臺灣博碩士論文加值系統

電子病歷紀錄（Electronic Medical Record – EMR）是記錄病患所有就醫以及診療資訊。將病患紀錄以電子化處理不但能使醫院獲得較完整的病患資訊，更有利於醫護人員進行有效率的疾病醫療。依Chang et al. (2012) 與Lehmann et al. (2015) 研究數據顯示大部分醫院的電子病歷仍然處於初期至中期階段，然而醫護人員抗拒使用行為乃其中影響成敗關鍵因素之一。因此，本研究主要以公平理論（equity theory）與心理抗拒理論（psychological reactance theory）之觀點，探討醫護人員評量醫院在執行EMR系統時的預期互惠義務表現是否讓醫護人員知覺未履行承諾與組織正義，進而導致醫護人員產生心理契約違背及抗拒使用EMR行為。另，探究醫護人員個人特質（如：個人科技創新性和醫療科技管理能力）及醫院管理方式（如：回應抗拒行為），是否能減緩醫護人員的抗拒行為。本研究同時採質性與量化分析，首先與12位資深醫護與資訊人員進行深度訪談，以確認研究架構的邏輯與適用性，再配合理論與文獻設計問卷。問卷調查對象為醫護與資訊人員，總共回收489份有效問卷做為量化分析與假設檢驗。資料分析結果顯示知覺未履行承諾與知覺組織正義皆會影響醫護人員之心理契約違背並產生抗拒使用EMR行為。干擾檢測顯示，承認系統問題並修正之回應策略是最有效回應醫護人員抗拒行為的方法。醫護人員個人於IT創新性與醫療科技管理能力的程度高低，在知覺組織正義對於心理契約違背或知覺未履行承諾與知覺組織正義對於抗拒使用EMR行為之間具有顯著的差異。因此，本文建議醫院在執行導入新病歷紀錄系統時應更重視醫護人員之負面使用經驗並改善之。此外，在系統導入的工作分配與程序上應更透明和尊重執行，避免讓較有能力的醫護人員承擔過多的責任與工作負擔，以降低其情緒耗竭。最後，建議醫院應建立一套完整的雙向溝通機制，以提升醫院和醫護人員彼此的了解，達成雙贏的效果。

Electronic medical record (EMR) system which records patients’ entire consulting and diagnostic information on electronic basis can not only provide hospital sufficient information but also enable physicians to make accurate disease diagnoses effectively. Chang et al. (2012) and Lehmann et al. (2015) indicated that most of the hospital’s medical record system is in the early to medium phase and healthcare professional resistance behavior to adopt the system is a crucial element to hinder success. Therefore, this study attempts to discuss whether the healthcare professional evaluation on the hospital performance of the expected reciprocal obligation will lead to healthcare professionals’ perceived unmet promises and perceived organizational justice, and results in psychological contract breach (PCB) and generated resistance behavior to EMR implementation from the perspective of equity and psychological reactance theory; furthermore, to study whether the effects of healthcare professionals’ personal trait (e.g., personal innovativeness in IT ＆ healthcare technology management (HTM) competency) and the hospital management practice (e.g., responses to resistance behavior) can potentially mitigate the healthcare professional resistance behavior. By applying both qualitative and quantitative research approach, 12 cases of in-depth interview was conducted with senior healthcare professionals and IT staffs to ensure the reliability of research framework and hypotheses; and develop survey questionnaire based on these outcomes. Four hundred and eighty-nine valid questionnaires have been collected from healthcare professionals and IT staffs for quantitative analysis and hypotheses testing. The results demonstrated that perceived unmet promises and perceived organizational justice had effect on healthcare professional PCB and generated resistance behavior to EMR implementation. In term of the moderating effects, acknowledgement and rectification responses approach was the most suitable method in response to the healthcare professional resistance behavior; healthcare professionals with high- or low-PIIT and high- or low-HTM competency had significantly different between groups in the effect of perceived organizational justice on PCB or the effect of perceived unmet promises and perceived organizational justice on resistance behavior to EMR implementation. The study suggested that the hospital should be more concentrated on the healthcare professional negative using experience and improves it; besides, the hospital should perform more transparent and respected in job and responsibility distribution, and avoid giving heavy workload and responsibility to the healthcare professionals who are more capable and talented to mitigate their emotional exhaustion. Finally, the study suggested that the hospitals should develop a complete two-way communication mechanism to increase the understanding between the hospitals and healthcare professionals to obtain a win-win situation.

