Authors Accepted Manuscript

Patient Health Records: An Exploratory Study of

Patient Satisfaction

Michele Heath, Tracy H. Porter

www.elsevier.com/locate/hlpt

PII: S2211-8837(17)30068-0
DOI: https://doi.org/10.1016/j.hlpt.2017.10.002
Reference: HLPT252
To appear in: Health Policy and Technology
Cite this article as: Michele Heath and Tracy H. Porter, Patient Health Records:
An Exploratory Study of Patient Satisfaction, Health Policy and Technology,
https://doi.org/10.1016/j.hlpt.2017.10.002
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 Patient Health Records: An Exploratory Study of Patient Satisfaction

*Michele Heath
Cleveland State University
1860 E. 18th Street, BU 347
Cleveland, Ohio 44114
440-864-7131
m.heath@vikes.csuohio.edu

Tracy H. Porter
Cleveland State University
1860 E. 18th Street, BU 428
Cleveland, Ohio 44114
216-687-3785
t.h.porter@csuohio.edu

Key words: health care, patient health records, patient satisfaction, social contagion theory
*Corresponding author
Patient PHR use

Compliance with Ethical Standards:

Funding: This study was not funded.

Ethical approval: All procedures performed in studies involving human participants were
in accordance with the ethical standards of the institutional and/or national research
committee and with the 1964 Helsinki declaration and its later amendment s or comparable
ethical standards.
Ethical approval: This article does not contain any studies with animals performed by any
of the authors.
Informed consent: Informed consent was obtained from all individual participants
included in the study.

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Patient PHR use

Patient Health Records: An Exploratory Study of Patient Satisfaction

Abstract

Objective: This study seeks to understand what factors might influence a patients perception of
PHRs in early adoption. We draw from social contagion theory to examine how beliefs and
behaviors are subject to those who are important to them.

Methods: This is a quantitative study with data collected information from a self-selected patient
panel residing in the United States. Cross-sectional data were used to examine a patient beliefs
and behaviors as they use personal health records.

Results: The findings demonstrated patient skills and abilities to conduct PHR tasks plays a role
in the feelings developed toward the change. Behavioral resistance was shown to negatively
impact patient satisfaction. Cognitive resistance was significant but, not in the hypothesized
direction. We found a strong relationship between affective and cognitive resistance. This
research suggests when affective is high, cognitive scope is out shadow and whereas affective is
low, cognitive scope will broaden.
Discussion: After adoption, a patient might still resistance the PHR system. Hospitals and
physicians should emphasize the importance of PHR to every patient, seek to offer training
opportunities, offer avenues for discussion, and recognize the existence of resistance factors.
Conclusion: This study illustrates the need for physicians and hospitals to reshape patients
beliefs about PHRs by helping individuals understand and internalize the change toward PHRs.
To ensure the promotion and engagement of the PHR system, all interested parties (hospital
administrators, government agencies, policy makers, and physicians) must communicate and
publicize a consistent message related to the importance of PHR use.

Key words: health care, patient health records, patient satisfaction, social contagion theory

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Patient PHR use

Introduction

The concept of patient-centered care is not new to the healthcare field [1]. Previous

research has demonstrated that engaging patients in the process of their medical care improves

patient satisfaction, quality of care, and ultimately clinical outcomes [2]. Consequently,

healthcare organizations have spent a great deal of time, money, and effort trying to effectively

incorporate patient-centered practices into their strategic plans. This is especially important given

the recent changes in the healthcare field and the associated government mandates. Patient

engagement and getting patients more involved in the healthcare process is an essential

component of the Affordable Care Act [3]. The guidelines within the law clearly define how and

when patient engagement should be accomplished. A key reason for the focus on patient

engagement is patient satisfaction scores [3]. A number of recent studies have demonstrated a

clear link between patient engagement efforts and subsequent patient satisfaction scores [4].

One important component of the patient-centered movement has been the push for

patients to utilize patient health records (PHR). A PHR is an electronic application through

which patients can access, manage, and share their health information, in a private, secure, and

confidential environment [5]. Though PHRs do vary somewhat the majority offer a number of

common features to patients such as the ability to renew prescriptions, access test results, receive

automated reminders, schedule appointments, and interact with their providers [6]. A fully

utilized PHR means the patient will be more involved in their health care, improve their health

literacy, and ideally practice preventative self-care routines [7]. It is also important to note PHRs

have the potential to reduce health care costs by promoting more active patient involvement in

their own healthcare and thereby reducing administrative functions [8]. PHRs have also been

shown to be beneficial within various medical contexts such as emergency situations where they

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Patient PHR use

can provide first responders with critical medical information [6] and for patient with chronic

illnesses who receive services from multiple health care providers [8].

A patients perception of a PHR can influence whether they are ultimately satisfied with

the new technology. Previous research has shown patients will often resist making a change to a

PHR as doing so might disrupt their traditional relationship with their healthcare provider [9].

