'For my Doctor told me so'. Examining the Influence of Trust on Citizens' Information Privacy Concerns and Health Technology Acceptance

Importance and Contribution Patient privacy has long been a fundamental component of healthcare delivery. For centuries, doctors around the world pledging the Hippocratic Oath explicitly promised to ‘respect the privacy of... [ view full abstract ]

Importance and Contribution

Patient privacy has long been a fundamental component of healthcare delivery. For centuries, doctors around the world pledging the Hippocratic Oath explicitly promised to ‘respect the privacy of my patients, for their problems are not disclosed to me that the world may know’ (Lasagna, 1964). This promise provides the foundation for the trusted patient-physician relationship. Individuals disclose sensitive, personal, and often embarrassing, health information to health professionals, who then use this information to diagnose and treat them. However, the growing prevalence of health information technologies such as electronic health records (EHRs) changes the nature of patient information and privacy in this context. EHRs enable physicians to create and store comprehensive digital patient records which can be seamlessly shared (Angst and Agarwal, 2009). The implementation of EHRs often fosters information privacy concerns (Clarke et al., 2009; Lafky and Horan, 2011), which is unsurprising due to the copious flows of patient data they facilitate. It has been posited that citizen acceptance of EHRs is paramount to their success, with citizens’ information privacy concerns cited as the biggest barrier to acceptance (Chhanabhai and Holt, 2007). In line with this assertion, one U.S. study found that information privacy concerns reduced individuals’ intentions to accept EHRs (Angst and Agarwal, 2009).

In Ireland, plans have been announced to introduce a national EHR (Department of Health, 2013). Therefore in order to ensure the successful implementation of a national EHR, it is imperative to understand and address citizens’ information privacy concerns. This paper has two aims. Firstly, the paper examines the influence of citizens’ information privacy concerns on their acceptance of EHRs in Ireland. Secondly, the paper explores how trust in health professionals influences the relationship between information privacy concern and EHR acceptance. This paper contributes in many ways. In terms of context, the study is the first to investigate citizens’ health information privacy concerns in Ireland. The paper adds to the Management Information Systems literature by elucidating the relationships between health information privacy concerns, technology acceptance, trust, and risk. The paper also extends the Protection Motivation theory to the health context. Lastly, the paper applies a mixed methods approach to gain a complete view into the constructs of interest.

Theoretical Base

The information privacy construct has attracted a great deal of interest from many academic disciplines including Psychology, Marketing, Law, and Management Information Systems (MIS). The myriad of studies across these disciplines has resulted in a fragmented body of knowledge on the role of information privacy. This paper reviews the existing information privacy literature in the MIS and Health Informatics literature. Within the Health Informatics literature, the few existing studies tend to examine information privacy concern as a one dimensional construct, many of which use one item constructs (Shaw et al., 2011). While these studies support the importance of citizens’ information privacy concerns in the health context, they do not offer insights into the specific concerns individuals express regarding their health information. Furthermore, the multidimensionality of the information privacy construct has been widely supported (Hong and Thong, 2013). In addition, these studies don’t explore factors which may influence citizens’ health information privacy concerns or factors which may mediate the relationship between concern and EHR acceptance. In contrast, the MIS literature offers a bounty of studies which have explored the role of information privacy in various contexts. Among the plethora of studies, a host of factors which may influence concern, and factors which may influence the concern-acceptance relationship have been explored. The context of the study largely determines the factors which are influential (Smith et al. 2011). In addition, a number of theories have been applied to explain the relationship between individuals’ information privacy concerns and their acceptance of technologies. However, in the context of health information technology, many studies lack a theoretical foundation (Or and Karsh, 2009). It is thus necessary to extend theories tested in other contexts, to the health context. This paper harnesses the Protection Motivation theory (PMT). PMT posits that individuals’ behaviours are influenced by their threat and coping appraisals (Rogers, 1975).

Threat appraisals consist of individuals’ perceptions of the various risks facing their information and the likelihood these threats will occur (Li, 21012). In this paper, citizens’ health information privacy concerns (HIPC) represent their perceptions of the risks facing their information across dimensions such as improper access to health data, and unauthorised secondary use of health data. Individuals’ perceptions of the risk that health professionals will misuse the health information they disclose represent the second element of their threat appraisal. Therefore, individuals with high HIPC and high perceptions of risk will be less likely to accept EHRs. Coping appraisal refers to individuals’ perceptions that the risks to their information can be managed (Li, 2012). In this paper, coping appraisal is measured as individuals’ trust in health professionals. It is expected if individuals express high levels of trust in health professionals, they will express lower perceptions of risk. It is also hypothesised that high trust will be associated with higher acceptance of EHRs.