TABLE OF CONTENT
中文摘要 ................................................ I
ABSTRACT ...............................................II
誌謝 ....................................................IV
TABLE OF CONTENT .......................................VI
LIST OF TABLE ......................................... XII
LIST OF FIGURE .........................................XIV
　 　
CHAPTER ONE INTRODUCTION

1.1. Research Background .............................. 1
1.2. Research Questions and Gaps ...................... 4
1.3. Research Objectives .............................. 14
1.4. Research Procedure ............................... 15
　 　
CHAPTER TWO LITERATURE REVIEW AND HYPOTHESES DEVELOPMENT

2.1. Electronic Medical Record (EMR) .................. 20
2.2. Psychological Reactance Theory ................... 28
2.3. Resistance to EMR Implementation ................. 35
2.4. IT Implementer Responses to Resistance Behavior... 54
2.5. Equity Theory .................................... 58
2.6. Perceived Unmet Promises ......................... 65
2.7. Perceived Organizational Justice ................. 71
2.8. Psychological Contract Breach .................... 82
2.9. Personal Innovativeness in IT (PIIT) ............. 91
2.10. Healthcare Technology Management (HTM) Competency 98
2.11. Hypotheses Development …………………………………………… 104
2.11.1. Psychological Contract Breach vs. Resistance to EMR Implementation …………………………………………………. 104
2.11.2. Moderating Effect of Responses to Resistance Behavior ………. 106
2.11.3. Perceived Unmet Promises vs. PCB ＆ Resistance to EMR Implementation …………………………………………………. 112
2.11.4. Perceived Organizational Justice vs. PCB ＆ Resistance to EMR Implementation …………………………………………………... 117
2.11.5. Moderating Effect of Personal Innovativeness in IT (PIIT) ……. 122
2.11.6. The Role of HTM Competency ………………………………… 125
　 　
CHAPTER THREE RESEARCH DESIGN AND METHODOLOGY

　 3.1. Operational Definitions ………………………………………………. 135
3.2. List of Hypotheses …………………………………………………….. 138
　 3.3. Research Design ＆ Questionnaire Development …………………… 139
　 3.4. Procedure of Data Analyses ………………………………………….. 146
3.4.1. Descriptive Statistics Analysis …………………………………… 146
3.4.2. Factor Analysis ………………………………………………….. 147
3.4.3. Structural Model Testing ………………………………………… 147
3.4.4. Hierarchical Regression Analysis for Moderating Effect ………... 147
3.4.5. Competing Model for Moderating Effect ………………………... 148
3.4.6. Post hoc Analysis ………………………………………………… 148
3.4.7. ANOVA Analysis ………………………………………………... 149

CHAPTER FOUR IN-DEPTH INTERVIEW

4.1. Interview Discussions …………………………………………………. 152
Interview A ………………………………………………………………. 152
Interview B ………………………………………………………………. 163
Interview C ……………………………………………………………… 170
Interview D …………………………………………………………….… 179
Interview E ……………………………………………………………… 188
Interview F ………………………………………………………………. 197
Interview G ……………………………………………………………… 205
Interview H ……………………………………………………………… 212
Interview I ………………………………………………………………. 219
Interview K ……………………………………………………………… 228
Interview L ……………………………………………………………… 238
Interview M ……………………………………………………………… 246
4.2. Summaries of In-depth Interview ……………………………………. 255
4.2.1. Verification of Research Model ………………………………….. 264
4.2.2. Verification of Measurement Scales ……………………………… 268
4.3. Pilot Testing …………………………………………………………… 272