This resistance is often attributed to a variety of concerns such as the increased workload seen by

the patient where they might be asked to schedule their own appointments, review laboratory

results, request medication refills, and use the PHR to ask medical questions [10]. The

introduction of PHRs has been shown to illicit anxiety, insecurity, inequity, and to make patients

feel threatened [9]. Patients need to gain an understanding of how they can and should use PHRs

most effectively [11]. Therefore, it is important to understand what factors might impact the

change process.

There have been a number of challenges in the full deployment of PHRs and little

research has been conducted to understand why this might be the case. Emont [12] found less

than one in ten Americans had a personal health record and only half were aware of PHR

existence. To help patients accept and utilize PHRs means helping them understand and

internalize the change [4]. Therefore, this study seeks to exam several research questions. First,

generally how satisfied are patients with PHRs early in their experience with such systems?

Second, how do resistance and change self-efficacy influence the patients satisfaction with the

PHR? Finally, do social mechanisms influence patient satisfaction with PHR? This research is

exploratory in nature and therefore takes a broad perspective in order to gain understanding of

patients general perceptions surrounding their experience with PHRs. The variables within this

study are change self-efficacy, cognitive resistance, affective resistance, and behavioral

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Patient PHR use

resistance. Behavior resistance refers to the fact that PHRs might be discussed in a negative light

with others within their social circle. This influence could impact how satisfied the patient is

with the PHR. Hence, within this research, we will draw from social contagion theory [13] to

gain insight into how individuals are social agents and their beliefs or behaviors are subject to the

beliefs or behaviors of others who are important to them.

Social Contagion Theory

Social influence refers to the ability of another person or group to effect cognitive

or behavioral change within an individual [15]. Social inuence theories postulate people are

neither born with beliefs or behaviors nor are beliefs or behaviors developed in isolation [16].

Social contagion theory (SCT) postulates individuals are social agents and their behaviors are

subject to those who are important to them [17]. SCT explains information, ideas, and even

behaviors spread through networks of people [18]. There is a level of mutual inuence between

individuals within an organization and information transmission occurs through direct contact or

observation [19]. Social contagion actually occurs when an individual adapts their behaviors to

those of others [16]. For example, watching a movie recommended by friends, reading a book

referred by colleagues, dressing up for a wedding (assuming everybody else will do the same),

and so on, are all examples of how other peoples opinions or behaviors affect our everyday

choices [16].

Previous research has demonstrated a relationship between social influence and various

facets of human behavior [17]. A relevant theory of human behavior for this research is the

technology acceptance model (TAM) as this brings light to the relationship between information

technology and human behavior surrounding such technology [20]. Previous research has

demonstrated how the TAM model demonstrates the relationship between social influences

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Patient PHR use

within the information systems literature (TAM) [20]. Peer pressure and superiors' influence

have been shown to be determinants in technology adoption contexts [21]. TAM is an

information systems theory which demonstrates how users come to accept and use a new

technology. The model suggests that when users are presented with a new technology, a number

of factors influence their decision about how and when they will use it. Technology Acceptance

Model 2 (TAM2) was introduced by Venkatesh and Davis [20] and adapted from TAM and

includes subjective norms. Subjective norm refers to a person's perceived social pressure to

engage or not engage in a behavior [20].

Social influences have been incorporated in prior models and have been suggested to be

critical determinants in the early stages of technology use [22], such social influences have

primarily been treated as external pressures exerted by peers and superiors such that they sway

an individuals perceptions related to system use [23]. Prior research has not fully taken into

account the richness of social interactions which can ensue during system implementation [23].

Social interaction [17] can help researchers gain insights into the dynamics of peer interactions

related to coping and influencing and their impact on system use.

Within this study we seek to explain the role of SCT with respect to patient satisfaction

with PHRs. The decision to accept or reject a PHR could be influenced through social contagion.

Social influences might be evident through family members who have adopted a PHR,

discussion of the topic on social media, or stories of acceptance/denial through news outlets.

Previous research has demonstrated individuals who are socially proximate (e.g. very near or

close) in an environment often use one another as information sources or behavior referents to

manage the uncertainty of adopting new technology [25]. Previous research has also

demonstrated such social circles influence the clinical decisions made by patients [16].

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Patient PHR use

Personal Health Record (PHR)

A personal health record (PHR) is an online tool designed for patients to interact with

their clinical providers. PHRs offer numerous benefits such as secure exchange of health

information, alleviation of cumbersome administrative functions (i.e. phone calls, test results),

and encourages the patient to become more fully involved in their own healthcare [26].

Ultimately, use of a PHR will allow patients to take partial ownership of their own wellness

journey, to make better healthcare decision-making, and to develop better communications with

their providers [27]. Increased ownership of a patients own healthcare has been shown to

increase patient satisfaction [26].

A 2008 Survey of Health Consumers reported more than 60% of patients reported that

they wished they had online access to their medical records [1]. A second survey in the same

year reported 79% of US consumers agreed that using electronic PHRs could provide significant

benefits in managing their health and healthcare services [8]. Based on the numerous benefits of

PHRs to both the patient and health care organizations, leaders within the health care field have

worked diligently to get patients to fully utilize their PHRs however; these efforts have not

proven to be unsuccessful. Utilization rate research has demonstrated very low adoption and

subsequent use rates on the part of the patient [28]. The low utilization rates have been explained

through a variety of reasons including, slow adoption of new technology by patients, lack of

perceived ownership, concerns about privacy issues, and lack of research into the engagement of

patients [4].