Research Questions & Method

This paper explores the following two broad questions:
RQ1: How do citizens’ health information privacy concerns (HIPC) influence their acceptance of EHRs?
RQ2: How does trust in health professionals influence the relationship between HIPC and acceptance?

A mixed methods approach was applied to test the model developed from the literature. Firstly, quantitative data was collected using a survey of Irish citizens aged 18-65+. This survey tested the hypothesised relationships. These relationships were then explored on a deeper level through semi-structured interviews. A total of 247 complete survey responses were received, and 25 interviews conducted. Quantitative data was first analysed using structural equation modelling in AMOS21. Qualitative data was then analysed using an approach similar to Harris et al. (2009) to explore these hypotheses further.

Findings

The proposed model met all model fit statistics and recommended thresholds for indicating reliability and validity. Many of the hypothesised relationships were supported in the data. For example, health information privacy concern was negatively associated with trust in health professionals as posited. HIPC also had a significant, positive, influence on individuals’ perception of risk as expected. HIPC negatively influenced citizens’ acceptance or willingness to opt in to an EHR. The qualitative data offered many insights into these relationships. For example, individuals’ trust in health professionals was largely influenced by their past experience and the rapport they had with health professionals. The importance of trusting health professionals was also apparent. While trust in health professionals did negate some privacy concerns, many individuals remained concerned due to a mistrust in the wider ‘health system’, or the commercial goals of technology companies which may provide the technical infrastructure for EHRs. The quantitative and qualitative findings are discussed further in the paper, with emphasis on extending the Protection Motivation theory to this context.

Implications

Our understanding of the information privacy construct remains fragmented particularly in the under examined health context. This paper supports the inhibiting influence citizens’ health information privacy concerns have on their acceptance of EHRs and highlights the importance of trust. The mixed methods approach provides an in-depth insight into Irish citizens’ HIPC. These insights can be leveraged by health bodies, policymakers, and technology companies to develop educational approaches which address and appease citizens’ HIPC, while also fostering trust.

References

Angst, C. M. and R. Agarwal (2009). “Adoption of Electronic Health Records in the Presence of Privacy Concerns: The Elaboration Likelihood Model and Individual Persuasion.” MIS Quarterly, 33(2), 339–370.
Chhanabhai, P. & Holt. A. (2007). Consumers are ready to accept the transition to online and electronic records if they can be assured of the security measures. Medscape general medicine, 9(1), 8.
Clarke, I., Flaherty, T.B., Hollis, S.M., & Tomallo, M. 2009. Consumer privacy issues associated with the use of electronic health records. AHCMJ, 5(2), 63–77.
Department of Health (2013). eHealth Strategy for Ireland. URL: http://health.gov.ie/wpcontent/uploads/2014/03/Ireland_eHealth_Strategy.pdf (visited on 02/12/2014)
Harris, M.L., Collins, R.W. and Hevner, A.R., 2009. Control of flexible software development under uncertainty. Information Systems Research, 20(3), pp.400-419.
Lafky, D. B. and T. A. Horan (2011). Personal health records: Consumer attitudes toward privacy and security of their personal health information. Health Informatics Journal 17(1), 63–71.
Lasagna, L. (1964). Hippocratic Oath, Modern version. John Hopkins Sheridan Libraries. [online] Available: http://guides.library.jhu.edu/content.php?pid=23699&sid=190964 [Accessed 10th Aug 2014]
Li, Y. (2012). “Theories in online information privacy research: A critical review and an integrated framework.” Decision Support Systems 54(1), 471–481.
Or, C.K.L. and B.T. Karsh (2009). “A systematic review of patient acceptance of consumer health information technology.” Journal of the American Medical Informatics Association: JAMIA, 16(4), 550–60.
Rogers, R.W. (1975) “A protection motivation theory of fear appeals and attitude change.” Journal of Psychology 91(1), 9–114.
Shaw, N. T. Kulkarni, A. and R. L. Mador (2011). “Patients and Health Care Providers’ Concerns about the Privacy of Electronic Health Records: A Review of the Literature.” Electronic Journal of Health Informatics 6(1), 1–5.
Smith, H. J. Dinev, T. and H. Xu (2011). “Information privacy research: an Interdisciplinary review.” MIS Quarterly 35(4), 989–1015.

citizens' health information privacy concern, electronic health records, patient trust. [ view full abstract ]

citizens' health information privacy concern, electronic health records, patient trust.