CHAPTER FIVE DATA ANALYSES AND HYPOTHESES TESTING

5.1. Descriptive Analysis …………………………………………………… 277
5.1.1. Response Rate ……………………………………………………. 277
5.1.2. Demographic Variables …………………………………………… 278
5.1.3. Description of Measurement Scale Items ………………………… 279

5.2. Factor Analysis ………………………………………………………… 288
5.2.1. Exploratory Factor Analysis (EFA) ………………………………. 289
5.2.2. Measurement Model ……………………………………………… 297
5.3. Hypotheses Testing ……………………………………………………. 301
5.3.1. Structural Model Testing ………………………………………….. 301
5.3.2. Path Analysis of Main Effects ……………………………………. 305
5.3.3. Test for Moderating Effects ………………………………………. 309
5.4. Summary Results of Hypotheses Testing …………………………….. 317
5.5. ANOVA Analysis ………………………………………………………. 319
5.5.1. Implementing Duration …………………………………………… 319
5.5.2. Hospital Level …………………………………………………….. 321
5.5.3. Property Categories ………………………………………………. 323
5.5.4. Location of hospital ………………………………………………. 324
5.6. Post hoc Analysis ………………………………………………………. 326
5.6.1. Path Analysis of Sub-constructs’ Main Effects ……………………. 326
5.6.2. Competing Model for Moderating Effects on Sub-constructs ……. 330

CHAPTER SIX DISCUSSION AND RECOMMENDATIONS

6.1. Discussion of Findings ………………………………………………… 335
6.1.1. Psychological Contract Breach vs. Resistance to EMR Implementation ………………………………………………… 336
6.1.2. Moderating Effect of Responses to Resistance Behavior ………… 337
6.1.3. Perceived Unmet Promises, PCB, ＆ Resistance to EMR Implementation …………………………………………………... 341
6.1.4. Perceived Organizational Justice, PCB, ＆ Resistance to EMR Implementation…………………………………………………… 344
6.1.5. Moderating Effect of Personal Innovativeness in IT (PIIT) ……… 346
6.1.6. Moderating Effect of HTM Competency ………………………… 351
6.1.7. HTM Competency vs. Resistance to EMR Implementation ……… 354
6.1.8. Demographics/ Control Variables ………………………………… 356
6.1.9. Perceived Unmet Promises, Organizational Justice, and Control Variables ………………………………………………………….. 359
6.2. Implications …………………………………………………………… 363
6.2.1. Theoretical Implications ………………………………………….. 364
6.2.2. Managerial Implications ………………………………………….. 365
6.3. Limitations and Suggestions for Future Research ………………….. 377

LIST OF REFERENCES ……………………………………………………… 381
APPENDIX A Barrier of HIT Adoption ……………………………………… 417
APPENDIX B Interview Questionnaire Items (English Version) …………… 419
APPENDIX C Interview Questionnaire Items (Chinese Version) ………….. 422
APPENDIX D Preliminary Measurement Items (English Version) ………… 424
APPENDIX E Preliminary Measurement Items (Chinese Version) ………… 429
APPENDIX F Formal Questionnaire (Chinese Version) ……………………. 439
APPENDIX G Loadings and Cross-Loadings ………………………………... 444