Patient Satisfaction

Patient satisfaction has been defined as a personal subjective evaluation of care in

reference to an individuals healthcare experience [29]. Satisfaction ratings demonstrate the

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Patient PHR use

patients reflection of what occurred during their care and with the introduction of the ACA

satisfaction ratings are closely tied to healthcare reimbursement. Hospital Consumer Assessment

of Healthcare Providers and Systems (HCAHPS) scores reflect patients evaluation of their

satisfaction with their treatment and are important outcomes of healthcare [30].

PHRs offer both the patient and the healthcare provider a number of benefits which

impact patient satisfaction ratings. Benefits such as improved communication between the

patient and physician, encouraging patients to become more engaged in their healthcare, giving

patients quick access their own test results, allowing them to make their own appointments [31],

and improving quality and patient satisfaction levels [1]. However, in order to fully benefit from

this new technology and the potential benefits to patients satisfaction; the individuals willingness

to adopt and use the PHR is key [31].

Change Self-Efficacy

Readiness for change is considered to be one of the most important factors involved in an

individuals initial support for any change initiative [40]. Readiness for change is defined as a

comprehensive attitude which is impacted simultaneously by the content (i.e., what is being

changed), the process (i.e., how the change is being implemented), the context (i.e.,

circumstances under which the change is occurring), and the individuals involved (i.e.,

characteristics of those being asked to change) [33]. Collectively, readiness for change reflects

the extent to which an individual or individuals are cognitively and emotionally inclined to

accept, embrace, and adopt a new standard course of action [33].

Previous studies have focused on the change process and the specific individual or

organizational facets impacting the success or failure of the change progression [34]. A change

process is understood through the steps followed during the implementation process [33]. The

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Patient PHR use

first step focuses on the level of participation allowed of the individuals being impacted by the

change, the second step focuses on the organizational change content (i.e., administrative,

procedural, technological, or structural characteristics) and the way in which each of these

impacts the process, the third step focuses on the organizational context (i.e., conditions and the

daily work environment), and the final step seeks to understand the individual differences or

attributes of the employees themselves. Each of these steps must be appreciated and work in

harmony in order for a change initiative to be effective. In addition, organizational leaders need

to understand to effectively manage each step in the change process [33].

Change within the health care field has been unprecedented in recent years. The

Affordable Care Act legislation [35], the implementation of electronic health records (EHR)

[36], and the move toward the use of PHRs [37] are three of the larger change initiatives within

the industry. The move to PHRs is a tremendous change for patients as it asks them to move

beyond the traditional approach to medicine where all health information is held within the

clinicians control and communication between the physician and patient was either face-to-face

or via phone.

Change self-efficacy is an important component of the move to PHRs [38]. Change self-

efficacy is define as an individual who possess the required skills and are able to perform the

tasks that are associated with the implementation of the prospective change [33]. Behavior

change and maintenance are a function of expectations about the outcomes that will result in an

individual engaging in a behavior and expectations about and individuals ability to engage in or

execute the behavior [38]. Therefore, the level of change self-efficacy that a patient would have

with respect to PHRs is an important aspect of the change process. Based on previous research

we propose the following:

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Patient PHR use

H1: A patients change self-efficacy toward PHR use will be positively related to patient

satisfaction.

Resistance

Resistance to change is frequently noted within the literature as an explanation as to why

large-scale changes in technology or management practices often fall short of original

expectation of fail completely [39]. Resistance to change comprises both cognitive and affective

components that come into play at differing points in a resistance process [39]. The majority of

resistances to change studies have focused on the contextual variables which might impact the

outcome of the change initiative [40]. Certainly, the contextual variables are an important

consideration however; it is also important to understand how the individual level might impact

resistance to change. Oreg [39] began to analyze the individual level components and found the

cognitive, affective, and behavioral components in any change resistance model to be impactful.

Affective Resistance

Oreg [39] developed the resistance to change scale (RTC) in order to measure the

personality components within the resistance to change. According to this theory an individual

differs in their approach to change and possess an internal inclination to resist or adopt changes.

These individual differences in turn predict an individuals attitude towards a specific change.

Those who are high in their dispositional resistance to change are less apt to voluntarily

incorporate changes into their lives and when the change if forced on them are more likely to

experience negative reaction [39].

The affective component is described as how one feels about a change initiative (e.g.

angry, anxious, and excited) [39]. In order for the change to be effective the individuals needs to

feel the change is in their best interest and also the best interest of the organization [40]. A strong

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Patient PHR use

component of the resistance to change personality trait [39] involves an individuals emotional

predispositions towards change. Emotions are a powerful influence on any task and can impact

the way patients might deal with the change. Emotions are typically connected with how the user

will either accept or resist the system [39]. Based on the literature we propose the following:

H2: A patients affective resistance toward PHR use will be negatively related to patient

satisfaction.

