the electronic

functionalities, which most of them are already

using.

The rejecter cluster is using IT within their

practices but lags behind significantly in terms of

Internet based communication matters in every

criterion measured. The rejecter cluster cannot be

characterized as opponents of IT, as they are using it

in their practices and have similar usage patterns for

the Internet concerning their personal skill

enhancement. The question why the internal usage is

common but the joint usage a matter of strong

resistance will be discussed in the following

sections.

4.3 Process Standardization

As one of the goals of the TI is the overcoming of

institutional boundaries within the public health

system, we asked for the current status of inter-

institutional communication during the treatment

processes. A majority of 56% of all respondents

reported having regular contact during treatments

and 33% at least partly. Only 7% stated being

isolated in inter-institutional treatments of patients.

A significant difference between the adopter cluster

and the laggards cluster could not be observed. As

the potential adopters often transmit information

electronically, it is likely that the rejecters still use

traditional communication matters for the

coordination of their treatments.

Both clusters do not significantly differ

concerning process documentation either. Practices

seem to document their treatment processes

extensively , as the experienced level of process

DO GERMAN PHYSICIANS WANT ELECTRONIC HEALTH SERVICES? - A Characterization of Potential Adopters

and Rejecters in German Ambulatory Care

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Figure 2: Adoption and Usage of conventional IT by Physicians in Ambulatory Care.

documentation standard is very high. 82% claim

that the processes are for the most part documented.

For the adopter cluster, significantly more processes

are derived from their IT systems, whereas the

laggards cluster has a lower level of IT orientation.

Whether these processes are based on best practice

or evidence-based-medicine cannot be determined in

this context. The potential adopters also show

significantly (p<0.001) higher interests in cost-

benefit analysis for their practices, while cluster 2

mostly does not regard this as being useful.

4.4 Processes and Infrastructure of the

EHC

Regarding the German telematics and processes,

infrastructures, applications and security standards

of the EHC, both clusters show a very low

knowledge level. Very few physicians have dealt

with the characteristics of the infrastructure as the

security standards and necessary hardware

infrastructure affecting their practices. Also, the

workflows which affect the practices when already

specified electronic health services such as

electronic prescriptions are introduced are hardly

known by both groups. Personal experience with the

particular EHC systems can therewith not be the

driver of the broad rejection among the physicians.

Just a small fraction has visited the sample

installation which is available in the testing region in

order to study a sample of the systems to be

deployed in all medical facilities in Germany. The

adopter cluster shows slightly more involvement in

the telematics; however, significant differences

cannot be seen, which excludes the system

knowledge as a criterion behind the adoption

decision.

4.5 Perceived Value of IT,

Documentation, Communication

and Patient Involvement

Ambulatory care needs IT in order to efficiently run

a practice today; this can be almost be regarded as

common sense within both groups. More than 80%

agree or strongly agree that they cannot productively

run their businesses without IT support. More than

70% do not see IT simply as a supportive

instrument, but believe that the technology provides

an added value to their practice. The adopter group

experiences a significantly higher value of IT

(p<0.01), even though the majority of both groups

see the necessity of using IT-Systems. As our results

have shown, electronic communication is already

very common among the group of potential

adopters.

The belief that electronic communication will

be common in the public health domain within 5

years seems to follow from the daily experience of

this group. Documentation, communication, and

treatment standards all show significantly higher

support (p<0.001) among the potential adopters. A

comprehensive medical documentation maintained

by all involved care providers is seen as being

essential by the adopter cluster, while the opposing

cluster is undecided. Patient involvement in medical

documentation shows similar tendencies and

significant differences between the two groups

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Figure 3: Process standardization and eHC related knowledge.

observed. The rejecters by trend doubt the benefits

of process standardization for their practices, and

fear an administrative overhead. They tend towards

the opinion that the daily work in practice is too

diverse to adopt standards for most workflows.

Standardized documentation for medical treatments

generally has lower support than does standardized

administrative documentation. While the adopter

cluster is rather supportive, the laggards are

undecided or dismissive. Expectedly, the potential

adopters regard e-health as a significant

development in medical treatment. Both groups

seem to have similar information providers

concerning e-health offers. As the total mean is

lower than the mean of both clusters, physicians

with missing contacts for information seeking have

not specified any preference concerning potential

adoption of electronic health services. Both groups

are rather undecided concerning the information

duty for patients about e-health risks and chances of

e-health services. As the adopter cluster has a higher

level of IT usage, the trend to see physicians as

information providers is well understandable since

the understanding of the services is likely to be

higher in this group.

4.6 Data Security

Ambulatory physicians generally show a very high

need for data security. National standards for the

handling of patients’ data are equally supported as

committing guidelines for the individual practices.

For most care providers, it is important to inform

their patients about the usage of medical data. The

adopters generally see a higher need for security

standards for their own practice and for the public

health system in general. Both groups are sceptical

about the central storage of medical data, and have a

tendency towards decentralized storage in patients’

hands to ensure their data sovereignty in the long

term. While the adopting cluster fears delays in

treatment processes when abandoning centralized

storage concepts, the laggards are significantly less

concerned (p<0.001). The group of potential

adopters certify themselves as having significantly

higher ability to inform their patients about the

usage of their medical data compared to the

opposing group.

5 SUMMARY AND

CONCLUSIONS

The results show that the group of physicians ready

to adopt EHS offered via the TI significantly differs

from the more dismissive group in many aspects.

Tendencies of the data security topic, dominating the

public opinion concerning telematics adoption in

Germany, do not differ when comparing the

potential adopters and rejecters telematics services.

Both groups strongly support nationwide unified

security standards for their own practices also.

DO GERMAN PHYSICIANS WANT ELECTRONIC HEALTH SERVICES? - A Characterization of Potential Adopters

and Rejecters in German Ambulatory Care

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Figure 4: Standards, patients’ involvement, communication standards, e-health, and IT-diffusion.

Adopters favor even higher security standards than

do the rejecters, independent of EHS offers. As the

eHC system tries to ensure exactly the demanded

security standards, other factors are more likely to be

responsible for the adoption decision. The two

identified clusters differ significantly in terms of

General IT adoption, process and documentation

standardization, patient involvement, cost-benefit

aspects, their medical specialization and their patient

throughput. The rejecters are not just lagging behind

in terms of IT adoption, but also in many aspects of

standardization, cost awareness and transparency. It

is likely that they regard the EHS as a mean to

enforce the aspects mentioned and therefore are less

supportive. The higher patient throughput of the

rejecters and their low interest in cost analysis for

their practices indicates that they are benefiting

above average from the status quo. EHS can be

further seen as a utility for patient involvement and

shared medical documentation, which show similar

answer patterns.

The German healthcare system has a group of

very progressive care providers. Conventional IT

can be considered to be a commodity for this group

of physicians. They are open for standards and

patient involvement, and therefore are keen to utilize

telematics services for this purpose. As both clusters

claim to maintain contact during treatments with

other medical institutions, but only the supporters

utilize IT for this purpose, the difference in IT usage

should not result in treatment quality, but in

efficiency increase. To investigate this, further

studies should be done to measure the impact of IT

in ambulatory care on both efficiency and medical

effectiveness.

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Figure 5: Security Standards for Medical Data.

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