LIST OF TABLE
Table 1-1 Top Four Reasons and the Rates of not to Adopt EMR …………… 6
Table 2-1 Related Definitions and Descriptions of Electronic Medical Records 23
Table 2-2 Psychological Reactance Theory Related Studies ………………… 30
Table 2-3 Resistance Behavior Related Studies ……………………………… 38
Table 2-4 Equity Theory Related Studies ……………………………………. 61
Table 2-5 Descriptions of User Resistance Determinants in using IS ……….. 69
Table 2-6 Organizational Justice Related Studies and Role Applications …… 73
Table 2-7 Psychological Contract Breach (PCB) Related Studies and Roles Played ……………………………………………………………… 87
Table 2-8 Personal Innovativeness in IT (PIIT) Related Topics and Roles Played ……………………………………………………………… 94
Table 3-1 Operational Definitions of all Constructs …………………………. 136
Table 3-2 List of Hypotheses of the Study …………………………………… 138
Table 4-1 Description of Interviewees ……………………………………….. 152
Table 4-2 Summary of In-depth Interviews ………………………………….. 263
Table 4-3 Verification of Hypotheses Causations ……………………………. 266
Table 4-4 Pilot Test Results (N=39) ………………………………………….. 274
Table 5-1 Description of Demographic Variables ……………………………. 279
Table 5-2 Description of Measurement Scale Items ………………………….. 286
Table 5-3 Exploratory Factor Analysis and Reliability ………………………. 292
Table 5-4 Inter-correlation of Subscales and Item Correlation Matrix ………. 296
Table 5-5 Factor Loading of First-order Constructs ………………………….. 298
Table 5-6 Reliability, AVEs, and Correlation Matrix of Constructs ………….. 300
Table 5-7 Weighs for Aggregate and Formative Constructs ………………….. 305
Table 5-8 Path Analysis of Main Effects (N=489) …………………………… 307
Table 5-9 Hierarchical Regression Analysis for Responses to Resistance Behavior …………………………………………………………… 312
Table 5-10 K-mean Clustering ………………………………………………… 314
Table 5-11 Competing Model for Moderating Effects ………………………… 316
Table 5-12 Summary Results of Hypotheses Testing ………………………….. 318
Table 5-13 ANOVA Analysis of Different Implementing Duration ……………. 321
Table 5-14 ANOVA Analysis of Different Hospital Level …………………….. 322
Table 5-15 ANOVA Analysis of Different Property Categories ……………….. 324
Table 5-16 ANOVA Analysis of Different Location of Hospital ……………….. 325
Table 5-17 Path Analysis of Sub-constructs’ Main Effects (N=489) …………... 328
Table 5-18 Competing Model for High/ Low Group Effects on Sub-constructs 334











LIST OF FIGURE
Figure 1-1 Research Procedure ………………………………………………… 17
Figure 2-1 Conceptual Framework …………………………………………….. 20
Figure 2-2 Fundamental Predictions Concept of Reactance Theory ………….. 28
Figure 2-3 Model of Multilevel Resistance to IT Implementation ……………. 44
Figure 2-4 Preliminary Conceptual Frameworks on Resistance Behavior Model ……………………………………………………………… 54
Figure 2-5 Preliminary Conceptual Frameworks on Equity Theory …………… 65
Figure 2-6 Full Research Frameworks ………………………………………… 134
Figure 4-1 Modification of Research Frameworks ……………………………. 267
Figure 5-1 Scree Plot for Resistance to EMR Implementation ＆ Responses to Resistance Behavior ………………………………………………. 293
Figure 5-2 Path Analysis of Full Structural Model …………………………… 308
Figure 5-3 Simple Slope for Interaction Effect of Inaction and PCB ………… 312
Figure 5-4 Simple Slope for Interaction Effect of A＆R and PCB ……………. 313
Figure 5-5 Simple Slope for Interaction of Dissuasion and PCB ……………… 313
Figure 5-6 High- and Low-PIIT Differences among Perceived Unmet Promises, Perceived Organizational Justice, and PCB ……………. 316
Figure 5-7 High- and Low-PIIT Differences among Perceived Unmet Promises, Perceived Organizational Justice, and Resistance to EMR Adoption ……………………………………………………. 317
Figure 5-8 High- and Low-HTMC Differences among Perceived Unmet Promises, Perceived Organizational Justice, and PCB …………… 317
Figure 5-9 Path Analysis of Sub-constructs …………………………………… 329

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