Cognitive Resistance

The cognitive component is described as the way an individual thinks about the change

initiative (e.g. is it necessary and will it be beneficial to me?) [39]. An important aspect of the

cognitive component is the information which is disseminated during the change process and the

way in which it is shared. Several studies looked at the cognitive component with respect to

information sharing and found highly detailed information assisted individuals in understanding

the change [39]. Individuals who were given timely, comprehensive, and seemingly useful

information regarding a change process presented a more positive evaluation of the change and

demonstrated a higher willingness to cooperate with the change [39]. Therefore, the

dissemination of timely and relevant information to patients during as they use their PHR would

likely impact a patients level of confidence and therefore satisfaction with the change. Based on

the literature we propose the following:

H3: A patients cognitive resistance toward PHR use will be negatively related to patient

satisfaction.

Behavioral Resistance

Behavioral resistance refers to actions or intention to act in response to the change (e.g.,

complaining about the change, trying to convince others that the change is bad) [39]. Behavioral

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Patient PHR use

resistance might manifest as ambivalence, refusal, negative influence, or a direct challenge to the

change. Behavioral resistance involves both the behaviors and intention to behave in a negative

fashion [39]. For example, a patient might decide to complain about PHRs to their family

members or friends. If a patient was displaying behavioral resistance then they would actively

work against the change and potentially use social influence to do so. The social influence

mechanism they might use could include complaining verbally to others, posting negative

statements to social media, or working to impede the change.

Previous research has demonstrated behavioral resistance is often a product of social

influence [39]. The social system within which an individual functions can have a substantial

role in determining an individuals feelings, beliefs, and behaviors regarding the change [16].

The influence of social networks on the actual behavior change suggests when an individuals

social environment (i.e. colleagues, supervisors, and subordinates) tend to resist a change, the

individual is more likely to resist the change as well [19]. Social structures are analyzed in terms

of networks and constraints placed on the individual by their embeddedness within the social

structure and the differential opportunities, such as resources or social support, afforded by an

individuals [16]. Figure 1 shows the hypothesized relationship between all the study variables.

Based on the previous literature we propose the following:

H4: A patients behavior resistance toward PHR use will be negatively related to patient

satisfaction.

Method

Sample and Procedures

Since this study is descriptive and exploratory, a large sample was recruited to maximize

the diversity of recruited patients. We chose a purposive snowball sample because we have a

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Patient PHR use

defined group of participants identified for this study. The study had several screener questions

to ensure the participant was familiar with PHR (Questions: What is PHR? What functionality

have you used in the past?). Data for this study were collected using Mturks. Amazons

Mechanical Turk (MTurk) is a relatively new website that contains the major elements required

to conduct research: an integrated participant compensation system; a large participant pool; and

a streamlined process of study design, participant recruitment, and data collection.

A total of 304 participants from MTurk completed the online survey. The HIT was posted

on September 13, 2016, and was restricted to US patients with at least a 95% approval rating and

100 or more approved HITs. We made these restrictions in the present and following studies in

order to accurately represent the modern MTurk study paradigm; most recent MTurk research

makes such sample restrictions, following the precedent and suggestions of influential MTurk

methods articles [41]. Selection criteria for the population included being US residents, over 18

years of age, and having used PHRs in recent months. Respondent identities were recorded by

Qualtrics and assigned unique identifier; however, the participants identities were not associated

with the data. The program automatically presented the questionnaire items to each respondent in

a random order, thereby mitigating negative effects of order and measures were taken to ensure

surveys could only be completed once.

After a careful analysis of the relevant literature the following study variables were

selected: affective resistance, behavioral resistance, cognitive resistance, change self-efficacy,

and patient satisfaction. A total of 304 survey responses were received and of this number 257

were usable, which represents an 85% acceptance rate. The other 15% (47 surveys) of the

surveys were incomplete. Respondents demographic characteristics are displayed in Table 1.

Within this sample there were more women (73.50 percent) than men. The smallest percentage

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Patient PHR use

of respondents came from the 18 to 24 year age group. One-third of the respondents had a high

school education or less. Almost all respondents were non-Hispanic Caucasian. Most of the

respondents had been using PHRs for an average of four to 12 months and had used it more than

four times during the five-month period before the survey was conducted.

Measures

Change self-efficacy. Armenakis, Feild, and Harris [40] nine item Change Self-Efficacy

measure (= .85) was selected. Change self-efficacy refers to the extent to which one feels that

they possess the necessary skills and are able to execute the tasks that are associated with the

implementation of the prospective change. Responses were collected using a five-point Likert

scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). Sample items from

subscale include: My past experiences make me confident I will be able to utilize the new

system successfully after this change is made (CSE).

Change attitude. Oregs [39] behavioral (= .77), cognitive (= .78), and affective

resistance (= .86) scale items were used to assess the change attitude. Behavioral resistance

refers to the impact of rejecting the change and trying to influence other through actions.

Cognitive resistance refers to the way an individual thinks about a change and the beliefs

surrounding the change. Affective resistance refers to the feelings associated with the change

initiative. Responses were collected using a five-point Likert scale with responses ranging from 1

(strongly disagree) to 5 (strongly agree). Sample items from subscale include: I complained

about the change to others (BEV); I was afraid of the change (AFF); and I believed that the

change would harm the interaction between me and my physician (COG).

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Patient PHR use

Patient satisfaction. Kims [14] four item Patient Satisfaction scale (= .87) were used

to assess patient satisfaction. Patient satisfaction within this study refers to a patients approval

and support of a change initiative.

Descriptive variables. Several descriptive variables were collected for this study. These

included gender, age, education level, and marital status.

Results

The means, standard deviations, and zero-order correlations of the study variables are

shown in Table 1. The results of the correlation analysis are presented in Table 1 and show that

all correlations were statically significant.

___________________________________

Insert Table 1 about here

___________________________________

Hypothesis 1

The first hypothesis tests the relationship between the level of change self-efficacy and

patient satisfaction. Change self-efficacy was proposed to positively predict patient satisfaction.

Multiple regression analysis was used to test this hypothesis, with patient satisfaction entered as

the dependent variable. Change self-efficacy towards PHRs significantly predicted participants'

patient satisfaction (Table 2). Our analysis found that change self-efficacy significantly predicted

aggressive tendencies ( = .440, p<.001). This suggests that patients who believe they have the

necessary skills and abilities to successfully adjust to the change will be satisfied with their use

of the PHR. Hypothesis 1 is supported.

Hypothesis 2

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Patient PHR use

Multiple regression analysis was used to test if affective resistance significantly predicted

participants' patient satisfaction in hypothesis 2 (Table 2). Our analysis found affective resistance

significantly predicted patient satisfaction ( = -.100, p<0.05). This suggests patients who

possess higher levels of affective resistance will negatively impact patient satisfaction. Thus, it

seems that affective resistance in the current context is mostly an inhibitor of patient satisfaction.

Hypothesis 2 is supported.

Hypothesis 3

Multiple regression analysis was used to test if cognitive resistance significantly

predicted participants' patient satisfaction (Table 2). Our analysis found that cognitive resistance

significantly predicted patient satisfaction ( = .597, p<.001) however; this was not in the

hypothesized direction. This finding can potentially be supported through prior research which

suggests that once a patient develops negative feelings about a change, the patient will not

consider their beliefs about the change [24]. In other words, their feelings about the change

might overshadow their beliefs. According to Harmon-Jones [24] found a negative affective state

regarding a change can consequently narrow the cognitive scope surrounding that change. The

reciprocal is also true, positive affective states broaden cognitive scopes [24]. Hypothesis 3 is not

supported.

Hypothesis 4

Multiple regression analysis was used to test if behavior resistance significantly predicted

participants' patient satisfaction in hypothesis 4 (Table 2). Our analysis found behavior resistance

significantly predicted patient satisfaction ( = -.198, p<.001). This suggests patients who are

high in behavioral resistance will negatively impact patient satisfaction. Thus, it seems that

behavior resistance in the current context is mostly a blockade toward patient satisfaction with

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Patient PHR use

respect to PHRs. Hypothesis 4 is supported. The summary of hypothesis testing is presented in

Table 3.

Discussion

This study set out to investigate the possible impact of change self-efficacy, affective

resistance, cognition resistance, and behavioral resistance on patient satisfaction with respect to

PHRs. The first hypotheses sought to understand the impact of change self-efficacy with PHR

use on patient satisfaction. In order to be satisfied with the new technology patients must feel

that they have the right skills and a capability to fully utilize the PHR. Self-efficacy is developed

through exposure, experience, and mastery of such experiences [38]. As PHRs are a completely

new tool in the healthcare environment and a drastic change for all stakeholders an

understanding of a patients CSE is especially important before such an initiative is attempted.

For example, if patients do not have a great deal of experience with computers prior to their PHR

use they may not feel proficient using them and subsequently less satisfied with them. Others

may not have convenient access to a computer, may have literacy challenges, or not trust

technology. The second hypotheses sought to understand the impact of affective resistance with

respect to PHR use patient satisfaction. The findings demonstrated patients who had a negative

feeling regarding PHRs were also more likely to claim to be less satisfied. Negative feelings are

usually the first to develop when a change takes place [39]. Some patients will be more open

minded than others and feelings can change overtime depending on exposure. Therefore, it will

be important for those in charge of such change initiatives to assess the level of feeling

individuals might have prior to the change and potentially offer a safe environment where they

can share their feelings (i.e. fear, anxiety, and depression) and possibly deal with those feelings.

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Patient PHR use

The third hypotheses sought to understand the impact of cognitive resistance on PHR use

and subsequent patient satisfaction. As previously noted out findings were significant but, not in

the hypothesized direction. Oreg's model notes the three dimensions of resistance do not function

independently. Each is impacted by the others and work in tandem. Previous research has

demonstrated how the relationships between the three dimensions might be evident within this

research. For example, the work of Harmon-Jones [24] demonstrated the power of a strong

negative affective state within an individual and how this might diminish the impact of one's

cognitive scope about a change. Alternately, a strong positive affective state would in turn

broaden an individuals cognitive scope [24]. In other words, it is possible the way the

respondents felt about the change was so strong it minimized the impact of how they thought

about the PHR. Therefore, how the individual thinks about the change is an important

consideration and health care leaders should assess the feelings surrounding the initiative before

the process begins and once a patient signs up for a PHR.

The fourth hypothesis sought to understand the influence of behavioral resistance on

patient satisfaction with PHR use. Our research demonstrated a patients behavioral resistance

will negatively impact patient satisfaction. Social influences (i.e. discussions with others,

opinions of friends and family, information given by peers) may impact how an individual thinks

about using their PHR and subsequently influence how satisfied the individual will be with the

new technology. Previous research has demonstrated the importance of social influence on an

individuals decision making process [38]. Therefore, with respect to this study social influences

or social contagion may be impactful with respect to how one thinks about the new online tool. It

will be important for health care leaders to gain an understanding surrounding the behavioral

resistance which might cause a patient to not be satisfied with PHRs.

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Patient PHR use

The findings of this study are in alignment with previous qualitative research on patient

acceptance of PHRs which demonstrated the importance of building the PHRs in a way which

engages the patient in the technology early [42, 43]. For example, several studies looked at the

development problems and the solutions to those problems which should be established.

Solutions such as patient-centered design of the technology, training and education programs

embedded in the roll-out of the PHR, and consistent promotional initiatives for the patient were

shown to mitigate some of the inherent development problems, such as resistance, associated

with such a change [42]. The findings of our research extend previous research and demonstrate

the barriers which might develop if the development problems are not recognized early in the

planning of such a change initiative and the solutions to those problems are not carefully

orchestrated. The resistance factors should be included as a preemptive element of a PHR change

process.

Another area of alignment with previous research was the importance of organizational

context and the subsequent contextual norms which develop and impact behaviors [44]. Such

research demonstrated the importance of embedded social dynamics and notes these dynamics

inform the norms, and communication patterns between stakeholders. Previous research also

noted these relationships were particularly important within an online community (i.e. PHR

community) [44]. With respect to the research for this paper it is important to understand the

dynamics of each hospital system specifically and consequently gain insight into the ways

resistance norms might be present within each context.

Given the importance of social influence in contemporary society we utilize SCT to gain

insight into the process of behavioral resistance and patient use of PHRs. Social contagion theory

postulates that as social agents, peoples beliefs or behavior are subject to the beliefs or behavior

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Patient PHR use

of others who are important to them [17]. We found in this study that patients developed

negative feelings, potentially because the PHR system doesn't fit into their daily lives, and were

looking for ways to express their discontent of the change to others. The internal influence on a

patients decision to use a PHR within their social structure is referred to as a social contagion

[16]. Previous research has shown patients who are socially proximate in a social environment

often use one another as information sources or behavior referents to manage the uncertainty

about technology adoption [25].

Limitations and future research

The contributions of this study should be considered in light of its limitations. The data

were collected via a snowball sample using third party provider. Consequently, we cannot infer

absolute causal relationships between the study variables. It is also possible that common method

variance had some impact in the relationships between the study variables [32]. The impact of

data collected from individuals in a single instrument may inflate observed correlations beyond

correct level [32].

Conclusion

Better physician-patient communication and increased patient involvement in decision

making are vital components of a successful self-management program with improved patient

outcomes and overall satisfaction with care [5]. As the population ages and technology provides

enhancements for healthcare, PHRs will become a more common option offered by providers

who are implementing electronic health records [1]. Healthcare organizations must define a clear

vision of patient engagement and use a variety of tactics: from communications and marketing to

upgrading and enhancing usability of PHRs and portals to training and engaging clerical, and

using staff and frontline caregivers as allies in promoting patient engagement [4]. Neither patient

21
Patient PHR use

nor provider can exist in a vacuum, and the ability to communicate in this manner may bridge the

gap of missing information needed for improved care management and patient satisfaction.

22
Patient PHR use

References

[1] Kaelber, D, Ashish K., Johnston, D., Middleton, B., and Bates, D. "A research agenda for
personal health records (PHRs)." Journal of the American Medical Informatics Association 15,
no. 6 (2008): 729-736.
[2] Nazi, K, Hogan, T., Wagner, T., McInnes, D., Smith, B., Haggstrom, D., and Chumbler.
"Embracing a health services research perspective on personal health records: lessons learned
from the VA My HealtheVet system." Journal of general internal medicine 25, no. 1 (2010): 62-
67.
[3] Buck, J. "The looming expansion and transformation of public substance abuse treatment
under the Affordable Care Act." Health Affairs 30, no. 8 (2011): 1402-1410.
[4] Kreofsky, L. (2013). Engaging staff to engage patients: Patient engagement is essential for
meaningful use, and studies show it is becoming more definitively linked to consumer
satisfaction. Health management technology, 34(2), 12-13.
[5] Sprague, L. "Personal health records: the peoples choice." NHPF Issue Brief 820 (2006): 1-
13.
[6] Civan, A, Skeels, M, Stolyar, A., and Pratt, W. "Personal health information management:
consumers' perspectives." In AMIA. 2006.
[7] Detmer, D, Bloomrosen, M., Raymond, B., and Tang, P. "Integrated personal health records:
transformative tools for consumer-centric care." BMC medical informatics and decision making
8, no. 1 (2008): 45.
[8] Tang, P, Ash, J., Bates, D., Overhage, J., and Sands, D. "Personal health records: definitions,
benefits, and strategies for overcoming barriers to adoption." Journal of the American Medical
Informatics Association 13, no. 2 (2006): 121-126.
[9] Lin, C, Lin, I., and Roan, J. "Barriers to physicians adoption of healthcare information
technology: an empirical study on multiple hospitals." Journal of medical systems 36, no. 3
(2012): 1965-1977.
[10] King, N., & Anderson, N. (1995). Innovation and change in organizations. Routledge.
[11] Moreno, L, Peterson, L., Bagchi, A., and Ursin. R "Personal health records: What do
underserved consumers want?" Mathematica policy research 4 (2007).
[12] Emont, S. "Measuring the impact of patient portals." California Healthcare Foundation
(2011): 1-20.
[13] Le Bon, G. The crowd: A study of the popular mind. Fischer, 1897.
[14] Kim, S, Kaplowitz, S., and Johnston, M. "The effects of physician empathy on patient
satisfaction and compliance." Evaluation & the health professions 27, no. 3 (2004): 237-251.

23
Patient PHR use

[15] French, J, Raven, B., and Cartwright, D. "The bases of social power." Classics of
organization theory 7 (1959).
[16] Zheng, K, Padman, R., Krackhardt, D., Johnson, K., and Diamond, H., "Social networks
and physician adoption of electronic health records: insights from an empirical study." Journal of
the American Medical Informatics Association 17, no. 3 (2010): 328-336.
[17] Merton, R, and Kitt., A. "Contributions to the theory of reference group behavior."
Continuities in social research: Studies in the scope and method of The American Soldier
(1950): 40-105.
[18] Christakis, N and Fowler, J. "Social contagion theory: examining dynamic social networks
and human behavior." Statistics in medicine 32, no. 4 (2013): 556-577.
[19] Angst, C, Agarwal, R., Sambamurthy, V., and Kelley, K. "Social contagion and information
technology diffusion: the adoption of electronic medical records in US hospitals." Management
Science 56, no. 8 (2010): 1219-1241.
[20] Venkatesh, V., & Davis, F. D. (2000). A theoretical extension of the technology acceptance
model: Four longitudinal field studies. Management science, 46(2), 186-204.
[21] Davis, F. D., Bagozzi, R. P., & Warshaw, P. R. (1989). User acceptance of computer
technology: a comparison of two theoretical models. Management science, 35(8), 982-1003.
[22] Venkatesh, V., Morris, M. G., Davis, G. B., & Davis, F. D. (2003). User acceptance of
information technology: Toward a unified view. MIS quarterly, 425-478.
[23] Sykes, T, Venkatesh, V., and Gosain., S. "Model of acceptance with peer support: A social
network perspective to understand employees' system use." MIS quarterly (2009): 371-393.
[24] Harmon-Jones, E., Gable, P. A., & Price, T. F. (2013). Does negative affect always narrow
and positive affect always broaden the mind? Considering the influence of motivational intensity
on cognitive scope. Current Directions in Psychological Science, 22(4), 301-307.
[25] Kaplan, B. "Evaluating informatics applicationssome alternative approaches: theory,
social interactionism, and call for methodological pluralism." International journal of medical
informatics 64, no. 1 (2001): 39-56.
[26] Kahn, J., Aulakh, V., and Bosworth, A. "What it takes: characteristics of the ideal personal
health record." Health affairs 28, no. 2 (2009): 369-376.
[27] Archer, N., Fevrier-Thomas., U, Lokker, C., McKibbon., K, and Straus., S. "Personal health
records: a scoping review." Journal of the American Medical Informatics Association 18, no. 4
(2011): 515-522.
[28] Otte-Trojel, T, de Bont, A., Rundall, T., and Klundert, J. "How outcomes are achieved
through patient portals: a realist review." Journal of the American Medical Informatics
Association 21, no. 4 (2014): 751-757.

24
Patient PHR use

[29] Pellino, T, and Ward, S. "Perceived control mediates the relationship between pain severity
and patient satisfaction." Journal of pain and symptom management 15, no. 2 (1998): 110-116.
[30] Megivern, K, Halm, M., and Jones, G. "Measuring patient satisfaction as an outcome of
nursing care." Journal of Nursing Care Quality 6, no. 4 (1992): 9-24.
[31] Wolter, J and Friedman, B. "Health records for the people: touting the benefits of the
consumer-based personal health record." Health Records for the People: Touting the Benefits of
the Consumer-based Personal Health Record/AHIMA, American Health Information
Management Association (2005).
[32] Conway, J, and Lance, C. "What reviewers should expect from authors regarding common
method bias in organizational research." Journal of Business and Psychology 25, no. 3 (2010):
325-334.
[33] Holt, D., Armenakis, A., Feild, H., and Harris, S. "Readiness for organizational change: The
systematic development of a scale." The Journal of applied behavioral science 43, no. 2 (2007):
232-255.
[34] Crant, J. "Proactive behavior in organizations." Journal of management 26, no. 3 (2000):
435-462.
[35] Kocher, R, Emanuel, E., and DeParle., N. "The Affordable Care Act and the future of
clinical medicine: the opportunities and challenges." Annals of internal medicine 153, no. 8
(2010): 536-539.
[36] Blumenthal, D and Tavenner, M. "The meaningful use regulation for electronic health
records." N Engl J Med 2010, no. 363 (2010): 501-504.
[37] Serocca, A. "Personal health record use by patients as perceived by ambulatory care
physicians in Nebraska and South Dakota: a cross-sectional study." Perspectives in Health
Information Management 5, no. 15 (2008): 1.
[38] Bandura, A. "Self-efficacy: toward a unifying theory of behavioral change." Psychological
review 84, no. 2 (1977): 191.
[39] Oreg, S. "Personality, context, and resistance to organizational change." European journal of
work and organizational psychology 15, no. 1 (2006): 73-101.
[40] Achilles A., Bernerth, J., Pitts, J., and Walker, H. "Organizational change recipients' beliefs
scale: Development of an assessment instrument." The Journal of applied behavioral science 43,
no. 4 (2007): 481-505.
[41] Goodman, J., Cryder, C., & Cheema, A. (2013). Data collection in a flat world: The
strengths and weaknesses of Mechanical Turk samples. Journal of Behavioral Decision Making,
26(3), 213-22.

25
Patient PHR use

[42] Otte-Trojel, T., de Bont, A., Rundall, T. G., & van de Klundert, J. (2015). What do we know
about developing patient portals? a systematic literature review. Journal of the American
Medical Informatics Association, 23(e1), e162-e168.
[43] Otte-Trojel, T., Rundall, T. G., de Bont, A., van de Klundert, J., & Reed, M. E. (2015). The
organizational dynamics enabling patient portal impacts upon organizational performance and
patient health: a qualitative study of Kaiser Permanente. BMC health services research, 15(1),
559.
[44] Visser, L. M., Bleijenbergh, I. L., Benschop, Y. W., Van Riel, A. C., & Bloem, B. R.
(2016). Do online communities change power processes in healthcare? Using case studies to
examine the use of online health communities by patients with Parkinson9s disease. BMJ open,
6(11), e012110.

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Patient PHR use

Table 1:

Summary of Intercorrelations, Means, and Standard Deviations

Measure Mean SD 1 2 3 4 5
Change Self Efficacy 2.15 .471 -------
Behavioral Resistance 4.16 .905 -.331** ----------
Cognitive Resistance 2.51 .553 .338** -.143* ------------
Affective Resistance 3.77 .763 -.292** .716** -.081 ----------
Patient Satisfaction 2.04 .802 .511** -.464** .542** -.404** ----------
*p < .05; **p < .01;

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Patient PHR use

Table 2

Regression Model Predicting Patient Satisfaction (N = 257)

Model 1

Independent Variables

b s.e. p-value
Change Self .440 .084 .258 .000**
Efficacy
Behavioral -.198 .057 -.223 .034*
Resistance
Cognitive .597 .068 .412 .000**
Resistance
Affective -.100 .067 -.136 .001**
Resistance
R2 = .505**
*p<.05 **p<.01

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Patient PHR use

Table 3: Summary of Hypothesis Testing

Hypotheses Supported/Not Supported

H1: A patients change self-efficacy toward Supported
PHR use will be positively related to patient
satisfaction.
H2: A patients affective resistance toward PHR Supported
use will be negatively related to patient
satisfaction.
H3: A patients cognitive resistance toward Not Supported
PHR use will be negatively related to patient
satisfaction.
H4: A patients behavior resistance toward PHR Supported
use will be negatively related to patient
satisfaction.

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Patient PHR use

Patient Health Records: An Exploratory Study of Patient Satisfaction

Highlights
This study builds on prior knowledge to understand what factors might influence a
patients perception of PHRs early in their adoption.
A patients perception of the proposed change can influence whether they are ultimately
satisfied with the change.
In this study, we seek to explain the role of social contagion theory with respect to patient
use of PHRs
This study set out to investigate the possible impact of change self-efficacy, affective
resistance, cognition resistance, and behavioral resistance on patient satisfaction with
respect to PHRs.

30
Patient PHR use

Figure 1: Hypothesized Model of Variable Relationship

H1+
Change Self Efficacy

H2-

Affective Resistance
Patient
Satisfaction

H3-
Cognitive Resistance

H4-

Behavioral Resistance

+positive

-negative

31